Editorial Note: Thank you to Heather Lanthorn ScD, MPH, a behavioral and political scientist who focuses on improving health systems and health communication, for co-authoring the “Technically Speaking” article this month.
Over the last couple of months, our “Technically Speaking” series has focused on tangible strategies for approaching vaccine conversations, including how to consider the attitude structure of the person you are speaking with as well as how to consider risk from the perspective of families. This month, we are focusing on another key ingredient of vaccine conversations: trust.
As we have described, health decisions are not solely based on information, but also how that information fits into a person’s existing attitude structure. Those attitude structures are built over time with input from many different people, places and experiences. Prior to the internet, access to information about specific health topics, such as vaccines, as well as the number of voices sharing that information was more limited. However, in the current information environment, an individual’s social networks are much larger and their access to information much more available. On one hand, this means people can more quickly get information and an array of viewpoints. On the other hand, information is often of lower quality and sometimes proffered — often without transparency — by people with ulterior motives. Added to this, the business models of social platforms ensure that algorithms designed to deliver information maximize profits rather than ensure quality. All of this has moved people toward extreme beliefs and decreased trust in historically valued institutions and experts. And, when asked, many cite “trust” as their guiding principle.
So, what makes one person trust another?
Three Cs: Credibility, Caring, Character
Studies have demonstrated that trustworthiness depends on three “Cs”: credibility, caring and character. “Credibility” is often granted to healthcare providers by their credentials, the backing of their institution or practice, and their track record and experience. Providers may have credibility before a family walks through the door, or they may build credibility through any type of care offered to that patient and family. “Caring” (or sometimes, “compassion”) cannot be declared, but it can be demonstrated through time, attention and respect. While extra time cannot always be given in the moment, attending to a family’s primary concern and respecting their questions and opinions can be. Finally, “character” helps a family know who they are choosing as a partner to care for their child or loved one. In this regard, they are looking for some evidence of the provider’s integrity and benevolence.
Keep in mind these elements do not just apply to you as an individual, but they are important across the healthcare experience. While individual trust is built between two people, in the healthcare setting everyone who interacts with a family will contribute to the foundation of trust. If a new family arrives for their first clinic visit and they hear different messages from the nurse, the doctor, and the person at the front desk, it will be impossible to build trust in the clinic at large, and possibly even with any of the three individuals.
Consistency in messaging is key. But these considerations also go beyond messaging. When families struggle to make an appointment, fail to get test results, or are unable to reliably access the patient portal, they are forming an attitude structure about the overall ability to get reliable healthcare at this facility. While “those days” happen, the bigger consideration is what is the repeat experience of your families? Chances are for most, they continue to return because some amount of trust has developed. However, trust is much easier to lose than to gain.
So, what does this mean clinically?
Building Credibility: Credibility is built over time and across situations, so while it is important to be credible on vaccines, it’s equally important to build trust by addressing the needs the family has in the moment. If they are navigating an ear infection, discuss what dose of antibiotic will work best, what side effects to anticipate, how many days it may take to resolve, and what to do with new concerns.
When discussing vaccines, share your resources and knowledge with the family, so they understand how you have come to your recommendations. And, if you aren’t sure of something, let them know that you will check on the information, and then get back to them. If a family is not ready to talk about vaccines, let them know that as partners in caring for their child, it’s important that you can pool your collective knowledge and speak together openly about all topics. Additionally, reassure them that you respect their role as the decision maker when it comes to their child. To demonstrate that respect, use the opportunity to speak to them about keeping their unvaccinated child healthy in the community while they are considering vaccines. Discuss ways that they can do this, such as described on the Vaccine Education Center resource, “Vaccinated or Unvaccinated: What You Should Know,” available in English and Spanish (which can be photocopied for sharing).
Treating patients with care: Recognizing time continues to be a limited resource for providers, care can be demonstrated through our choice of words and topics. Address what is most important to the family by asking, “What’s your biggest concern about this vaccine?” Validate those concerns by letting families know that you, yourself, or other families in the practice have wondered about this as well. Then have a conversation about what you have found and how you have come to the conclusion that vaccination is worth it. Many providers practice the language that works best to express this until it becomes a natural part of their patient care approach.
For example, if the parent is worried that getting the HPV vaccine will promote sexual activity, don’t pivot to cervical cancer statistics. Validate that many families have asked you about this. Then, let the family know that this has been questioned since the vaccine came out, so some scientists studied it, and they found that HPV vaccination did not increase the likelihood for sexual activity.
Demonstrating character: Clinicians can make their behaviors visible through words, body language and tone. For example, consider how these two phrases sound to a parent: “Today, I’m recommending the pertussis vaccine” versus “Today, I’m recommending a vaccine to prevent whooping cough. The reason we give this to our youngest patients is that whooping cough infections in young infants makes it very hard for them to breathe, and this is the group most frequently going to the hospital for the infection.”
The second statement gives the family a sense of what you are most concerned about for their child. In areas of uncertainty, show humility by sharing what is known and what is not known, and how you weigh that information. If you are uncertain how communication is landing with families, practice with peers to assess your tone, facial expressions, and body language to identify whether you may be unintentionally communicating impatience, annoyance or dismissiveness. Likewise, tips like sitting down instead of standing and moving the computer screen out of the way to make eye contact have been shown to be remarkably important to families.
Building trust across the healthcare spectrum: Work with your entire staff to take stock of how everyone’s voices are coming together. In-the-moment dialogue with anyone within the healthcare system offers responsiveness and connection. Every conversation seeds the next. A respectful dialogue — whether or not it ends in a “yes” — builds trust for future visits and ripples outward through social networks. Positive encounters can turn individual acceptance into broader community confidence.
Unfortunately, when conversations with different healthcare workers don’t align, we lose the opportunity to build this confidence. For example, consider the parent of a 2-month-old who is due for pertussis vaccine:
- The physician says, “I strongly recommend that all babies be protected against whooping cough.”
- When the family is waiting for the immunization, they ask the nurse whether all babies get this vaccine, and she responds quickly, ”Some do. Some don’t.”
- While they are waiting at the checkout window, they hear office staff behind the window discussing another family who opted out of the vaccine, adding a negative comment about the family.
These three micro-experiences in the context of the appointment will create dissonance and leave the parent with negative emotions, whether confusion, fear or stress. Where there are different communication styles among staff, talk through the importance of sharing a common message, and ensure that everyone in the office feels comfortable to share that message in their own style. In the scenario described above, a clear response aligned with the practice message could be, “The vast majority of our patients have gotten the pertussis vaccine because we recommend it for all babies, given that whooping cough can make our littlest patients really sick.” The more we consider each encounter as part of sustained relationship-building, rather than a one-time persuasion effort, we can remove the pressure from a single encounter for both ourselves and families, while also leaving families feeling more informed, cared for, and valued as important agents in their own and their family’s healthcare decisions.
Series summary
We hope you have found this three-part series about vaccine communication to be both thought-provoking and helpful. In this moment, healthcare providers remain among the most trusted group of individuals; however, with this trust comes both responsibility and work. Restoring trust in vaccines will not come as a result of federal policies or online conversations with strangers, it will come from conversations with trusted individuals — one conversation at a time answering personal questions with respect, care and empathy. Together, families and clinicians can navigate the complex and chaotic communication environment to give children and families the best opportunity to live healthy lives.
Resources
Editorial Note: Thank you to Heather Lanthorn ScD, MPH, a behavioral and political scientist who focuses on improving health systems and health communication, for co-authoring the “Technically Speaking” article this month.
Over the last couple of months, our “Technically Speaking” series has focused on tangible strategies for approaching vaccine conversations, including how to consider the attitude structure of the person you are speaking with as well as how to consider risk from the perspective of families. This month, we are focusing on another key ingredient of vaccine conversations: trust.
As we have described, health decisions are not solely based on information, but also how that information fits into a person’s existing attitude structure. Those attitude structures are built over time with input from many different people, places and experiences. Prior to the internet, access to information about specific health topics, such as vaccines, as well as the number of voices sharing that information was more limited. However, in the current information environment, an individual’s social networks are much larger and their access to information much more available. On one hand, this means people can more quickly get information and an array of viewpoints. On the other hand, information is often of lower quality and sometimes proffered — often without transparency — by people with ulterior motives. Added to this, the business models of social platforms ensure that algorithms designed to deliver information maximize profits rather than ensure quality. All of this has moved people toward extreme beliefs and decreased trust in historically valued institutions and experts. And, when asked, many cite “trust” as their guiding principle.
So, what makes one person trust another?
Three Cs: Credibility, Caring, Character
Studies have demonstrated that trustworthiness depends on three “Cs”: credibility, caring and character. “Credibility” is often granted to healthcare providers by their credentials, the backing of their institution or practice, and their track record and experience. Providers may have credibility before a family walks through the door, or they may build credibility through any type of care offered to that patient and family. “Caring” (or sometimes, “compassion”) cannot be declared, but it can be demonstrated through time, attention and respect. While extra time cannot always be given in the moment, attending to a family’s primary concern and respecting their questions and opinions can be. Finally, “character” helps a family know who they are choosing as a partner to care for their child or loved one. In this regard, they are looking for some evidence of the provider’s integrity and benevolence.
Keep in mind these elements do not just apply to you as an individual, but they are important across the healthcare experience. While individual trust is built between two people, in the healthcare setting everyone who interacts with a family will contribute to the foundation of trust. If a new family arrives for their first clinic visit and they hear different messages from the nurse, the doctor, and the person at the front desk, it will be impossible to build trust in the clinic at large, and possibly even with any of the three individuals.
Consistency in messaging is key. But these considerations also go beyond messaging. When families struggle to make an appointment, fail to get test results, or are unable to reliably access the patient portal, they are forming an attitude structure about the overall ability to get reliable healthcare at this facility. While “those days” happen, the bigger consideration is what is the repeat experience of your families? Chances are for most, they continue to return because some amount of trust has developed. However, trust is much easier to lose than to gain.
So, what does this mean clinically?
Building Credibility: Credibility is built over time and across situations, so while it is important to be credible on vaccines, it’s equally important to build trust by addressing the needs the family has in the moment. If they are navigating an ear infection, discuss what dose of antibiotic will work best, what side effects to anticipate, how many days it may take to resolve, and what to do with new concerns.
When discussing vaccines, share your resources and knowledge with the family, so they understand how you have come to your recommendations. And, if you aren’t sure of something, let them know that you will check on the information, and then get back to them. If a family is not ready to talk about vaccines, let them know that as partners in caring for their child, it’s important that you can pool your collective knowledge and speak together openly about all topics. Additionally, reassure them that you respect their role as the decision maker when it comes to their child. To demonstrate that respect, use the opportunity to speak to them about keeping their unvaccinated child healthy in the community while they are considering vaccines. Discuss ways that they can do this, such as described on the Vaccine Education Center resource, “Vaccinated or Unvaccinated: What You Should Know,” available in English and Spanish (which can be photocopied for sharing).
Treating patients with care: Recognizing time continues to be a limited resource for providers, care can be demonstrated through our choice of words and topics. Address what is most important to the family by asking, “What’s your biggest concern about this vaccine?” Validate those concerns by letting families know that you, yourself, or other families in the practice have wondered about this as well. Then have a conversation about what you have found and how you have come to the conclusion that vaccination is worth it. Many providers practice the language that works best to express this until it becomes a natural part of their patient care approach.
For example, if the parent is worried that getting the HPV vaccine will promote sexual activity, don’t pivot to cervical cancer statistics. Validate that many families have asked you about this. Then, let the family know that this has been questioned since the vaccine came out, so some scientists studied it, and they found that HPV vaccination did not increase the likelihood for sexual activity.
Demonstrating character: Clinicians can make their behaviors visible through words, body language and tone. For example, consider how these two phrases sound to a parent: “Today, I’m recommending the pertussis vaccine” versus “Today, I’m recommending a vaccine to prevent whooping cough. The reason we give this to our youngest patients is that whooping cough infections in young infants makes it very hard for them to breathe, and this is the group most frequently going to the hospital for the infection.”
The second statement gives the family a sense of what you are most concerned about for their child. In areas of uncertainty, show humility by sharing what is known and what is not known, and how you weigh that information. If you are uncertain how communication is landing with families, practice with peers to assess your tone, facial expressions, and body language to identify whether you may be unintentionally communicating impatience, annoyance or dismissiveness. Likewise, tips like sitting down instead of standing and moving the computer screen out of the way to make eye contact have been shown to be remarkably important to families.
Building trust across the healthcare spectrum: Work with your entire staff to take stock of how everyone’s voices are coming together. In-the-moment dialogue with anyone within the healthcare system offers responsiveness and connection. Every conversation seeds the next. A respectful dialogue — whether or not it ends in a “yes” — builds trust for future visits and ripples outward through social networks. Positive encounters can turn individual acceptance into broader community confidence.
Unfortunately, when conversations with different healthcare workers don’t align, we lose the opportunity to build this confidence. For example, consider the parent of a 2-month-old who is due for pertussis vaccine:
- The physician says, “I strongly recommend that all babies be protected against whooping cough.”
- When the family is waiting for the immunization, they ask the nurse whether all babies get this vaccine, and she responds quickly, ”Some do. Some don’t.”
- While they are waiting at the checkout window, they hear office staff behind the window discussing another family who opted out of the vaccine, adding a negative comment about the family.
These three micro-experiences in the context of the appointment will create dissonance and leave the parent with negative emotions, whether confusion, fear or stress. Where there are different communication styles among staff, talk through the importance of sharing a common message, and ensure that everyone in the office feels comfortable to share that message in their own style. In the scenario described above, a clear response aligned with the practice message could be, “The vast majority of our patients have gotten the pertussis vaccine because we recommend it for all babies, given that whooping cough can make our littlest patients really sick.” The more we consider each encounter as part of sustained relationship-building, rather than a one-time persuasion effort, we can remove the pressure from a single encounter for both ourselves and families, while also leaving families feeling more informed, cared for, and valued as important agents in their own and their family’s healthcare decisions.
Series summary
We hope you have found this three-part series about vaccine communication to be both thought-provoking and helpful. In this moment, healthcare providers remain among the most trusted group of individuals; however, with this trust comes both responsibility and work. Restoring trust in vaccines will not come as a result of federal policies or online conversations with strangers, it will come from conversations with trusted individuals — one conversation at a time answering personal questions with respect, care and empathy. Together, families and clinicians can navigate the complex and chaotic communication environment to give children and families the best opportunity to live healthy lives.