The SAGE Working Group on Vaccine Hesitancy concluded that vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. It is characterized by different factors in different contexts (political, ideological, social, etc.). Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines. [1]

When approaching a hesitant parent, one must never forget that all his doubts are dictated by a strong perception of risk and by the consequent concern for the safety of his offspring. In this context, information concerning the “danger” or the factor considered as such, is connected and elaborated not only at the cortical level, but also in the limbic system which, thanks to its connections with the pre-frontal cortex, comes into play in the decision-making process, based on emotional reactions.

For this reason, any information you want to transmit to the defaulting mother or father, this must be simple, immediate and preferably proposed using the visual means (eg: simple graphs or sample images that can visually reproduce what you intend to explain), according to the rules of cognitive ergonomics. [2]

In the United States in 2010 Dr. Singer developed a communication model that, referring to Aristotelian rhetoric, provides an effective and efficient approach to communicate with the hesitant parents (C.A.S.E. approach). C.A.S.E. is an acronym that identifies the four phases of the communicative approach, Corroborate, About me, Science, Explain / advise (Fig.1). [2,3]

The first phase, Corroboration, which coincides with the Aristotelian technique of pathos, consists in proving emphatic towards parents who do not want to vaccinate their children, that is to listen, welcome and understand their doubts and their fears. Parents must perceive that who they are in front of is not an enemy whose purpose is to oppose them and impose on them a different way of thinking and acting, but it is a person who shares their primary interest, the health of the child. To achieve this, it is very important to find a point of agreement from which to start. [3,4]

In the second phase, About me, or ethos according to Aristotle’s rhetoric, the health worker should explain to parents what is his working mission (e. g. to advance the health of all people, the children’s sake) and what path he has taken to realize it (the studies, conferences or courses in which he participated, various studies). [3,4] The objective is to qualify the speaker, increasing its credibility and making it an authoritative source of information.

The logos of Aristotle is taken up again in the Science phase of Dr. Singer, in which the scientific evidence about the vaccines is presented to the parents. [3,4] It is in this phase when the cognitive ergonomics, mentioned above, comes into play strongly. To make the interview less dispersive, it is advisable for the doctor, already in the corroboration phase, to let the parents express the factors of greatest concern. This on one hand allows to partially reduce the anxiety of mothers and fathers, on the other hand allows the doctor to focus only on some aspects related to the vaccines and not on all the knowledge about the subject.

Fig. 1 Example of C.A.S.E. approach proposed by dr. Singer (2010)

Finally, to conclude the interview, the explain / advise phase should allow to sum up what has been said and give advice to the hesitant parents based on scientific evidence. [4]

The effectiveness of the C.A.S.E. method against hesitant parents has not yet been evaluated in any study. Therefore, assessing effectiveness in the field would be appropriate.

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References

  1. Mac Donald N, the SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine 33(2015) 4161-4164 2)
  2. Pezzullo L. “The psychological mechanisms underlying the fear of the vaccine”. From the Congress “Vaccines, how to embrace and dispel parents’ doubts”. Treviso, 3rd February 2018
  3. Singer A. Making the CASE for vaccines: A new model for talking to parents about vaccines. NJP CORE VFC Conference 2010. Retrieved from http://www.aapnj.org/uploadfiles/documents/f73.pd
  4. Stevens JC. The C.A.S.E. approach (Corroboration, About me, Science, Explain/advise): improving communication with vaccine-hesitant parent. https://arizona.openrepository.com/ ,2016

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Davide Pezzato
School of Specialization in Hygiene and Preventive Medicine – University of Padua, Italy

Stefania Bellio
School of Specialization in Hygiene and Preventive Medicine – University of Padua, Italy