Background
Development of the framework
Stage 1: Literature review
Study | Setting/sample | Method | Results |
---|---|---|---|
Gust et al., 2005[28] | US population-based sample of 584 parents with at least one child aged 6 years and under (The ConsumerStyles and HealthStyles surveys 2002) | Telephone administered questionnaire. | 3.9% reported that child had not had all recommended immunisations. |
44 questions about beliefs and attitudes towards vaccination, influence of family and friends on vaccination decisions and dependence on doctor’s advice. K-means cluster ANOVA analysis to group like responses. | Five attitudinal categories: | ||
‘immunisation advocate’ (33%); ‘go along to get along’ (26%); ‘health advocate’ (25%); ‘fence sitter’ (13%); and ‘worried’ (2.6%). | |||
Downs et al., 2007[30] | 30 US parents of children aged 18–23 months, recruited from three cities with diverse socio-demographic profiles and vaccination attitudes | Mixed methods ‘mental models’ interviews conducted by telephone. Open and closed ended questions were designed to identify predominating cognitive pathways in decision making about vaccination. | Two main decision making types although views were overlapping: |
‘health oriented’ (n = 16) trusted anecdotal communication more than statistical arguments; | |||
‘risk oriented’ (n = 14) trusted communication with statistical arguments more than anecdotal information. | |||
Benin et al., 2006[29] | 33 US mothers recruited post partum in one hospital or in the care of participating midwifery practices in one US state | All mothers were interviewed face to face in immediate postpartum period and 19 mothers were interviewed by telephone when baby was 3–6 months old to determine attitudes towards vaccinating; risks and benefits of vaccination; and requirements for, and sources of, information. Respondents categorised into groups, based on behaviours and attitudes. | Two main categories – Vaccinators (n = 25) with sub-categories: ‘acceptors’ (n = 20) and ‘vaccine hesitant’ (n = 5). |
Non-vaccinators (n = 8) with subcategories: ‘late (or partial) vaccinators’ (n = 3) and ‘rejectors’ (n = 5) who refused all vaccines. |
Stage 2: Identifying parental positions on vaccination
Unquestioning acceptor 30–40%
| These parents vaccinate, or want to, vaccinate their children and have no specific questions about the safety and necessity of vaccines. In Gust’s study, they corresponded with the ‘immunisation advocates’ or ‘go along to get along’ groups who see the importance of childhood vaccination and are confident in its safety [28]. They report a good relationship with their healthcare provider and agree that medical professionals have their child’s best interests at heart. This group tend to have less detailed knowledge about vaccination [29, 30]. |
Cautious acceptor 25–35%
| These parents vaccinate their children despite minor concerns. They may exhibit a ‘hope and pray’ mentality recognising that vaccines carry rare but serious side effects and hoping that their child is not affected [45]. Both this category and ‘unquestioning acceptors’ were drawn from Benin’s category of ‘vaccination acceptors’ [29]. |
The hesitant 20–30%
| These parents vaccinate their child but have significant concerns [29]. In Gust’s study, they most closely correspond to the ‘fence-sitter’ who only slightly agrees about the benefits and safety of vaccination and is neutral about their relationship and trust with their healthcare provider [28]. Hesitants are also more focused towards vaccine risk, and are aware of issues surrounding the MMR vaccine and of other parents not vaccinating their children [30]. Trust in their doctor or nurse is key for this group who are keen to have discussions in which their questions are answered satisfactorily and completely by knowledgeable health professionals with relevant information [29]. |
Late or selective vaccinator 2–27%
| Concerns about vaccination result in this group choosing to delay or select only some recommended vaccines [38]. This group most closely correspond with Gust’s ‘worried’ category with significant doubts about the safety and some doubt about the necessity of vaccines [28]. They have concerns about the number of vaccines children have [39]. They experience conflicting feelings about how to get their questions answered and who to trust, [39] and are similar to the vaccine hesitant in actively seeking information [29, 46]. Probably because they actively seek information, in Benin’s study they had the highest levels of knowledge about vaccination [29] and in Downs' study prefer red statistical arguments to anecdotal information [30]. With a specific vaccine scare hesitant parents may ‘select-out’ the vaccine and move to this category, as was the case with MMR vaccine in the UK [40]. |
Refuser <2%
| Parents in this group refuse all vaccines for their child. This results from either their existing philosophical position on vaccination, negative experiences with the medical system, or religious beliefs [9]. Contact with the medical establishment and doctors often results in feelings of alienation and disenchantment and they tend to prefer the advice of alternative health professionals [29, 41]. Respondents in Benin’s study indicated a desire for a doctor with whom they could enjoy a trusting relationship and who would accept their decisions about vaccination. Benin’s sample of 33 mothers had less accurate knowledge about vaccination than all other groups except ‘acceptors’ [29]. These parents tend to cluster in communities who share certain religious, philosophical or alternative beliefs [47]. |
Stage 3: Matching strategies to parental positions
Stage 4: Seeking feedback from health professionals
The framework
How discussions are addressed
Unhelpful | Helpful [51] |
---|---|
Directing style – “this is what you should do” | Guiding style – “may I help you?” |
Righting reflex – using information and persuasion to achieve change | Care with body language |
Missing cues | Eliciting concerns |
Using jargon | Asking permission to discuss |
Discrediting information source | Acknowledging/listening/empathising |
Overstating vaccine safety | Determining readiness to change |
Confrontation | Informing about benefits and risks |
Giving or signposting appropriate resources |
Parental position | Key indicators | Goal | Strategies* |
---|---|---|---|
See also Table3
| |||
Unquestioning acceptor
| Present for vaccination when it is due | Child vaccinated and parent positive about decision | Build rapport |
Cautious acceptor
| Child is fully vaccinated to date | Accept questions and concerns | |
Use verbal and numerical descriptions of vaccine and disease risks | |||
Explain common side effects and rare, important risks | |||
Aim to keep discussion brief but flexibly addressing parent’s needs | |||
The hesitant
| Present on time or slightly late | Child vaccinated and parent accepts decision | Use guiding style |
Late or selective vaccinator
| Child is fully or partially vaccinated | This group may need most time but are most likely to change behaviour | Provide risk and benefit information (as above) |
Present late | Use decision aids and other quality information tools | ||
Child is partially vaccinated | Book another appointment to re-visit discussion | ||
Refuser
| Present for another reason. Subject of vaccination may have to be raised by health professional. | Parent prepared to think about vaccination and attend clinic for further discussion | Avoid scientific ‘ping pong’ – debating back and forth about vaccination. |
Child is partially or completely unvaccinated | Feels concerns heard and not critical of providers | Ask about importance of protecting child against infectious disease and confidence in the vaccine and respond accordingly | |
Parent is aware of the risks of not immunising the child | Explore receptivity to an individualised schedule | ||
Aim to keep discussion brief but leaving door open to further discussion if parent is moving towards considering vaccination | |||
Offer attendance at special clinic†
|
Health professional:
| Hello Mrs Cheung. I understand you have brought Lily for her vaccinations today. |
Mother:
| Yeah, that’s right. |
Health professional:
| Hello, Lily. OK, have you read the leaflet about the injections? I’d be happy to share with you more information about vaccination. (build rapport, seek questions and concerns) |
Mother:
| Well only one thing. She had a slight cold last week, she seems to be over it now but I just wondered if it was safe. |
Health professional:
| She’s back to her normal self now? |
Mother:
| Yes she is |
Health professional:
| Then it is safe for Lily to have them today. (pausing to allow mother to interject if she has questions and observing body language) We are vaccinating her against measles, mumps and rubella, Hib, meningococcal C disease and pneumococcal disease* – all serious diseases which have been made much rarer through vaccination programs. It will be three injections and I will give her two in one arm and one in the other arm. They may upset her for a few moments but most children settle straight away after some comforting and 90% don’t have any other side effects at all (positive framing of risk using percentages). If there is a problem, the commonest thing is a slightly sore arm that will last for a few days and then settles (pause to allow questions or clarification – chunking and checking). |
Mother:
| OK – anything else? |
Health professional:
| One of the vaccines contains a small amount of weakened measles, mumps and rubella viruses which stimulate Lily’s immune system to respond and develop protection to these infections. That means she may have some mild symptoms of measles, such as a rash and a fever, and she may feel a bit off-colour 7 to 11 days after the vaccine.(pause) About 3 weeks after the vaccine, she may get a mild form of mumps, with swelling under her jaw. But this is less common and happens in only about 1% of children (qualitative and quantitative risk estimates). These symptoms are not infectious so she can’t pass them onto to anyone else and they usually go away after 1 to 2 days. The side-effects of the vaccine are usually mild and they are milder than the risks of having measles, mumps or rubella diseases. If you have worries afterwards, bring her back to the clinic and we can check her over. How does that sound? (structured information using chunks and checks and unbiased expectation of consent) |
Mother:
| Fine, yeah, that’s OK. |
Health professional:
| Good morning Mrs Wilkinson. I understand you have brought Robbie for his first infant vaccinations today. |
Mother:
| That’s right. |
Health professional:
| OK, have you read the leaflet about the injections? What questions are on your mind? (build rapport, seek questions and concerns) |
Mother:
| Well, I’m pretty nervous – he seems so young. |
Health professional:
| You sound quite worried (empathic response), let’s talk it through together, tell me what you are concerned about? (further building rapport and eliciting concerns) |
Mother:
| One of the mums in my mothers’ group said that one of the injections has got five ingredients and that’s too many for their immune systems to cope with. He does seem so young to be having injections against all these diseases at once. Won’t it make him ill? |
Health professional:
| OK, we can talk about this (guiding) but do you have other worries as well? (eliciting further concerns)
|
Mother:
| Well I read also that they can get a sore leg afterwards, so that’s another worry. |
Health professional:
| (pausing to allow mother to interject if she has questions and to observe body language) Right, let’s talk about the five ingredients and then we can talk about the chances of getting a sore leg (signposting and structuring of explanation). You’re right that the injection has got five ingredients which would protect Robbie from the diseases called diphtheria, tetanus, whooping cough, polio and Haemophilus influenzae b (Hib). It seems a lot doesn’t it (empathic response). Children, even newborn babies, have to deal with enormous amounts of bacteria and other foreign material every day, and the immune system responds to each of these in various ways to protect the body. Babies’ immune systems can handle this, and the vaccines these days are so refined that babies can easily cope with several vaccines in one go. (chunk of information provided followed by pause for mother to raise further questions and health professional to observe mother’s body language). |
Mother:
| OK, and will he get a sore leg? |
Health professional:
| Most children don’t have any reaction at all, other than having a cry with the injection, and even then they generally settle really quickly with a cuddle and some comforting words from mum (empowering). It’s true that a small number of children, about 10%, or 1 in 10, can get a redness or a sore area where the needle goes in (acknowledging) – but these reactions don’t usually distress the child, and only last a couple of days, then go away. So what I ask mothers to do is to watch their child and if they are concerned bring them back to the clinic so we can check them over. How does that sound? (avoid being overly persuasive, positive framing of risk) |
Mother:
| Is there anything in particular I should watch for? |
Health professional:
| Robbie may be a bit unsettled for a day or so after his injection but he shouldn’t be ill with it. The leaflet tells you about what to look out for and what to do if you are concerned. |
Mother:
| Thanks – I’m still a bit nervous but I think we should get it done. |
What to include in discussions with parents
A tailored approach
There is a discussion about Oliver’s upper respiratory tract infection then:
| |
Health professional:
| Do you mind if we take a moment to talk about Oliver’s vaccinations? |
Mother:
| Ah, yes, we did some research into it and decided not to vaccinate him. |
Health professional:
| OK, can I just talk it through so I understand your decision? (asking permission to discuss and use of a guiding style) |
Mother:
| Yeah, OK.
|
Health professional:
| To start with can I just ask you how important you think it is to get Oliver protected from the diseases vaccines are designed to prevent? (assessing importance) |
Mother:
| Well, mostly the diseases aren’t that much of a problem in healthy children and we keep Oliver very healthy with a good diet, organic food, and plenty of fresh air. |
Health professional:
| You’re right, most children will overcome illnesses without too much of a problem (acknowledging). Unfortunately, there are still children that get pretty sick with these diseases, and sadly a significant number of children end up in hospital with complications from the disease. With measles, for example, 9 in every 100 children get pneumonia and some need to go to hospital (pause). |
Mother:
| I didn’t know that. |
Health professional:
| Yes, it can still be a serious problem. Could I ask now how confident you are that the vaccinations are safe? (assessing confidence)
|
Mother:
| I’m not all confident in them being safe. |
Health professional:
| What have you heard? (exploring)
|
Mother:
| Well on one internet site it said that children can get brain damage and all kinds of problems after vaccination. And the drug companies try to cover it up. |
Health professional:
| That sounds frightening (empathic response). Which vaccines are you most concerned about? (eliciting specific concerns) |
Mother:
| The MMR one because it can cause autism. |
Health professional:
| I understand you are concerned about vaccinations (building rapport by accepting rather than rebutting concerns) but I’d just like to give you my view if that’s OK? (Mother nods.) Although there has been some research that raises concerns about vaccine safety, each time a concern comes up, new research is done to check whether the results are consistent or not. The vaccines that we use are very safe and serious side effects are very rare. Would you like to look at the MMR vaccine decision aid which can help you weigh up the risks of the vaccine and the diseases? (respecting autonomy, offering information) |
Mother:
| Well, I guess I could have a look but I’m still pretty cautious about Oliver getting these jabs. |
Health professional:
| Well, take a look at the decision aid and then if you like, come back to the clinic for another talk. We have a clinic each Tuesday and I’ll be here most weeks. Would you like to come back in two weeks? (leaving door open to further discussion) |
Mother:
| OK thanks. |