Commentary on “Parental vaccine-hesitancy: Understanding the problem and searching for a resolution”

Abstract

The increasing numbers of vaccine-hesitant parents poses a threat to personal and public health through a resurgence of vaccine-preventable diseases. Understanding the factors underlying vaccine-hesitant parents’ fears is a necessary step toward designing interventions to overcome them. Educational interventions appear more successful when combined with personal interactions. Providers are the most important influence on parental vaccine decisions. Research should focus on designing effective interventions that facilitate effective parent-provider communication around this issue

Keywords:

• effective communication
• factors
• vaccination
• vaccine hesitancy
• vaccine-preventable disease
• parent provider communication
• safety

Abbreviation:

• VPD, Vaccine-preventable Diseases

The paper by Williams,¹ addresses a very important issue that poses a risk for personal, community and public health. There are many reasons why children are under-immunized, including economic and social disparities. Increasing numbers of parents who are vaccine-hesitant and deliberately seek delayed or alternate vaccination schedules for their children is a matter of great concern in an era when outbreaks of previously well-controlled vaccine preventable diseases (VPD), such as measles or pertussis, are reported.^2-3 This report is timely because recent US data show that under-vaccination of children is a national trend and no longer confined to states where philosophical exemptions from immunization mandates are easily obtained.⁴ Recognizing the problem of vaccine-hesitancy, as Williams correctly emphasizes, is only the first step. Understanding the factors that motivate and drive vaccine-hesitant behavior is a necessary pre-requisite to reaching a solution.

Concerns about vaccine safety are the dominant factor influencing those who refuse vaccines.⁵ Historically, while specific fears have changed over the years, the general themes behind those fears remain remarkably constant-namely that vaccines are “unnatural” and not effective, contain harmful ingredients (and the targeted ingredient may change over time as science proves the safety of initial target), that vaccination overwhelms the immune system, and that immunity from natural disease is superior to vaccine-induced immunity, always assuming that one survives the natural disease, preferably without long-term sequelae.⁶ These fears are exacerbated in the modern era by an under-appreciation for the dangers posed by VPDs, simply because robust immunization programs mean VPDs are uncommon, thereby inappropriately skewing the perceived threat construct for many vaccine-hesitant parents.⁷ The influence of print and broadcast media, internet and social media sources on parents exacerbates this parental misperception of harm from vaccines,⁸ because they may perpetuate misinformation simply by repeating it, and because they often include emotionally-charged personal accounts of children apparently harmed by vaccines to which parents easily relate. Pro-vaccine advocates and websites often find it difficult to counterbalance such messages and effectively communicate the science to counter these arguments. Put simply, it is more difficult to “take away the fear” once doubts have been raised. In this instance framing the message as a positive one, namely that vaccines are safe and are the most effective means to protect you and your child from disease, needs to be the focus of such interventions. Countering successful anti-vaccine strategies such as personal storytelling, but focusing on first person accounts of harmful effects of VPDs while stressing the benefits of vaccination may be beneficial. Quantifying the benefit of such strategies should remain the focus of future research.

Interventions focusing on reducing vaccine-hesitancy, both for routine vaccines and HPV were critically evaluated by Williams.¹ These studies suggested that providing educational materials that were tailored to the needs of the population targeted, either by age for school based intervention or culturally appropriate for other populations, has a positive effect on attitudes and in some cases vaccination rates.^9-15 These studies also highlight 2 important points in designing interventions. First, understanding the particular fears and hesitancies of your target individual or population is crucial. Second and very importantly, educational aids may be more effective when they are delivered in conjunction with personal interaction with a knowledgeable source such as a researcher in the field.¹² These data support findings by Nyhan and colleagues that educational aids used without personal interaction to place them in their proper context may have unintended consequences such as increasing misperceptions among vaccine-hesitant parents.¹⁵ In practice, this knowledgeable source will most often be a healthcare provider, the person who is, for even vaccine-hesitant parents, the most important influence on their ultimate decision on vaccination.^{5, 16-20}

Providers have an essential role in ensuring that individuals and the community receive vaccines in a timely fashion and the difficult task of reassuring vaccine-hesitant parents falls ultimately to them. Understanding the specific concerns of vaccine-hesitant parents is demanding and time-consuming, especially for providers with a busy clinical schedule, but is very worthwhile. A recent study demonstrated that providers may make inaccurate assumptions about parental attitudes to vaccines.²¹ It is possible that provider misperceptions of parental attitudes, combined with the same societal and media influences that parents are subjected to, make providers reluctant to engage with parents about this topic with subsequent effects on parent-provider interactions and behavior. Further, non-physician providers may have personal concerns about vaccine safety leading to vaccine-hesitant parents receiving inconsistent messages during healthcare encounters which may exacerbate the problem.

Resources to educate providers about vaccines are available from a number of sources along with guidance on possible communication strategies;⁶ these strategies need to be tailored to the individual.¹ In addition while some providers may be tempted to allow delayed or alternative schedules in the interest of maintaining the provider-patient relationship, providers should be cognizant that such schedules are not founded in science, are cumbersome, encompass multiple visits thereby increasing the likelihood of non-compliance, and most importantly leave children unnecessarily vulnerable to acquiring serious, potentially fatal VPDs.²² Finally, assuming that the ultimate parental decision will be in favor of vaccinating their child and incorporating that assumption into the discussion seems to be more effective than other styles of discussion, and such a discussion style is still compatible with allowing parental participation and effectively addressing parental concerns.²³

In conclusion, as outlined by Williams¹ the problem of vaccine hesitancy is not easily remedied. The ultimate parental decision regarding the vaccination of a child is a complex interaction of social, practical and other factors, some of which are poorly understood. Educational tools appear to have an important role in helping parents negotiate these factors. The effectiveness of the provider-parent interaction, however, appears to be a key determinant in ensuring success. Education, advocacy and research efforts will need to specifically target this interaction and develop resources that enhance the ability of providers to allay parental fears and misperceptions and ensure personal and public health is improved through achieving high vaccination rates.

Disclosure of Potential Conflicts of Interest

Dr. Healy has received research grants from Sanofi Pasteur and Novartis Vaccines and serves on an Advisory Board for Novartis Vaccines and Pfizer Inc.