Increasing immunization confidence

Objective

Reduce the spread of vaccine preventable diseases by empowering healthcare staff to have effective conversations with families on the topic of immunization

Goals

• Establish a culture that promotes immunization confidence
• Open the conversation with a strong recommendation
• Respond with empathy to concerns about immunization
• Tailor your communication to different individuals and situations

What you can do to promote immunization confidence

• Use positive body language, with a smile!
• Display information posters to educate families
• Communicate honestly and openly
• Adopt an attitude of empathy and collaboration
• Don’t be afraid to bring up immunization
• Take the time to listen
• Solicit and/or welcome questions
• Use trusted sources of information

The presumptive format

Using the presumptive format – asserting your position using a closed-ended statement – is the most effective way to deliver an immunization recommendation.

It works because it sets immunization as the default option, presenting the decision to immunize a child as an ‘opt-out’ rather than offering a binary set of options – yes or no. This promotes vaccination as a social norm – most families choose to accept the recommended immunizations for their children.

Presumptive format examples

• (I know we talked about delaying the schedule before, but) I’d like to get Davey caught up on his shots today.
• We’re recommending that all patients get the flu shot right now too, so I’ll go ahead and get that ready.
• The COVID vaccine is an important way to protect Jasleen. I recommend it for all of my patients.
• We'll plan to give the recommended vaccines at Shula’s check up appointments.
• I recommend these vaccines for all my patients, and my children are vaccinated because I wanted to protect them from these diseases.

Five motivational interviewing techniques

The five skills used in motivational interviewing: 

• Open-ended questions
• Affirmations
• Reflections
• Ask permission before sharing
• Autonomy support

Ask open-ended questions

Open-ended questions help you to explore and understand a parent or caregiver’s stance on immunization.

When you want to understand and explore where somebody’s hesitancy is coming from, open-ended questions leave space for them to answer as fully as possible and give you all the information you need.

Example: “Tell me more about…”

Affirmations

Hesitant parents and caregivers are not bad people, they only want what they believe is best for their child.

Affirmations improve engagement by showing parents and caregivers that you see how much they care, making them feel supported, appreciated, and understood.

Example: “You’re a good parent. Your concern shows how much you care about your child’s safety.”

Reflections

Reflecting a parent or caregiver’s concern back to them confirms your understanding of what they’ve told you and shows them that you understand their perspective.

Reflections also encourage the other person to see their own concerns in a different light – to understand themselves and their own motivations on a deeper level. This is particularly useful when a parent or caregiver’s attitude is extremely hesitant.

Example: “You’re concerned about what you’ve read online and you want to make the best decision.”

Ask permission before sharing

Most of the time, motivational interviewing remains focused on the parent or caregiver’s thoughts, concerns, and motivations. But there are times when you will need to bring something new to the conversation.

Asking permission before sharing a new fact or your own opinion makes them feel less defensive and more receptive to what you have to say.

Example: “Would you mind if I shared [...] with you?”

Autonomy support

Autonomy support means making it clear to a parent or caregiver that, whatever else has been said, the decision to immunize their child is theirs and theirs alone.

Reinforcing their autonomy enhances their sense of control and makes them feel more at ease with the conversation.

Example: “You’re the only one who can make the decisions for your child.”

Name
Anton Drake

Reason for visit
Concerned that his unvaccinated daughter Zara (16 months) may have been exposed to measles.

Notes from Ella

• Initially declined MMR because he didn’t think measles was a threat anymore
• Revealed a new concern about a link between MMR and autism
• Very concerned about Zara’s safety

MMR vaccine and autism – what to share

If a parent or caregiver is worried about a link between the MMR vaccine and autism, you could share a piece of evidence-based information – like the fact that the study linking vaccines to autism was debunked and retracted. You could also share a personal story or experience, but only if it’s both true and relevant.

It is also important to acknowledge that vaccines are not risk free. Zara may have a fever or soreness for a few days after getting the vaccine, but the benefits of the vaccine outweigh the risks posed by both the vaccine and illness caused by wild virus.

Name
Diya Khan

Reason for visit
Routine six-month check-up for daughter Fatima (6 months).

Notes from Ella

• Up-to-date with recommended immunization schedule
• Due three more shots today per the routine infant series
• Has not yet had seasonal flu and COVID shots – should be offered as well
• This will be the first time the seasonal shots have been recommended to Diya

Too many vaccines – what to share

As well as reassuring her that the vaccines are safe, Diya might be interested to know that infants can get in fact seriously ill from flu and COVID. Often when parents or caregivers have concerns about the COVID shot, I’ll also mention potential complications including long COVID and multisystem inflammatory syndrome in children (MIS-C).

Diya has mentioned her elderly mother already – she may also respond well to a reminder that vaccines protect everyone, including elderly or otherwise vulnerable members of the community.

It is also important to acknowledge that vaccines are not risk free. Zara may have a fever or soreness for a few days after getting the vaccine, but the benefits of the vaccine outweigh the risks posed by both the vaccine and illness caused by wild virus.

Name
Katya

Reason for visit
Son Ando (12 months) is scheduled for varicella and MMR vaccines, Katya has asked for an appointment to discuss this with the pediatrician.

Notes from Ella

• Ando is up-to-date with the immunization schedule
• Katya seems hesitant about these particular vaccines, but she didn’t say why

Side effects of live vaccines – what to share

Katya is motivated by not wanting to see her son in pain. Learning about how serious these diseases would be for Ando, compared to the side effects she’s read about, might help Katya to reframe her motivations and start to feel more confident.

It may also be helpful to talk about the common side effects and to explain that those things are temporary. You could then acknowledge that there are some more serious side effects that are very rare and are more of a concern for immunocompromised people.

Name
Oliver Williams

Reason for visit
Attending with daughter Natasha (14 years) for a well child visit.

Notes from Ella

• Natasha has not yet received her HPV vaccine
• Oliver has declined this vaccine for Natasha multiple times, and is still feeling hesitant today
• Natasha is otherwise up-to-date with the recommended schedule

Doesn’t think HPV shot is necessary – what to share

Focusing on HPV vaccine as cancer prevention is the key message here. Oliver wants to protect his daughter, and decreasing her risk of cancer is an important way to keep her healthy in the future.

Oliver doesn’t understand why this vaccine is given so young, so I might also tell him that younger adolescents respond better to it – if Natasha is still unvaccinated after the age of 15, she’ll need an additional dose. It may also help to point out that vaccines work best if they’re given before exposure to the disease occurs – so the fact that Natasha isn’t sexually active yet makes this the ideal time to give the HPV vaccine.

Oliver and Natasha (teen) – presumptive format

When you’re talking to a parent or caregiver and an adolescent, the presumptive recommendation should be addressed to both.

For example, you might say: "Natasha is overdue for her HPV vaccine, which protects against cancer. I understand that you’ve felt uncomfortable about this in the past, Oliver, but I’d like to get her caught up today. Do either of you have any questions?”