Conversation approaches

Presume that patients and parents are ready to vaccinate when they attend a particular appointment.

A presumptive approach significantly increases the likelihood of agreement and is also a measure for the level of hesitancy.

Example

Don’t: “What do you want to do about your son’s shots?”

Do: “Your son is due for his MMR booster. As soon as we’re done here, my nurse will come in to administer it.”

Tip: Avoid using the word “shot”, which can be scary for the patient. Instead, say “vaccine” or “injection.”

The ‘Ask-Tell-Ask’ model is based on a two-way communication strategy used to correct a behaviour or belief. This model helps narrow down the individual’s concerns when unsure and tailor information to their needs.

The ‘Ask-Tell-Ask’ model consists of three steps:

1. Ask patients and parents what they know about the vaccine, issue or concern
2. Tell them what they need to know (providing truth via facts and real-life examples)
3. Ask whether they understood the information or have more questions

‘Ask-Tell-Ask’ is one of the best conversation strategies to adopt in vaccine discussions for two reasons—it helps you:

• Understand an individual’s current thinking so that you can address their specific concerns
• Build trust because it shows you are willing to listen

Ask

1. Start with open-ended questions

This will allow you to evaluate patients’ and parents’ level of knowledge and better understand their concern(s).

Example:

“What would it take for you to accept vaccines for your child?”

“Can you tell me more about why you don’t want vaccination?”

2. Follow up with a silent pause and non-verbal encouragement

Example: Leaning forward and/or nodding.

3. Listen carefully

Avoid engaging in distracting activities, such as reviewing medical records, while the patient or parent is talking. Avoid giving premature reassurance before listening to all the patient or parent has to say about an issue, because it may make them feel ignored. Use their own language where possible.

Example:

Instead of saying "This is a fairly common concern," say "My understanding is that you are concerned about the effect of mercury. Is that correct?"

4. Express empathy

Show empathy by communicating your understanding of their concerns and respect for them as an individual.

Example:

“It sounds like you are worried about your child developing autism and that you want to do everything you can to prevent that. You’re a good parent for wanting to keep your child safe.”

5. Continue to dig deeper

Dig into the individual’s concern(s) by inviting them to elaborate on something you picked up on earlier.

Example:

“So, you’re concerned that you may get the flu after the flu vaccine. Can you tell me more about what you’ve heard?”

6. Keep asking “Is there something else?”

Do this until the patient or parent runs out of objections. Using the term “something” is typically more effective than “anything.”

7. Ask permission

After the patient or parent has finished talking, ask their permission before providing any information. This shows respect and indicates that you don’t intend to waste their time.

Taking a patient-centered approach like this increases the chances of your recommendations being accepted.

Tell

Offer evidence-based information and personal stories.

Provide a clear medical recommendation for vaccination and respect the patient’s or parent’s autonomy to choose.

For children, make sure you address the fear of immunization pain and distress that is felt by many parents.

1. Acknowledge the individual’s concern(s)

For example, “That’s a good question – I’m glad you asked it.”

2. Provide information specific to the concern

Supply facts in short, simple chunks (avoid medical jargon). A useful rule of thumb is not to give more than three pieces of information at a time.

Focus on the facts

Research shows that the more you try to beat a myth, the less success you’ll have at changing a person’s mind about it. Instead, to correct a misconception, communicate the relevant facts using clear language in a non-confrontational manner.

Example:

Parent: “Won’t having so many vaccines overwhelm my child’s immune system?”

Physician: “A child’s immune system has to deal with thousands of germs on a daily basis. Research suggests that babies can actually handle up to 10,000 injections at one time.”

Discuss the benefits of vaccination and the risks of not doing so

If a patient or parent has vaccine safety concerns, briefly explain the robust Canadian vaccine development and safety testing process, such as evidence-based approval process, manufacturing regulations, independent recommendations for vaccine use and ongoing monitoring of adverse events.

Tell personal stories related to vaccination

You could tell patients and parents that you have immunized yourself, your children or grandchildren. This demonstrates your confidence that vaccination is safe. You can also tell stories about children who were sick with vaccine-preventable diseases.

Be honest about vaccination side effects

Example:

“There is a small risk with vaccines, just as with everything we do in life, like driving a car or riding a bike.”

Instruct the patient on how to reduce the risk of side effects that are preventable

The following step-by-step approach can be used with patients with a history of feeling dizzy or fainting. The focus is on using muscle tension, which helps to prevent fainting by elevating blood pressure:

1. Start either before the injection or as soon as symptoms of low blood pressure appear
2. Instruct the patient to tense large, lower-body muscle groups (for example, squeezing legs together or pushing feet into the ground)
3. Hold for 20 seconds, then release
4. Repeat five to 10 times or until symptoms resolve

Frame your message clearly and positively

Example:

Instead of saying “Only one out of 100 people experience side effects,” say “99 out of 100 people experience no side effects.”

Use absolute, rather than relative, numbers

Example:

“The risk of anaphylaxis after vaccination is about one in a million. This is the same likelihood as being struck by lightning.”

Emphasize that both you and the patient or parent want what’s best for them and that you are working together towards a common goal – looking after their wellbeing.

End the discussion

Finish with a strong but simple message that the individual will easily remember.

Example:

“If you wait for a disease outbreak before vaccination, it’s often too late to benefit from the protection vaccines can offer.”

Sample Q&A

Interventions to reduce vaccination-associated pain 

Addressing pain is important for both children and adults, since negative experiences with vaccination can lead to needle fears (four to 10 per cent of adults have a fear of needles) and vaccine refusal.

Use injection techniques that minimize pain (e.g., injection without aspiration, most painful vaccine last).

Ask patients and parents about their preferences for pain management interventions that are within their control. For example, do they want topical anesthetics? Do they want to be distracted during the injection?

Consider using the CARD^TM System (Comfort, Ask, Relax, Distract) as a tool to educate and engage patients in participating in their own pain management. This approach can help decrease a patient’s anxiety and fear around vaccination.

Ask

1. Ask if they understood

Ask the patient or parent if they’ve understood what you have just discussed. This will give you an opportunity to address any misunderstandings.

Example:

“To make sure I explained this well, would you mind telling me what you got from our conversation?”

2. Make the final ask

Once you get to the end of the conversation, make the final ask.

Example:

“What are your thoughts now about getting a flu shot?”

After hearing the facts as part of the ‘Ask-Tell-Ask’ model, many patients and parents agree to vaccination.

If your patients or their parents decline vaccination once, don’t give up. Let them know that you will bring it up during future visits to make sure they, or their child, will be protected.

Focus on finding common ground—both parents and you as their physician want to do what is best for the child.

You can close the conversation with a comment like:

“Thank you very much for your openness to this discussion about vaccination. I know that we both want the best for your child. I’ll give you some time to reflect on what we talked about today. It might lead you to other questions and of course, I am always here to answer any questions you may have.”

If they agree to leave the door open for future conversations, this could be considered a success.

Next steps

• Continue the conversation during future visits and repeat your strong recommendation to vaccinate
• Agree on at least one follow-up action with your patient or their parents, such as scheduling another appointment or reading the extra information that you’ll provide to them
• Educate patients and parents about early symptoms of vaccine-preventable diseases

For parents, remind them to call before bringing their child into the office or other health-care settings when the child is ill so that health-care staff can take precautions to protect others.

Don’t withhold care from a child if parents refuse to immunize, as this is not in the child’s best interest, and may result in non-vaccinating families concentrating on certain practices, turning them into outbreak hubs.

See professional rights and responsibilities regarding vaccines.

Conversations with vaccine-hesitant patients and parents often take time and may interfere with your busy practice routine. These discussions are certainly worth the effort when you consider the impact on public health.

For children, start vaccine discussions as early as possible in prenatal appointments. This will help you to identify possible vaccine-hesitant parents sooner. It also gives them more opportunities to express their concerns while giving you more of a chance to find answers to their questions. If parents are hesitant, continue the discussion in early visits, and consider having a special visit to review vaccines when the child is six weeks old.

Focus on patients and parents who are undecided and those who only delay or skip some vaccines. This group is more likely to accept your recommendations compared with firm refusers and deniers. Even if parents are hesitant, break down the benefits of each vaccine. Sometimes parents are willing to do one or some vaccines, but not others. Avoid an all-or-nothing approach.

Get help from other health-care team members at your office. For example, assign a nurse to have pre-visit conversations with the individual to determine their attitudes towards vaccine acceptance. If they decline, the nurse can ask them if they mind sharing their fears and concerns. The nurse can then give you this information before you see the patient next. Also consider working with pharmacists to reinforce messages where possible and appropriate.