What works with parents in promoting vaccinations
By Leah Shaffer
Almost everyone is vaccinated. “Almost everyone” means the 90 percent of U.S. children ages 1-3 that are getting the scheduled shots needed to prevent diseases such as measles, mumps, rubella, and pertussis. Just as most parents would never think to put their child in a car without a car seat, most would never prevent their child from being immunized against these potentially deadly and debilitating diseases.
But that’s not the typical story covered in the news. Search through Google news under “vaccines” and the headlines paint a very different picture: You’ll likely find stories about the resurgence of measles in pockets of the country where sizable minorities of parents opt out of vaccinating their children. You’ll probably see an image of Jenny McCarthy, a celebrity who has spread misinformation and fear about vaccinations. That’s the nature of the news business: to highlight the danger, the fear and controversy. We do have problems in this country with a resurgence of diseases like measles or pertussis. But to really improve vaccination rates, it might be time to stop focusing on those who don’t vaccinate and instead learn why most people do.
Diagnose the concern
Scientists have only recently begun testing the efficacy of vaccination messaging. Studies that address whether this messaging works are rare, says Brendan Nyhan, an assistant professor at Dartmouth College who studies political beliefs.
Nyhan is co-author of a recent study published in Pediatrics which examines the effect of different messages promoting measles-mumps-rubella (MMR) vaccination. Approximately 1700 parents participated in a web-based survey in which they responded to four pro-vaccination messages taken mostly from the CDC website. One message explained the lack of evidence linking MMR vaccines to autism; a second message highlighted the dangers of diseases prevented by the MMR vaccine; a third message showed images of children with diseases prevented by the vaccine; the fourth message was the story of an infant who almost died from measles. Here’s the bad news: None of these messages increased parental intent to vaccinate. Among parents who received the message debunking the link between vaccines and autism, intent to vaccinate actually decreased.
Nyhan wasn’t surprised by that finding. Providing parents with information refuting the link between vaccines and autism may have prompted them to think of other reasons they object to vaccines, he says.
The results were discouraging. How can public health officials encourage greater vaccination if the facts don’t sway parents?
Here is another way to think about the results. In Nyhan’s study, parents were only shown one of these messages on a computer screen in an experimental setting.
“Would two or three paragraphs be enough to change your mind about something that you were afraid of?” asked Harold Willaby, a researcher who studies how non-rational beliefs influence decisions involving risk.
“To say that it doesn’t work to talk to parents about the safety of vaccines, I think that’s an over-generalization,” says Willaby.
In the real world, people develop their views on vaccinations from many sources. A study published last year in Pediatrics (covered by Tara Haelle here) showed the major impact social networks have on how people make vaccination decisions. The study contained another notable fact. Besides their spouse, people pay the most heed to their healthcare provider’s opinion. And doctors can get better at convincing people to trust vaccinations.
Willaby and his colleagues at the University of Sydney School of Public Health are developing a communication framework to help healthcare providers address the concerns of vaccine-hesitant or vaccine-refusing parents. In Australia, 92 percent of the population is fully vaccinated by age five. Only two percent of Australia’s population are considered staunch anti-vaxxers, says Willaby. The remaining six percent are composed either of vaccine-hesitant parents, those people who might be delaying vaccines, or groups of people who have mobility or access challenges to health care.
It may sound obvious, but the simplest ways to increase vaccination rates are to first make vaccinations more available and accessible, and second, give doctors better tools to “win over” parents who are undecided about vaccines.
Willaby’s colleague at the University of Sydney, Dr. Julie Leask, has authored a set of guidelines for how doctors or nurses can engage with groups of parents, including those who unquestioningly accept vaccines, those who are hesitant, and those who refuse vaccines. Their guidelines include sample dialogues showing how health professionals can respond to questions from the different parent types. In each of these scenarios, the doctor lets the parent set the tone and course of the conversation.
“It’s not let me tell you, it’s you tell me, you tell me what you’re concerned about” says Willaby about how doctors should speak to patients.
“You’re really trying to diagnose the concern,” he says.
Emotions and facts
Improving the doctor–patient relationship and access to healthcare are obvious starting places to improve vaccination rates. But we’re still not quite there in terms of understanding what messages connect to parents outside of the doctor’s office.
A 2012 survey conducted by Women Thinking Inc., offers some insight into what messages may be most effective.
The survey: “Immunization: Myths, Misconceptions and Misinformation” was co-authored by Jamie Bernstein, who was finishing her master’s in public policy when she started volunteering with Women Think Inc.’s “Hug me, I’m Vaccinated” program. Though CDC funding for their program has since dried up, “Hug me, I’m Vaccinated,” offered booster shots for adults at various skeptic community conventions. Bernstein, with her background in market research, wanted to understand what kinds of messages would help them promote vaccinations.
“Should we be scaring parents, should we be using anecdotes? We didn’t know how to best frame our messages,” says Bernstein.
The group administered their survey at three parenting expos in Illinois, Florida, and Maryland. The objective was to understand parents who might be hesitant about vaccines.
Parents described as “vaccine hesitant” know vaccines are important, says Bernstein, but they also have vague fears about ‘toxins’ or that some ingredient in the vaccine is somehow dangerous.
This group of vaccine-hesitant parents often opts for what they might see as a compromise by delaying vaccinations until the child is older. In the survey, Bernstein found that these parents were most persuaded by the anti-vaccine message that a baby is somehow too small and fragile for vaccinations, when in fact, they are most vulnerable to disease.
Much like the Nyhan study, Bernstein also found that refuting the autism/vaccine myth did little to promote vaccination. A summary of how the study linking autism to vaccines was retracted was the least convincing pro-vaccination message they tested, she says.
“It’s too convoluted a story,” says Bernstein.
The most convincing message was not a message at all but a metaphor, the same metaphor used in the beginning of this story. That message in Bernstein’s survey was as follows:
I wouldn’t put my child into a car without a safety belt or a car seat. I won’t put my child at risk by leaving him/her without immunizations, either. It’s my responsibility to make sure my child is protected from dangerous illnesses.
Of those surveyed, 66 percent found that message to be persuasive.
“That was the most persuasive thing we could possibly tell parents was just this metaphor that vaccinating was like a car seat,” says Bernstein.
The idea that you need to appeal to people’s emotions rather than logic is a difficult concept for many in the sciences to understand. Bernstein recalls that when their organization talked to pediatricians about the survey, they got some pushback to the idea that doctors shouldn’t talk about evidence debunking the autism/vaccines link. In sample dialogue in Leask’s report, a healthcare provider addresses a vaccine-refusing parent’s autism concern without even using the word, “autism.”
Here’s the sample response:
…”Although there has been some research that raises concerns about vaccine safety, each time a concern comes up, new research is done to check whether the results are consistent or not. The vaccines that we use are very safe and serious side effects are very rare. Would you like to look at the MMR vaccine decision aid which can help you weigh up the risks of the vaccine and the diseases?”
Scientists are responding to the need for better research about vaccine messaging. In April 2014, the American Academy for Arts and Sciences released a report that offers guidelines for further research. The report, titled: “Public Trust in Vaccines: Defining a research agenda” outlines a road map for future studies in this area.
It concludes: “It is critical that government agencies and private foundations support and prioritize cross-disciplinary research on immunization decision-making, as well as evaluate the effectiveness of health communication strategies.”
Bernstein sums it up succinctly:
“We need to follow the data and we need to think about the messaging.”
[Featured image credit: David R. Tribble, used under Creative Commons Attribution Share-Alike 3.0 license]
Surveys and links:
CDC data on childhood vaccinations:
http://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/figures/2012-map.html
Effective Messages in Vaccine Promotion: A Randomized Trial
http://pediatrics.aappublications.org/content/early/2014/02/25/peds.2013-2365
Communicating with parents about vaccination: a framework for health professionals
http://www.biomedcentral.com/1471-2431/12/154
Immunization: Myths, misconceptions and misinformation
http://womenthinking.org/Vax_Survey_Report21.pdf
“Public Trust in Vaccines: Defining a research agenda”
http://www.amacad.org/multimedia/pdfs/publications/researchpapersmonographs/publicTrustVaccines.pdf