http://www.medscape.com/viewarticle/839980?src=wnl_edit_specol&uac=20010AY

Changing Minds About Vaccination

Gregory A. Poland, MD, Caroline M. Poland, LMHC, LCAC, NCC

February 23, 2015

Measles Outbreak and Failure to Vaccinate

As of February 2015, the United States is experiencing a large measles outbreak, with more than 120 cases scattered across 17 states. The primary cause of this outbreak is the failure to vaccinate, although smaller numbers of cases have occurred in persons previously vaccinated.^[1] The outbreak highlights the need to increase rates of vaccine acceptance among those who are either vaccine hesitant or refuse vaccines.

Addressing vaccine hesitant/resistant patients and parents remains a difficult but important task to tackle. Critical to this task is the need for physicians and other healthcare workers (HCWs) to use effective communication and education strategies (informed by psychology, counseling, and behavioral psychology^[2]) in ways that allow parents and patients to make data-informed choices that benefit individual and community health.

Consider this common case study example:

Jane is a 36-year-old mother of three, her youngest having just celebrated her first birthday. Although she chose to have her oldest two children vaccinated, she has since started reading blogs and Internet sites, many of which tout the importance of "natural" living and condemn the use of "vaccine toxins." Some of these blogs have also shared winsomely written, highly emotional stories of the negative effects of vaccines like measles-mumps-rubella (MMR) vaccine. Jane, who cares deeply about the health of her children, has made the decision to not vaccinate her 1-year-old, reinforced by a support group of mothers who all believe similarly. She is in your office and has informed you of her decision. Consistent with national recommendations, you are about to recommend that she give her daughter the MMR vaccine. How do you most effectively proceed?

This scenario, in many familiar variations, occurs in medical offices across America every day. It is critical to be able to communicate effectively with the patient, using the patient's preferred cognitive style, if we are to influence decision-making.

Preferred Cognitive Styles and Health Decision-Making

One overarching strategy, first outlined in our 2011 commentary, is the Preferred Cognitive Styles and Health Decision-Making Model.^[3] A cognitive style is best understood as the basic thinking or cognitive strategy that an individual uses to make decisions—particularly under conditions of uncertainty—based on, among other things, cultural frames and beliefs.^[4] This style affects how an individual hears and conceptualizes information, and therefore can influence or drive how an individual perceives the issue at hand and how that person then behaves.

Individuals may process and make decisions with just one cognitive style, whereas others might have a primary, secondary, and tertiary cognitive style. Because these preferred cognitive styles so deeply affect how individuals process and react to information, it is imperative that HCWs learn to identify and use appropriate communication and education strategies for each type of style.

Communication Strategies

We expanded on many of these communication strategies in an earlier article.^[3] Among these include Prochaska and DiClemente's Transtheoretical Model, which outlines stages of change in behaviors. In the Transtheoretical Model, behavior change is conceptualized as a process that unfolds over time and involves progression through a series of five stages: precontemplation, contemplation, preparation, action, and maintenance.^[5] "By understanding each of these stages and their importance, we can assist patients who are not even considering vaccination to accept vaccines to protect their health throughout their lifetime."^[3] With an understanding of where a patient is in the stages of change, this information, along with understanding the preferred cognitive style of the patient, can guide the conversation in which HCWs engage their patients.

The Health Belief Model is another communication strategy that may be helpful in assisting with behavior change in the area of vaccine acceptance. This model suggests that individuals make health decisions based on "perceived susceptibility to disease, perceived severity of disease, perceived benefits of preventive action, perceived barriers to preventive action."^[3] By addressing these issues through the patient's preferred cognitive style, we enter into a deeper and more richly informative and trust-building discussion with the patient.

How to Present Vaccine Information

It has been our observation that few HCWs have received any formal instruction on patient decision-making styles and tend to default to a common education style—a highly analytic style informed by numbers, statistics, and nuanced probabilities. Many HCWs and government health agencies operate out of the analytical style that is focused on science-based facts and statistics. This style is evident in the Vaccine Information Statements that are required to be provided before vaccinations are given in the United States.

By presenting information through this primary analytic cognitive style, HCWs routinely miss opportunities to engage in meaningful educational conversations with parents/patients who use other styles. We would be wise to learn from and engage with various other disciplines to create a well-informed, multimodal approach to patient education in the arena of vaccine acceptance. This idea was explored briefly in an article by Poland and Brunson.^[6]

If HCWs can effectively understand a patient's preferred cognitive style and communicate with that person based on the patient's needs for decision-making, there is a far better chance of helping the patient make healthy decisions and engage in healthy behaviors. As examples, some of these cognitive styles are identified in the table.

Table. Cognitive Styles

Republished with permission from: Poland CM, Poland GA. ^[3]

The table above outlines six primary cognitive styles, gives examples of how these cognitive styles appear in communication, and includes a few practical communication strategies to employ. Although statistics and facts are critical to making decisions, for individuals who don't operate with an analytical cognitive style, particularly innumerate individuals, statistics and probabilities serve only to confuse and are unlikely to move them to a desired behavior (in this case vaccine acceptance). We have illustrated this in the case of fear-based decision-making over Guillain-Barré syndrome and concerns over receipt of the pH1N1 vaccine.^[7]

Vaccination: Convincing Jane

In the case of Jane, she employs a primary style of "bandwagoning" (or social peer pressure), with her secondary cognitive style being a fear-based heuristic. How might the clinician proceed in this case? First, it is important to comment upon and endorse the fact that she is a caring parent who is trying to make the best decisions for the health of her child. Affirm the goal of making healthy decisions for her child. (eg, "Jane, it is obvious that this is an important decision for you and your daughter, and I know how much you care about her health and want to make a good decision.")

Second, explore and understand her preferred cognitive style and explore the influence that blogs and others' opinions have had on her decision-making (eg, "Jane, what type of information have you read so far? Where did the information come from? Was it from qualified medical professionals? What does the information you read mean to you?"). Lead her to discover that the blogs she reads (perhaps even pull one up on the computer during your discussion) are written by people with limited medical knowledge and credentials. Discuss the qualifications of these bloggers and perhaps widen the umbrella, asking if she would accept medical opinions as fact from other nonmedical people, such as celebrities, sports figures, or politicians. This allows the individual to start thinking through where her trusted information comes from in decision-making.

Third, it might be helpful to discuss the possible ramifications of her daughter not receiving the vaccine, using her fear-based secondary decision-making style. Discussing the medical risks of contracting a vaccine-preventable disease and helping her to imagine the emotions surrounding possible complications (eg, "By not giving your daughter the vaccine, if she gets measles here is what happens to her health [consider showing photos or videos]. Are these acceptable risks to you?") may be a good way to begin this conversation. Ask questions to understand the patient's fears and the sources of these fears.

Using social norming in this and other situations would also probably be helpful. Social norming examines appropriate rules and behaviors within a defined group of people, so in this case it might be helpful to give information about the decisions that other moms make when they give their children the MMR vaccine. For example, point out that physicians—like you—give this vaccine to their own children. Point out that fears about MMR vaccine and autism are unwarranted and that the study suggesting this connection has been debunked, with the primary author stripped of his medical license, and judged to be unethical.

A self-efficacy approach may also be helpful in this situation. Albert Bandura, a well-known psychologist, said the following about self-efficacy: "People need enough knowledge of potential dangers to warrant action, but they do not have to be scared out of their wits to act, any more than homeowners have to be terrified to purchase fire insurance for their households. What people need is knowledge about how to regulate their behavior and firm belief in their personal efficacy to turn concerns into effective preventive actions. Thus, a shift in emphasis is required, from trying to scare people into health to providing them with the tools needed to exercise personal control over their health habits."^[8]

Pearls for Practice

HCWs are in a unique position to engage in conversations that can empower patients to choose wisely in their health decision-making. Educating patients/parents about the steps they can take to have control (in healthy ways) over their health, as well as their children's health, is important. This empowerment and increased self-efficacy can have powerful effects on healthy decision-making and vaccine acceptance.

Physicians and nurses should acknowledge that a hurried minute or two of discussion will usually not be sufficient in helping a vaccine-resistant or -hesitant parent move toward acceptance, particularly if this is a long-standing and entrenched belief. It might be helpful to think in terms of mid- to long-range behavior change. A patient may not accept the vaccine immediately, but with patience, empathy, and appropriate communication and education strategies, it has consistently been our clinical experience that patients will move towards vaccine acceptance.

One thing is clear: There is no "one size fits all" strategy that will accommodate the needs and cognitive styles of each patient who walks into your clinic. The strategies defined above (eg, understanding cognitive styles and the appropriate strategies and communication patterns helpful with each, social norming, and empowerment through increasing self-efficacy) are all of critical importance as HCWs seek to help patients make healthy decisions about vaccines. Additional helpful strategies are outlined in the authors' other published work on this topic, including how to counter the common immunologic claims often brought up by vaccine-hesitant individuals.^[2,4,9,10]

Effective herd immunity requires that a large percentage of the population be immunized to control and eliminate indigenous transmission of disease, and protect those who cannot be immunized. In the midst of current measles, mumps, and pertussis outbreaks, and shockingly low rates of HPV and other vaccine acceptance, HCWs must employ effective communication and education strategies that improve vaccine acceptance. Clinical pearls for such success that we have found useful include:

• Acknowledge the common goal of protecting health. We as HCWs have the same goal the patient/parent does: staying healthy and preventing disease.

• Understand your patients' preferred cognitive styles. How do they tend to process information and make decisions as you talk with them about medical decisions?

• Turn patient education around. Communicate not on the basis of your preferred style but on the patient's style.

• Tailor communication not only to a patient's cognitive style but also on the stage of change that the patient is in in terms of vaccine behavior.

• Don't be afraid to use emotional stories (there are many excellent examples on the Internet) to illustrate what complications occur from vaccine-preventable diseases. Remember: Most parents have never seen these diseases, and discussions of risks may have no foundational meaning to them.

• Acknowledge that decision-making, relationship, and trust-building take time. Leave the door open for further conversations on the topic.

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Cite this article: Gregory A. Poland, Caroline M. Poland. Changing Minds About Vaccination. Medscape. Feb 23, 2015