20 September 2019

Negotiating the spectrum of vaccine hesitancy

General practice Vaccination

Australian skiers returning from New Zealand in recent months have been bringing back more than just snowfield injuries. Some have been testing positive for measles after hitting their home shores.

And New Zealand, which has experienced an outbreak of more than 1200 cases since the start of the year, is not the only Western country to be affected by waning MMR coverage.

Australia and the US have also experienced an upsurge in measles cases in 2019, despite vaccines being widely, and often freely, available.

This regression in modern medicine has been attributed in part to the emergence of “vaccine hesitancy” according to an article published by US researchers in Cureus. Hesitant individuals often have lots of questions about vaccines, or only want their children to receive some vaccines, and not others.

Vaccine-hesitant parents make up approximately 12% of the population, according to the Australian child health poll by the Royal Children’s Hospital in Melbourne. These parents sit on the fence between acceptance and refusal to vaccinate (compared with 2% of people who are “anti-vax” or refusing all vaccines.)

The World Health Organisation sees this reluctance to vaccinate as one of the top global health threats of our time.

But GPs can play a key role in guiding parents along the spectrum of vaccine hesitancy and towards vaccine acceptance.

RADICAL EMPATHY

Associate Professor Mary Politi, a clinical psychologist at the University of Washington and researcher in vaccine adherence, said the first step to opening up effective communication was to show empathy towards parents, rather than judgement.

“For that [vaccine-hesitant] group, finding common ground is important. Parents and GPs both want what is best for children,” she said.

While parents with little scientific knowledge are stereotyped as the “typical” vaccine-hesitant patient, studies have found that highly educated and affluent individuals are also likely to question childhood vaccination.

Back in 1735, the famous polymath and inventor Benjamin Franklin decided against vaccinating his son for smallpox.

Unfortunately it was only later, when his son died of the virus, that Franklin realised he had grossly miscalculated the consequences of his decision to avoid the perceived short-term risk of the procedure in exchange for life-long immunity.

Professor Politi’s study on the response of clinical trainees to vaccine-hesitant parents found professionals struggled to deal with parents who questioned evidence-based recommendations.

Regardless of a clinician’s frustration with a patient’s “logic”, these same patients tended to be more amenable to adopting vaccination when presented with the option as part of a shared decision-making approach.

And as part of a shared approach it is important to understand the motivations behind the patient (usually the parent).

“I often advise stepping back and trying to imagine each patient’s history to better understand their fears and concerns,” she said.

“It’s hard to do when one has been in a medical field for a while and understands the evidence, but a lot of health-related concepts are quite new to parents.”

Improving non-verbal expressions of empathy with parents can involve simple measures, such as looking patients in the eye and trying to position themselves face-to-face with the parent, without a computer screen in the way.

DON’T FEAR QUESTIONS

Even when a parent seems willing to vaccinate and has booked an appointment, it is important to show an open line of communication about vaccination.

According to the National Centre for Immunisation Research and Surveillance (NCIRS), even parents who are ready to vaccinate often still have questions they want to ask their health professional.

This should not be of concern. While the ideal encounter is the parent who arrives at the appointment ready to vaccinate, a couple of questions from that parent does not mean vaccination necessarily has to be delayed.

Clinicians should not act abruptly when parents ask questions, or it could actually make them more hesitant to vaccinate at that appointment.

Alternatively, providers sometimes prematurely assume a parent does not want to vaccinate and try to avoid engaging the parent in a discussion about vaccination.

Instead, to get some support, the busy clinician can refer to a resource called Sharing Knowledge About Immunisation (SKAI). This is an online portal developed by NCIRS, in collaboration with the University of Sydney, and has been designed to answer many of these questions and guide parents through the vaccination schedule.

Common questions from parents answered on the website include:

  • What about autism?
  • Why is the schedule the way it is?
  • What is in the vaccine?
  • How do I know the vaccines are safe?
  • How can I make things easier for my child?
  • How do vaccines affect my immunity?

Professor Julie Leask, from the University of Sydney Nursing School, was involved in the development of SKAI. Directing patients to quality resources before the first appointment helps support parents in the lead up to vaccination, she says.

“Then once the parent gets to the doctor or nurses office, it’s a simple matter of saying, ‘Okay, so [the child] is here for the DTP vaccine today. Do you have some questions?’

Asking for some questions appeared to work better as research had shown it more conducive to allowing parents to raise their concerns. Asking parents if they had any questions tended to be received as a closed approach, where the only appropriate answer was either a yes or no, rather than inviting the questions they actually might have.

Professor Leask says that in most circumstances, providers could address concerns quickly, and proceed to vaccinate in the same appointment, but not always.

ELICIT MOTIVATION

When someone declines to vaccinate, it can feel like a real defeat for a health professional. But even when this does happen, it’s worthwhile understanding their reasons for refusing or delaying and to make note of it, Professor Leask says.

Consider adopting flexible goals, such as getting parents to consider a few vaccines.

“Often clinicians will assume that from just what people are saying, they know a parent has no intention to vaccinate, when in fact they may actually be ready to try a couple of vaccines,” she says.

Asking about how the individual’s partner feels about vaccination can often add to the clinician’s understanding of the patient’s viewpoint and their reservations or concerns.

The discussion should help in recognising the patient’s motivations. It will also help to provide appropriate resources that address the patient’s specific concerns, and hopefully reassure the patient that the benefits of vaccination far outweigh the risks.

“Guiding parents is that nice middle ground where you show that you think vaccination is really important, but you also want to work with them where they are at and address their concerns,” Professor Leask says.