Talking with parents who have questions

Talking with parents who have questions

 

Hesitant parents have many serious or complex questions. They may be mistaken for parents who have decided to decline vaccination completely. Ask if you are unsure.

The goals for a consultation with a hesitant parent are:

  • to vaccinate
  • to increase vaccine confidence   
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How to recognise parents who have questions

Hesitating parents:

  • primarily have questions or concerns about vaccine safety
  • may come with lots of written questions
  • are not intending to decline vaccination altogether, however have come with plans to vaccinate, delay vaccination or select out vaccines
  • may have had a bad experience such as an Adverse Event Following Immunisation (AEFI) or a birth trauma; their trust may be diminished
  • may have heard or read something frightening
  • may feel a strong sense of responsibility around making the ‘right’ decision
  • want their child treated individually
  • differ from parents who intend to decline vaccinations altogether.

Tips for supporting parents who have questions

Most of these parents will decide to accept vaccination, but want to actively participate in the process of decision-making. This sense of agency is important.

The process we recommend below has been designed to manage hesitancy well and prevent extended, unproductive consultations. It supports you in identifying, prioritising, and addressing parents’ concerns so they can vaccinate their children with confidence.

< Elicit

Elicit readiness to vaccinate

“Have you had a chance to read the information we gave you? Do you have some questions to ask before we give Daisy her vaccinations today?”

Some parents report feeling they are not sufficiently informed to agree to vaccination confidently1. They prefer to be given information about the vaccines their children will receive well before their appointment (see consent resources) and to be invited to discuss their questions and concerns1. Some parents need permission to express and explore their concerns1.

Elicit questions and concerns to saturation

“Do you have some more questions?”

Using a positively framed question such as “Do you have some questions?”  has been found to reduce unmet patient concerns when compared with the more familiar “Do you have any questions?”  perhaps because this negatively framed question signals the end of a consultation2.  

 

“Is there something else you’re concerned about?”

“Are these all of your questions, or do you have some more?”

Eliciting all the parents' concerns (to saturation) early in the consultation enables parents to lay out all their questions at the start. This reduces the chance of ‘late breaker’ questions, makes consultations more satisfying and can reduce consultation time2.

Hesitant parents may often mention their key concern only after first testing out your willingness to accept their minor concerns without judgement. One way to do that is through summarising and paraphrasing. This demonstrates that you have understood the nature and seriousness of parents’ concerns or questions4.

Elicit views of partner (where relevant)

“Does your partner share your concerns?” 

Sometimes the parent in front of you is not the primary decision-maker.  If the presenting parent is not empowered to accept vaccination, we recommend inviting them to schedule another consultation where the other parent attends, too.

Resist the righting reflex

“Can you tell me more about that?” 

“Good question. How about we get all of your questions into a list and then work through them one by one?”

Wanting to correct misinformation when you hear it is a reflexive response for health professionals. But psychological evidence suggests it can actually reinforce or strengthen mistaken ideas5 and establish an adversarial climate6 in people who are wary. Correcting misinformation before a parent has had the chance to express all of their concerns or ask all of their questions tends to close down the conversation. Parents may perceive this as adversarial and feel the need to defend themselves. This can consume consultation time that might otherwise be spent more productively. Instead we suggest waiting to share your knowledge until after the next step of agenda-setting.

< Set and maintain the agenda

Acknowledge parent

“I can see you have done a lot of thinking about this.”

A parent who feels acknowledged is more willing to hear your information. It can be difficult to offer acknowledgement to a parent who is expressing ideas you disagree with or know to be false. Acknowledging a parent’s effort or intent does not require you to agree with the subject of their questions or concerns4. This kind of acknowledgement signals respect for the parent and builds their trust in you1. This can help you avoid the righting reflex (see Resist the righting reflex above).

Summarise concerns

“So it sounds like you’re concerned about what’s in the vaccines, particularly the preservatives, and you have questions about mercury and fluoride?”

Summarising and paraphrasing shows parents you have been listening and provides an opportunity for them to clarify or prioritise their questions or concerns4. It can also help you to identify information material to them, avoid consuming consultation time with unnecessary information, and structure the remainder of the consultation time effectively4

Establish agenda

“I’d like to get a little bit of history about Kali and the family background first. And then we can talk about some of your concerns and hopefully try and answer some of them. Would that be okay?”

“It sounds like you are most worried about whether it is safe to vaccinate Josh given he was so ill when he was born. Should we start with that question and then we can talk about the vaccines he’s due for today?”

Checking that the parent is comfortable with your proposed agenda provides another opportunity for the parent to identify their most important concern. It can signal the need to book an extended consultation or referral for specialist advice (see Rebook or refer below).

Signal time

“We have about ten minutes left. Let’s spend a few minutes talking about your most serious concern and then I’d like to tell you why I think it’s important to vaccinate Khalid.”

This is called ‘temporal signposting’. Temporal signposting helps you maintain control of the consultation’s timeframe and enables parents to develop reasonable expectations of what can be achieved4. It helps keep the conversation focused on matters that are material to the parent’s vaccination decision.

< Share knowledge about immunisation

Use Common questions resources

“Lots of parents ask questions about that. I have a fact sheet here that explains it really well. Would you like me to work through it with you now or would you prefer to read it at home and then come back next week?”

Some parents prefer to read and digest information on their own and others find it reassuring to work through new information with support1. Common questions addresses the five most commonly asked questions about vaccination7 using a non-threatening, conversational style. These resources have been thoroughly tested with parents and checked for accuracy by vaccination experts, infectious disease paediatricians, vaccination nurses and GPs1.

Recommend vaccination confidently and explain why

“I recommend giving Ivy all the vaccinations due today because I am convinced that’s the best way to protect her from some diseases that can be serious.”

“Perhaps the best recommendation I can give is that I have vaccinated all of my own children.”

Confidence is contagious and there is evidence that when consultations include a clear, confident recommendation to vaccinate, parents are more likely to accept vaccination for their children3. Some parents are not comfortable accepting population-based recommendations and will need you to explain why you recommend vaccinating their child in particular. Telling a story about how you came to your position, or about how you decided to vaccinate your own children, illustrates your confidence in a concrete and familiar way that some parents find particularly reassuring.

< Plan and close

Recheck intentions

“You’ve heard why I think it’s important to vaccinate Leo. How are you feeling about that now?”

“Would you be comfortable starting with the tetanus-containing vaccine today and coming back next week to discuss next steps?”

“Which vaccines would you like to give Ping today?”

Presumptive communication is associated with vaccination during consultations3. However, some very hesitant parents may only be willing to start with one vaccine and ‘see how it goes’. Parents who experience uneventful vaccination events may feel confident enough to go on to complete the schedule8.

Rebook

 “Would you like to take this information home to read? We can then book another appointment next week.”

 “Let’s make sure you are able to get an appointment for Aria’s next dose before you leave today.”

Booking an appointment for the next dose and sending parents reminders results in more timely vaccination9. It may also reduce the risk of days spent under-vaccinated.

Refer

“Because he had the reaction after the last one, would you like me to refer you to a paediatrician who specialises in vaccination? Then you can discuss your concerns in detail with them and they may be able to vaccinate on-site if it’s safe to do so.”

Recognising and admitting that you aren’t able to answer all of a parent’s questions may actually increase their assessment of your competence and build their trust in your advice1

Resources
  1. Berry, NJ, et al. Sharing knowledge about immunisation (SKAI): An exploration of parents’ communication needs to inform development of a clinical communication support intervention. Volume 36, Issue 44, 22 October 2018, Pages 6480-6490): https://doi.org/10.1016/j.vaccine.2017.10.077
  2. Heritage J & Robinson JD ‘Some’ versus ‘Any’ Medical Issues: Encouraging Patients to Reveal Their Unmet Concerns. In: Antaki C. (eds) Applied Conversation Analysis. 2011 Palgrave Advances in Linguistics. Palgrave Macmillan, London
  3. Heritage J, et al. Reducing patients' unmet concerns in primary care: the difference one word can make. J Gen Intern Med 2007;22:1429-33. https://doi.org/10.1007/s11606-007-0279-0 
  4. Silverman J, et al. Skills for communicating with parents 3rd. 2013; CRC Press: London, UK
  5. Cook, J & Lewandowsky, S, The Debunking Handbook. 2011 St. Lucia, Australia: University of Queensland. November 5. ISBN 978-0-646-56812-6. [http://sks.to/debunk]
  6. Berry, N, et al, When parents won’t vaccinate their children: a qualitative investigation of Australian primary care providers’ experiences. BMC Pediatrics. 2017; 17: 19 https://doi.org/10.1186/s12887-017-0783-2
  7. Chow MYK, et al. Parental attitudes, beliefs, behaviours and concerns towards childhood vaccinations in Australia: A national online survey. Australian Family Physician. 2017; 46(3): 145-1519.
  8. Danchin, M & Nolan, T. A positive approach to parents with concerns about vaccination for the family physician. Australian Family Physician. 2014; 43(10):690-4.
  9. Jacobson Vann JC, et al. Patient reminder and recall systems to improve immunization rates. Cochrane Database of Systematic Reviews 2005(3). https://doi.org/10.1002/14651858.CD003941.pub2

Talking with parents who have questions