This Policy Meeting report examines educational gaps and behavioral change in vaccination uptake, among both healthcare professionals and parents. Presented at the 11th Excellence in Pediatrics Conference, it brings together expert briefings on improving HCP education and on applying adult learning principles and motivational interviewing to conversations with parents, alongside country updates from Serbia, Spain and Finland and a proposed action plan for 2020/2021.
Meeting Report
Policy Focus Group Meeting on Education — 11th Excellence in Pediatrics Conference, 6 December 2019
Barbara Rath1, Paul Brand2, Martine Ingvorsen3, Siddhartha Datta4, Malcolm Taylor5, Radovan Bogdanovic6, Irene Rivero-Calle7, Timo Vesikari8, Simon de Lusignan9, Simon Kroll10, Philip Weiss11, Philippe de Wals12, Gary Finnegan13, Marc Van Ranst14, Catherine Weil-Olivier15, Kare Molbak16, Elena Moya17, Anna Odone18, Carlo Signorelli19, Gertraud Daye20
1Pediatric Consultant and Infectious Disease Specialist, Chair of the Vienna Vaccines Initiative, Germany, 2Professor of Clinical Medical Education, University of Groningen; Dean of Medical and Faculty Development, Isala Hospital, Netherlands, 3Policy Officer, European Commission, Belgium, 4Programme Manager, Vaccine-preventable Diseases and Immunization Division of Health Emergencies and Communicable Diseases, WHO, Denmark, 5General Secretary, Coalition for Life-Course Immunisation (CLCI), United Kingdom, 6Professor of Pediatrics & Pediatric Nephrologist, Paediatric Association of Serbia, Serbia, 7Consultant in Pediatrics and Pediatric Infectious Diseases, University Clinical Hospital of Santiago de Compostela, Spain, 8Professor Emeritus of Virology and Paediatrics, Director of Vaccine Research Center, Finland, 9Professor of Primary Care and Clinical Informatics, University of Oxford, Nuffield Department of Primary Care, Director, Royal College of General Practitioners Research and Surveillance Centre, United Kingdom, 10Professor of Paediatrics and Molecular Infectious Diseases, Imperial College and St Mary's Hospital, Member of the UK Health Protection Agency Meningococcus Forum, United Kingdom, 11Founder and CEO, ZN Consulting, Belgium, 12Professor and Director of the Department of Social and Preventive Medicine at Laval University, Quebec, Canada, 13Editor, 7/11 - Vaccines Today, Ireland, 14Professor, Department Chair of the Department of Microbiology, Immunology and Transplantation, Head of the Laboratory of Clinical and Epidemiological Virology, Rega Institute for Medical Research, Belgium, 15Honorary Professor of Pediatrics and Independent Expert, Paris VII University, France, 16Executive Vice President, Statens Serum Institut; Professor, Faculty of Health and Medical Sciences, University of Copenhagen; State Epidemiologist, Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark, 17Co-ordinator for Europe and Africa, COMO - Confederation of Meningitis Organisations, Spain, 18Associate Professor of Public Health, Director of the School of Public Health, Vita-Salute San Raffaele University Milan, Italy, 19Professor of Hygiene and Public Health at the University of Parma and the University Vita-Salute San Raffaele of Milan, Director of the Postgraduate School in Hygiene and Preventive Medicine, Italy, 20Board Member of the NGO Committee on Ageing, UN, Vienna, Austria
Since 2015 the Excellence in Pediatrics Institute (EIP) has worked with European and global partners to help overcome the many remaining barriers to vaccination uptake. By connecting and working with colleagues across Adolescent Medicine, General Practice, Pharmacy and Nursing, and uniting behind the EU Commission's Coalition on Vaccination, EIP's goals is to promote a LifeCourse approach to vaccines.
Most notably, EIP believes that the following barriers remain: 1) Policy discrepancies - Heterogeneous national vaccination policies. Differences in approach, prioritisation and decision making processes. 2) Overarching barriers - Lack of policies to increase vaccines confidence, counteract misinformation, increase awareness and mobilise medical communities, and 3) Failure to adopt a LifeCourse approach - Prevention Policies not adapted to demographic changes and an increasingly ageing population. Disease prevention in all stages of life is not yet a priority.
As part of EIP's work within the EU Coalition on Vaccination, 8 Stakeholder Working Groups, as well as a joint EU Commission and WHO plenary briefing, took place at 11th EIP Annual Conference in Copenhagen in December 2019. During the Working Groups, speakers were asked to share their opinions on ways to increase vaccination uptake in both the general public and healthcare professionals, on the current state and progress made in increasing vaccination coverage rates in different countries, and to mention the obstacles faced in the process. Four of the Working Groups looked at vaccine-specific barriers, while four looked at policies focusing on overarching barriers.
One of the Policy Focus Groups was tasked with looking at education and behavioural-change-based barriers. In particular, the Group explored supporting continuing education and training on behaviour change as essential tools in overcoming vaccine hesitancy. It further explored how combining the power of face-to-face communication in practices, while utilising modern communication channels to spread interesting and engaging messages at scale, can best be utilised and managed.
The following report summarises the invited experts' briefings, discussions, and proposed action plans that were debated during the proceedings of the Education and Behavioural Change Policy Focus Group.
Focus Group Briefing
Presenter: Dr Barbara Rath, Pediatric Consultant and Infectious Disease Specialist, Chair of the Vienna Vaccines Initiative, GermanyDr Rath was invited to deliver the opening briefing to establish what can be done to improve current standards of HCP education. She began by pointing out that healthcare professionals should devote much of their time and energy to interacting better with parents and their children. There are two concepts every parent wants to talk about: necessity and safety.
Dr Rath presented a vaccine perception survey conducted in collaboration with the US CDC, orchestrated by a think tank and carried out by five doctoral students who surveyed parents picking their children up from kindergarten. The results showed a disaster when it comes to the flu vaccine — one of the least popular yet necessary vaccines — and these results came right before the flu pandemic, which made things even worse.
She suggested that one question still unanswered is whether everyone perceives vaccines as a measure to prevent severe cases rather than to decrease mortality rates, and another is what exactly our expectations from a vaccine are, given collateral pressure from stakeholders. Dr Rath proposed using a specific score — one that could also live in a mobile application — to represent the severity of the flu disease and rank patients accordingly, making a useful collaboration tool among HCPs. It would not measure case numbers but put the individual's disease severity under the spotlight, addressing the issue where we can decrease viral load and burden yet fail to make the patient in front of us feel better.
Dr Rath then questioned the accuracy of expert laboratory reports: all flu-like illnesses fall under the same category, and it becomes extremely difficult to distinguish severe cases, making treating patients in need practically impossible. She noted the system also lacks standardization, billing processes, consistent case definitions, surveillance and tracking systems and documentation. She stressed that something must be done at the point of care, otherwise it is of no use, finding the way the doctor communicates with the patient — and the specific things communicated — extremely important.
Dr Rath concluded by presenting her approach: consult the vaccination records, estimate disease severity clinically, then run bacterial tests to determine whether antibiotics should be prescribed. This way, vaccination is integrated into the decision-making process and based on solid test results rather than physician's discretion.
Focus Group Briefing
Presenter: Prof. Paul Brand, Professor of Clinical Medical Education, University of Groningen; Dean of Medical and Faculty Development, Isala Hospital, NetherlandsProf. Brand opened by expressing his worries about decreasing vaccination rates, and marked information-sending as the usual approach to convincing parents to vaccinate their children — an approach that has obviously failed.
He suggested that paediatricians have failed to connect with parents at a more meaningful level, and that our aim should not be to increase their knowledge but to change their behaviour. This requires a different approach than just sending information. Children learn through play and by listening to what we tell them; adults do not. For adults it is different — we decide what we learn and how we employ it. Prof. Brand insisted that we don't learn by listening to things; we learn by processing them, working with them and reflecting. Engaging and reflecting back on what we are trying to learn are key principles for learning something and, most importantly, for changing behaviours.
He believes HCPs should not tell parents off, because if that is what parents feel, it will have a boosting effect on vaccine hesitancy — the opposite of what we are trying to accomplish. Instead, it should begin with building trust and teamwork between the HCP and the parent, starting with parents knowing that you are going to discuss the same goal. Prof. Brand concluded that the study of adult learning principles may help us understand that in talking to parents about vaccination, we need to stop talking and start listening more. It is essential that HCPs present this not as a prescription but as one of the potential options we can have a meaningful conversation about.
Prof. Brand noted that overall hesitancy is measured at 15% to 50%, while those against vaccination count for a much smaller 3-4% of the total, so spending time trying to convince someone ideologically against vaccines is not a good idea — we should focus on the hesitant 15-50%. The concept of motivational interviewing was discussed: taking time and encouraging parents into comfortable conversations they are delighted to participate in, with a key element being that the doctor should always ask permission before sending information or giving advice, changing the parents' motivation to listen. On the other hand, there is strong evidence that a forceful recommendation increases compliance, which does not fully agree with the "listen first" concept.
Dr Rath mentioned that there is also marketing, targeted at changing behaviour but with little to do with education. Prof. Brand replied that when parents have concerns, the first thing to do is take those concerns very seriously, because parents will know and feel that and may even have decided based on it. When they open up and say they would like to hear what science has to say, that is the time to be firm and present scientific data. Prejudice is an enemy here — we have to know why they are hesitating first, then hold our position as HCPs. Counteracting a myth directly is also not a good idea: the steps are to listen to the myth and understand the parents have read or heard it, ask permission to state the scientific facts, and then explain that the myth is not real.
Mr Taylor linked vaccination with a healthy, ordinary lifestyle including — but not limited to — a healthy diet, exercise and living a normal life. He underlined the importance of everyday heroes and their impact on changing human behaviour, because it is about ordinary people giving real testimony about their lives. However, since everyday heroes are not common in everyday medical practice, we need to build relationships and trust with patients, which takes a lot of time — a luxury HCPs often do not have.
Prof. Catherine Weil-Olivier asked whether we should digitally infiltrate the anti-vaccine group to better understand their perspective. The reply was that in the world of Wikileaks, this is simply too dangerous, corroborated by Prof. Brand's earlier briefing — though the topic was examined in further detail by the Misinformation Policy Focus Group that also took place at the conference. Mr Philip Weiss commented that the UN has a phenomenal ambassador program with stars and celebrities who support causes and know how to activate them, proposing a vaccine network of ambassadors — rock stars, footballers and others with millions of followers — who by sharing a simple, emotional human story could have a huge impact on vaccine uptake.
Prof. Bogdanovic reported that two groups are targeted by vaccination education in Serbia: medical workers and parents. Over the past five years, the Paediatric Association of Serbia — in cooperation with the Ministry of Health, National Institute of Health, UNICEF and other professional societies — has undertaken continuing action to promote vaccination among paediatricians, including vaccination topics at each association meeting, articles in annual paediatric school courses and congresses, and materials posted on the association website based on findings of knowledge, attitudes and practices related to childhood immunization. UNICEF and partners have organised training courses on interpersonal communication.
The National Institute of Health has designed leaflets distributed among parents and visitors to primary healthcare centres and posted popular educational materials online. Lectures on vaccination are delivered to primary and secondary schools and the local community, and experts are often invited by printed or electronic media to advocate vaccination, especially during outbreaks or flu season. Finally, the Roma population, where vaccination coverage is lower than the general rate, has been targeted and educated through specific campaigns with the help of Roma mediators.
Dr Rivero-Calle noted that there are several workshops for both nurses and doctors, held once a year. A leaflet is given to parents containing information about the vaccines in the immunization calendar, with contact information shared in case parents want to discuss their concerns. Healthcare professionals ensure parents get all the help they need, especially in special cases involving organ transplant, immunodeficiencies and so on, and a profound, effective collaboration among different specialties is important for many parents. A specific educational module in schools, plus a game and an escape room designed for educational purposes around vaccination, have also been implemented.
Most impressively, in Galicia there is an electronic register for all vaccines, available to both GPs and hospitals, so regardless of where the vaccine is given, anyone can access that immunization planning and interact with parents on real-time vaccination status data. Due to its success, this is being planned and implemented nationwide over the coming years.
Prof. Vesikari reported that vaccination coverage in Finland has reached an impressive 95%, so they do not need special programs given the current results. There was a problem with the injectable flu vaccine, solved by introducing the intranasal flu vaccine, which was better perceived by parents.
He then gave an example where mandatory vaccination of HCPs may not be the best approach compared to education. Recently the Ministry of Social Affairs and Health passed a law making flu vaccination of healthcare personnel mandatory. This created a reaction against a situation where there was no problem in the first place; by making the vaccine mandatory a problem was created, the nurses filed a lawsuit against the government, and in the end they won. Prof. Vesikari concluded that making vaccination mandatory is a mistake and should be avoided to prevent repeating this situation in other countries.
Prof. Simon Kroll (Professor of Paediatrics and Molecular Infectious Diseases, Imperial College and St Mary's Hospital, UK) began the discussion by reporting that a lot is happening within the College of GPs to encourage professionals to be more enthusiastic and supportive of vaccination strategies, with social media and digital marketing playing a huge role.
Mr Philip Weiss (Founder and CEO, ZN Consulting, Belgium) stated there is a matter of terminology when we talk about education versus influencing or modifying behaviour. He suggested there absolutely needs to be an organised, effective way of delivering information to the public audience, and a serious effort to debunk myths in a more systematic way. Using online methods is an absolute necessity because it is cheaper and scales much more than traditional methods — online conversations, YouTube channels and Q&A concepts will enhance the pro-vaccine message more efficiently around the globe.
Prof. Philippe de Wals (Professor and Director of the Department of Social and Preventive Medicine at Laval University, Quebec, Canada) underlined that it is much easier to change the behaviour of parents than of health professionals, as professionals keep doing what they have learned. Not everyone agreed, arguing that some bad habits must be abandoned since there is no benefit at all for the patient.
On face-to-face intervention and targeted messaging for ultra-suspicious audiences, Mrs Elena Moya (Co-ordinator for Europe and Africa, COMO - Confederation of Meningitis Organisations, Spain) pointed out that suspicious parents are not dumb — they are often college graduates who may speak several languages. To deal with them, we have to learn from teachers and best practices: it needs patience, being keen to listen, being able to relate to what they say, and not being judgemental. Sometimes the doctor needs to be aware of what has already happened at home, for example whether the couple has been fighting over vaccination issues. Playing the blame game is not a good idea; we should try to figure out what is best for their children instead.
Mr Weiss added that many perspectives are missing from media and from experts across fields — we may have the expertise, but a whole set of skills is missing to go deeper and be smarter in finding solutions. He seriously suggested trying to have genuinely multidisciplinary conversations, where not everybody has a background in medicine but there is also a real media skill set.
The Focus Group was dedicated to improved education and behavioural change — of both healthcare professionals and parents — in relation to vaccine uptake rates around Europe and where barriers to uptake still remain, in terms of policy and approach. It was concluded that although progress has begun in educating HCPs as effective communicators who can change behaviours, there is still much work to be done for doctors and parents to walk the same path towards better prevention of vaccine-preventable diseases.
In particular, the Group raised the following areas that need to be explored in more detail, with necessary actions taken, to achieve improved vaccination coverage, they include:
There is an urgent need to apply theories of behavioural change for this missing element to become more effective. We need to train HCPs on behavioural science. While vaccine promotion and knowledge acquisition are necessary to improve coverage, will it be enough? Repeatedly stating the facts does not work.
A webinar series for European HCPs providing practical tips, techniques and case studies on motivational interviewing and behaviour change, to overcome vaccine hesitancy in a constructive way.
There is a huge need to develop a more effective way of organising and delivering information to the public audience, as well as a strategy to debunk myths more systematically. We need to make vaccination a lifestyle choice that complements a healthy diet and physical exercise in a holistic health prevention strategy.
An HCP-led campaign to identify and segment the audience based on age, education, reach, hesitancy and so on, working on messages that get read and increase engagement with the target audience.
