Sharing Knowledge about Immunisation (SKAI): An Exploration of Parents' Communication Needs to Inform Development of a Clinical Communication Support Intervention

"Regardless of their attitude to immunisation,...participants wanted to be involved in decisions about vaccinating their children."

Physicians' communication behaviours have been shown to influence parents' acceptance of vaccinations, which suggests primary health providers are well placed to address vaccine hesitancy by focusing consultations on building rapport, supporting the cognitive and emotional aspects of decision making, and/or addressing socio-cultural factors that may be fuelling parents' distrust. Australia's SKAI (Sharing Knowledge About Immunising) Project is developing a communication support system (the SKAI System) to improve communication during primary health care consultations about routine childhood vaccinations. This study aimed to explore the communication needs of Australian parents in order to guide iterative development of the information and decision support tools included in the SKAI System.

The SKAI System is informed by J. Leask et al.'s Vaccination Communication Framework and is based on an established approach to clinical assessment and care known as "triage and treat". This approach involves assessing parents for vaccination concerns early in the consultation and selecting information and communication strategies tailored to address their concerns and meet their communication needs. It includes a suite of printable resources (information and decision support tools - see Table 1 in the paper) for primary healthcare professionals to use with parents before, during, and after immunisation consultations.

More specifically, the SKAI System blends written information with modified clinical communication strategies and targeted application of providers' existing clinical communication skills to vaccination encounters. Design of the system is informed by evidence from communication science, motivational interviewing, and shared decision making. The content design drew on linguistic principles describing the conventions by which language is normally used to achieve social purposes beyond information exchange. It is informed by: an audit of existing vaccination communications; established debunking strategies; application of the principle of informed consent to childhood vaccination; established personal counselling techniques; and research identifying Australian parents' most common concerns about vaccination.

Conducted over a 3-week period during March and April 2016, focus groups were selected as the appropriate data collection strategy because geographical clustering of families who reject some or all vaccines for their children suggests vaccination behaviour may be at least partially socially determined. This strategy facilitates observation of the effects of social interaction on participants' responses. Thus, the unit of measurement is the group and not the individual (63 parents participated in 11 focus groups). To facilitate open discussion of parents' concerns about routine childhood vaccination, the researchers structured group composition according to parents' level of concern as described in the Vaccine Communication Framework. Focus group categories included: Unquestioning acceptors; Cautious acceptors; Hesitant or undecided; Delaying or selective; and Mixed.

First, they asked each group to describe experiences of clinical interactions with health professionals around childhood vaccination and their concerns about childhood vaccination. They then showed parents draft SKAI resources: the hesitancy assessment tool (see Appendix 1), consent information (see Appendix 2), and Q&A resources (see Appendix 3). The Hesitant and Delay/selective groups were also shown the decision support tool (see Appendix 4), the referral resource (see Appendix 5), and the anticipatory guidance (see Appendix 6). The researchers asked participants to discuss their understanding of the content, whether each resource adequately addressed their concerns, and whether it employed appropriate language and presentation that met their needs.

Two themes emerged with strength and consistency from the discussions; they guided iterative modification of the overall system and resources. First, parents across all groups reported wanting to participate in the decision to vaccinate their children. Second, parents in all the groups wanted to be able to access more information about childhood vaccination than was currently available to them, and they viewed their health professionals as trusted sources of credible information. Only 2 parents expressly disagreed. For them, vaccinating their children was not a decision but an accepted parenting practice. This divergence suggests that vaccination information provision should be tailored, to avoid sparking a deliberative process that could trigger some parents to reconsider presumptive acceptance of childhood vaccination.

Selected findings:

• With regard to the hesitancy assessment tool, the concept of being asked for their questions was welcomed in all the groups; parents wanted to feel welcome to ask questions during consultations. With the exception of some parents in the delay/selecting groups, parents in all of the groups were comfortable with being asked for their questions on an intake form or with an SMS (text messaging) appointment reminder prior to attending a clinic. Those parents who objected preferred to be asked by their provider during the consultation.
• Parents in most of the groups described gaps in existing consent processes for childhood vaccination, or encounters during which consent was never explicitly sought from them prior to vaccinating their child. Across the groups, parents wanted to be given consent information well in advance of the consultation. They wanted time to think about what they had read, and they expected to have questions in response to it.
• Responses given in all of the groups indicated that parents were seeking information about the everyday implications of each option (vaccinating/not vaccinating) to inform their decision, rather than looking for ways to understand or compare complicated numerical information about risks and benefits.
• The use of language that assumes parents will have questions seemed to alleviate concern that they would be judged by healthcare professionals for having concerns about vaccination.
• Parents perceived a level of transparency through having the opportunity to access to more detailed information about prevalence of vaccine preventable diseases and complications, signs and symptoms of these diseases, and safety and effectiveness of vaccines indicated transparency. Knowing that this information was available to them engendered trust, even amongst the more accepting parents who did not want to actually access it.
• The inclusion of a referral mechanism to a specialist immunisation service may prevent extended or adversarial consultations and protect therapeutic trust in primary health care providers.

Overall, the least hesitant parent groups reported feeling reassured upon reading resources designed to address commonly observed concerns about vaccination. As hesitancy of the group members increased, so did their accounts of the volume and detail of information they required. More hesitant groups displayed increased sensitivity and resistance to persuasive language forms.

The researchers are planning further research to investigate whether clinicians can use the SKAI System to structure and support consultations with concerned parents and to evaluate the feasibility of integrating the SKAI System into existing clinical workflows. In future, an appropriately designed trial may able to detect whether implementation of the SKAI System at scale in Australia could reduce the prevalence of parents declining or delaying one or more vaccinations for their children.