Vaccine Hesitancy: What is it? What can you do about it?

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1 Vaccine Hesitancy: What is it? What can you do about it? November 12, 2016 Family Medicine Forum, Vancouver Monika Naus MD MHSc FRCPC FACPM BC Centre for Disease Control School of Population and Public Health University of British Columbia BC Centre for Disease Control Christine Halpert RN MA Stephanie Meier RN Shaila Jiwa RN MScPPH

2 Conflict of interest declaration: On behalf of all 4 presenters as this session (Naus, Halpert, Jiwa, Meier): We have no competing financial interests associated with industry.

3 Objectives Learning Objectives: 1. define the term vaccine hesitancy and explain the impact of vaccine hesitancy on practice 2. identify strategies to improve the immunization experience for patients, including techniques to reduce pain during immunization 3. identify accurate sources of information about vaccines and use effective communication techniques when responding to parental concerns about immunization 3

5 What is vaccine hesitancy? Spectrum from: active demand for all vaccines to complete refusal of all vaccines

6 Vaccine hesitancy: May result in delays but not complete refusal May be affected by local environment (social circle social norms national traits - health services) May be vaccine specific e.g., MMR May be focused on new vaccines (e.g., HPV), with older vaccines well accepted Is a global issue Is not new, but some of its drivers are. Drivers include: an increasingly crowded immunization schedule, heightened societal concerns about risk over benefit and preference for natural alternatives, distrust in government and the pharmaceutical industry, and a rise in health consumerism. Needs to be addressed at every level including the provider client encounter

7 In order for behaviour to change, people must feel personally vulnerable to a health threat, view the possible consequences as severe, and see that taking action is likely to either prevent or reduce the risk at an acceptable cost with few barriers. In addition, a person must feel competent (have self-efficacy) to execute and maintain the new behaviour. Some trigger, either internal... or external..., is required to ensure actual behaviour ensues. Nisbet and Glick. Canadian Psychology

8 Shahrabani Health Education & Behavior 39(5)

9 Evidence based strategies: Start the conversation with an opt-in approach Non-judgmental listening Establish trust Motivational interviewing open questions guiding style to identify whether parent is responsive to change and their motivations Emphasize benefit to the child Use stories Elicit specific concerns & tailor response Be well informed do not oversell outline expected side effects and how to manage these give clear recommendation Naus M. eng.php Halperin S. CdnJof CME ZDoggMD.com Magna Cum Measles

10 Additional resources: Halperin S. How to Manage Parents Unsure About Immunization. The Canadian Journal of CME Jan: Available at MacDonald NE, Finlay JC; Canadian Paediatric Society Infectious Diseases and Immunization Committee.Working with vaccine-hesitant Parents. Paediatr Child Health 2013;18(5): Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatr Sep 21;12:154. Healy CM, Pickering LK. How to communicate with vaccine-hesitant parents. Pediatrics May;127 Suppl 1:S Offit PA, Moser CA. The problem with Dr Bob's alternative vaccine schedule. Pediatrics Jan;123(1):e Offit PA, Jew RK. Addressing parents' concerns: do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics Dec;112(6 Pt 1): Offit PA, Hackett CJ. Addressing parents' concerns: do vaccines cause allergic or autoimmune diseases? Pediatrics Mar;111(3): Offit PA, Quarles J, Gerber MA, Hackett CJ, Marcuse EK, Kollman TR, Gellin BG, Landry S. Addressing parents' concerns: do multiple vaccines overwhelm or weaken the infant's immune system? Pediatrics Jan;109(1): Centers for Disease Control and Prevention, American Academy of Family Physicians, American Academy of Pediatrics. Provider Resources for Vaccine Conversations with Parents. 10

11 A Better Immunization Experience For Babies, Parents, and Immunizers Christine Halpert RN BSN MA Senior Practice Leader Immunization Programs and Vaccine Preventable Diseases 11

12 What image comes to mind when you think about vaccinating babies?

13 13

14 Outline Importance Evidence Strategies 14

15 Why is this topic important? Pain associated with immunization Causes distress Long term consequences Needle fear Deferral of future vaccinations Avoidance of medical procedures

16 The Evidence Guidelines published in Canadian Medical Association Journal: 2010 September 22, 2015 Summarize the evidence and recommendations Immunization related pain contributes to needle fear and vaccine hesitancy Interventions are available Providers not using these interventions routinely

17 Strategies 17

18 Comfort Make sure everyone is comfortable babies are happier in a secure, upright position 18

19 Comfort Psychological comfort Address parents fears Distraction

20 Comfort

21 Breastfeeding Incorporates several principles of pain relief including tasting a sweet solution, distraction, suckling, and physical contact.

22 Sweet Tasting Solutions Sucrose for nonbreastfeeding babies Rotavirus vaccine at 2 & 4 month visit

23 Injection Technique Do not use aspiration during intramuscular injections 23

24 Order of vaccines Give most painful vaccine last 24

25 Topical Anaesthetics 25

26 26

27 27

information needs - Fence sitters Relaxed

Follows routine vaccine schedule Keane et

28 Attitudes to Immunization A Continuum Vaccine Beliefs Anti-vaccine Pro-vaccine Conscientious Objector - Low or no informational needs - Rejects vaccines - Unimmunized Cautious - Low to moderate commitment to vaccination - High information needs - Fence sitters Relaxed - Low to moderate information needs - High commitment to vaccination Believer - Highest commitment to vaccination - Follows routine vaccine schedule Keane et al. (2005). Confidence in vaccinations: A parent model, Vaccine 23,

Effective Immunization Communication Principles Adopt a vaccine recipient-centred approach Clearly communicate knowledge Respect differences of opinion

29 Effective Immunization Communication Principles Adopt a vaccine recipient-centred approach Clearly communicate knowledge Respect differences of opinion Represent risks and benefits fairly Canadian Immunization Guide. Public Health Agency of Canada. Part 1: Key Immunization Information [Internet]. Ottawa: 2016

30 The A-S-K Approach

31 The A-S-K Approach Reassures client of your recommendation Systematic method The A-S-K Approach Helps answer difficult immunization questions Communicates the benefit of immunization Is evidence-based Corrects misinformation

32 The A-S-K Approach Helps to bring attitude, skill and knowledge together as one in the pursuit of communication excellence

33 The A-S-K Approach Helps to bring attitude, skill and knowledge together as one in the pursuit of communication excellence

34 The A-S-K Approach Helps to bring attitude, skill and knowledge together as one in the pursuit of communication excellence

35 Case Scenario 1 Multiple Injections I don t want my baby to get ALL these shots today, that s just too much. They will overwhelm my baby s immunize system. So I ll just get one of the vaccines. Which one should my baby receive?

38 Case Scenario 2 Vaccine Ingredients I ve read that vaccines have dangerous ingredients. I don t want to inject those harmful ingredients into my child.

Naturally found in the human body Quantity does not exceed 0.1mg Infant s circulation naturally contains about 1.

40 Vaccine Ingredients Knowledge ALUMINUM Used as an adjuvant Present in our environment Rapidly eliminated from the body GELATIN Used as an stabilizer Protects against degrading Approved by various religious groups FORMALDEHYDE Kills or inactivates viruses/bacteria Naturally found in the human body Quantity does not exceed 0.1mg Infant s circulation naturally contains about 1.1 mg THIMEROSAL Preservative Ethylmercury more easily excreted Does not cause neurological issues Not in childhood vaccines since 2001 except multidose influenza vaccine

41 Complex Conversations Vaccine Facts New Info. Vaccine Myths Equip Yourself With Current, Evidence-Based Information Know Your Resources!

43 Immunization Infographic

44 Immunization Infographic

45 Immunization Infographic

46 The Immunization Communication Tool

52 EKOS RESEARCH ASSOCIATES INC. September 2011

53 EKOS RESEARCH ASSOCIATES INC. September 2011

54 The Power of Your Recommendation Primary care physicians are the most common interface for parents with the immunization delivery system and are likely to have the greatest opportunity for exposure and experience with parental vaccine safety concerns. (Freed et al., 2004) 88% follow what their doctor recommends regarding the provision of vaccines for their children. (Freed et al., 2010) British Columbia research suggests that a strong influencer of parental intention to vaccinate against HPV is the recommendation of their GP. (Ogilvie et al., 2010)

55 In the last century, vaccines have saved more lives than any other health intervention. Public Health Agency of Canada Thank You!

OVERCOMING VACCINE HESITANCY

OVERCOMING VACCINE HESITANCY Lisa Barker, MD St. Luke s Treasure Valley Pediatrics Impact of Vaccines MMWR Jan 7 2011, JAMA. 2007;298(18):2155-2163 1 The Good Old Days Vaccines save lives, therefore your