The ARM approach: Making vaccine conversations easier

What is ARM?

ARM is an evidence-based and provider-reviewed three-step approach for effective vaccine conversations.

Step 1

Act

If a parent is in your office, then assume intent to vaccinate.

Step 2

Recommend

If a parent is unsure, then recommend vaccination.

Step 3

Motivate

If a parent is hesitant, then empower them to be confident in their decision to vaccinate.

Why ARM works

ARM uses what works and builds on it. It marries proven behavior change models:

Health belief model: Focuses on a parent’s beliefs and perceptions.
Theory of planned behavior: Considers a parent’s attitude, social norms, and perceived control.
Social norms theory: Acknowledges behavior is influenced by normative perceptions.
Motivational interviewing: Uses a parent-centered counseling approach.

ARM’s integrated approach uses these behavior change models to provide a strong foundation for successful vaccine conversations.

Who is ARM for?

ARM is for all health care providers (HCPs):

Newer HCPs: ARM provides a blueprint for more confident conversations.
Experienced HCPs: ARM combines proven tactics in a time-saving approach.

The Immunization Challenge

Most parents vaccinate their children, but the number of children not up to date on their routine vaccines has increased since the COVID-19 pandemic. From January to September 2020, there was up to a 26% drop in polio, MMR, and DTaP vaccinations.source: ¹

But there is good news:

76% of parents “have a lot of trust” in their child’s doctor when it comes to vaccine information.source: ²

About half of hesitant parents will eventually vaccinate their child when a provider discusses their concerns and provides positive recommendations at each visit.source: ³

What you say makes a difference.

HOW you say it matters even more.

How to use ARM

ARM uses three steps that are important in building a parent’s confidence and self-efficacy when it comes to vaccinating their child. The steps are designed to build on each other to help a parent feel in control of their child’s health.

Step 1

Act

If a parent is in your office, then assume they intend to vaccinate their child.

This step is all about the words you choose:

Use a presumptive “act now” approach that reinforces the norm.

Make statements, rather than ask questions. But take care to ensure they are inclusive statements, not authoritative statements.

Using inclusive language like “let’s” can help parents know this is a decision you want to make with them, not for them.

“Let’s” is a powerful word. It signals a participatory approach that empowers parents as co-decision makers. The participatory approach is newer and may feel strange to more established HCPs, but it has been proven effective. Empowered parents are likely to make different choices than those who are simply advised by an HCP.source: ⁴

What to Say to Parents
Say this...	Not that...
Your child needs the meningitis vaccine. Let’s give that at the end of the visit.	Do you want your child to get their meningitis vaccine today?
Today, let’s get your child up to date and fully protected against measles, mumps, and rubella.	How do you feel about your child getting the MMR vaccine today?
Flu season is around the corner, so let’s make sure your child gets the flu vaccine today.	What would you like to do about the flu vaccine today?

I noticed a huge difference in the last 2 years because I started using ‘they need this’ and ‘let’s do it at the end of the visit.’ We have had a good increase in vaccines in my office by approaching it this way. If they say they want to research it, I say okay, let’s make another appointment.

— Pediatric Nurse Practitioner

Keys to successful storytelling:

Identify stories for common concerns so you are ready to share.
Practice your stories so they are short but compelling.
Make them personal. We all have children we love even if we are not parents.

One in 3 parents who initially refuse a vaccine will choose to vaccinate after receiving education that addresses their questions and concerns.source: ⁸

Brainstorm with your staff about how to address these questions and concerns beyond conversations in the exam room.

The Anatomy of a Strong and Effective Recommendation

Four Principles for a Strong and Effective Communication
What	Why	How
Communicate the benefits	Reinforces a parent’s desire to prevent their child from getting sick and the effectiveness of the vaccine in doing that. Health Belief Model	“I recommend Jack gets the chickenpox vaccine today to make sure he is protected before he’s most likely to be exposed to chickenpox.”
Share personal, positive vaccination experiences	Signals that you are part of the norm, and you are asking them to join and boost parents’ confidence. Social Norms Theory	“I made sure my son got the chickenpox vaccine on time. There was an outbreak at his school. Because he was protected, he didn’t miss school or his soccer tournament.”
Acknowledge and respond to questions and concerns	Tailors your answers to help a parent understand the susceptibility and potential severity of the vaccine-preventable disease. Health Belief Model	“It’s true that chickenpox is mild or moderate for most kids, but some will have serious problems like pneumonia. Plus, chickenpox puts Jordan at risk for shingles later in life.”
Restate the benefits	Ends on a positive note and identifies motivational factors that could influence behavior. Theory of Planned Behavior	“With school starting, let’s get Sally caught up on her chickenpox vaccine. If she’s vaccinated, she’ll be less likely to miss school because she got sick. She’ll also have a lower risk of developing shingles later in life.”

Step 3

Motivate

Empower hesitant parents to be confident in their decision to vaccinate.

Maintaining the patient–provider relationship is an important goal in what can sometimes feel like emotionally charged conversations. When parents have questions or concerns, how you respond is almost as important as the answers themselves. Listen to questions or concerns and respond with:

Patience
Empathy
Respect

Important notes about Step 3:

For some HCPs, asking permission and affirming autonomy can feel foreign. But evidence shows us that parents who feel in control of their child’s health are empowered to make positive health decisions.

Use these best practices to make an informed health decision

Best Practices to Motivate Parents
Best Practice	Example
Identify the single biggest concern. This way you can tailor your answer to provide them with the information they really need.	“What’s the most important question that you have about this vaccine?”
Validate their questions. Empathizing with parents and validating their questions builds trust.	“It’s okay to have questions. Some other parents have asked me the same thing.”
Find common ground. Finding something you both agree on helps parents feel heard and understood.	“We both want the same thing—for Alesha to be as healthy as possible.”
Affirm their autonomy. Reinforce that you respect that vaccination is their decision. Your job is to answer their questions.	“This is your decision. I just want to make sure you have the information you need to make an informed decision.”
Ask permission. Don’t share information until you’ve asked them if that is okay. Parents need to feel in control of the conversation.	“Can I share with you some information I think you may find useful?”
Find their own personal motivation. Ask how their child getting a vaccine-preventable disease could negatively impact their family. Affirm the vaccine’s ability to mitigate that.	“What would your family miss out on if Brittany got chickenpox?” “If she’s vaccinated, you don’t have to worry that chickenpox will ruin the trip to visit the grandparents.”

Tips and timesavers:

Train staff to remind parents about upcoming vaccines at checkout and in appointment reminders.
Reinforce the social norm of on-time routine vaccination in communications and health portals.
Use reminder/recall systems to get in touch with parents whose children are not up to date.
Through reminder/recall systems or a message via your patient portal, encourage them to visit LetsGetReal.hhs.gov before an appointment to learn about the vaccines their child is due for.
Tailor your approach based on your knowledge of what you think will be most effective with each parent.

Some parents just want the facts—answering their question may be enough for them. Others want to contextualize the facts—they will appreciate hearing your story.

Encourage your staff to come up with their own personal stories about positive vaccine experiences and share them with parents.

What if a parent remains hesitant?

Vaccine hesitancy is a continuum—some parents may need quick answers and others need time.

Don’t give up! Encourage parents to schedule a follow-up appointment before they leave the office. Use the ARM approach to continue the conversation at their next visit.
Refer parents to LetsGetReal.hhs.gov as a trusted source for information about vaccines and the diseases they prevent.
If your office uses an online portal, then invite parents to submit questions through the portal as they continue their research. Letting them know you are available to help can make them feel more confident.

The best option is to prevent vaccine hesitancy altogether, so have conversations early and often. Reinforce the benefits of vaccination and signal that it is a norm at every opportunity. Although it may seem time consuming, once your practice has the ARM approach down, it takes little time. And the more vaccinated children in your practice, the less time you have to spend treating vaccine-preventable diseases.

About us

The ARM approach is part of the Let's Get Real campaign to reinforce on-time vaccination as the norm. The campaign is led by the U.S. Department of Health and Human Services (HHS) Office of Infectious Disease and HIV/AIDS Policy (OIDP) with public health and community partners. We thank you and all health care providers for making strong vaccine recommendations and ensuring the health and safety of our children.

The ARM approach: Making vaccine conversations easier

What is ARM?

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Why ARM works