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Immunisation Conversations and Vaccine Hesitancy Nikki Turner Director, Immunisation Advisory CentreUniversity of Auckland

Acknowledgement: With grateful thanks to contribution from Mark Wallace-Bell, University of Canterbury

Complacency

ConvenienceConfidence

Factors influencing decisions in immunisation uptakeThe WHO’s 3 Cs

Lack trust in vaccines, in delivery systems, in policy-makers. Antivaxers may influence

Low perception of the risks of vaccine preventable diseases. Choose other life/health alternatives as a priority

Physical access, availability, affordability, willingness to pay; geographical access, ability to understand (language, health literacy); appeal of immunisation services. Address these first!

SAGE report on Vaccine Hesitancy

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Vaccine hesitancy• Vaccine hesitancy = delay or refusal of vaccines

• Complex and context specific

= <15%= >80% = <3%

Image: Adapted from World Health Organisation (2014) Report of the SAGE Working Group on Vaccine Hesitancy

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There is little point in having the best science in the world if we can’t

communicate it effectively

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What is the question?• My child is sick• My child is not at high risk• My child is too young• Vaccines are unsafe• I don’t trust the authorities

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Typologies

• Nuturers – children at low risk of disease• Fearfuls – experience emotionally distressing• Vulnerables – barriers to access• Unwell - child poor health• Rejectors - opposed

6Litmus: Immunisation Audience Research, Feb 2011

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Tailoring conversations• Vaccine decisions are

complex

• No “one size fits all”

• Match your dialogue and time to the audience

• Vulnerables – refer to outreach

• Fearfuls – mitigate pain of vaccination

• Unwell – support not delaying unless contraindicated i.e. mildly unwell

• Nurturers – emphasise disease protection

• Rejecters – acknowledge, leave the door open

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• Open ended questions• Affirmations• Reflections• Summarising

The cores skills of Motivational Interviewing - OARS

9Slide from Mark Wallace-Bell, University of Canterbury

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Successful Conversations

• A successful conversation about vaccines involves a two-way conversation, with both parties sharing information and asking questions.– Take time to listen– Solicit and welcome questions. If parents seem

concerned about vaccines but are reluctant to talk, ask them open-ended questions and let them know that you want to hear their questions and concerns.

– Put yourself in parents’ shoes and acknowledge parents’ feelings and emotions, including their fear and desire to protect their children.

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Successful Conversations• Acknowledge benefits and risks.

– Explore both sides• Respect parents’ authority/autonomy.

– By talking respectfully with parents about their immunization concerns, you can build on this partnership, build trust, and support parents in the decision to choose vaccination.

• Building trust– Building trust begins with open conversations, during which you

provide balanced answers to questions• Be careful with information

– Remember, not all parents want the same level of medical or scientific information about vaccines. By assessing the level of information that a particular parent wants, you can communicate more effectively and build trust.

Slide from Mark Wallace-Bell, University of Canterbury

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Active listening

• Continue the discussion using your reflective listening skills by summarizing what you heard using statements.– “So correct me if I’m wrong, but you are worried the

vaccine will make your arm sore and you might feel sick, but you are unsure what happens when someone gets X disease?”

• Ask permission to give advice– Provide clarifying information in a non-judgmental way. – “Would you mind if I provided you more information about

X disease so you have all the facts before you decide not to get the vaccine?”

Slide from Mark Wallace-Bell, University of Canterbury

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Normalising Concerns

• Normalize the patient’s concerns by helping her or him understand that many of your patients share similar concerns and why you continue to believe it is a good idea to take the vaccine– “Many of my patients are concerned about the safety

of vaccines and whether they are more likely to get sick from the shot that the actual disease. I understand their concern because many vaccine preventable diseases are less common now that we use vaccines regularly.”

Slide from Mark Wallace-Bell, University of Canterbury

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Use Affirmations

• Combining affirmative statements with advice can be an effective approach.

– “I am glad you took the time to research the vaccine before your visit today. Being well informed about your health is very important. I recommend patients use these sources of information when making vaccine decisions.”

Slide from Mark Wallace-Bell, University of Canterbury

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Assess readiness

• Gauge where the patient is in the change process by using the readiness rule– “On a scale of 0 to 10 where 10 is ready to get the

vaccine today and 0 is I’m never going to get the vaccine.

• For patients at a 0 or 1, your time may be better spent on other preventive health measures though you may provide them with additional information about things to consider when choosing not to vaccinate.– For ambivalent patients, provide them with additional information to

consider before your next visit, and let them know you can talk about it more then.

Slide from Mark Wallace-Bell, University of Canterbury

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Guiding style

• Ask permission to discuss a parent’s concerns and then utilise active listening techniques –

• Guide the conversation using open questions and reflections

• Discuss both the vaccine and disease risks and benefits, supported by easily digestible written and online resources –

• Provide a positive recommendation to vaccinate

Slide from Mark Wallace-Bell, University of Canterbury

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Participatory or Presumptive• Research shows that when providers use participatory language to

initiate vaccine discussions, parents are more likely to voice resistance than when providers use presumptive language.

• An example of participatory language is asking a question like,– "What do you want to do about vaccines?"

• A presumptive approach would be to say, – "Your child needs three vaccines today."

• If parents voice resistance when you use the participatory approach, consider restating your original vaccine recommendations. – "These vaccines are very important to protect him from serious

diseases." • Data show that when restated like this, half of parents accept

vaccines.

Opel DJ, Mangione-Smith R, Robinson JD, et al. The influence of provider communication behaviors on parental vaccine acceptance and visit experience. Am J Public Health. 2015;105:1998-2004

Adapted from slide from Mark Wallace-Bell, University of Canterbury

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…tips on misinformation

• Avoid repeating myths: – Countering misinformation can be counterproductive (Boomerang effect)

• Direct the conversation to the disease itself and the effective action they can take

• Before a myth is mentioned, clearly indicate the subsequent information is false– Provide an alternative explanation bout why the myth is

wrong/or why it is being promoted

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Tools

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“Let’s talk about immunisation”A flipchart to use for inform consent and conversations

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Resources• Talking With Parents About Vaccines for

Infants: http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/talk-infants-color-office.pdf

• Savoy ML, Yunyongying P. Getting through to your patients. FamPract Manag 2013 Nov-Dec;20(6):36. (Available at http://www.aafp.org/fpm/2013/1100/p36.html)

• Standards for Practice: Vaccine Recommendation: http://www.cdc.gov/vaccines/hcp/patient-ed/adults/for-practice/standards/recommend.html

• Provider Resources for Vaccine Conversations With Parents: http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/

• CDC Provider Resource Page: http://www.cdc.gov/vaccines/hcp.htm

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IMAC factsheets

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0800 IMMUNE (466 863)

www.immune.org.nz