Leask et al. BMC Pediatrics 2012, 12:154
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CORRESPONDENCE

Open AccessCommunicating with parents about vaccination: aframework for health professionals
Julie Leask1*, Paul Kinnersley2, Cath Jackson3, Francine Cheater4, Helen Bedford5 and Greg Rowles6

Abstract
Background: A critical factor shaping parental attitudes to vaccination is the parent’s interactions with healthprofessionals. An effective interaction can address the concerns of vaccine supportive parents and motivate ahesitant parent towards vaccine acceptance. Poor communication can contribute to rejection of vaccinations or
dissatisfaction with care. We sought to provide a framework for health professionals when communicating withparents about vaccination.
Methods: Literature review to identify a spectrum of parent attitudes or ‘positions’ on childhood vaccination withestimates of the proportion of each group based on population studies. Development of a framework related toeach parental position 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 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%).
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 hesitant, late or selective vaccinators, or refusers, strategies should include use of a guiding style andeliciting 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 positions on vaccination andprovide a structured approach to assist professionals. They advocate respectful interactions that aim to guideparents towards quality decisions.

BackgroundThe 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 tosocioeconomic 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 suchas a lack of transport or childcare [2,3]. The second factor,* Correspondence: Julie.Leask@sydney.edu.au
1
School of Public Health, and Discipline of Paediatrics and Child Health
University of Sydney and National Centre for Immunisation Research andSurveillance, The Children’s Hospital at Westmead, Sydney, Australia
Full list of author information is available at the end of the article

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 theconcerns of vaccine supportive parents and motivate ahesitant parent towards vaccine acceptance [5,6]. Conversely, poor communication can contribute to rejectionof vaccinations or dissatisfaction with care [7-9]. Suchpoor communication often results from a belief by thehealth professional that vaccine refusal arises from ignorance which can simply be addressed by persuadingor providing more information. Such an approach iscounter-productive because it fails to account for thecomplexity of reasons underpinning vaccine refusal and© 2012 Leask et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

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may even result in a backfire effect [10]. Parental vaccination decisions are based on an array of factors and parents
integrate information according to their experiential andsocial contexts [11,12]. A parent’s trust in the source of
information may be more important than what is in theinformation [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 thesehave focused on what is said, that is, the informationthat 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 oncommunication processes that build rapport and trust
between the health professional and the parent [25-27].
We propose here a framework to guide health professionals in communicating with parents about vaccination. By focusing on both what is said and how it issaid, we attempt to provide an integrated, generic approach going beyond simply the one-way provision of
information.
The framework is informed by evidence from decision
making and communication research and is applicablefor 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 andsuggest specific communication strategies tailored toeach position. The overarching goal of the encounter isto promote quality decisions and, ultimately, vaccination.
Development of the framework

Page 2 of 11e) encourage uptake of recommended vaccines.
There were four stages in developing the framework: aliterature review, classifying parental positions on vaccination, matching strategies to these positions andassessing 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 andbehaviours 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 theparental positions on vaccination. These are described inTable 1 [28-30]. We found nine papers advising healthprofessionals on communicating with patients about
vaccination but none that tailored communication toempirically derived parental positions [17-21,31-34].
Stage 2: Identifying parental positions on vaccination

We reviewed the classifications presented within thethree identified studies, [28-30] summarised parental
positions from each study, and discussed their relevanceto 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 [4,28,35-44].

The framework was developed to:Stage 3: Matching strategies to parental positionsa) be acceptable to health professionalsb) increase health professional and parent satisfaction
with discussions about vaccinationc) increase a health professional’s self-efficacy (sense ofconfidence and competence) in relation tocommunicating about vaccinationd) increase the likelihood of the parent making adecision based on evidence (by increasing access toquality information)

For each parental position, we proposed an overall communication approach then more specific guidance tailored to each parental position (Tables 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 professionaland educational experience; valid consent principles, [50]and those of motivational interviewing which uses a guiding style to promote healthy behaviours [51].

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Table 1 Summary of studies identifying parental positions on vaccination
Study

Setting/sample

MethodResults

Gust et al.,
2005[28]

US population-based sample
of 584 parents with at least
one child aged 6 years andunder (The ConsumerStyles
and HealthStyles surveys 2002)

Telephone administered questionnaire.

3.9% reported that child had not had allrecommended immunisations.

Downs et al.,
2007[30]30 US parents of children aged
18–23 months, recruited fromthree cities with diverse sociodemographic profiles andvaccination attitudes

44 questions about beliefs and attitudes
towards vaccination, influence of family
and friends on vaccination decisions anddependence on doctor’s advice. K-meanscluster ANOVA analysis to group like responses.
Mixed methods ‘mental models’ interviews
conducted by telephone. Open and closed
ended questions were designed to identify
predominating cognitive pathways indecision making about vaccination.

Five attitudinal categories:‘immunisation advocate’ (33%); ‘go along
to get along’ (26%); ‘health advocate’ (25%);‘fence sitter’ (13%); and ‘worried’ (2.6%).
Two main decision making types althoughviews were overlapping:‘health oriented’ (n = 16) trusted anecdotal
communication more than statisticalarguments;‘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 telephonewhen baby was 3–6 months old todetermine attitudes towards vaccinating;risks and benefits of vaccination; andrequirements for, and sources of, information.
Respondents categorised into groups, basedon behaviours and attitudes.

Stage 4: Seeking feedback from health professionals

To assess general acceptability of the framework andrecommendations, 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 medianscore for usefulness of 8.8 (range 3–10); 74% rated theframework 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 framework. All feedback wasused to inform revisions of the recommendations.
The framework
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 toensure that parental consent for vaccination is valid.
This requires more than simply giving information andis 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 andTwo main categories – Vaccinators (n = 25)
with sub-categories: ‘acceptors’ (n = 20) and‘vaccine hesitant’ (n = 5).
Non-vaccinators (n = 8) with subcategories:‘late (or partial) vaccinators’ (n = 3) and‘rejectors’ (n = 5) who refused all vaccines.

parent; listened to, accepted and addressed their concerns;
possesses the necessary scientific information; and uses awhole-person approach that is not patronising but treats
parents and their children as individuals [29]. Table 3 lists
unhelpful and helpful approaches to communication withall parents.
Health professionals’ body language ideally indicatesthat the discussions are important and distractions, suchas using computers while talking, are best avoided. They
need to speedily establish rapport and clarify parental concerns, avoiding the temptation to minimise or dismissthese (“Oh there’s nothing to worry about, vaccination isvery safe nowadays”) [27,53]. Instead it is important tofully understand parents’ concerns and motivations using
open questions and empathic responses [27]. Althoughhealth 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 Tables 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’sunderstanding. This technique contrasts with the common practice of providing much larger amounts of information before checking, which can lead to information
overload.

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Table 2 Parental positions on vaccination according to attitudes and behaviours
Unquestioning acceptor 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
advocates’ 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 tohave less detailed knowledge about vaccination [29,30].

Cautious acceptor 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 acceptors’ were drawn from Benin’s
category of ‘vaccination acceptors’ [29].

The hesitant 20–30%

These parents vaccinate their child but have significant concerns [29]. In Gust’s study, they mostclosely correspond to the ‘fence-sitter’ who only slightly agrees about the benefits and safety ofvaccination and is neutral about their relationship and trust with their healthcare provider [28].
Hesitants 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 areanswered satisfactorily and completely by knowledgeable health professionals with relevant
information [29].

Late or selective vaccinator 2–27%

Concerns about vaccination result in this group choosing to delay or select only somerecommended 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 aresimilar to the vaccine hesitant 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 hesitant 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 ofalienation and disenchantment and they tend to prefer the advice of alternative healthprofessionals [29,41]. Respondents in Benin’s study indicated a desire for a doctor with whomthey 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 othergroups except ‘acceptors’ [29]. These parents tend to cluster in communities who share certain
religious, philosophical or alternative beliefs [47].

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 canbe 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 aparents’ MMR pre-vaccination invitation letter as an appropriate way to support parents coming to the consultation [61]. Written resources may be available inelectronic/online or paper format. These vary widely between countries and clinicians should be familiar withhow 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

Table 3 Unhelpful and helpful strategies for addressing parental concerns about vaccination
Unhelpful

Helpful [51]Directing style – “this is what you should do”

Guiding style – “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

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Table 4 Parental position, with the recommendations for each group
Parental position

Key indicators

Goal

Strategies*
See also Table 3

Unquestioning
acceptor

Present for vaccination
when it is dueChild vaccinated and parent
positive about decision

Build rapport

Cautious
acceptor

Child is fully vaccinatedto dateAccept questions and concerns
Use verbal and numerical descriptions ofvaccine and disease risks
Explain common side effects and rare,important risks
Aim to keep discussion brief but flexibly
addressing parent’s needs

The hesitant

Present on time or slightly lateChild vaccinated and parent
accepts decision

Use guiding style

Late or selective
vaccinatorChild is fully or partially
vaccinatedThis group may need most time
but are most likely to change
behaviour

Provide risk and benefit information(as above)

Present lateChild is partially vaccinatedRefuser

Use decision aids and other quality
information tools
Book another appointment to re-visit
discussion

Present for another reason.
Subject of vaccination may
have to be raised by healthprofessional.

Parent prepared to think about
vaccination and attend clinic
for further discussion

Avoid scientific ‘ping pong’ – debatingback and forth about vaccination.

Child is partially or completely
unvaccinatedFeels concerns heard and notcritical of providers

Ask about importance of protecting childagainst 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].

(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 consistentdenominator should be used when presenting event rates
for comparison [65]. Visual representations of probability
have also been recommended and are commonly used indecision 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 toseek help if they have further concerns [66].
A tailored approach

Evidence from other areas of healthcare practice suggests
adapting the principles of motivational interviewing. Thisis a form of communication that uses a guiding style, rather than a directing style, for discussions where there isambivalence 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 thisparticular context, the ambivalence and resistance tochange relates to whether or not a parent should havetheir 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 Model [68]. Thisis a framework for understanding the process of behaviourchange 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

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Table 5 Example of dialogue with the unquestioning or cautious acceptor 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 sharewith 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* – allserious 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 aftersome comforting and 90% don’t have any other side effects at all (positive framing ofrisk using percentages). If there is a problem, the commonest thing is a slightly sorearm that will last for a few days and then settles (pause to allow questions orclarification – chunking and checking).

Mother:OK – anything else?

Health professional:

One of the vaccines contains a small amount of weakened measles, mumps andrubella viruses which stimulate Lily’s immune system to respond and develop
protection to these infections. That means she may have some mild symptoms ofmeasles, 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 formof 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 thatsound? (structured information using chunks and checks and unbiased expectation of consent)

Mother:Fine, yeah, that’s OK.

* Based on UK vaccination schedule in 2011 [55].

if successful, leads to maintenance of that behaviour, thefifth 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 acceptors). Somewill 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 ahealth professional [5]. ‘Vaccine refusers’ are usuallyin the pre-contemplation stage where they are notconsidering 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 andcons 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 acceptors, hesitant, andrefusing parents. For late or selective vaccinators, strategies can apply from those suggested for hesitant andrefusing 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 orconcerns 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]. Specificallyparents reported that the prompt sheet enabled them tofeel confident in ‘raising the issue of MMR’ with their
GP or nurse.
The goals for the consultation will vary according to theparent’s position. Health professionals should avoid a mismatch between the parent’s expectations and needs andtheir own assumptions. For example, a ‘hesitant’ father
may be planning only to obtain information but feels he isbeing pressured to vaccinate. The cost may be loss of histrust 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

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Table 6 Example of dialogue with the hesitant 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 structuringof explanation). You’re right that the injection has got five ingredients which would protect Robbie from thediseases 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 toprotect the body. Babies’ immune systems can handle this, and the vaccines these days are so refined thatbabies can easily cope with several vaccines in one go. (chunk of information provided followed by pause formother 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 theygenerally settle really quickly with a cuddle and some comforting words from mum (empowering). It’s truethat 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 themback 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.

rather than finding out patients’ concerns or points ofview. 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 scheduleand may be willing to hear how to recognise and respondearly to signs that their child may have a vaccinepreventable 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 ofvaccines. This could lead to a decline in vaccination uptake rates to a level which allows the diseases to reemerge 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 needsof 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 tochildren, their safety, composition and necessity.
Since interactions with health professionals provide a
focal point for parents’ concerns to be expressed, it isimportant that communication during these interactions
is effective [26]. The parental positions described in thispaper act as a starting point for health professionals tochoose the most appropriate communication strategy.
Naturally these will vary according to the parent’s individual needs and circumstances.
The literature review informing the parental positions
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], wesought to identify only studies that would provide aspectrum of attitudinal positions that would theoreticallyaccount for all parents.

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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 style)

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 witha 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 andsome 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 liketo 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 tofurther discussion)

Mother:OK thanks.

However, the spectrum described does simplify what isoften 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 achild’s health, personal experiences, perceived norms,
and trust in health systems and professionals [12,29,76].
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 groupare estimates from population-based surveys and willvary 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 muchhigher 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 andstrategies.
We have proposed an approach to communicationthat encourages questions and employs a guiding rather
than directing style. The reality of busy clinical environments can act as a disincentive for health professionals
to actively seek out questions and concerns [54]. However, the framework 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 specificconcerns of the parent. In interactions with vaccinerefusing parents, some health professionals attempt tochange the parent’s mind [70]. As this goal is usually

Leask et al. BMC Pediatrics 2012, 12:154
http://www.biomedcentral.com/1471-2431/12/154

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 havedescribed a framework for talking with parents about
vaccination. It is informed by evidence and acceptable tothe health professionals involved in the formative evaluation sessions, but now needs to be more fully evaluated.
This may involve group or individual training of healthprofessionals who undergo assessment using standardised patients and validated scales that measure qualityof communication [78]. To measure effectiveness of theframework 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 measuresneeded to maintain high uptake of child vaccines. Strategies must also continue to address barriers such as accessto 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 anyorganisation for the submitted work; no financial relationships with anyorganisations that might have an interest in the submitted work in theprevious three years, no other relationships or activities that could appear tohave influenced the submitted work.
Authors’ contributions
JL and PK had the idea for the article, CJ and FC performed the literaturesearch, JL, PK, CJ, FC, HB and GR developed the framework and wrote thearticle. JL is the guarantor. All authors read and approved the final
manuscript.
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 theframework. We also thank Lynne Sturm and Nick Sevdalis for theirconstructive suggestions as peer reviewers. NCIRS is supported by theAustralian 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.
Author details
1
School of Public Health, and Discipline of Paediatrics and Child Health
University of Sydney and National Centre for Immunisation Research andSurveillance, The Children’s Hospital at Westmead, Sydney, Australia.
2
Institute of Primary Care and Public Health, Cardiff University, 3rd floor,
Neuadd Meirionydd, Heath Park, Cardiff CF14 4XN, UK. 3York Trials Unit,
Department of Health Sciences, University of York, York YO10 5DD, UK.
4
Institute for Applied Health Research, Associate Dean (Research) School ofPage 9 of 11

Health and Life Sciences, Buchanan House, Glasgow Caledonian University,
Glasgow G4 OBA, UK. 5Centre for Paediatric Epidemiology and Biostatistics,
UCL Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK.
6
Greg Rowles, General practitioner, 9 Station St, Riddells Creek, VIC 3431,
Australia.
Received: 14 March 2012 Accepted: 4 September 2012
Published: 21 September 2012
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doi:10.1186/1471-2431-12-154
Cite this article as: Leask et al.: Communicating with parents about
vaccination: a framework for health professionals. BMC Pediatrics 201212:154.

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