Talking with hesitant parents and carers about COVID-19 vaccines and their children

This article expands on a podcast conversation recorded on October 2021, between NPS MedicineWise medical advisor Dr Caroline West and internationally recognised expert in vaccination uptake Professor Julie Leask. It outlines strategies to help manage conversations with vaccine-hesitant parents and carers in the face of time-limited consultations and continually changing information.

Talking with hesitant parents and carers about COVID-19 vaccines and their children

After a bumpy start, Australian COVID-19 vaccination rates are high. As of mid-December 2021, 89.7% of Australians over the age of 16 years have received at least two doses (currently considered fully vaccinated) of an approved COVID-19 vaccine.

General practice healthcare providers have been pivotal in achieving this high vaccination rate. Of the 24 million doses administered so far in Commonwealth facilities, more than 20 million have been in general practice.1

This has not been an easy task. To make an impact, general practitioners (GPs) need to stay up to date on changes to the vaccine rollout, of which there have been many.

“I think a lot of GPs are actually quite fatigued with COVID-19 messaging, and you just think you’re on top of it and the information changes,” says NPS MedicineWise medical advisor Dr Caroline West.2

In recent months, the focus of COVID-19 vaccinations has shifted to those who are aged 16 years and younger. This means that conversations about vaccine hesitancy are increasingly parent or carer facing.

Conversations with vaccine-hesitant patients have added an additional layer of stress to the demanding workload of GPs. These conversations can be emotional, and providing an adequate response can extend a consultation outside its allocated timeframe.

Difficult as they can sometimes be; these discussions make a difference. University of Melbourne research found that 29% of Australians who are COVID-19 vaccine hesitant – or not willing to get vaccinated at all – are more likely to be persuaded by health professionals to have the vaccine. This is compared with 10% who may be influenced by community leaders, and 8% by celebrities.3

 

Vaccines: a parent's perspective

Parents who are vaccinated against COVID-19 are more likely to vaccinate their children, but this acceptance cannot be assumed. A recent Melbourne Institute survey reported that 26% of parents with children aged 5–12 years – who were themselves not hesitant in receiving a COVID-19 vaccine – were unsure or unwilling to vaccinate their children against COVID-19.4

Parents think about health risks differently when it comes to their children. Speaking on the NPS MedicineWise podcast Talking to parents about the COVID vaccine, Professor Julie Leask said it’s not uncommon for people to worry about their children’s health more than their own.2

“There is a lot of concern out there among parents that, as we open up in Australia, in particular the states that have a lot of COVID, that kids will be vulnerable to getting COVID. That whatever the risk... no matter how small, ... that risk is unacceptable because of the way we value children in society.”2

In contrast, evidence suggests that complications associated with COVID-19 infection seem to be less prevalent and less severe in children than in adults. Some parents might be concerned that the perceived risk of vaccine side effects is greater than the health risks associated with a COVID-19 infection – thus leading to hesitancy.

Where possible, encourage parents to see the larger picture. Vaccinating those in the 5–16-year-old age group can help decrease the likelihood of children having a severe COVID-19 infection, as well as provide a layer of protection for grandparents, other carers and those from more vulnerable cohorts.

“Very few children will go to ICU, and even fewer will die from COVID. However, we know that having outbreaks of COVID in schools represents a significant disruption. We know also that there are some children with chronic diseases who are at greater risk of the severe effects of COVID if they get it and they need to be protected. There’s both those direct and those indirect benefits of vaccinating the kids.”

Professor Julie Leask NPS MedicineWise podcast Episode 33.2

 

Make the best use of your time

Some parents are hesitant about vaccinating their children because they are anxious, while others are going to decline the COVID-19 vaccine because they are certain in their beliefs.

To make the best use of your consultation time, try and identify which category of parent you are speaking to. There are no hard-and-fast rules, but the table below might help.

Vaccine-hesitant parents:

Declining parents may:

  • have questions or concerns about vaccine safety
  • may come with lots of written questions
  • are not intending to decline vaccination altogether but have come with plans to vaccinate, delay vaccination or select out vaccines
  • may have had a bad experience, such as an adverse event following immunisation, or a birth trauma; their trust may be diminished
  • may have heard or read something frightening
  • may feel a strong sense of responsibility around making the ‘right’ decision
  • want their child treated individually
  • differ from parents who intend to decline vaccinations altogether.5
  • not want to discuss vaccination at all
  • present for other reasons or medical exemption
  • believe that COVID-19 and other vaccine preventable diseases are benign or beneficial
  • distrust ‘big pharma’ and conventional medicine
  • be more likely to seek complementary and alternative medicine
  • have had a bad experience, such as an adverse event following immunisation, or a birth trauma, and be intent on getting the ‘right’ information
  • have alternative lifestyle approaches and feel that conventional medical treatments do not align with their personal values
  • have a general sense of vigilance and a sense of responsibility around making the ‘right’ decision.5

It is worth exploring if the parent or child may have a needle phobia. The Melbourne Vaccine Information Centre has some advice and resources for parents of these children on their website.

 

Working with vaccine-hesitant parents

When working with vaccine-hesitant parents, it’s important to involve them in the decision-making process. Parents who are vaccine hesitant tend to value their sense of agency.

These conversations take time, but can lead to a change of behaviour.5

Research has shown that approaching the discussion with the following in mind can be effective:

Lean into the risk

When a parent or carer is concerned about vaccine safety, your instinct may be to reassure them and say there is a no need to worry, but validating a parent’s concern shows that you are willing to explore their questions without judgement.

“If someone signals somehow that they’re very hesitant and unsure about having a vaccine – any vaccine – then asking them a few questions and eliciting their questions and concerns to saturation is more likely to be effective, because you’re more likely to cover all the things that they might have on their agenda.”

Professor Julie Leask NPS MedicineWise podcast Episode 33.2

Set the agenda

Find out what the parent or carer’s questions are. Continue to prompt until you are confident they have asked all their questions. As an example, Professor Julie Leask suggests asking, “Do you have some other questions? ...You’ve said so far, ‘you’ve got this one and that one’. Do you have any more?”2

Once you have heard the questions in their entirety, draw out the predominant concern and summarise the conversation back to them, outlining the agenda for the consultation. Professor Julie Leask suggests saying something like, “It sounds like your biggest concern is about [insert issue eg, the mRNA, the spike protein]. Let’s focus on that and, if we have time, we’ll get to your other two concerns. How does that sound?”2

The question at the end is important because you are asking permission and collaboratively setting the agenda as a discussion, not a lecture. It also helps to plan your appointment timekeeping and will help prevent veering into less-important concerns.

Read the FAQs about children and COVID-19 from the National Centre for Immunisation Research and Surveillance. 

Communication 101

As you start answering questions, keep an open and approachable style of communication. Parents who hesitate or decline to vaccinate their children respond better to a guiding style of communication, rather than a didactic style. This should be used to develop a relationship with the individual based on empathy, which will allow you to assess them as the conversation progresses.6

Acknowledge but don’t argue with the worries of the parent. Treat each concern as valid throughout your consultation. Acknowledging does not mean agreeing, but shows you’re not dismissing their fears and concerns. This will set up a precedent, where the parent will hopefully listen to you in turn.5

“Once the agenda setting’s happened, then it’s that communication 101 – it’s listening reflectively, acknowledging when people have sent out emotional cues – because if they feel like their emotions are acknowledged it can be easier for them to then subsequently process what you have to say to them afterwards.”

Professor Julie Leask NPS MedicineWise podcast Episode 33.2

If you have a good relationship with the parent or carer, it may help to speak about your own experience receiving the COVID-19 vaccine or taking your child for their COVID-19 vaccine.

Motivational interviewing skills – similar to the techniques you might employ during smoking cessation counselling – may also be helpful to explain the individual benefits of vaccinating their child. These benefits could include protecting a vulnerable relative, or reducing time in self-isolation if they are deemed to be a close contact of someone with COVID-19.

Pivot vaccine risks raised by the parent into vaccine benefits – even though there are risks with COVID-19 vaccines; the risks associated with a COVID-19 infection are higher.2

The closer

Once you have addressed the concerns of a vaccine-hesitant parent, summarise your argument and reiterate any motivational factors that could increase the likelihood of their child receiving a COVID-19 vaccine.

The Sharing Knowledge About Immunisation (SKAI) website recommends using presumptive communication. This approach means you assume that the vaccine-hesitant parent is satisfied with your responses to their concerns. For example, you could say, “Now that you’ve heard why it’s important for [insert child’s name] to be vaccinated against COVID-19, should we make an appointment for them next week?”5

Research suggests that presumptive language is more effective than conversational language. A US study found that 74% of parents accepted their health provider’s recommendation when presumptive language was used, while only 4% accepted the recommendation when the health provider used conversational language.7

Professor Julia Leask believes that some vaccine-hesitant parents reach a point where they almost want the clinician to make the decision for them. In such situations the conversation could be framed as, “You’re clearly torn about this, but I’d love to see [insert child’s name] vaccinated today. Would you be willing to do that?”

She notes that the ‘would you be willing?’ question is important because it reinforces that the parent has agency. It’s a decision they are making, and they are in charge of.2

THE 5 Cs of vaccine hesitancy

Vaccine hesitancy has existed long before COVID-19. Researchers have found that, in high-income countries, people are concerned about vaccines for the following reasons:8,9

  • Confidence: a patient does not trust vaccine efficacy and safety, the motives of the health services offering them, and the policymakers who plan the rollout.
  • Complacency: a patient believes that the disease itself is not a risk to their health.
  • Calculation (risk): a patient has weighed up their own research and concluded that the risks of the vaccine are higher than the benefits.
  • Constraints (or convenience): the vaccine may be difficult to get due to time constraints, or costs.
  • Collective responsibility: the patient may not understand or be willing to protect others from infection, by getting themselves or their child vaccinated.
 

What not to do

Here are some points to be wary of:

  • Do not use a one-size-fits-all approach. Vaccine-hesitant parents are a diverse group: some have children who are needle phobic, others are fearful, and some have experienced medical trauma. Try to take the parent’s experience and background into account during your consultation.
  • Do not make any guarantees about safety: acknowledge that there are risks and limitations to science.
  • Do not correct a patient/parent when they are listing their concerns. Fact-checking might be reflexive, but it will set up a combative environment rather than a collaborative discussion. Instead, wait until the patient has finished naming their concerns and address each one in the order of priority that you establish in your agenda.5
  • Do not argue with a parent’s belief outright. Not only is the back-and-forth counter-productive, you also run the risk of pushing the person, who may already feel stigmatised, to disengage with primary care.10
 

Vaccine decliners

When discussing vaccines with parents who are likely to decline them, it’s best to keep the conversation short. Rather than change behaviour, your goal is to encourage trust and engagement with primary care services.

The SKAI website notes, “Declining parents have made their decisions and will resist attempts to persuade them to vaccinate their children. Engaging them in debate about the validity of their beliefs can result in extended, unproductive consultations and should be avoided; it can increase their risk of disengaging from the healthcare system altogether.”10

Parents who are likely to decline the COVID-19 vaccine for their children will probably be seeing you for another health-related concern. If you are going to raise the vaccine conversation, ask for permission to discuss vaccines first to ensure that it is a patient-led conversation, eg, “I’ve noticed that your family has not had the COVID-19 vaccine. Can we discuss this?”

If the parent has agreed to discuss the COVID-19 vaccine with you, use open-ended questions to set the tone for a collaborative discussion. For example ask, “Can you tell me what led to your decision?”

SKAI recommends acknowledging the patient’s beliefs. This is different to agreeing with them. After they have given the reasons behind their decision you could say, “I can see you have done a lot of thinking”. Consider exploring possible reasons that might prompt or encourage them to reconsider, such as travelling overseas to see family or access to certain venues that require a parent to be vaccinated.

After explaining how the COVID-19 vaccine is ultimately beneficial to the child, ask if you could revisit this conversation at a later date. This is an opportunity to give the parent resources that address the reasoning behind the vaccine status. Keep the conversation short then pivot to address the original reason for the visit. This reassures the person that the practice is a safe, non-judgemental space.10

 

Vaccine hesitancy and cultural beliefs

Cultural beliefs add another layer of complexity to vaccine hesitancy. Globally, there are geographical patterns in low vaccine uptakes. Former communist countries, for example, have high rates of vaccine scepticism because of endemic government distrust.11

In Australia, some culturally and linguistically diverse (CALD) communities have been reading false claims about vaccine side effects on Facebook, while others have been confused by conflicting public messaging, especially the communication accompanying changes to the Vaxzevria (AstraZeneca) rollout and the accompanying translated resources in their native language.12

If you know in advance that English is not your patient’s first language, you could organise an interpreter from Translating and Interpreting Services.

There have also been reports of low vaccination rates in Aboriginal and Torres Strait Islander communities due to misinformation.13 The National Aboriginal Community Controlled Health Organisation has fact-based COVID-19 vaccine resources on their website, including general information as well as fact-busting resources.

COVID-19 resources for CALD communities

 

Resources to address vaccine hesitancy

Department of Health

National Centre for Immunisation Research and Surveillance

Videos

  • The University of Melbourne: VaxFacts videos provide straightforward answers to frequently asked questions

Podcasts

 

References

  1. Australian Government Department of Health. COVID-19 vaccine rollout update – 30 November 2021. Canberra: Commonwealth of Australia (accessed 30 November 2021).
  2. NPS MedicineWise Podcast. Episode 33. Talking to parents about the COVID vaccine. Sydney: NPS MedicineWise, 2021 (accessed 15 November 2021).
  3. Jun D, Scott A. So you don’t want the COVID-19 vaccine? Here’s what research shows will change your mind. Melbourne: University of Melbourne, 2021 June 2021 (accessed 10 November 2021).
  4. Denby C. Survey of the Impact of COVID-19 in Australia. Melbourne: Melbourne Institute, 2021 (accessed 15 December 2021).
  5. Sharing Knowledge About Immunisation. Talking with parents who have questions. Talking about immunisation. Evidence-based support for conversations with parents who have questions about immunisation. Sydney: National Centre for Immunisation Research and Surveillance (NCIRS), 2021 (accessed 15 November 2021).
  6. Nolan T, Danchin M. A positive approach to parents with concerns about vaccination for the family physician. Aust Fam Physician 2014;43:690-4
  7. Jacobson RM, St Sauver JL, Griffin JM, et al. How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation. Hum Vaccin Immunother 2020;16:2131-5.
  8. Machingaidze S, Wiysonge CS. Understanding COVID-19 vaccine hesitancy. Nat Med 2021;27:1338-9.
  9. Robson D. Why some people don't want a Covid-19 vaccine. London: BBC Future, 2021 (accessed 22 December 2021).
  10. Sharing Knowledge About Immunisation. Talking with parents who are declining. Sydney: National Centre for Immunisation Research and Surveillance (NCIRS), 2021 (accessed 22 December 2021).
  11. Ghodsee K, Orenstein M. Why won't Eastern Europeans get vaccinated? New York: Project Syndicate, 2021 (accessed 22 December 2021).
  12. SBS News. 'Big wake-up call': Authorities urged to tackle COVID-19 vaccine misinformation in diverse communities. 2021 (accessed 22 December 2021).
  13. The Guardian. ‘Tinfoil hat wearing tossers’: NT chief minister and Aboriginal elders hit back at Covid ‘false information’. 2021 (accessed 22 December 2021).