Strategies for Talking With Parents About Vaccines
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From the JAMA Network, this is JAMA Clinical Reviews, interviews and ideas about innovations in medicine, science, and clinical practice. Hello, and welcome to our listeners around the world. You're listening to JAMA Clinical Reviews. Thanks for joining us. I'm Dr. Anne Coppola, Senior Editor at JAMA, Professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania, and Director of the Penn Medical Communication Research Institute.

Joining me today is Dr. Sean O'Leary, who is Professor of Pediatrics in the Section of Infectious Diseases at the University of Colorado Denver Anschutz Medical Campus and Children's Hospital Colorado.

We will be discussing his piece from JAMA's Communicating Medicine series titled Strategies for Communicating with Parents About Vaccines. Welcome, Sean. Happy to be here. Let's start with what you call the single most important thing to recognize when communicating with families about vaccines. What is it?

Yeah, thanks for bringing that up. So the most important thing to think about when you're talking with a family about vaccines is that we're really on the same page. So when you're having a conversation with a parent,

The parent wants to do what's best for their children, and that's really your goal as well. So recognizing that you just have a shared goal of the health of the child. Now, you may get into some arguments, et cetera. We're trying to avoid arguments in this situation. But really, the basic core values of caring for the child, you have that in common with the parent.

So it seems like a great way to start from a place of shared values and common ground with parents. Why don't you take me through how you would introduce vaccination to parents of newborns who are new to your practice and describe some of the evidence that supports the approach.

Sure. Yeah. So when introducing vaccines, it's been studied both in observational studies and one large randomized controlled trial, the format of introducing the vaccine. And by that, I mean the first words out of the clinician's mouth when they're introducing the vaccine. And what researchers have broken this down into is what's been termed a presumptive approach or a participatory approach. So a presumptive approach

assumes that the parents will get the child vaccinated. So something like Maya's due for three vaccines today.

as opposed to our participatory approach, which would be, what do you think about vaccines today? Have you thought about what vaccines you want today? So in studies, it's been shown both in, again, observational and randomized controlled trials that introducing vaccines in a presumptive manner leads to much higher vaccination uptake than if you introduce in a participatory manner. And I'm kind of fascinated by why that might be.

And a lot of it has to do with normalization of the vaccine conversation. So social norms are very powerful influencers of health behavior. And so as a pediatrician or other pediatric clinician introducing vaccines, when you state it in a presumptive fashion,

Johnny's due for three vaccines today, that is normalizing that behavior. This is what we do. This is what we do in our clinic. And so you can imagine a parent who might have some questions about vaccines might be on the fence. Giving a nice, strong recommendation like that makes them more comfortable in their decision to then vaccinate. Whereas if you introduced in a participatory fashion, what do you think about vaccines today? Even if the parent ends up getting vaccinated, they may leave the office that day wondering if

the right thing to do. Now, how much do you try to say anything up front about information they may have heard that would dissuade them from vaccines? And what I'm talking about here is you mentioned in your article the idea of pre-bunking. Sure. Explain that a little bit to us.

Yeah, that's a really important question. So pre-bunking is a concept that's been studied and shown to be effective at reducing people's receptivity to bad information, misinformation, disinformation, et cetera. So in the pediatric clinical setting, the way that might work, for example, is if you're meeting a family for the first time at a newborn visit, the child may not even be due for vaccines at that visit. Say it's a three-day visit or a two-week visit after the child's been born.

going over the things that you're going to be kind of explaining, you know, this is how our office works. This is what you're going to expect in the coming months. That might be a good place to introduce the concept of pre-bunking. And that could be as simple as saying, you know, there's a lot of information out there on the internet and a lot of it is actually incorrect. And this can be true about everything related to children's health, not just vaccines. And so you can broaden the discussion there, but it's particularly true for vaccines, warning them that

If they go look for information about vaccines on the internet, they may find some incorrect information. And then you could go into, depending on your level of comfort or how much time you have in the particular visit, could go into the techniques that some of the anti-vaccine literature will use, but importantly, offering them information

resources that you recommend that they could use, like the American Academy of Pediatrics website or the website of a big academic medical center that has good vaccine information, just giving them some alternative if they do want to seek out information.

That's great. And the majority of time, from what I read in your article, it goes well. You use the presumptive approach. Maya is due for three shots today or three vaccines today. And perhaps you warn them that they may have been hearing something out there and it goes well. But then there are cases in which it doesn't go as well. And what does the evidence suggest you do if parents resist an initial presumptive recommendation?

Yeah, great question. So the World Health Organization, the CDC, as well as the American Academy of Pediatrics all recommend the use of motivational interviewing in that setting.

Motivational interviewing is a technique that I've come to think of as a really useful piece in any kind of health communication. It's really trying to build a productive conversation as opposed to getting into an argument, which is often what happens when we get into some of these vaccine conversations.

So the evidence behind it is very strong for things outside of vaccination. Within vaccination, the best evidence we have is from a cluster randomized trial as part of here in Colorado where we randomized 16 practices, eight to receive a motivational interviewing-based training curriculum, eight to usual care. And in the adolescents in the practices that had received this motivational interviewing-based communication training curriculum,

they had HPV initiation rates 9.5 percentage points higher than in the control practices.

And there's other work going on looking at the use of motivational interviewing and other types of vaccine conversations. And I should say that the motivational interviewing we're talking about here is what some might call brief MI, where you're really using a few techniques from a much broader armamentarium. So it's not something that you need to spend many days getting trained to do. You could simply adopt a few simple techniques into these conversations, and it really may make them more productive.

And you mentioned in the article permission to share. Can you elaborate on that? Of course, yeah. So asking permission to share is a technique within the motivational interviewing literature is also called elicit, provide elicit. And it's a really simple technique. Let's say you run into a question from a family or a parent about vaccines or even not a question. They just resist you. They just say, I don't want to do vaccines because of X.

Rather than just spewing the information and getting into an argument with them, asking permission to share, you would simply say, oh, you know what? I've looked into that. Would it be okay if I went over what I found out about it? And simply inserting that little question makes the parent then more receptive to the information that you're then going to share as opposed to if you had just sort of dumped it on them immediately.

Great. All right. In the limited time we have left, I'm just going to rapid fire. So some parents raise specific concerns. What I'm going to do is present you a concern a parent may state, and you can provide me with a response that you might provide. So let's start with, I'm a parent and I say vaccines are not safe.

Sure. Well, so I'm just going to say you could put all of this into a motivational interviewing framework. I'm just going to go ahead and give you the specific answer that you could then put into that framework. In terms of vaccines aren't safe, my response to that is because vaccines are given to prevent disease, they undergo a lot of testing and they're held to a much higher safety standard than any other medicine that we give. Think about that. We take a lot of medicines that we'll tolerate side effects for because we're trying to treat a condition. Be

Because we are giving vaccines to healthy individuals to prevent disease, they have to be safe. And so they're very well studied to show that they are safe.

One of the parents says, "I do not trust pharmaceutical companies." Well, I think you could acknowledge that, that there are reasons perhaps for them not to trust pharmaceutical companies. On the other hand, there is extensive monitoring of both vaccine effectiveness and safety that is done independently of the manufacturers. And the manufacturers do have to meet a very high bar to get a vaccine to market through the FDA and the ACIP.

Once that happens, though, that safety monitoring, effectiveness monitoring, et cetera, continues completely independent of these pharmaceutical companies.

What if they say vaccines are not needed? Well, that's the one where the quote I like to use is that vaccines really have become victims of their own success, right? In the world of prevention, when you do things really well, nothing happens. And so that's what we're seeing nowadays with vaccines is that most parents haven't seen the diseases that we are trying to prevent. And so that's a conversation you can have with families is even though you think they're not needed, most of these diseases are only a plane flight away. What

What if the parent says, my child is not at risk because she is healthy? Well, unfortunately, a lot of kids who get sick and unfortunately pass away from vaccine-preventable diseases are completely healthy children. So while there are risk factors for certain diseases, many of the diseases we're talking about are severe in both children who have chronic medical conditions and those who do not.

What if the parent says vaccines cause autism? Well, that's a myth that's been really hard to debunk for a long time. So I think what I would say here is use some of the tools from the debunking literature, meaning you want to lead with the fact vaccines don't cause autism. You want to acknowledge why that type of a myth is sticky.

The reason this one's sticky is it's very simple and it scares parents of young children. And then you want to explain the basis of the myth. So this was a fraudulent study that was retracted by the journal that published it many years ago, yet the myth persists. And then you want to restate the fact. So share that there have been dozens of studies showing that there's no link between vaccines and autism.

One of the parents says vaccines can cause long-term adverse effects. Well, that has also been well studied, and vaccines are absolutely not associated with long-term health problems like asthma, autism, autoimmune problems. What we do know is that the diseases we prevent with vaccines can cause long-term health problems. So in a sense, vaccines are preventing long-term health problems. One of the parents says too many vaccines at once weakens the immune system. I would like to spread them out over time.

So the immune system of a child can handle literally thousands of different things at once. And so there's really no issue there in terms of the biology or our immune systems. And the problem with spreading out vaccines is that it leaves children exposed to diseases that we're trying to prevent when they are at the highest risk of getting them.

What if Barron says the ingredients in the vaccines are harmful? Yeah, what I like to do in that situation is acknowledge that the terms that are unfamiliar on ingredients lists of any product can be frightening and just mention that the ingredients that in vaccines are there in really small quantities, much less than what we experience in the environment on a regular basis. And then to emphasize that the ingredients in vaccines are there to create immunity and to make vaccines safe and make them effective.

And last one, what if they say getting the disease naturally is better than vaccination? So the concept of things that are natural might be appealing, but unfortunately, that just means exposing children to potentially fatal diseases. And so that couldn't be further from the truth. So vaccines, in a sense, are training your body to respond to these potentially fatal diseases. And my final question, what do you suggest to the clinician if the parent rejects vaccination at that visit?

I like to keep a friendly open dialogue because you're most likely to be able to convince the family to vaccinate if you build a trusting relationship over time. And so I would suggest just continuing an open dialogue with future visits.

I am Dr. Ann Coppola, and I have been speaking with Dr. Sean O'Leary about strategies for communicating with parents about vaccines. You can find a link to the article in this episode's description. This episode was produced by Daniel Musisi at the JAMA Network. To follow this and other JAMA Network podcasts, please visit us online at jamanetworkaudio.com or search for JAMA Network wherever you get your podcasts. Thanks for listening.

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