Conversations about vaccines with many patients can be easy. For some patients, vaccines can be a difficult topic. Talking with patients about uncomfortable topics can be challenging. However, it is part of providers’ everyday interactions with patients. Within these interactions, the uneasiness surrounding certain topics more often emanates from the patient than the provider. In many cases, providers are able to overcome patients’ uneasiness, as they have dealt with a particular topic frequently and are thus comfortable addressing it.
Talking about vaccines with patients who have concerns or questions can be difficult, given the unfortunate and abundant misinformation surrounding vaccines in the media and communicated by peers. Uneasiness can be more mutual when discussing vaccines. In this book, we provide many of the facts you will need to address both simple and complicated questions, including ACIP recommendations, a description of the disease(s) being prevented, the vaccine(s) available, contraindications, vaccine effectiveness, and an overview of safety for the particular vaccine or combined vaccine. For obstetric providers, we include a section on important information for obstetric providers and considerations in pregnancy.
A presumptive approach to vaccinating on time should be the framework you use when you approach vaccination. Getting vaccines according to the Advisory Committee on Immunization Practice (ACIP) schedule should be the default choice for your patients. The way physicians introduce vaccination can be very influential on patients’ willingness to vaccinate 1,2. Instead of asking patients, “Would you like to get your influenza vaccine today?” changing that simple question into the statement “It’s time to get your influenza vaccine today” can make a dramatic difference. The latter phrasing presumes that vaccination will occur, and therefore frames vaccination as the default. Framing vaccine receipt as a routine procedure indicates to the patient that vaccination is expected, and it is the standard of care in your practice. It sets getting vaccinated on time as the default for the patient in the decision-making process. This phrasing does not take a patient’s choice away. A patient always has the final say in deciding whether or not to vaccinate. The advantage to presuming vaccination is that it clearly and confidently indicates to the patient that vaccination is important and is the standard of care that you endorse for them.
While the majority of patients that you encounter may be accepting of the vaccines you recommend, some may be more reluctant. This reluctance can exist for a variety of reasons and may not always be due to a lack of awareness or knowledge of the recommended vaccines. Vaccine hesitancy often involves deeply held world views, misperceptions adopted over time, or beliefs adopted from others in their family or social circles. When you encounter a patient who is hesitant about receiving vaccines, whether he/she has just a few specific questions or seems more reluctant overall, how you discuss vaccines is very important. Listen to the patient to understand what they believe and why.
Vaccine conversations can be broken down into messaging framing and message content. It is often intuitive when a patient has a misperception to attempt to counter or debunk that myth or misperception. However, correcting misinformation alone can, in fact, reinforce the misperception or backfire 3.
We provide a five-step strategy to work with vaccine hesitant patients:
- Establish empathy and credibility
- Briefly address specific concerns, if any
- Pivot to disease risk
- Convey vaccine effectiveness
- Give a strong and personalized recommendation.
It is very important to establish empathy and credibility with the patient. This is especially important for patients with specific concerns that may stem from popular myths or claims from invalid research, as this approach allows you to connect on a broader sentiment or value that you both find important 4. With this said, you must be very careful to not affirm a myth or misperception while attempting to make that connection. For example, if a patient says that he/she is concerned about getting a flu shot because the flu shot will cause the flu, don’t attempt to connect with the patient by affirming this misconception with “I understand why you are worried the flu vaccine might cause the flu”. Restating the concern, even if later addressed in an effort to overcome it, can ultimately reinforce the false belief. Instead, connect first with the deeper desire to stay healthy since the patient is clearly interested in staying healthy. An empathetic and credible response to this concern might start with “So what I hear you saying is that you want to avoid the flu and stay healthy”. By connecting with the value or sentiment underpinning a misguided concern, you are likely to find common ground on the topic without affirming or confirming misguided beliefs.
For patients with specific concerns, it may be helpful to begin by borrowing a technique from the field of Motivational Interviewing – that is, asking permission to share. “I’ve looked into this a great deal. Would it be okay if I shared with you what I’ve found out about this?” By doing this, assuming the patient says yes, which most will, you have made the patient more receptive to your next statements.
After establishing an empathetic and credible conversation and obtaining permission to share, there is now an opportunity to discuss the specific concern or concerns originally raised by the patient. The detail of your response may need to be tailored to the educational level of the patient and how much evidence they desire. Often, you may find yourself walking a fine line between providing information and coming off sounding like you’re giving a lecture, which can be off-putting. Be careful about bringing up potential concerns the patient didn’t raise in the first place, and in general, keep explanations simple. A simple myth is more cognitively attractive than an overcomplicated correction. Remember: “less is more.”
Once you have respectfully acknowledged a patient’s concern, the next important approach of message framing is pivoting to the disease. Instead of persisting in an attempt to dissuade them from a misguided belief, turn instead to emphasizing the susceptibility to and severity of the diseases vaccines protect against, since the risk of contracting a vaccine preventable disease is much greater than the risk of suffering a severe adverse reaction from a vaccine 5. This allows you to steer the conversation in an educational direction around a common enemy (i.e., the diseases) instead of toward a potentially adversarial back and forth about a specific vaccine or vaccine components. Because overall childhood vaccination rates are high in the U.S. and have been for some time, patients are often not familiar with how dangerous some of these diseases can be for themselves and/or their children. Instead, they may be more familiar, and more fearful of, highly publicized reports of rare adverse events or myths generated by some and propagated by many on social media. It is important to emphasize that diseases like influenza and pertussis have not been eradicated and continue to pose a substantial risk. When pivoting to the disease, there is a fine line between informing a patient and intimidating or scaring a patient. The goal is not to scare patients into getting vaccinated but rather to shift the focus of the conversation from myths about vaccines to facts about the diseases they prevent.
Emphasize what can be done to protect from these diseases. Provide the patient with the fact that vaccination is a highly effective and very safe way to prevent these diseases. The immunization schedule for children recommended by the ACIP begins providing protection to infants as young as they can safely and adequately respond to the vaccine. Protecting infants as young as possible, rather than delaying vaccines or using an alternative schedule, protects these very vulnerable babies when they are often at increased risk of serious complications from vaccine preventable diseases. Waiting to vaccinate leaves the patient or child at risk of disease.
Those with lower perceptions of risk or lower perceptions of efficacy are significantly less likely to take action 6. Translating these concepts to vaccine acceptance means that individuals with the greatest understanding of disease risk as well as the greatest awareness that the act of vaccinating will protect them from that disease risk will be more likely to vaccinate. Discussions of disease risk must always be paired with self-efficacy and a call to action to be effective. Follow discussions about disease risk with the message that vaccination is the single best decision a patient can make to protect himself, herself or their child. By doing this, a patient will have a clearer understanding that his/her conscious decision to vaccinate will indeed help protect from disease.
Close the conversation with a strong and personalized recommendation. Offer that you strongly recommend vaccination to your friends and family in addition to your patients. If you have children and they are vaccinated (or will be vaccinated), mentioning this as well can help increase patient trust in your recommendation.
While all health care providers want the best care and education for their patients, time and resources are limited. In this book, you will find an organized repository of the most salient information about vaccination. Consisting of a compilation of brief summaries about vaccines that are recommended (and not recommended) for their patients, you will be able to quickly find useful, evidence-based answers to safety and effectiveness questions that you or your patients have. Summaries include systematically-developed reviews of the scientific literature around a broad range of vaccine safety issues and talking points to help guide you through some of the more challenging provider-patient discussions you may encounter.
The framework of the talking points provided in each summary is based on the five-step strategy detailed above. All five steps will be included in each set of talking points. This means there will be some redundancy between the talking points in different summaries, especially in the first and last steps. However, it also means that each set of talking points will be able to stand on its own without this explanation. In some, there will be talking points for Step 2 to address common concerns (such as influenza vaccine causing influenza). In other cases, this section is left blank and is left to the provider to determine the answer based on the specific concern. In some of these talking points, we have given suggested wording while in others, we simply provide the facts for the provider to adapt to his or her own personal communication style. The framework to be used for each set of talking points is demonstrated in the below example.
Framework for Talking Points
| Step 1: Establish empathy and credibility |
| As your doctor, I know that you want to make the best choices about vaccines for you and your family. I also know there is a lot of information out there, and it is difficult to figure out who to trust. Would it be okay if I share with you what I have learned from my experience, and what I share with my patients, my family, and my friends about this topic? |
| Step 2: Briefly address specific concerns, if any |
| Step 3: Pivot to disease risk |
| Vaccine-preventable diseases are real and dangerous. |
| Step 4: Convey vaccine effectiveness |
| The good news is that there are vaccines that prevent these diseases. Vaccines have been shown to be very safe and effective. |
| Step 5: Give a strong and personalized recommendation |
| You and I have the same goal: to keep you and your family healthy. You have the power to protect yourself and your family from these diseases through vaccination.I strongly recommend vaccination to my patients, my family, and my friends. |
To further reinforce these messages, we have developed an individually-tailored app for smartphones, tablets, and computers that surveys and then provides vaccine information for patients. Vaccine information is provided in the form of video content that is tailored to the specific vaccine attitudes and beliefs of the patient, and messages are presented in a manner consistent with the framework described in this chapter. The vast majority of patients who have used the app found it interesting, clear to understand, helpful, and trustworthy. For more information about this app, please visit https://www.letstalkshots.com.
There are many evidence-based strategies for increasing vaccination rates beyond conversations with patients. While these are not the focus of this book, providers should consider which of these may be practical for implementation within their offices. Many of these are fairly straightforward, such as standing orders for vaccination, and can markedly increase vaccination uptake in an office (standing orders can be thought of as the ultimate ‘presumptive’ recommendation). The Community Preventive Services Task Force (CPSTF) has reviewed many of these strategies, and their findings can be accessed at their website: https://www.thecommunityguide.org/topic/vaccination.
We hope you find this book useful in your conversations with patients. As one of their most trusted sources for medical advice, the more confident you are in promoting vaccines, the more confident they will be in accepting them for themselves or their children.
References
1. Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. Dec 2013;132(6):1037-46. doi:10.1542/peds.2013-2037
2. Brewer NT, Hall ME, Malo TL, Gilkey MB, Quinn B, Lathren C. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial. Pediatrics. Jan 2017;139(1)doi:10.1542/peds.2016-1764
3. Nyhan B, Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: a randomized trial. Pediatrics. Apr 2014;133(4):e835-42. doi:10.1542/peds.2013-2365
4. Heritage J, Maynard D. Communication in Medical Care: Interaction Between Primary Care Physicians and Patients. 2006.
5. Horne Z, Powell D, Hummel JE, Holyoak KJ. Countering antivaccination attitudes. Proceedings of the National Academy of Sciences of the United States of America. Aug 18 2015;112(33):10321-4. doi:10.1073/pnas.1504019112
6. Barnett DJ, Balicer RD, Thompson CB, et al. Assessment of local public health workers’ willingness to respond to pandemic influenza through application of the extended parallel process model. PloS one. Jul 24 2009;4(7):e6365. doi:10.1371/journal.pone.0006365
