Julie LeaskpersName, Paul KinnersleypersName, Cath JacksonpersName, Francine CheaterpersName, Helen BedfordpersName, Greg RowlespersName (2012date). “Communicating with parents about vaccination: a framework for health professionals.” BMC Pediatricstitle·venue.
Object of study — parents as five named positions on vaccination - A CONTROLLED VOCABULARY BUILT BY CROSSWALKING THREE INCOMPATIBLE TAXONOMIES, with a prevalence attached to each category
Research question — how a health professional should talk to a parent about vaccination, given that what to say depends on which kind of parent they are
Contribution — five parental positionsterm·var with prevalence ranges, each mapped to prior classifications and to a stage of the Transtheoretical Modelterm, with tailored communication goals and strategies
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | parental vaccine attitudes distributed across a spectrum that no single prior study had described exhaustively — “The literature review informing the parental positions found only three papers providing a spectrum of attitudes to vaccination.” | |
| claim-type | method — “We reviewed the classifications presented within the three identified studies, [ 28 - 30 ] summarised parental positions from each study, and discussed their relevance to vaccine communication. A discrete number of parental positions relating to vaccination attitudes and behaviour were proposed, discussed and revised based on the categories’ applicability to clinical interactions and international relevance. The final set of five parental positions are described in Table 2 . A range for the approximate proportion of each group is given based on population surveys or registers from the USA, European Union, New Zealand, and Australia” | |
| method — evidence | — “The searches identified 3168 total hits (including duplicates) which was reduced to 112 after screening titles and removing duplicates. Of these, we identified three studies that proposed a spectrum spanning the parental positions on vaccination.” | |
| object of study — evidence | — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | |
| research question — evidence | — “We found nine papers advising health professionals on communicating with patients about vaccination but none that tailored communication to empirically derived parental positions” | |
| contribution — evidence | — “The parental positions described in this paper act as a starting point for health professionals to choose the most appropriate communication strategy. Naturally these will vary according to the parent’s individual needs” | |
| mechanism | THE VOCABULARY IS A CROSSWALK, AND THE PAPER SHOWS ITS WORKING. Three prior studies with three incompatible category sets - Gust's five attitudinal clusters, Downs's two decision-making types, Benin's vaccinator/non-vaccinator tree - reconciled into five positions, with each mapping stated: `In Gust's study, they CORRESPONDED WITH the immunisation advocates or go along to get along groups`; `Both this category and unquestioning acceptors were DRAWN FROM Benin's category of vaccination acceptors`; `they most closely correspond to the fence-sitter` — “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” | mechanisms[0] |
| mechanism | AND A SECOND CROSSWALK ONTO A THEORY OF BEHAVIOUR CHANGE: `The majority of parents are in the ACTION AND MAINTENANCE stage (cautious or unquestioning acceptors). Some will be CONTEMPLATING or even PREPARING to immunise - WHAT WE DESCRIBE AS HESITANT parents ... Vaccine refusers are usually in the PRE-CONTEMPLATION stage`. The five positions are simultaneously an attitude taxonomy and a stage model — “The majority of parents are in the action and maintenance stage (cautious or unquestioning acceptors). Some will be contemplating or even preparing to immunise – what we describe as ‘hesitant’ parents. Late or selective vaccinators, who are willing to have some vaccines, may also contemplate full vaccination if guided by a health professional [ 5 ]. ‘Vaccine refusers’ are usually in the pre-contemplation stage where they are not considering vaccinating at all.” | mechanisms[1] |
| mechanism | the design criterion for the vocabulary is EXHAUSTIVENESS, and it is printed: `we sought to identify only studies that would provide a spectrum of attitudinal positions that would theoretically account for all parents`. Three of 112 screened papers met it — “While there is a vast literature exploring attitudes to vaccination among parents [ 3 , 7 , 74 , 75 ], we sought to identify only studies that would provide a spectrum of attitudinal positions that would theoretically account for all parents.” | mechanisms[2] |
| mechanism | and the failure mode it is designed against is the INFORMATION DEFICIT MODEL: poor communication `often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information ... and may even result in a backfire effect` — “Such poor communication often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information. Such an approach is counter-productive because it fails to account for the complexity of reasons underpinning vaccine refusal and may even result in a backfire effect” | mechanisms[3] |
| extends | Gust 2005, Downs 2007 and Benin 2006 - the three studies whose incompatible classifications this paper reconciles into one vocabulary — “We reviewed the classifications presented within the three identified studies, [ 28 - 30 ] summarised parental positions from each study, and discussed their relevance to vaccine communication. A discrete number of parental positions relating to vaccination attitudes and behaviour were proposed, discussed and revised based on the categories’ applicability to clinical interactions and international relevance. The final set of five parental positions are described in Table 2 . A range for the approximate proportion of each group is given based on population surveys or registers from the USA, European Union, New Zealand, and Australia” | claim_relations[0] |
| extends | the Transtheoretical Model of behaviour change, applied to vaccination decisions with the five positions mapped onto its five stages — “The majority of parents are in the action and maintenance stage (cautious or unquestioning acceptors). Some will be contemplating or even preparing to immunise – what we describe as ‘hesitant’ parents. Late or selective vaccinators, who are willing to have some vaccines, may also contemplate full vaccination if guided by a health professional [ 5 ]. ‘Vaccine refusers’ are usually in the pre-contemplation stage where they are not considering vaccinating at all.” | claim_relations[1] |
| contradicts | the information-deficit approach to vaccine refusal - 'a belief ... that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information', which 'may even result in a backfire effect' — “Such poor communication often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information. Such an approach is counter-productive because it fails to account for the complexity of reasons underpinning vaccine refusal and may even result in a backfire effect” | claim_relations[2] |
| extends | the nine prior sets of recommendations for vaccine communication, 'none that tailored communication to empirically derived parental positions' — “We found nine papers advising health professionals on communicating with patients about vaccination but none that tailored communication to empirically derived parental positions” | claim_relations[3] |
| sense | `the hesitant` HERE - ONE OF FIVE MUTUALLY EXCLUSIVE POSITIONS, at 20-30%, defined behaviourally as parents who `vaccinate their child but have significant concerns` and mapped to Gust's `fence-sitter`. A BIN, not a scale — “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” | senses[0] |
| sense | `late or selective vaccinator` - THE ONLY POSITION DEFINED BY WHAT THE PARENT DOES RATHER THAN BELIEVES: `Concerns about vaccination result in this group choosing to delay or select only some recommended vaccines`. And it is porous - `With a specific vaccine scare hesitant parents may SELECT-OUT the vaccine and move to this category` — “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” | senses[1] |
| sense | `unquestioning acceptor` - A CATEGORY BUILT BY MERGING TWO OF GUST'S: `In Gust's study, they CORRESPONDED WITH the immunisation advocates OR go along to get along groups`. Two source categories, one target, and the merge is stated but not justified — “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” | senses[2] |
| sense | and `unquestioning acceptor` + `cautious acceptor` TOGETHER come from ONE of Benin's: `Both this category and unquestioning acceptors were DRAWN FROM Benin's category of vaccination acceptors`. SO ONE SOURCE CATEGORY SPLITS INTO TWO TARGETS WHILE TWO OTHER SOURCE CATEGORIES MERGE INTO ONE OF THEM — “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’” | senses[3] |
| sense | `Transtheoretical Model` - the second vocabulary the five positions are mapped onto: `a framework for understanding the process of behaviour change where individuals may pass through FIVE STAGES: precontemplation, contemplation, preparation, action ... maintenance`. Five positions, five stages, and the mapping is not one-to-one — “It should also be borne in mind that motivational interviewing builds upon the Transtheoretical Model [ 68 ]. This is a framework for understanding the process of behaviour change where individuals may pass through five stages: precontemplation , where they are not considering change; contemplation , where they seriously consider change; preparation , where they plan and commit to change; action , where they make a specific behavioural change which if successful, leads to maintenance of that behaviour, the fifth stage.” | senses[4] |
| control | a face-validity survey of 104 accredited nurse immunisation providers, plus verbal feedback from 20 coordinators, experts and a consumer representative — held — “To assess general acceptability of the framework and recommendations, accredited nurse immunisation providers were presented with them in three annual update sessions, and 104 completed a short questionnaire about usefulness (scored from 1 ‘not at all useful’ to 10 ‘extremely useful’), realism (not at all/somewhat/very), strengths (open question), and areas for improvement (open question). Feedback was positive with a median score for usefulness of 8.8 (range 3–10); 74% rated the framework as ‘very realistic’, 26% as ‘somewhat realistic’, while no-one rated it as ‘not at all realistic’” — rules out the objection that a framework built from three US studies would be unrecognisable in practice - '74% rated the framework as VERY REALISTIC, 26% as SOMEWHAT REALISTIC, while NO-ONE rated it as not at all realistic' — “To assess general acceptability of the framework and recommendations, accredited nurse immunisation providers were presented with them in three annual update sessions, and 104 completed a short questionnaire about usefulness (scored from 1 ‘not at all useful’ to 10 ‘extremely useful’), realism (not at all/somewhat/very), strengths (open question), and areas for improvement (open question). Feedback was positive with a median score for usefulness of 8.8 (range 3–10); 74% rated the framework as ‘very realistic’, 26% as ‘somewhat realistic’, while no-one rated it as ‘not at all realistic’” | controls[0] |
| control | a systematic search designed to find every classification that spans the whole spectrum - 3,168 hits, 112 after screening — partial — “While there is a vast literature exploring attitudes to vaccination among parents [ 3 , 7 , 74 , 75 ], we sought to identify only studies that would provide a spectrum of attitudinal positions that would theoretically account for all parents.” — rules out the objection that the five positions were chosen rather than found; the criterion was stated in advance - a spectrum that would 'theoretically account for all parents' - and only three papers met it — “The searches identified 3168 total hits (including duplicates) which was reduced to 112 after screening titles and removing duplicates. Of these, we identified three studies that proposed a spectrum spanning the parental positions on vaccination.” | controls[1] |
| control | whether the framework changes anything - satisfaction, self-efficacy, decision quality or vaccination uptake — absent-declared-unreported — “The parental positions described in this paper act as a starting point for health professionals to choose the most appropriate communication strategy. Naturally these will vary according to the parent’s individual needs” — rules out nothing, and the paper names the trial that would do it: 'a randomised controlled trial delivered at cluster ... or individual level WOULD THEN ESTABLISH ITS EFFECTIVENESS compared with usual care' — “Communication strategies to date have lacked clear evidence of efficacy in vaccination settings. We have described a framework for talking with parents about vaccination. It is informed by evidence and acceptable to the health professionals involved in the formative evaluation sessions, but now needs to be more fully evaluated. This may involve group or individual training of health professionals who undergo assessment using standardised patients and validated scales that measure quality of communication [ 78 ]. To measure effectiveness of the framework against the aims described above (satisfaction, self-efficacy, decision quality and vaccination uptake), a randomised controlled trial delivered at cluster (e.g., GP practice) or individual level would then establish its effectiveness compared with ‘usual care’.” | controls[2] |
| control | whether the five positions are stable categories at all — failed — “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” — rules out nothing - the paper concedes they are not: 'the spectrum described does simplify what is often a complex process of decision making which may involve parents moving between positions over time' — “However, the spectrum described does simplify what is often a complex process of decision making which may involve parents moving between positions over time.” | controls[3] |
| weight | Gust 2005, Downs 2007 and Benin 2006 - the three studies whose incompatible classifications this paper reconciles into one vocabulary — 0.9 — “We reviewed the classifications presented within the three identified studies, [ 28 - 30 ] summarised parental positions from each study, and discussed their relevance to vaccine communication. A discrete number of parental positions relating to vaccination attitudes and behaviour were proposed, discussed and revised based on the categories’ applicability to clinical interactions and international relevance. The final set of five parental positions are described in Table 2 . A range for the approximate proportion of each group is given based on population surveys or registers from the USA, European Union, New Zealand, and Australia” | claim_relations[0] |
| weight | the Transtheoretical Model of behaviour change, applied to vaccination decisions with the five positions mapped onto its five stages — 0.8 — “The majority of parents are in the action and maintenance stage (cautious or unquestioning acceptors). Some will be contemplating or even preparing to immunise – what we describe as ‘hesitant’ parents. Late or selective vaccinators, who are willing to have some vaccines, may also contemplate full vaccination if guided by a health professional [ 5 ]. ‘Vaccine refusers’ are usually in the pre-contemplation stage where they are not considering vaccinating at all.” | claim_relations[1] |
| weight | the information-deficit approach to vaccine refusal - 'a belief ... that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information', which 'may even result in a backfire effect' — 0.8 — “Such poor communication often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information. Such an approach is counter-productive because it fails to account for the complexity of reasons underpinning vaccine refusal and may even result in a backfire effect” | claim_relations[2] |
| weight | the nine prior sets of recommendations for vaccine communication, 'none that tailored communication to empirically derived parental positions' — 0.7 — “We found nine papers advising health professionals on communicating with patients about vaccination but none that tailored communication to empirically derived parental positions” | claim_relations[3] |
| note | unquestioning acceptor —distinct-from→ cautious acceptor — 'Five distinct parental groups were identified' - and the paper then says parents move between them over time, so the distinctness is a working assumption rather than a claim about parents — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | concept_edges[0] |
| weight | unquestioning acceptor —distinct-from→ cautious acceptor — 0.95 — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | concept_edges[0] |
| note | hesitant —distinct-from→ late or selective vaccinator — the boundary the paper itself calls porous: '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' — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | concept_edges[1] |
| weight | hesitant —distinct-from→ late or selective vaccinator — 0.95 — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | concept_edges[1] |
| weight | Transtheoretical Model —is-a→ framework — 0.95 — “It should also be borne in mind that motivational interviewing builds upon the Transtheoretical Model [ 68 ]. This is a framework for understanding the process of behaviour change where individuals may pass through five stages: precontemplation , where they are not considering change; contemplation , where they seriously consider change; preparation , where they plan and commit to change; action , where they make a specific behavioural change which if successful, leads to maintenance of that behaviour, the fifth stage.” | concept_edges[2] |
| note | guiding style —contrasted-with→ directing style — 'a form of communication that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change'. The whole framework turns on this contrast, and it is the one relation in the paper stated with a word the gate holds — “Evidence from other areas of healthcare practice suggests adapting the principles of motivational interviewing. This is a form of communication that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change” | concept_edges[3] |
| weight | guiding style —contrasted-with→ directing style — 0.95 — “Evidence from other areas of healthcare practice suggests adapting the principles of motivational interviewing. This is a form of communication that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change” | concept_edges[3] |
| outcome | control — held — “To assess general acceptability of the framework and recommendations, accredited nurse immunisation providers were presented with them in three annual update sessions, and 104 completed a short questionnaire about usefulness (scored from 1 ‘not at all useful’ to 10 ‘extremely useful’), realism (not at all/somewhat/very), strengths (open question), and areas for improvement (open question). Feedback was positive with a median score for usefulness of 8.8 (range 3–10); 74% rated the framework as ‘very realistic’, 26% as ‘somewhat realistic’, while no-one rated it as ‘not at all realistic’” | controls[0] |
| outcome | control — partial — “The searches identified 3168 total hits (including duplicates) which was reduced to 112 after screening titles and removing duplicates. Of these, we identified three studies that proposed a spectrum spanning the parental positions on vaccination.” — “While there is a vast literature exploring attitudes to vaccination among parents [ 3 , 7 , 74 , 75 ], we sought to identify only studies that would provide a spectrum of attitudinal positions that would theoretically account for all parents.” | controls[1] |
| outcome | control — absent-declared-unreported — “Communication strategies to date have lacked clear evidence of efficacy in vaccination settings. We have described a framework for talking with parents about vaccination. It is informed by evidence and acceptable to the health professionals involved in the formative evaluation sessions, but now needs to be more fully evaluated. This may involve group or individual training of health professionals who undergo assessment using standardised patients and validated scales that measure quality of communication [ 78 ]. To measure effectiveness of the framework against the aims described above (satisfaction, self-efficacy, decision quality and vaccination uptake), a randomised controlled trial delivered at cluster (e.g., GP practice) or individual level would then establish its effectiveness compared with ‘usual care’.” — “The parental positions described in this paper act as a starting point for health professionals to choose the most appropriate communication strategy. Naturally these will vary according to the parent’s individual needs” | controls[2] |
| outcome | control — failed — “However, the spectrum described does simplify what is often a complex process of decision making which may involve parents moving between positions over time.” — “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” | controls[3] |
| limitation | THE CATEGORIES ARE NOT STABLE AND THE PAPER SAYS SO: `the spectrum described does simplify what is often a complex process of decision making which may involve parents moving between positions over time`. A discrete five-way classification of something the authors describe as continuous and time-varying - the same tension macdonald2015 states about hesitancy, arriving here from the practice end three years earlier — “However, the spectrum described does simplify what is often a complex process of decision making which may involve parents moving between positions over time.” | limitations[0] |
| limitation | THE VOCABULARY RESTS ON THREE US STUDIES TOTALLING 647 PEOPLE, two of them n=30 and n=33: `While the parental positions were developed from three US studies, we have applied our knowledge and experience from other countries to their modification`, and the proportions `will vary over time, within regions, and between practices` — “While the parental positions were developed from three US studies, we have applied our knowledge and experience from other countries to their modification. The approximate proportions of each parental group are estimates from population-based surveys and will vary over time, within regions, and between practices.” | limitations[1] |
| limitation | one category's extension is uncertain by a factor of THIRTEEN - `late or selective vaccinator` is given as 2-27% - and the smallest category fails exactly where it matters: `the estimate for the percentage of parents completely refusing all vaccines is given as less than 2% based on population data but there are clusters of much higher refuser rates in specific localities` — “For example, the estimate for the percentage of parents completely refusing all vaccines is given as less than 2% based on population data but there are clusters of much higher refuser rates in specific localities [ 43 , 44 , 77 ]. Nevertheless, giving ranges for the sizes of the groups may assist health professionals and programme coordinators in planning for targeted information and strategies.” | limitations[2] |
| limitation | the framework has FACE VALIDITY AND NOTHING ELSE, which the paper states plainly: 104 nurses gave a median usefulness of 8.8 and `74% rated the framework as VERY REALISTIC`, but `Communication strategies to date have lacked clear evidence of efficacy in vaccination settings ... now needs to be more fully evaluated` by a randomised trial that had not been done — “Communication strategies to date have lacked clear evidence of efficacy in vaccination settings. We have described a framework for talking with parents about vaccination. It is informed by evidence and acceptable to the health professionals involved in the formative evaluation sessions, but now needs to be more fully evaluated. This may involve group or individual training of health professionals who undergo assessment using standardised patients and validated scales that measure quality of communication [ 78 ]. To measure effectiveness of the framework against the aims described above (satisfaction, self-efficacy, decision quality and vaccination uptake), a randomised controlled trial delivered at cluster (e.g., GP practice) or individual level would then establish its effectiveness compared with ‘usual care’.” | limitations[3] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | — “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” | content_tags.findings[0] |
| finding | — “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’” | content_tags.findings[1] |
| finding | — “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” | content_tags.findings[2] |
| finding | — “The majority of parents are in the action and maintenance stage (cautious or unquestioning acceptors). Some will be contemplating or even preparing to immunise – what we describe as ‘hesitant’ parents. Late or selective vaccinators, who are willing to have some vaccines, may also contemplate full vaccination if guided by a health professional [ 5 ]. ‘Vaccine refusers’ are usually in the pre-contemplation stage where they are not considering vaccinating at all.” | content_tags.findings[3] |
| finding | — “While there is a vast literature exploring attitudes to vaccination among parents [ 3 , 7 , 74 , 75 ], we sought to identify only studies that would provide a spectrum of attitudinal positions that would theoretically account for all parents.” | content_tags.findings[4] |
| finding | — “However, the spectrum described does simplify what is often a complex process of decision making which may involve parents moving between positions over time.” | content_tags.findings[5] |
| finding | — “The searches identified 3168 total hits (including duplicates) which was reduced to 112 after screening titles and removing duplicates. Of these, we identified three studies that proposed a spectrum spanning the parental positions on vaccination.” | content_tags.findings[6] |
| finding | — “We found nine papers advising health professionals on communicating with patients about vaccination but none that tailored communication to empirically derived parental positions” | content_tags.findings[7] |
| finding | — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | content_tags.findings[8] |
| finding | — “For example, the estimate for the percentage of parents completely refusing all vaccines is given as less than 2% based on population data but there are clusters of much higher refuser rates in specific localities [ 43 , 44 , 77 ]. Nevertheless, giving ranges for the sizes of the groups may assist health professionals and programme coordinators in planning for targeted information and strategies.” | content_tags.findings[9] |
| finding | — “While the parental positions were developed from three US studies, we have applied our knowledge and experience from other countries to their modification. The approximate proportions of each parental group are estimates from population-based surveys and will vary over time, within regions, and between practices.” | content_tags.findings[10] |
| finding | — “Such poor communication often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information. Such an approach is counter-productive because it fails to account for the complexity of reasons underpinning vaccine refusal and may even result in a backfire effect” | content_tags.findings[11] |
| finding | — “Parental vaccination decisions are based on an array of factors and parents integrate information according to their experiential and social contexts [ 11 , 12 ]. A parent’s trust in the source of information may be more important than what is in the information” | content_tags.findings[12] |
| finding | — “righting reflex’ is the natural response of health professionals to instinctively ‘put right’ healthcare problems rather than finding out patients’ concerns or points of view. It may lead to an adversarial position and further entrench the parent’s views, closing the door to any future possible gains” | content_tags.findings[13] |
| finding | — “To assess general acceptability of the framework and recommendations, accredited nurse immunisation providers were presented with them in three annual update sessions, and 104 completed a short questionnaire about usefulness (scored from 1 ‘not at all useful’ to 10 ‘extremely useful’), realism (not at all/somewhat/very), strengths (open question), and areas for improvement (open question). Feedback was positive with a median score for usefulness of 8.8 (range 3–10); 74% rated the framework as ‘very realistic’, 26% as ‘somewhat realistic’, while no-one rated it as ‘not at all realistic’” | content_tags.findings[14] |
| finding | — “Communication strategies to date have lacked clear evidence of efficacy in vaccination settings. We have described a framework for talking with parents about vaccination. It is informed by evidence and acceptable to the health professionals involved in the formative evaluation sessions, but now needs to be more fully evaluated. This may involve group or individual training of health professionals who undergo assessment using standardised patients and validated scales that measure quality of communication [ 78 ]. To measure effectiveness of the framework against the aims described above (satisfaction, self-efficacy, decision quality and vaccination uptake), a randomised controlled trial delivered at cluster (e.g., GP practice) or individual level would then establish its effectiveness compared with ‘usual care’.” | content_tags.findings[15] |
| quantity | to 30 per cent - the prevalence assigned to `the hesitant`, against the 13% Gust reported for the `fence-sitter` it is mapped onto — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | content_tags.quantities[0] |
| quantity | to 27 per cent - the range for `late or selective vaccinator`, a thirteen-fold uncertainty in one category's extension — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | content_tags.quantities[1] |
| quantity | search hits, reduced to 112 by screening and to THREE studies with a full spectrum — “The searches identified 3168 total hits (including duplicates) which was reduced to 112 after screening titles and removing duplicates. Of these, we identified three studies that proposed a spectrum spanning the parental positions on vaccination.” | content_tags.quantities[2] |
| quantity | nurses in the face-validity survey - the only empirical evaluation the framework has — “To assess general acceptability of the framework and recommendations, accredited nurse immunisation providers were presented with them in three annual update sessions, and 104 completed a short questionnaire about usefulness (scored from 1 ‘not at all useful’ to 10 ‘extremely useful’), realism (not at all/somewhat/very), strengths (open question), and areas for improvement (open question). Feedback was positive with a median score for usefulness of 8.8 (range 3–10); 74% rated the framework as ‘very realistic’, 26% as ‘somewhat realistic’, while no-one rated it as ‘not at all realistic’” | content_tags.quantities[3] |
| variable | parental positions — “The parental positions described in this paper act as a starting point for health professionals to choose the most appropriate communication strategy. Naturally these will vary according to the parent’s individual needs” | content_tags.variables[0] |
| definition | hesitant — “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” | content_tags.definitions[0] |
| definition | late or selective vaccinator — “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” | content_tags.definitions[1] |
| definition | Transtheoretical Model — “It should also be borne in mind that motivational interviewing builds upon the Transtheoretical Model [ 68 ]. This is a framework for understanding the process of behaviour change where individuals may pass through five stages: precontemplation , where they are not considering change; contemplation , where they seriously consider change; preparation , where they plan and commit to change; action , where they make a specific behavioural change which if successful, leads to maintenance of that behaviour, the fifth stage.” | content_tags.definitions[2] |
| definition | guiding style — “Evidence from other areas of healthcare practice suggests adapting the principles of motivational interviewing. This is a form of communication that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change” | content_tags.definitions[3] |
| concept | unquestioning acceptor — not defined in this paper's own words; 30-40% - parents who vaccinate with no specific questions about safety or necessity — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | concepts[0] |
| concept | cautious acceptor — not defined in this paper's own words; 25-35% - parents who vaccinate despite minor concerns — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | concepts[1] |
| concept | hesitant — not defined in this paper's own words; 20-30% - parents who vaccinate but have significant concerns — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | concepts[2] |
| concept | late or selective vaccinator — not defined in this paper's own words; 2-27% - parents who delay or select only some recommended vaccines — “Five distinct parental groups were identified: the ‘unquestioning acceptor’ (30–40%), the ‘cautious acceptor’ (25–35%); the ‘hesitant’ (20–30%); the ‘late or selective vaccinator’ (2–27%); and the ‘refuser’ of all vaccines (<2%).” | concepts[3] |
| concept | immunisation advocates — not defined in this paper's own words; one of Gust's five attitudinal clusters, merged here into 'unquestioning acceptor' — “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” | concepts[4] |
| concept | fence-sitter — not defined in this paper's own words; Gust's category at 13%, mapped here onto 'the hesitant' at 20-30% — “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” | concepts[5] |
| concept | vaccination acceptors — not defined in this paper's own words; Benin's single category, split here into 'unquestioning' and 'cautious' acceptors — “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’” | concepts[6] |
| concept | Transtheoretical Model — not defined in this paper's own words; a five-stage model of behaviour change - precontemplation, contemplation, preparation, action, maintenance — “It should also be borne in mind that motivational interviewing builds upon the Transtheoretical Model [ 68 ]. This is a framework for understanding the process of behaviour change where individuals may pass through five stages: precontemplation , where they are not considering change; contemplation , where they seriously consider change; preparation , where they plan and commit to change; action , where they make a specific behavioural change which if successful, leads to maintenance of that behaviour, the fifth stage.” | concepts[7] |
| concept | framework — not defined in this paper's own words; the kind of thing the Transtheoretical Model is said to be — “It should also be borne in mind that motivational interviewing builds upon the Transtheoretical Model [ 68 ]. This is a framework for understanding the process of behaviour change where individuals may pass through five stages: precontemplation , where they are not considering change; contemplation , where they seriously consider change; preparation , where they plan and commit to change; action , where they make a specific behavioural change which if successful, leads to maintenance of that behaviour, the fifth stage.” | concepts[8] |
| concept | guiding style — not defined in this paper's own words; the motivational-interviewing stance the paper recommends - eliciting the parent's own motivations rather than supplying reasons — “Evidence from other areas of healthcare practice suggests adapting the principles of motivational interviewing. This is a form of communication that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change” | concepts[9] |
| concept | directing style — not defined in this paper's own words; the stance it is recommended against — “Evidence from other areas of healthcare practice suggests adapting the principles of motivational interviewing. This is a form of communication that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change” | concepts[10] |
| concept | backfire effect — not defined in this paper's own words; the outcome of treating refusal as ignorance and answering it with more information — “Such poor communication often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information. Such an approach is counter-productive because it fails to account for the complexity of reasons underpinning vaccine refusal and may even result in a backfire effect” | concepts[11] |
| median | — “To assess general acceptability of the framework and recommendations, accredited nurse immunisation providers were presented with them in three annual update sessions, and 104 completed a short questionnaire about usefulness (scored from 1 ‘not at all useful’ to 10 ‘extremely useful’), realism (not at all/somewhat/very), strengths (open question), and areas for improvement (open question). Feedback was positive with a median score for usefulness of 8.8 (range 3–10); 74% rated the framework as ‘very realistic’, 26% as ‘somewhat realistic’, while no-one rated it as ‘not at all realistic’” | content_tags.statistics[0] |
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Abstract. Abstract Background A critical factor shaping parental attitudes to vaccination is the parent’s interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitantterm parent towards vaccine acceptance. Poor communication can contribute to rejection of vaccinations or dissatisfaction with care. We sought to provide a frameworkterm for health professionals when communicating with parents about vaccination. Methods Literature review to identify a spectrum of parent attitudes or ‘positions’ on childhood vaccination with estimates of the proportion of each group based on population studies. Development of a frameworkterm related to each parental positionterm·var with determination of key indicators, goals and strategies based on communication science, motivational interviewing and valid consent principles. Results Five distinct parental groups were identified: the ‘unquestioning acceptorterm’ (30–40%), the ‘cautious acceptorterm’ (25–35%); the ‘hesitantterm’ (20–30%); the ‘late or selective vaccinatorterm’ (2–27%); and the ‘refuser’ of all vaccines (<2%). The goals of the encounter with each group will vary, depending on the parents’ readiness to vaccinate. In all encounters, health professionals should build rapport, accept questions and concerns, and facilitate valid consent. For the hesitantterm, late or selective vaccinatorsterm, or refusers, strategies should include use of a guiding styleterm and eliciting the parent’s own motivations to vaccinate while, avoiding excessive persuasion and adversarial debates. It may be necessary to book another appointment or offer attendance at a specialised adverse events clinic. Good information resources should also be used. Conclusions Health professionals have a central role in maintaining public trust in vaccination, including addressing parents’ concerns. These recommendations are tailored to specific parental positionsterm·var on vaccination and provide a structured approach to assist professionals. They advocate respectful interactions that aim to guide parents towards quality decisions. Background The benefits of childhood vaccination are well established [ 1 ]. Vaccine uptake rates in most industrialised countries are generally high. However, two broad parental factors are associated with under-vaccination. The first relates to socioeconomic disadvantage where, despite some motivation to have their children vaccinated, parents or carers (hereafter referred to as ‘parents’) lack access to adequate resources and support to overcome logistical barriers such as a lack of transport or childcare [ 2 , 3 ]. The second factor, and the focus of this paper, relates to parents’ concerns about the safety or necessity of vaccines [ 4 , 5 ]. A critical factor shaping parental attitudes to vaccination is the parents’ interactions with health professionals. An effective interaction can address the concerns of vaccine supportive parents and motivate a hesitantterm parent towards vaccine acceptance [ 5 , 6 ]. Conversely, poor communication can contribute to rejection of vaccinations or dissatisfaction with care [ 7 - 9 ]. Such poor communication often results from a belief by the health professional that vaccine refusal arises from ignorance which can simply be addressed by persuading or providing more information. Such an approach is counter-productive because it fails to account for the complexity of reasons underpinning vaccine refusal and may even result in a backfire effectterm [ 10 ]. Parental vaccination decisions are based on an array of factors and parents integrate information according to their experiential and social contexts [ 11 , 12 ]. A parent’s trust in the source of information may be more important than what is in the information [ 13 , 14 ]. Health professionals have a central role in maintaining public trust in vaccination; this includes addressing parents’ vaccine concerns [ 15 ]. These concerns will likely increase as vaccination schedules inevitably become more complex, and parents have increased access to varied information through the internet and social media [ 16 ]. In recognition of the need to support health professionals in this challenging communication task conducted in usually short consultations, recommendations have been proposed [ 17 - 21 ]. Previously, most of these have focused on what is said, that is, the information that should be given to parents. Few have addressed how health professionals should engage with parents [ 17 - 21 ]. Since it is clear that parents want an improved dialogue about vaccinations [ 22 - 24 ], it is essential to focus on communication processes that build rapport and trust between the health professional and the parent [ 25 - 27 ]. We propose here a frameworkterm to guide health professionals in communicating with parents about vaccination. By focusing on both what is said and how it is said, we attempt to provide an integrated, generic approach going beyond simply the one-way provision of information. The frameworkterm is informed by evidence from decision making and communication research and is applicable for use by all health professionals in their vaccination discussions, particularly where there might be parental reluctance to vaccinate. It focuses on recommended childhood vaccines but is also applicable to discussions with other groups recommended for vaccination. We propose categories or ‘positions’ that reflect different parental attitudes and behaviours regarding vaccination and suggest specific communication strategies tailored to each position. The overarching goal of the encounter is to promote quality decisions and, ultimately, vaccination. Development of the frameworkterm The frameworkterm was developed to: a) be acceptable to health professionals b) increase health professional and parent satisfaction with discussions about vaccination c) increase a health professional’s self-efficacy (sense of confidence and competence) in relation to communicating about vaccination d) increase the likelihood of the parent making a decision based on evidence (by increasing access to quality information) e) encourage uptake of recommended vaccines. There were four stages in developing the frameworkterm: a literature review, classifying parental positionsterm·var on vaccination, matching strategies to these positions and assessing their face validity with heath professionals. Stage 1: Literature review This aimed to (1) identify existing research that had classified parents’ positions based on their attitudes and behaviours regarding childhood vaccination and (2) identify articles that contained strategies to communicate with parents about vaccination. We searched MEDLINE (1996–), PsycINFO (1967–), CINAHL (1982–), and EMBASE (1980–) in September 2010. The following combination of keywords and associated MESH headings (identified for each database) was used: child$ or infant$ or newborn$ or baby or babies AND vaccin$ or immunis$ or immuniz AND decision$ or choice behavio$ or choic$ or communicat$ or consult$. The searches identified 3168 total hits (including duplicates) which was reduced to 112 after screening titles and removing duplicates. Of these, we identified three studies that proposed a spectrum spanning the parental positionsterm·var on vaccination. These are described in Table 1 [ 28 - 30 ]. We found nine papers advising health professionals on communicating with patients about vaccination but none that tailored communication to empirically derived parental positionsterm·var [ 17 - 21 , 31 - 34 ]. Table 1 Summary of studies identifying parental positionsterm·var on vaccination 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 advocateterm’ (33%); ‘go along to get along’ (26%); ‘health advocate’ (25%); ‘fence sitterterm’ (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 hesitantterm’ (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 positionsterm·var on vaccination We reviewed the classifications presented within the three identified studies, [ 28 - 30 ] summarised parental positionsterm·var from each study, and discussed their relevance to vaccine communication. A discrete number of parental positionsterm·var relating to vaccination attitudes and behaviour were proposed, discussed and revised based on the categories’ applicability to clinical interactions and international relevance. The final set of five parental positionsterm·var are described in Table 2 . A range for the approximate proportion of each group is given based on population surveys or registers from the USA, European Union, New Zealand, and Australia [ 4 , 28 , 35 - 44 ]. Table 2 Parental positionsterm·var on vaccination according to attitudes and behaviours Unquestioning acceptorterm 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 advocatesterm’ 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 acceptorterm 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 acceptorsterm’ were drawn from Benin’s category of ‘vaccination acceptorsterm’ [ 29 ]. The hesitantterm 20–30% These parents vaccinate their child but have significant concerns [ 29 ]. In Gust’s study, they most closely correspond to the ‘fence-sitterterm’ who only slightly agrees about the benefits and safety of vaccination and is neutral about their relationship and trust with their healthcare provider [ 28 ]. Hesitantsterm 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 vaccinatorterm 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 hesitantterm 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 hesitantterm 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 positionsterm·var For each parental positionterm·var, we proposed an overall communication approach then more specific guidance tailored to each parental positionterm·var (1 3 and 4 ). Given that no tailored guidance was identified in the literature review, the specific strategies were informed by the literature on health communication; [ 48 , 49 ] our professional and educational experience; valid consent principles, [ 50 ] and those of motivational interviewing which uses a guiding styleterm to promote healthy behaviours [ 51 ]. Table 3 Unhelpful and helpful strategies for addressing parental concerns about vaccination Unhelpful Helpful [ [ 51 ] ] Directing styleterm – “this is what you should do” Guiding styleterm – “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 Table 4 Parental positionterm·var, with the recommendations for each group Parental positionterm·var Key indicators Goal Strategies* See also Table 3 Unquestioning acceptorterm Present for vaccination when it is due Child vaccinated and parent positive about decision Build rapport Cautious acceptorterm 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 hesitantterm Present on time or slightly late Child vaccinated and parent accepts decision Use guiding styleterm Late or selective vaccinatorterm 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 † * Most strategies are applicable to all groups but located beside those with the most relevance. † Specialists in some countries offer clinics for children who have experienced an adverse event following immunisation [ 72 ]. Stage 4: Seeking feedback from health professionals To assess general acceptability of the frameworkterm and recommendations, accredited nurse immunisation providers were presented with them in three annual update sessions, and 104 completed a short questionnaire about usefulness (scored from 1 ‘not at all useful’ to 10 ‘extremely useful’), realism (not at all/somewhat/very), strengths (open question), and areas for improvement (open question). Feedback was positive with a median score for usefulness of 8.8 (range 3–10); 74% rated the frameworkterm as ‘very realistic’, 26% as ‘somewhat realistic’, while no-one rated it as ‘not at all realistic’. General practice immunisation coordinators, immunisation experts, and a consumer representative (n = 20) all provided verbal feedback on the draft frameworkterm. All feedback was used to inform revisions of the recommendations. The frameworkterm How discussions are addressed While the majority of parents accept vaccination (Table 2 ), attendance at the consultation should not be presumed to indicate consent. Ideally parents will receive credible information prior to their child’s appointment. Health professionals have a responsibility to ensure that parental consent for vaccination is valid. This requires more than simply giving information and is built upon a relationship and interaction [ 50 , 52 ]. Building trust is paramount in any healthcare interaction. As noted by Benin et al, the trusted health professional is one who: has spent time with the child and parent; listened to, accepted and addressed their concerns; possesses the necessary scientific information; and uses a whole-person approach that is not patronising but treats parents and their children as individuals [ 29 ]. Table 3 lists unhelpful and helpful approaches to communication with all parents. Health professionals’ body language ideally indicates that the discussions are important and distractions, such as using computers while talking, are best avoided. They need to speedily establish rapport and clarify parental concerns, avoiding the temptation to minimise or dismiss these (“Oh there’s nothing to worry about, vaccination is very safe nowadays”) [ 27 , 53 ]. Instead it is important to fully understand parents’ concerns and motivations using open questions and empathic responses [ 27 ]. Although health professionals may be reluctant to encourage questions [ 27 , 54 ], with practice, targeted questions allow health professionals to tailor their discussions [ 51 ]. Giving information is an integral part of the immunisation encounter. Here, the skills for efficient information provision are useful - primarily ‘signposting’ and ‘chunking and checking’ (see 1 5 , 6 and 7 for examples) [ 49 ]. Signposting is the skill of clearly indicating to the parent (or patient) the different phases of the consultation. Chunking and checking refers to the provision of information in small chunks followed by checking the person’s understanding. This technique contrasts with the common practice of providing much larger amounts of information before checking, which can lead to information overload. Table 5 Example of dialogue with the unquestioning or cautious acceptorterm parent 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. Table 6 Example of dialogue with the hesitantterm parent 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. Table 7 Example of dialogue with the vaccine-refusing parent 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 styleterm ) 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. What to include in discussions with parents It is important to communicate risk effectively [ 56 ]. It is recommended that health professionals give information about common but minor side effects, and rare but serious ones [ 57 ]. Written materials, web links, or decision aids given prior to, or used during, the consultation can be helpful [ 58 - 60 ]. In a recent UK survey 156 primary health care professionals viewed the inclusion of a web link for an online MMR decision aid contained in a parents’ MMR pre-vaccination invitation letter as an appropriate way to support parents coming to the consultation [ 61 ]. Written resources may be available in electronic/online or paper format. These vary widely between countries and clinicians should be familiar with how to locate them. Risk communication is best tailored to individuals. In general terms outcomes are better understood when they are specified and when their probability is given in numbers (e.g. 1 in 1000) although some may prefer words [ 62 ]. When presenting probabilities, there remains conflicting evidence over whether natural frequencies (e.g., 1 in 100) or percentages are preferable [ 63 ]. A recent study concluded that percentages may be better understood than natural frequencies [ 64 ]. To avoid confusion, a consistent denominator should be used when presenting event rates for comparison [ 65 ]. Visual representations of probability have also been recommended and are commonly used in decision aids [ 59 , 61 ]. Specific information is most helpful when it is timely, consistent, relevant, up to date, and, where available, local. Parents should also be advised about how to manage the common side effects of vaccinations and how to seek help if they have further concerns [ 66 ]. A tailored approach Evidence from other areas of healthcare practice suggests adapting the principles of motivational interviewing. This is a form of communication that uses a guiding styleterm, rather than a directing styleterm, for discussions where there is ambivalence and resistance to change [ 51 ]. Motivational interviewing involves asking questions that clarify an individual’s responsiveness to change and elicits their own motivations for change. The method has demonstrated effectiveness in a range of health behaviours [ 67 ]. In this particular context, the ambivalence and resistance to change relates to whether or not a parent should have their child vaccinated rather than focusing on a behaviour such as quitting smoking. It should also be borne in mind that motivational interviewing builds upon the Transtheoretical Modelterm [ 68 ]. This is a frameworkterm for understanding the process of behaviour change where individuals may pass through five stages: precontemplation , where they are not considering change; contemplation , where they seriously consider change; preparation , where they plan and commit to change; action , where they make a specific behavioural change which if successful, leads to maintenance of that behaviour, the fifth stage. Accordingly, Table 4 strategies tailored to the parent’s stage. The majority of parents are in the action and maintenance stage (cautious or unquestioning acceptorsterm). Some will be contemplating or even preparing to immunise – what we describe as ‘hesitantterm’ parents. Late or selective vaccinatorsterm, who are willing to have some vaccines, may also contemplate full vaccination if guided by a health professional [ 5 ]. ‘Vaccine refusers’ are usually in the pre-contemplation stage where they are not considering vaccinating at all. It is unrealistic to expect such parents to move to the action stage at one visit. However, the goal may be to guide them toward contemplating vaccination. This would be done by asking permission to discuss; encouraging them to explore the pros and cons of their decision; and eliciting their own possible motivations to change (Table 4 ). Tables 5 , 6 and 7 give examples of suggested dialogue for unquestioning and cautious acceptorsterm, hesitantterm, and refusing parents. For late or selective vaccinatorsterm, strategies can apply from those suggested for hesitantterm and refusing parents. A parent’s starting position can be clarified with initial questions (How do you feel about the vaccinations?) and observation of their body language. It may also be possible to flag specific questions or concerns for discussion prior to the consultation. For example, a question prompt sheet for parents to use in consultations about MMR vaccination was positively evaluated by 46 parents in a UK study [ 69 ]. Specifically parents reported that the prompt sheet enabled them to feel confident in ‘raising the issue of MMR’ with their GP or nurse. The goals for the consultation will vary according to the parent’s position. Health professionals should avoid a mismatch between the parent’s expectations and needs and their own assumptions. For example, a ‘hesitantterm’ father may be planning only to obtain information but feels he is being pressured to vaccinate. The cost may be loss of his trust and a subsequent unwillingness to return. Similarly, a ‘refusing’ mother might be approached by a health professional who is intent on changing her mind [ 70 ]. This ‘righting reflex’ is the natural response of health professionals to instinctively ‘put right’ healthcare problems rather than finding out patients’ concerns or points of view. It may lead to an adversarial position and further entrench the parent’s views, closing the door to any future possible gains [ 71 ]. In this situation, a better goal would be to build a rapport that may lead to willingness for further discussion or partial vaccination. Vaccine-refusing parents may be willing to consider an alternative schedule and may be willing to hear how to recognise and respond early to signs that their child may have a vaccine-preventable disease (Table 4 ). Discussion As vaccine preventable diseases become less common, parents in industrialised countries appear to be expressing more concerns about the safety and necessity of vaccines. This could lead to a decline in vaccination uptake rates to a level which allows the diseases to re-emerge and become significant health problems [ 73 ]. Health professionals have to juggle the need to consider the population at risk of the disease (particularly if vaccination rates drop) alongside addressing the needs of the particular parent who is raising concerns about what to do for their particular child. These concerns centre on an increasing number of vaccines given to children, their safety, composition and necessity. Since interactions with health professionals provide a focal point for parents’ concerns to be expressed, it is important that communication during these interactions is effective [ 26 ]. The parental positionsterm·var described in this paper act as a starting point for health professionals to choose the most appropriate communication strategy. Naturally these will vary according to the parent’s individual needs and circumstances. The literature review informing the parental positionsterm·var found only three papers providing a spectrum of attitudes to vaccination. While there is a vast literature exploring attitudes to vaccination among parents [ 3 , 7 , 74 , 75 ], we sought to identify only studies that would provide a spectrum of attitudinal positions that would theoretically account for all parents. However, the spectrum described does simplify what is often a complex process of decision making which may involve parents moving between positions over time. Indeed, as noted in the wider literature, parents’ decisions are also made in a broader context of beliefs about a child’s health, personal experiences, perceived norms, and trust in health systems and professionals [ 12 , 29 , 76 ]. While the parental positionsterm·var were developed from three US studies, we have applied our knowledge and experience from other countries to their modification. The approximate proportions of each parental group are estimates from population-based surveys and will vary over time, within regions, and between practices. For example, the estimate for the percentage of parents completely refusing all vaccines is given as less than 2% based on population data but there are clusters of much higher refuser rates in specific localities [ 43 , 44 , 77 ]. Nevertheless, giving ranges for the sizes of the groups may assist health professionals and programme coordinators in planning for targeted information and strategies. We have proposed an approach to communication that encourages questions and employs a guiding rather than directing styleterm. The reality of busy clinical environments can act as a disincentive for health professionals to actively seek out questions and concerns [ 54 ]. However, the frameworkterm we propose may ensure that consultations are more time efficient because it provides a structure to more rapidly identify the parent’s position on vaccination, the most appropriate goals for that consultation, and the parent’s specific information needs. Practised interviewing techniques enable the health professional to quickly focus the discussion on the specific concerns of the parent. In interactions with vaccine-refusing parents, some health professionals attempt to change the parent’s mind [ 70 ]. As this goal is usually unrealistic, the consultation can become long and difficult and result in an impasse. Having more realistic goals will facilitate a more satisfying and time efficient discussion which may then be followed-up as needed. Communication strategies to date have lacked clear evidence of efficacy in vaccination settings. We have described a frameworkterm for talking with parents about vaccination. It is informed by evidence and acceptable to the health professionals involved in the formative evaluation sessions, but now needs to be more fully evaluated. This may involve group or individual training of health professionals who undergo assessment using standardised patients and validated scales that measure quality of communication [ 78 ]. To measure effectiveness of the frameworkterm against the aims described above (satisfaction, self-efficacy, decision quality and vaccination uptake), a randomised controlled trial delivered at cluster (e.g., GP practice) or individual level would then establish its effectiveness compared with ‘usual care’. Conclusion Good communication is part of a suite of measures needed to maintain high uptake of child vaccines. Strategies must also continue to address barriers such as access to healthcare and provider factors [ 79 - 81 ]. Nevertheless, there is an urgent need to build an evidence base which informs vaccine communication, given that the parent–provider interaction remains integral to maintaining public confidence in vaccination. Competing interests All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work. Authors’ contributions JL and PK had the idea for the article, CJ and FC performed the literature search, JL, PK, CJ, FC, HB and GR developed the frameworkterm and wrote the article. JL is the guarantor. All authors read and approved the final manuscript. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2431/12/154/prepub Contributor Information Julie LeaskpersName, Email: Julie.LeaskpersName@sydney.edu.au. Paul KinnersleypersName, Email: kinnersleypersName@Cardiff.ac.uk. Cath JacksonpersName, Email: cath.jacksonpersName@york.ac.uk. Francine CheaterpersName, Email: Francine.CheaterpersName@gcu.ac.uk. Helen BedfordpersName, Email: h.bedfordpersName@ich.ucl.ac.uk. Greg RowlespersName, Email: growles@riddellcp.com.au. Acknowledgements The authors are grateful to Helen Moore, Michelle A’Deggers and Kate Russo from the Australian General Practice Network and staff at the National Centre for Immunisation Research and Surveillance for providing feedback on the frameworkterm. We also thank Lynne Sturm and Nick Sevdalis for their constructive suggestions as peer reviewers. NCIRS is supported by the Australian Government Department of Health and Ageing, the NSW Department of Health and The Children’s Hospital at Westmead. This research was carried out independent of its funding sources.