Episode 33: Talking to parents about the COVID vaccine

Dr. Caroline West

Hello and welcome. I'm Dr. Caroline West. I'm a GP and I'm the new NPS MedicineWise Medical Advisor. Today's podcast is brought to you by NPS MedicineWise and the National Center for Immunization Research and Surveillance.

Now, getting kids vaccinated for COVID is thought to be a community game changer, and in Australia, those over the age of 12 are now eligible for the Pfizer vaccine. The good news is that vaccine rates in general are nudging towards levels that will allow us to return to a new normal. Kids will be getting back to the classroom, seeing their friends again, and that will be a welcome relief. But for health professionals, there's still much to be done and many questions to be answered, especially from parents who may be hesitant. Just why is it important to vaccinate kids over 12? Is it safe? And how do we have conversations about all of this?

Joining me on the program today is Professor Julie Leask, who's at Sydney University School of Nursing and Midwifery, and she's an expert in immunization and an advisor to the World Health Organization.

Welcome, Julie. I know as a GP, there are still plenty of questions that we're all fielding out there about the COVID vaccine and the advice is constantly updated. Why, in particular, is it important to vaccinate kids from the age of 12 onwards?

Julie Leask:

There are a number of reasons that this is a good thing. I think, by and large, the risk for COVID among children is quite a bit lower than it is for adults. 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. I think also on that more sort of social and psychological level, 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 there, no matter how small, is an unacceptable risk because of the way we value children in society.

I think that's a relevant part of the whole notion of vaccinating children as well.

Dr. Caroline West:

Do you think that message is getting out there? That people understand that, sort of, proposition in a way?

Julie Leask:

Probably not so much. I think the nuance is often lost and certainly we've seen some of the rhetoric around risk for children sort of descend into a bit of a debate. Where you have one camp saying the risk for kids is totally unacceptable and it's worse than people portray it and here look at this data. Whilst others are saying, well, overall it is low. I think one thing that will happen is once we get quite a lot of COVID, which we will. Even though it might mean less in terms of hospitalization and death with more people vaccinated, if there is a lot of COVID circulating, then we will see COVID in children and even a small proportion of kids getting hospitalized. Even if it's a large population of children getting COVID will be less acceptable. We've had actually very, very rapid take-up of the vaccine in Australia for the 12 to 15 year olds in just a few weeks. I think we're just over 44% of kids have had a first dose and that is through the primary care system. It's not even through schools. That is an incredible achievement. When you think about how long it took to roll out the HPV vaccine, for example. Now, that doesn't mean that we'll easily reach 80%. There are always going to be these inequities in access to vaccination. But it's certainly a sign that there's a lot of motivation out there among parents to get the teenagers protected and also a lot of questions about when the younger children will be able to have the vaccine as well.

Dr. Caroline West:

Its fantastic to see it rolling out so quickly in that age group. I've worked a lot in the field as a GP and for the last 18 months I've been very COVID focused working in respiratory clinics and then actually rolling out the vaccine in remote areas. One of the things that parents have talked to me about is this whole question of, well, how safe is the vaccine? Given that early in the process it wasn't prioritized for younger people and they're sort of wondering what is the situation here? What do you say to those sorts of questions around discussing safety and risk?

Julie Leask:

Certainly in our research, particularly with parents who are hesitant about vaccines for their kids. Other vaccines, non COVID vaccines, we've found that leaning into that risk communication is a good thing. Often that's counter-intuitive. When someone's worried about risk you want to reflectively reassure them and say no need to worry, this is a low risk I really want your child to have this vaccine. But in fact, when people are quite hesitant, it can help them to have a discussion about what is known. Acknowledge where there is limitations and uncertainty in the science and then move on to a recommendation. That's about helping people cope with living with uncertainty and also living with trade-offs because the risks with the Pfizer vaccine, which is licensed for children in Australia, is very small. So we're looking at the usual sort of common side effects and systemic side effects then we're looking at the risk of myocarditis and pericarditis which, for the most part, are mild or going to be mild conditions for children if caused by the vaccine and quite rare as well. As I said, I certainly think that people understanding what the risk is, what the boundaries are, what the rate is and what to look out for is empowering information for those who think about risk. But also it's important to pivot to that notion of vaccine benefit and what you stand to gain through getting your child vaccinated. Caroline as a GP you're living this you're walking this talk. So I'm curious to know what your experiences have been too.

Dr. Caroline West:

It's really important to be very inclusive in how you discuss risk and safety. Certainly as you say, pivot it back to being a story about the benefits. The old school way of just telling people to get vaccinated is certainly past its use by date. I think that what I've observed is that parents in particular have got a range of information from lots of different sources. So they're trying to do their due diligence in a way and doing a bit of research by themselves. But they often arrive to see me with a bundle of very confused messages that they've received along the way. When I've been working in lots of different parts of Australia, a lot of their sort of local news and information will come via platforms like Facebook. It's often that they're having to sift through a lot of, sometimes, credible information backed up against stories that are very scary and misinformation. Off the back of that there's been some hesitancy that's been generated and so it's been a really tricky time. I think a lot of GPs are actually quite fatigued with COVID messaging and you just think you're on top of it and the information changes.

Julie Leask :

That's been a huge challenge, hasn't it? I'm curious to know, as well, what you do when somebody does turn up with, clearly when they turn up to a clinic appointment they're wrestling with the idea of vaccination. Certainly we know that, with our research, that can be challenging for GPs who are always time poor that these conversations can take a long time. That sense of this is going to blow my appointment times out and I've got a clinic full of people waiting. It must be quite difficult to manage that time limitation and also be effective with that conversation.

Dr. Caroline West:

What I've observed you need a lot of patience because you imagine often that it's just going to be one conversation that you're going to need with one person, but some people that are really wrestling with it might have multiple appointments around this. I had one person that came back three times for a sort of 25-30 minutes each consultation. That was what it took to, sort of, get them to that point where they were happy to go ahead with vaccination. So I think that there's a big time factor in here. I think that GPs, like myself, would be interested to hear from you about what are some of the tips that you'd have for effectively communicating and sort of using our time wisely and being able to, sort of, have those difficult conversations without us burning out from just the sheer volume of repetition.

Julie Leask:

So these are burning questions. I've been doing this kind of research for 24 years and a lot of the tips and processes that we've put together come from that clinical experience. So we were talking to GPs and nurses in particular, about how they manage conversations. In a sense we've tried to bottle the useful stuff and what we've learnt, and also listening to conversations between hesitant parents and clinicians in our research, is that agenda setting is quite important. Which is where you lay out the expectations about what's going to be covered in that conversation. 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. Once you do that, and it can be re relatively brief, it can be tell me what your questions are. Do you have some other questions? Do you have any more? You've said so far, 'you've got this one and that one,' do you have any more? That's the eliciting to saturation and then just briefly signaling what the agenda is. It sounds like your biggest concern is about 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? You're asking that permission and collaboratively setting that agenda, and that enables you to pace out the conversation and know how much time to proportion to each part of it. If you get lost down a rabbit hole on one topic because you have reflexively addressed a question or a bit of wrong thinking to start with, then you can end up losing the things that actually might be more important to that parent or patient.

Once the agenda settings 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. When you share your own knowledge and your answers to their questions and using quality sources of information is important. I know NCRs had some great resources for providers that are sort of a one-stop shop with all the latest recommendations. Then, finally, that part of if someone's really hesitant and you know that they might be willing to consider vaccination, is to find out what might make them want to consider vaccination. This is an element of motivational interviewing that GPs will be familiar with from smoking cessation counseling, for example, where you elicit the things that might make them feel that vaccination is important. Like, protecting their mother when they go to visit her or being able to travel or making sure their child is protected when they go to school and then amplifying that. So encouraging them in that motivation and agreeing with that. Then coming in with a recommendation to vaccinate because no matter where somebody stands, we know that recommendations are powerful. They can influence people. We actually saw in some of those conversations, that some of those parents who are terribly torn about vaccinating their child, almost wanted the clinician to say, look, I've heard your concerns I know where you stand. You're clearly torn about this, but I'd love to see you vaccinated today. Would you be willing to do that? The 'would you be willing' is important because that seems to be quite a key term.

Dr. Caroline West:

What about using your own life story? I noticed that various public health officials, for example, have willingly talked about their kids or their partners being vaccinated along the way. Which, we didn't hear so much about before COVID came along. Is that a useful thing for somebody to leverage as well? The fact that their own family members or their own kids are being vaccinated. Is that a path you'd never follow?

Julie Leask:

It can be. It depends on the relationship and whether the clinician is comfortable sharing that information. That will vary if it does happen. There's studies to show that that's actually quite powerful, particularly with someone who's on the fence. That's definitely an option for people to consider. I know, for me, when I was doing a lot of public communication, when we had all the concerns about the AstraZeneca vaccine, where Pfizer was preferred for the under 50 then under sixties and a lot of concerns about clotting. I, being in my early fifties, decided to be quite public about having the vaccine. This was in, I think this was May or June. So it was at a time when I think, no, it was actually late April and this is just after they made the announcement.

Julie Leask:

So it was a time when a lot of people were struggling with the idea of vaccinating if they were in their fifties and it was still you couldn't have Pfizer when you were in your fifties at the time. That day I opportunistically was able to get the SBS film crew along to film my vaccination as well, because they weren't doing another story. That was great because I wanted to put my money where my mouth was. I wanted to show that I've looked at the risk, I've confronted it. I've got a plan. I know what to look out for with headaches and so forth. I was going to take that risk for the huge benefit that I saw it having for me.

Dr. Caroline West:

I was the same that when I had my vaccine, which I got AZ because I was at the beginning of the queue and that was all that was available regionally, anyway, regardless of age. I was very excited about having the vaccine because I had worked for almost a year in the frontline by that stage. I felt so grateful that the vaccines had come along and they were potentially going to change the future for everyone and without the vaccines that were in a terribly difficult place. So, for me, when the vaccine arrived I was extremely excited about it. I was excited about it when it rolled out for my children to have too. I was happy to share my feelings about that. Normally, as medicos, you sort of keep all of that stuff to yourself. You wouldn't, sort of, publicize that you've just had a certain procedure done or you're on a certain medication. Normally that's fairly private information. But I felt in this instance that this was important in some ways, to be influencer maybe to, NAFA word, but modeling, I guess that I was happy to have it. I was very happy for my kids to have it. I felt conveying that to some people was reassuring for certain people who were thinking, well would you do this for your kids? It's a really interesting one, isn't it? COVID vaccination has really changed the conversations we're having. I think the other thing is that we've got to be really careful, in these conversations, not to stigmatize when somebody is pushing back because there will be people that have lots of reasons for wanting to know more or have hesitancy. We've got to be really careful not to alienate people as well, because then they're lost completely. What do you think about that area of things?

Julie Leask:

It's both a clinical problem and a societal problem as we head towards a time where non vaccination is more unusual. It's what 90%, I think, nearly 90% have had a first dose in New South Wales, for example, as a whole population. That's very high uptake. So the people who are holding out are quite a diverse bunch of people; the needle phobic, the vaccine fearful, the mistrusting, people who've had medical trauma, there's all sorts of reasons that people really hold out this much. It is going to be a harsh environment for them, particularly in those early stages where they're unable to travel or move about as easily as the vaccinated. But also in a clinical setting where you've got, it really is the pointy end of that isn't it, because for people who don't vaccinate often that clinical encounter, particularly with a GP, will represent the place at which they see into that expert knowledge system. If they're not vaccinating and for example, they can't get a medical exemption from the doctor they're seeking it from, they can get quite upset, sometimes angry and even really abusive. We are heading into very challenging times and it's not just challenging for the clinicians. It's also challenging for the people who don't vaccinate, who are facing these kinds of pressures on them. Social and [cross talk 00:22:49]

Dr. Caroline West:

We've covered quite a bit of ground today, Julie. I guess what I heard loud and clear, from a perspective of being a health professional in the field, is that having, and correct me if I'm wrong here, but having some sort of agenda setting when you're discussing a vaccination with somebody and covering what you're going to cover in that conversation. Is that right? To, sort of, at the beginning of the consult just listen to their concerns and set a bit of a framework for how you're going to manage those concerns.

Julie Leask:

I think so. Just with that example of the medical exemption request, I've just been working with some colleagues around this, looking at, at how to set that agenda. For example, saying, what I'll do is ask a few questions to look at whether there are grounds for an exemption for you. I'll ask you a few standard questions to see if you qualify. If I can't grant one, then can we look at your options and work out a way forward? So it's clear that there's a set criteria that the GP is working with and that they have a responsibility to abide by those rules. Not just as a professional, but legally as well, they must. Then the patient, it's easier then to distance oneself from the need to implement the rules because the rules are external to that provider. It's then easier to step into the way of relating that's more about how can I help you look at your options and consider what's best for you. I would like to see you vaccinate. But let's plan that together because, unfortunately, with these rules I can't give you that exemption. That sort of, deescalation starts with that agenda setting. It starts at the very beginning of the conversation.

Dr. Caroline West:

Hopefully if everyone continues this, sort of, focus of listening to people, encouraging those who are still vaccinated to consider vaccination, and hopefully more of them will get vaccination along the lines. We'll move towards a community where we're able to enjoy things again and get back to some semblance of normal. It'll be a very new normal, but that'll be good to open up again. It's been a really interesting conversation and I know that there's so much more that we could cover. It's great to have your thoughts on all of this Julie and share your wisdom. I guess it would also be great to send a big thank you to all of those healthcare workers out there who have been part of the COVID vaccine rollout. In my team, in remote Australia, we had pharmacists and dieticians, nurses, doctors, everybody was getting involved at various levels. I think it's the first time in medicine that I've ever seen that sort of collective effort applied to one particular situation. It's been incredible to see people really step forward. So a big, thank you. Did you have any final message that you'd like to share with our listeners Julie, on what you feel is an important takeaway from all of this?

Julie Leask:

I co your sentiments Caroline, that there's a lot of people who've worked incredibly hard through from day one of this pandemic. As a person in public health, I'm particularly grateful to those people who are often hidden in those government departments who are working so hard to control COVID. Then of course, the clinicians who are looking after people managing their health services, doing that big sort of pivot towards managing COVID and also to the primary care providers. As a former nurse myself, I have a particular shout out to all of the registered nurses and midwives who have been part of the vaccination rollout. Some of them have been doing vaccination for a long time because we know that nurses along with GPs are the cornerstone of vaccination in Australia. But others have jumped in including some of our students at the University of Sydney's Nursing School. It's been wonderful to see that the way that health professionals and public health people have come together and made this happen. Also, the way the public have really gotten on board. We've seen so much solidarity around controlling COVID in Australia and that's quite inspiring.

Dr. Caroline West:

As many nurses as are out there, they were really running most of the clinics that I was working at in terms of the vaccination rollout. I was always in awe of how much they knew about vaccination. I always turn to them for extra advice. That's for sure. So thanks Julie, and thank you to our listeners out there. If you'd like any more information on this story, or you'd like suggestions for further reading, go to our website at nps.org.au.

I'm sure there'll be plenty more to discuss on the topic of kids in COVID, but that's all we have time for today. Professor Julie Leask has been my guest today. So thank you and I look forward to you all joining us next time. I'm Dr. Caroline West. Bye for now. (recording 2)