This is part of a series by the STFM Group on Immunization Education for National Immunization Awareness Month.
Immunization conversations can be a challenge even for the most experienced family physician. Even when both the physician and patient agree on the benefit of vaccination, the discussion may require navigating a complicated mix of public health, infectious disease, and immunology interspersed with patient fears about safety and benefit. Fitting that neatly into an already jam-packed 15-minute encounter can be difficult.
Immunization counseling provides a great opportunity for shared decision-making with your patients and lays the foundation for successful health maintenance decisions in the future. Applying some basic knowledge about communication styles, using your motivational interviewing skills, and being prepared to respond to common questions can allow even a busy provider to experience success with vaccine counseling.
Consider Flexing to Your Patient’s Preferred Communication Style
Learning styles and personality types are often an untapped resource when communicating during office visits. In general, people tend to fall into four major types: Thinkers, Planners, Dreamers, and Feelers. Figuring out your patient’s preferred style and crafting your message to make it easiest for him or her to understand the message. Table 1 reviews the common types and examples of tools that may work better with one group over another.
|Table 1: Patient Communication Preferences and Conversation Strategies|
|Type||Preferences and Tendencies||Immunization Conversation Strategies||Example Patient Tools/Resource|
|Thinkers||Prefer numbers, graphs, and expert opinions
Tend to make quick rational decisions
|Handouts with statistics about the disease burden and impact of vaccination
Share statistics, ACIP recommendations, and CDC guidance
|Vaccine Preventable Disease e-book PDF created for online viewing of information about 16 vaccine-preventable diseases. From Every Child by Two|
|Planners||Prefer organized information
Tend to need time to process, analyze, and reflect
|Anticipatory guidance about vaccines needed at the next visit, allowing time to process
Share ACIP schedule and CDC and MMWR website
|Well Visit Tracker
2-page document for parent/guardian to record a child’s immunizations, developmental milestones, and growth at each well-child visit.
|Dreamers||Prefer big picture ideas, risk taking
Tend to respond well to creative examples and metaphors
|Share the constant innovation and development of new and better vaccine coverage
Use metaphors and analogies to explain (see http://www.metamia.com/analogize.php?q=vaccination for some examples)
|Parent’s Guide to ImmunizationThe booklet offers an overview of how vaccines work and how to prepare for a doctor’s visit.|
|Feelers||Prefer people-based stories and explanations
Tend to be concerned about impact on others
|Use stories of vaccine preventable disease outcomes to highlight decision and link decision to family/community impact
Share recent outbreak stories and the impact on the community
|Diseases and the Vaccines That Prevent ThemFacts and true stories about the different diseases that childhood and adolescent vaccines help prevent; many available in Spanish as well as English.For Parents of Infants and Young Children (Birth through Age 6)For Parents of Preteens and Teens (7 through 18 years old)|
Dust Off Your Motivational Interviewing Skills
Motivational Interviewing is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.
Using active listening as a base, your role is to reflect back to your patient what you are hearing in an attempt to guide them to reach a conclusion about their decision. For example if you encountered a patient who was hesitating about receiving a particular vaccine, open the discussion by asking permission to discuss it further: “You are due for the following immunizations today, but I heard you declined them from the nurse, do you mind if we talk about it more today?” Then engage the patient in a change conversation by eliciting more information such as “What do you think will happen if you get the vaccine?” or “What do you think will happen if you get X disease?”
Continue the discussion using your reflective listening skills by summarizing what you heard using statements like, “So correct me if I’m wrong, but you are worried the vaccine will make your arm sore and you might feel sick, but you are unsure what happens when someone gets X disease?” Provide clarifying information in a nonjudgmental way. “Would you mind if I provided you more information about X disease so you have all the facts before you decide not to get the vaccine?”
Normalize the patient’s concerns by helping her or him understand that many of your patients share similar concerns and why you continue to believe it is a good idea to take the vaccine. “Many of my patients are concerned about the safety of vaccines and whether they are more likely to get sick from the shot that the actual disease. I understand their concern because many vaccine preventable diseases are less common now that we use vaccines regularly.”
Combining affirmative statements with advice can be an effective approach. For example, “I am glad you took the time to research the vaccine before your visit today. Being well informed about your health is very important. I recommend patients use these sources of information when making vaccine decisions.”
Finally, gauge where the patient is in the change process by using the readiness ruler. “On a scale of 0 to 10 where 10 is ready to get the vaccine today and 0 is I’m never going to get the vaccine, where are you?” For patients at a 0 or 1, your time may be better spent on other preventive health measures though you may provide them with additional information about things to consider when choosing not to vaccinate. A good handout is available from the CDC titled “If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities.” For ambivalent patients, provide them with additional information to consider before your next visit, and let them know you can talk about it more then.
For additional details about the motivational interviewing techniques, a good resource is available from Sobel and Sobel (2008): http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf.
Prepare Yourself with Responses to Common Questions
Anticipate that patients will have questions about immunizations and be prepared to answer them honestly. Common questions typically include which immunizations are being recommended, what side effects should be expected, and are the vaccines safe. Having resources available at your fingertips will make those conversations flow easier. Keep a laminated copy of easy to read child and adult vaccine schedules in your exam room. Use the Vaccine Information Statements (VIS) to review common side effects. Some practices place a set of laminated VIS in each exam room for the provider discussion and then they print out the specific ones for the day for patients to take home. Finally, use the CDC’s Understanding Vaccines and Vaccine Safety handouts to provide specific information about the safety of the vaccines, what the Advisory Committee on Immunization Practice (ACIP) is, how the Vaccine Adverse Event Reporting System (VAERS) works, and more.
Putting It All Together
Plan ahead by making your own go-to immunization conversation exam room kit. Kick off the conversation by giving your strong recommendation for the vaccines due today. Gauge your patient’s reaction and engage in a dialogue using his or her preferred communication style and leveraging your motivational interviewing skills to help your patient resolve any ambivalence. If you can’t get the patient to budge today—it’s okay! Document your progress and pick up where you left off at the next visit!
- Talking With Parents About Vaccines for Infants: http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/talk-infants-color-office.pdf
- Savoy ML, Yunyongying P. Getting through to your patients. Fam Pract Manag 2013 Nov-Dec;20(6):36. (Available at http://www.aafp.org/fpm/2013/1100/p36.html)
- Standards for Practice: Vaccine Recommendation: http://www.cdc.gov/vaccines/hcp/patient-ed/adults/for-practice/standards/recommend.html
- Provider Resources for Vaccine Conversations With Parents: http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/
- CDC Provider Resource Page: http://www.cdc.gov/vaccines/hcp.htm
I would include: “experiencers” in your groups to influence. Those of us hospitalized in 1976 due to severe side-effects to H1N1 vaccination (forced on us when in the Coast Guard) are a hard sell.
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