Program Name:
Faculty:
Immunization Competencies Education Program
Module 6 - Communication
Adapted by:
Michael Boivin, B. Pharm.
Susan Bowles, BSc Phm, PharmD, MSc
Capital District Health Authority and Dalhousie University, Geriatric
Ambulatory Care
Danielle Grenier, MD
Canadian Paediatric Society
Alex Henteleff, BN, MEd
Consultant Public Health
Expert video commentary was kindly provided by:
Upton Allen, MD, FRCPC, MBBS, FAAP
Maryanne Crockett, MD, MPH
Andrea Derban, BScN
Simon Dobson, MD
Joanne Embree, MD
Ian Gemmill, MD, CCFP, FCFP, FRCP(C)
Caroline Quach, MD, FRCPC, M. Sc.
CCCEP:
This continuing education lesson is designed primarily for
community pharmacists and has been accredited by the Canadian
Council on Continuing Education in Pharmacy (CCCEP) for 1 CEUs.
CCCEP File Number: 1066-2010-092-I-P
This online CME event is an Accredited Group Learning Activity
(Section 1) as defined by the Maintenance of Certification program
of the Royal College of Physicians and Surgeons of Canada. This
program is recognized as 1 hour(s) of Continuing Professional
Development.
Family physicians may claim one (1) credit per hour of participation
under Mainpro-M2.
Course Expiration Date:
June 15, 2013
Sponsor:
This module is developed in collaboration with the Canadian Paediatric
Society, the Public Health Agency of Canada and Health Canada.
Competency: Communicates effectively about immunization, as relevant to the practice
setting(s).
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Learning Objectives
Upon successful completion of this section the health professional will be able to perform the
following:
1. List the components of the evidence-based decision-making process.
2. Explain the importance of risk perception for immunization decision making.
3. Respond appropriately following an assessment of client knowledge, attitudes, and
beliefs regarding immunization.
4. Deliver clear, concise messages about the risks of vaccine-preventable diseases and the
benefits and risks of vaccines.
5. Provide appropriate evidence-based information and resources to clients regarding
immunization and vaccines.
6. Provide guidance to clients so they can correctly identify credible sources of information
on immunization and vaccines.
7. Apply, as appropriate to the practice setting, mass media strategies for public
communication.
Test your Current Knowledge:
Based on your current knowledge, determine if the following statements are true or false.
1. Concerns regarding safety of vaccine is a major issue for parents refusing immunization
for their children
a. True
b. False
2. A patient centered approach and partnership is crucial for proper vaccination education
a. True
b. False
3. Close to 80% of American adults use the internet for health related information
a. True
b. False
4. Approximately 10% of websites on immunization have an anti-vaccination message
a. True
b. False
5. Personal and anecdotal stories about the risks of immunization are stronger for all
parents than scientific data
a. True
b. False
6. The most effective approach to immunization education is to provide consistent
information to all patients, delivered in the same way for everyone.
a. True
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b. False
Evidence-Based Medicine
When communicating risk and benefit of immunizations, it is important clinicians utilize the
principles of evidence based medicine. Evidence based medicine is defined as:1
“The conscientious, explicit, and judicious use of current best evidence in making decisions
about the care of individual patients. The practice of evidence-based medicine requires the
integration of individual clinical expertise with the best available external clinical evidence from
systematic research and our patient’s unique values and circumstances.”
There are four cardinal components to the practice of evidence based medicine. These
components are:1
1. External evidence from systematic research—Valid and clinical findings from patientcentered clinical research
2. Individual clinical expertise—Experience and skills to rapidly identify a patient’s health
state, diagnosis, risks and benefits of interventions, and their personal expectations
3. Patient values
4. Patient circumstances
Each of these components is important to consider when communicating immunization risks
and benefits. Immunizers should base their education and counselling based on clinical research
and their clinical expertise and should consider the patients values and circumstances towards
immunizations.
Why Don’t All Parents Immunize?
Vaccines are one of the greatest public health initiatives in modern medicine.2 With
immunization programs we have seen the elimination of some of the most contagious and
deadly diseases from our families, our cities and the world and have undoubtedly saved millions
of lives.2
With such a positive effect on public health, why do many parents decide that their children
should not be vaccinated? Unfortunately the reasons for vaccine refusal are complex and
variable.2 Table 1 lists some of the cited reasons for vaccine refusal in patients.2
Table 1 – Some of the Reasons Parents use for not Vaccinating their Child2
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Effective vaccine programs have decreased the incidence of vaccine-preventable
diseases. Today, parents lack the direct link between disease risk and vaccine. Many feel
the risk of vaccine side effects outweighs the risk of disease. In the 1950-60’s nearly
everyone knew a person with paralytic polio and most had seen the effect of a pertussis
(whooping cough) infection.
Pain, inconvenience, and cost are also mentioned for vaccine refusal. Many children
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express anxiety about injections, which can be distressing to parents as well, even
though topical analgesia is now available.
Some church leaders counsel against immunizations. They perceive vaccines as invasive,
unnatural, immoral or directly prohibited by God or another supreme authority.
Misunderstanding of the immune system. The complexity of the immune system is
overwhelming. Many clinicians have a difficult time understanding the cascade of
reactions that occur once a vaccine is injected. This can then make it very difficult to
explain it to a parent.
Mass media influence from campaigns promoting anti-immunization stories with “shock
value”.
The proliferation of the anti-immunization message throughout the internet.
One of the major concerns cited by parents who do not immunize their children is the safety of
the vaccine product (specific questions will be addressed in a later section). Many of these
concerns about vaccines may occur due to the direct result of the immunization program
success.3 As the burden of the disease falls and memory of the severity wanes, concern shifts
from the disease that is rarely seen, to the vaccine that is widely used.3
To complicate the issue, vaccine immunology is very difficult to explain. For this reason many
patients turn to the internet for clarification and further information on immunization.2 A study
found that close to 43% of site results by seven major search engines are opposed to
vaccination.2 Most of these sites have emotional stories and testimonials from families whose
loved ones were allegedly harmed by immunizations.2 More than 90% of these internet sites
contain claims that vaccines cause idiopathic illness, immunity erosion, and increased incidence
of adverse reactions and suggest that vaccine policy is motivated by institutional profit. In
addition, all of the sites contain links to other anti-immunization web sites.2
Clinical Notes:
Close to 80% of American adults with internet access use it to research health-related
information. 13% identify immunizations and vaccinations as their primary search subject
The Importance of Communication
Public concern regarding vaccine safety can reduce vaccine coverage rates and can result in the
resurgence of vaccine-preventable diseases.4 Healthcare professionals have a vital role in the
success of the immunization program by providing information on the principles of
immunization and through risk communication.4 The Canadian Immunization Guide provides
some tips on these principles of risk communication.4
The goal of effective risk communication is to develop an informed decision-making partnership.
An individual’s perception of risk is influenced by experience as well as personal, religious and
cultural contexts.4 Events that are familiar, are perceived as natural, seem to be under an
individual’s control, are of a voluntary nature or involve a decision to forgo something are
generally perceived as less risky than those that are unfamiliar, involve a man-made process,
involve loss of control, are mandatory or involve a decision to do something rather than avoid
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something.4A decision to become immunized or immunize a child clearly falls into the latter
“high risk” category regardless of the true odds. Framing the risks and benefits in the right
context is very important. Countering an individual’s concerns by citing the greater dangers of a
familiar event, like driving a car, while true, may be counterproductive.4
Table 2 lists some of the key principles of risk communication from the Canadian Immunization
Guide.
Table 2 – Principles of Risk Communication4
Communicate Current
Knowledge
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Take into account what an individual already knows
and the level of detail requested.
Respect time allocation, the process need not be
time-consuming. It is useful to have varied
information formats (visual, audio, printed material,
Web sites) tailored to a range of educational levels
and languages as appropriate to a given
practice/clientele.
Give the volume, accessibility and variable quality of
material available on the internet, it is also helpful to
provide guidance on how to assess Web site
reliability and provide a list of reliable ones (see
website list at the end of this lesson).
Your Opinion Matters
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The impact providers have on their patients/clients
within a trusting relationship. The statement “I
believe in immunization and have/will immunize my
children” is very powerful.
Respect differences of opinion
about immunization
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Some individuals will express reluctance or refusal to
accept immunization for themselves or their children.
It is important to both gauge the strength of this
stance as well as discover its underlying reasons.
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Represent the risks and
benefits of vaccines fairly and
openly.
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Adopt a patient-centred
approach.
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Contrast the known versus theoretical risks of
vaccine with the known risks associated with the
vaccine-preventable infection.
More information is available on specific questions in
a later section.
Effective decision making is best done in a
partnership between the provider or vaccinator and
the parent or patient.
Central to this is the acceptance that individuals have
input into the decision to immunize and retain
responsibility for their own or their child’s health.
A decision to do something rather than to avoid
something may cause greater concern when it comes
to immunizing children.
Make the most of each
opportunity to present clear,
evidence-based messages
regarding vaccines and
immunizations.
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Encourage questions, address misinformation, and
provide valid and appropriate resources, including
authoritative Web sites, for those who want more
information.
Remember that a trusted health care provider is
proven to be essential in the decision making
process.
Reaffirm your conviction that immunizations are
important to prevent serious diseases and
complications.
Basic Communication Skills
Although healthcare professionals are good communicators, almost everyone can improve the
method in which the immunization information is provided to patients. Basic communication
skills can help to improve the delivery and acceptance of the vaccination message. Table 3 lists
some of the key principles of communication. Table 4 lists some principles of effective
persuasion.
Although healthcare professionals are good communicators, almost everyone can improve the
method in which the immunization information is provided to patients. Basic communication
skills can help to improve the delivery and acceptance of the vaccination message. Table 3 lists
some of the key principles of communication. Table 4 lists some principles of effective
persuasion.
Table 3 - Principles of Communication
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Know your audience
Know the purpose of the communication. (What you hope to achieve by discussing
immunization with this patient)
Know your topic well. Be able to provide evidence based information
Anticipate objections
Present a rounded picture
Communicate a little at a time
Present information in several ways
Table 4 – Principles of Effective Persuasion
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Do not overstate your case.
Outline the topic you are trying to cover into two parts. The first part should give
broad background information, while the second part provides a detailed summary.
(e.g. “Mrs. Smith I am glad you are here today to discuss your son’s immunization, let
me overview the immunizations we will be giving him today”).
Persuasion depends on clarity and simplicity. Avoid the use of technical and medical
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terms.
Be prepared to back up claims or facts immediately. (Have the immunization guide
and other tools like “Your Child’s Best Shot” publication,so they are easily accessible).
Incorporate major anticipated objections into your program or presentation.
Address all relevant aspects of a topic, especially those that may affect the
functioning of an organization.
Consider ways to get meaningful input from people. If they feel they have an input
they are more likely to accept your message.
Communication Strategies
Start Early and Provide Resources
An excellent opportunity to open the discussion is not at the 2 month visit when the first vaccine
is going to be administered but shortly after the child is born. This provides clinicians an
opportunity to open the dialogue and state that they believe in immunization. They can also
provide some information booklets or sources of good information such as reputable websites.5
Simply providing information early allows the parents to digest the information and it allows you
to review and expand upon it the next time you see them.5
Take Time to Listen
If a parent starts to talk about a vaccine, try to give them your full attention.5 Maintain eye
contact, restate their concerns to be sure that you fully understand their question and pause to
thoughtfully prepare your reply.5 Taking the time to listen can have a dramatic effect on a
parent’s decision to immunize.5 Anticipating certain questions and having a prepared answer
may help to reduce the time of the intervention. These common questions and answers will be
provided in a later section of this module.
Ask and Welcome Questions
Parental concerns about vaccine safety are on the rise and this is fuelled by anti-vaccine
messages on web sites, media attention to alleged or false claims about vaccine safety and the
decrease in vaccine-preventable diseases.6 Although it is impossible to identify every parent that
may be vaccine hesitant, table 5 provides some characteristics that may help to identify this
population early.
Four questions may help to start the
conversation and identify the information
needs of the parent
1. Do you have any personal belief or
question regarding immunization?
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2. Has your child or any child you know
had a serious vaccine preventable
disease or a reaction after an
immunization?
3. Do you have any vaccine safety
concerns?
4. What vaccine safety information can I
provide?
Table 5 – Common Characteristics of Vaccine-Hesitant Parents7, 5
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The child is more likely to be Caucasian and male
The household has a higher income
The mother is married with a college education
Live with four or more children
The parent:
o
Believes they can control susceptibility to disease
o
Has doubts about the reliability of vaccine information
o
Prefers outcomes due to inaction (not vaccinating) versus negative outcomes
due to action (vaccinating)
o
Is willing to rely on herd immunity to protect their child
o
Has alternative (complementary) health beliefs
o
Has had direct experience with adverse events to vaccines
Don't be offended and don't offend
A group of parents will come with a large
amount of information from a large variety
of information sources.5 This is not to
second guess the clinician’s judgement and
should not be interpreted as such. If you
appear offended by a question, or if you
imply the parent’s questions are not called
for, you may erode the trust with the
patient and may completely shut down
dialogue.5
Science, anecdote or both?
Too much science will frustrate some
parents.5 Too little science will frustrate
others.5 For some parents a personal story
of how you witnessed the severe cough of
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Quick Tip:
Children who are not vaccinated are
likely to belong to families that
intentionally refuse vaccines.
Children who are undervaccinated
are likely to have missed some
vaccinations because of factors
related to the health care system or
sociodemographic characteristics
a pertussis of an unimmunized child or
that you vaccinate all your children can be
helpful for some patients. Other patients
find these anecdotal stories not very
helpful.5 Which approach to use will
depend on the family. Watch and listen
and tailor your message (science versus
personal) based on the individual patient.5
Acknowledge benefits and risks
No vaccine is risk-free and an honest discussion of known side effects is recommended.5 But
don’t forget to remind parents that the diseases vaccines prevent can return. It’s honest to say
that not vaccinating is a risk for the child that worries you.5
Respect the parent’s authority
Many parents want to work in partnership with their clinicians to manage their child’s care.5 By
talking respectfully with parents about their immunization concerns, you can build on this
partnership, build trust and support parents in the decision to choose vaccination.5
Document parent’s questions and concerns and follow up if needed
A documentation of the parent’s concerns and questions can be an invaluable reference during
the child’s future visits.5 If the parent is very concerned a follow-up telephone call or email in a
few days may illicit further discussion that was not brought forth in the office visit.5
Preparing for the Questions
One task that immunizers may find useful is to be prepared for the most common questions
asked by parents. By having some of the answers to these questions ready, it may shorten the
time discussing the issue with the parent and instil confidence in you and the immunization
system.
ImmunizeBC has developed an excellent tool to help you address and answer many of your
patient’s concerns regarding immunizations. The common questions from this guide are listed in
Table 6. Immunizers are encouraged to download the communication tool by clicking:
Table 6 – Responses to Common Questions8, 9
Myth
1. Multiple Injections
overwhelm the baby’s
immune system
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Suggested Points for Response
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Babies are born with thousands of antibodies.
New babies come in contact with millions of germs
when born and their immune system can respond
immediately.
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2. Babies are getting too
many shots
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3. The link of vaccines to
autism
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4. The preservative
thimerosal contains mercury
and it causes severe problems
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5. Vaccines contain
formaldehyde which is very
dangerous
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6. Vaccines contain aluminum
and this is very toxic to
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Babies can make over 1 billion antibodies, and could
theoretically handle up to 10,000 shots at any one
time.
New vaccines have significantly fewer antigens than
their counterparts in the past.
Vaccines are just a small part of what babies encounter
every day.
Babies are most susceptible to the severe
consequences of many vaccine-preventable diseases.
Most vaccines are formulated in multi-antigen formats
to limit the need for office visits and injections.
Multiple vaccines are safe to give at one time. They
only use a fraction of the immune system to generate
the immune response.
Vaccines do not harm the immune system but prime
and train it to defend, rapidly against vaccinepreventable diseases before illness can occur.
Parents may encounter poorly designed and conducted
studies, misleading summaries of well-conducted
studies, or anecdotes made to look like science—
claiming that vaccines cause autism.
The onset of regressive autism symptoms often
coincides with the timing of vaccines but is not caused
by vaccines.
Many studies refute the link of MMR vaccine to
autism.
Autism rates have increased even though fewer
children have been vaccinated with the MMR vaccine.
Thimerosal has not been used in routine childhood
vaccines in Canada since 2001.
There is no scientific evidence that thimerosal has
caused brain damage or other neurologic problems as
a result of vaccination.10 Ethylmercury in thimerosal is
very different from methylmercury, which can cause
severe brain damage.10
Formaldehyde is used in the production of vaccines to
kill and inactivate viruses and bacteria.
It is naturally found in our bodies and is essential for
human metabolism and the synthesis of amino acids.
The amount in an infant’s circulation is much higher
than the amount contained in any vaccine.
Aluminum has been used as an adjuvant for the past
70 years in vaccines.
children
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7. Vaccines contain human
and animal cells
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8. Natural infection is better
than a vaccine
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9. Vaccines cause more harm
than the disease they are
preventing
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10. Vaccines don’t prevent
diseases, they were already
on the decline due to better
sanitation and clean water
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It enhances the immune response to vaccines.
Vaccines contain the same amount in breast milk and
infant formula.
They have been found to be very safe.
Although human and animal cells may be used in the
production of vaccines, they have been removed by
the purification process.
Trace amounts of cellular proteins may remain.
The immune response after most vaccines is similar to
immunity that is induced by the disease without the
risk of disease.
Natural disease can kill or seriously harm the child,
where vaccines have the benefit of protection and the
lack of problems of disease.
Fever, redness and tenderness where a shot was given
and fussiness are common post-vaccination.
Remind parents that serious adverse effects are
uncommon and consider sharing your own experience,
if any, with seeing serious side effects from a vaccine.
Vaccines are one of the most monitored tools in
modern medicine. Serious reactions such as
anaphylaxis are so rare and occur in 2 patients per
1,000,000 immunizations given.
Diseases dropped rapidly with the introduction of new
vaccines to the Canadian market.
Better living conditions did not reduce the risk of
disease but decreased the mortality rate from these
infections.
Excellent resources on vaccine myths
• Immunization Communication Tool – for Immunizers
• Talking with Parents about vaccines for infants
• Vaccine Concerns
• Vaccine Myths
• Addressing Parents' Concerns: Do Vaccines Contain Harmful Preservatives, Adjuvants,
Additives, or Residuals?
• Communicating Effectively about Immunization
• Immunizations: get the facts
• Some common misconceptions about vaccination and how to respond to them
• Communicating the benefits and risks of vaccines
•
Reputable internet resources for your patients
• Immunization Information on the internet: Can you trust what you read?
• Caringforkids.cps.ca
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Canadian coalition for immunization awareness & promotion
Your child’s best shot (book)
Immunization Action Coalition
Key Learning Points
1. The reasons for parents not immunizing their children are diverse and are many times
patient specific.
2. Risk communication can help you to partner with your patients on the health role of
immunizations.
3. Basic communication skills can have a dramatic impact on the delivery of your
immunization message.
4. Clinicians are encouraged to ask questions and welcome questions from parents.
5. The delivery of the immunization message may vary based on the patient. Some may
want more scientific information where others may prefer personal stories.
6. Strategies will vary depending on the type of parent that you are counselling (i.e.
believers, relaxed, cautious or conscientious objectors).
7. Prep for common question to help facilitate the delivery of your immunization message.
8. Direct patients to reputable websites and resources.
Discussion Forum
You must participate in all discussion forum questions in order to qualify for your certificate.
1. In your clinical practice what is the most common reason for refusing immunization and what
strategies have you used to address this?
2. What communication style (scientific or anecdotal) works best with your patients and why?
3. Do you have any anecdotal stories that you use in your practice that you can share with your
colleagues?
Post Test
Mary T. is in to discuss the immunizations of her 2 month daughter Stephanie. She has heard
from multiple people and internet sites that the number of immunizations at 2 months is not
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appropriate and she should refuse the forced immunization program by the Government. She
has heard they can lead to serious disease states and adverse effects. She wants to know if she
needs to give Stephanie all the vaccines or can she just give a few as she really wants to do the
best for her child’s health.
1. Which type of parent group would BEST describe Mary T.?
a. Believer
b. Relaxed
c. Cautious
d. Conscientious objector
2. Which of the following statements would be the MOST appropriate response to Mary’s
statement on the number of immunizations for her daughter?
a. Mary, you are wrong your daughter needs all these vaccines
b. Mary, I can’t believe that you read all that stuff written online
c. Mary, if the number of vaccines worries you, why don’t we sit down together to
see which ones we can eliminate
d. Mary, I can understand your concern on the number of vaccines but we have
found that administering these combination vaccines to be safe and can reduce
the pain, number of visits associated with vaccines
3. When responding to Mary’s question about vaccines causing serious disease which of the
following statements is the MOST appropriate?
a. Mary, I know more about this than you do and you will just have to believe me
that they don’t cause serious disease
b. Mary, I can understand that you are concerned about serious disease. I have
immunized many patients for a long time and I have not seen this link in my
practice and in any of the literature that I have read
c. Although the link to serious disease can occur, it is only in a small subsection of
children and Stephanie would not be at risk
d. Mary, it sounds like you don’t want to give the vaccines so please sign this form
and I will not ask you about this again
4. When discussing adverse effects with Mary which of the following statements is the MOST
appropriate to use?
a. Mary, vaccines don’t have side effects
b. Mary, the most common side effects after immunization are redness and pain at
the injection site but it is only temporary
c. Mary, some vaccines have some serious side effects because of their
ingredients. Would you like to hear more about them?
d. Mary, although severe reactions are not very common, I can guarantee that a
severe reaction will not happen to Stephanie
5. Which of the following characteristics are linked to conscientious objector?
a. Family has low income
b. Parents are high-school graduate
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c. Child is of female sex
d. Child lives with four or more children
References
1. Bradt DA. Evidence-based decision-making (part 1): Origins and evolution in the health
sciences. Prehosp Disaster Med. 2009;24(4):298-305.
2. Lyren A, Leonard E. Vaccine refusal: issues for the primary care physician. Clin Pediatr
(Phila). 2006;45(5):399-404.
3. Purssell E. Uncertainties and Anxieties about Vaccination, Answering Parent's Concerns.
Journal of Pediatric Nursing. 2009;24(5):433-440.
4. National Advisory Committee on Immunization. Canadian Immunization Guide. Seventh
edition. Ottawa, Ontario: Public Health Agency of Canada; 2006.
5. NCIRD. Talking with Parents about Vaccines for Infants. Available at:
http://www.cdc.gov/vaccines/spec-grps/hcp/conv-materials.htm#providers [Accessed
April 20, 2010].
6. AAP. Strategies for Pediatricians: Addressing Concerns of Vaccine-Hesitant Parents.
Available at: http://www.aap.org/immunization/pediatricians/pdf/VaccineHesitant%20Parent_Final.pdf [Accessed April 19, 2010].
7. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine Refusal, Mandatory
Immunization, and the Risks of Vaccine-Preventable Diseases. N Engl J Med.
2009;360(19):1981-1988.
8. NCIRD. Vac-Gen/Some Misconceptions. Available at: http://www.cdc.gov/vaccines/vacgen/6mishome.htm [Accessed April 21, 2010].
9. ImmunizeBC. Immunization Communication Tool for Immunizers.; 2008. Available at:
http://www.immunizebc.ca/NR/rdonlyres/8F63F288-F027-4A78-B0D2AFDE8548F982/28623/CDC_IC_Tool.pdf [Accessed April 20, 2010].
10. Gold R. Your Child's Best Shot. 3rd ed. Ottawa, Ontario: Canadian Paediatric Society;
2006.
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