Rights of Parents to Vaccinate or Not Peer Review Article

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Addressing Parental Vaccine Concerns: Engagement, Rest, and Timing

• Jason M. Glanz,
• Courtney R. Kraus,
• Matthew F. Daley

x

• Published: August 7, 2015
• https://doi.org/ten.1371/periodical.pbio.1002227

Abstract

The recent United States measles epidemic has sparked some other contentious national word about childhood vaccination. A growing number of parents are expressing concerns most the condom of vaccines, often fueled by misinformation from the internet, books, and other nonmedical sources. Many of these concerned parents are choosing to turn down or delay childhood vaccines, placing their children and surrounding communities at risk for serious diseases that are nigh 100% preventable with vaccination. Betwixt 10% and 15% of parents are asking physicians to space out the timing of vaccines, which frequently poses an ethical dilemma for physicians. This trend reflects a tension between personal freedom and public health, equally parents fight to control the decisions that affect the health of their children and public health officials strive to maintain high immunization rates to prevent outbreaks of vaccine-preventable diseases. Interventions to address this emerging public health issue are needed. We describe a framework past which spider web-based interventions can be used to aid parents make evidence-based decisions virtually childhood vaccinations.

Citation: Glanz JM, Kraus CR, Daley MF (2015) Addressing Parental Vaccine Concerns: Engagement, Balance, and Timing. PLoS Biol 13(8): e1002227. https://doi.org/ten.1371/periodical.pbio.1002227

Published: August 7, 2015

Copyright: © 2015 Glanz et al. This is an open admission article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Funding: This manuscript was supported past a research grant from the Agency for Healthcare Research and Quality (R01HS021492). The funders had no role in study design, data collection and assay, decision to publish, or preparation of the manuscript.

Competing interests: The authors accept declared that no competing interests exist.

Near the Writer

Jason Glanz, PhD, is an epidemiologist and senior inquiry investigator at Kaiser Permanente Colorado, Institute for Health Research. He is also an assistant professor in the Department of Epidemiology, Colorado School of Public Health. Dr. Glanz's research focuses on vaccine safe and vaccine hesitancy. Dr. Glanz is currently a principal investigator with the Vaccine Condom Datalink, a national Centers for Illness Command and Prevention (CDC)-funded projection that examines the rubber of vaccines. Dr. Glanz too leads enquiry efforts to develop adventure communication strategies to assistance reduce parental vaccination concerns.

Introduction

In response to the recent US measles epidemic (that started in Disneyland of all places), vaccines accept one time again become the focus of a vigorous and contentious national discussion. The most recent controversy stems from evidence linking the outbreak to vacationing children who were intentionally unvaccinated, probable out of concerns that the risks of vaccination outweigh the benefits [one,ii]. Media outlets sometimes refer to the parents of these children as "anti-vaxxers"—a pejorative term suggesting that such parents are combative towards science. In public wellness, we prefer to use the term "vaccine hesitant," which has evolved into an sick-defined concept roofing any parent with concerns about the condom of babyhood vaccination. However we narrate these parents, vaccine concerns are leading to behaviors that threaten the health of children and the communities they live in.

The issue of vaccine hesitancy tin be examined from several different angles, many of which betoken to the delicate residual betwixt personal liberty and public health. On one paw, in this age of shared decision making in health care, parents want control over the decisions that affect the wellness of their children. Ideally, parents would like to be armed with authentic scientific information and then that they tin objectively weigh the benefits and risks of vaccination and make informed decisions about immunizing their children. Through this process, some would argue, parents should have the correct to refuse vaccines for their children.

On the other manus, it is essential to maintain loftier immunization rates to go along vaccine-preventable diseases at bay. In the case of measles, approximately 95% of the population needs to be immunized to prevent outbreaks. High vaccination rates, in turn, provide protection to vulnerable populations, such equally those who cannot receive vaccinations for medical reasons, those whose immune systems do not reply to vaccines (vaccine failure), and children who are too young to be vaccinated. Compulsory vaccination laws help ensure that these vulnerable populations are protected. Mandatory schoolhouse immunization laws in particular take been instrumental in helping to eradicate or control diseases that were in one case responsible for thousands of hospitalizations and deaths in the US each year [3,4].

In the past, when vaccine-preventable diseases were notwithstanding prevalent in the U.s., it was abundantly articulate to parents that the benefits of vaccination profoundly outweighed the risks. Although pockets of vaccine resistance have existed since the start of vaccination, confidence in our national immunization program was high—physicians recommended vaccines, schools required them, and parents vaccinated their children [5]. Today, public trust in this model appears to be eroding to some extent. While vaccination remains the norm and immunization rates in the US are at an all-time high, national survey data testify that greater than 20% of parents have concerns about the safety of babyhood vaccination [6,7]. Xx states at present permit personal belief exemptions to school immunization requirements, which allow parents to opt out of vaccinations at school entry if they have a "philosophical" objection to them. Over the last two decades, a growing number of parents accept been choosing to refuse or delay vaccines for their children. Between 10% and 15% of parents are requesting what are known every bit "alternative immunization schedules," in which the spacing and timing of the vaccines are determined by the parent and not based on scientific evidence [8,9]. Research has shown that children on these alternative (or delayed) schedules are at profoundly increased run a risk for pertussis, pneumococcus, and varicella infection [x–12].

Requests for alternative schedules pose an ethical dilemma for physicians. They have to simultaneously respect the parent's right to choose and consider what is all-time for the wellness of the child and community. Persuading parents to immunize can be an uphill boxing, as parents may come to cheque-up visits armed with data gathered from the internet, books, and other nonmedical sources that question the safety of vaccines. This prompts a negotiation between physicians and vaccine-hesitant parents, and physicians frequently accept to invest substantial time during the 20-minute check-upwards visits trying to refute the misinformation. These visits may, in turn, cease with the child leaving the doctor's role underimmunized, having received but a subset of the recommended vaccines [13–17].

The increasing prevalence of parental vaccine concerns and the pressure information technology places on doctors are conspicuously pressing public health bug. Medical providers, policy makers, and researchers are all trying to figure out how to influence parental immunization attitudes and behaviors. It's becoming apparent that we likely need better doc–patient communication strategies, public health messaging campaigns, reliable spider web-based resource for parents, and stronger mandatory immunization laws. Recently, there have been vigorous discussions centered around strengthening country-level schoolhouse immunization mandates. For case, in California, a bill (SB277) that eliminates personal belief exemptions to vaccination faced strident, song opposition as it progressed through the land legislature [18]. Although the pecker was recently signed into law, political obstacles may be insurmountable in other states. For the other strategies to boost vaccine acceptance, we need interventions designed to examination whether or not the strategies help parents in the determination-making procedure for vaccination.

Testing Strategies to Help Parents Make Evidence-Based Decisions about Vaccines

Numerous intervention studies accept examined approaches to encourage vaccination. These include online decision aids, reminder/recall systems, patient and provider education, provider communication techniques, and financial incentives [xvi,xix–24]. However, systematic reviews (including a review of published reviews) concluded that disarming show to support any intervention to specifically address vaccine hesitancy is lacking [25–27]. Contempo studies show that stiff provider recommendations and individually tailored approaches may be effective in increasing vaccine acceptance [28,29]. However, the results from these investigations are preliminary and demand farther written report. In full general, nigh studies in this expanse have either been observational or underpowered (i.due east., small sample sizes) or have measured immunization attitudes and intentions rather than actual immunization behaviors as outcomes.

At Kaiser Permanente Colorado, we are one of several inquiry groups that accept started to develop and test interventions targeting parental vaccine hesitancy. Nosotros are currently conducting a randomized intervention trial to evaluate the effectiveness of a web-based resource that applies interactive social media technologies (blogs, discussion forums, and conversation rooms) to engage parents, allay their concerns, and touch their immunization beliefs. The evolution of this intervention was informed by a theoretical framework, existing evidence, and data collected from focus groups, surveys, in-depth interviews, and usability testing with a diverse group of parents [fourteen,30]. Through this formative enquiry, we have identified and have been applying the following themes in our intervention study: engagement, balance, and timing.

Appointment

Increasingly, social media interventions are being used to promote health and behavior change across an array of health domains, including weight loss, smoking abeyance, concrete activity, and sexual health [31]. One theoretical basis for using social media is the multidirectional communication model, a social marketing framework that specifies a top-down, side-to-side, and lesser-up process for creating, presenting, and sharing information [32]. Acme down refers to a traditional approach (spider web 1.0) in which web developers simply nowadays information to users. Side to side and bottom upwards stand for dynamic communication modes by which users can create and share content (web two.0). The objective is to empower and engage users through open give-and-take and idea sharing.

The internet is rife with vaccine information that ranges from supportive to highly disquisitional. Typically, vaccine advocates accept employed the top-downwardly arroyo to disseminate evidence-based data. These online resources are frequently sponsored by authorities agencies, public health departments, pharmaceutical companies, universities, and advocacy groups. Survey enquiry has shown, notwithstanding, that vaccine-hesitant parents in particular tend to exist distrustful of such sponsors [33–35,six]. Moreover, the websites primarily present factual information that may seem dry and impersonal, and the extent to which they can engage parents is limited. While the Centers for Disease Control and Prevention (CDC) has adult a detailed website with useful information, parents in our studies have told u.s.a. anecdotally that they find it difficult to navigate and wish that it had outlets to enquire questions or interact with other users. It is therefore unclear if such height-downwards information-focused resources have a positive impact on parent conclusion making in regards to vaccines [26]. In fact, a recent study showed that presenting vaccine-hesitant parents with prove-based information from government health agencies actually decreased their intentions to vaccinate [36].

Antivaccination advocates, in contrast, tend to use side-to-side and bottom-upward approaches to present their messages on the cyberspace. These groups are particularly good at using social media to spread misinformation, frequently in the course of narratives and personal testimonials to entreatment to parents' emotions [37]. There are also numerous parenting blogs and discussion forums that promote conversations near vaccines among online communities of bearding users. While the touch and reach of these forums is not known, they represent a potential source of misinformation that could be influencing parents' vaccine decisions. In contempo years, responding to vaccine concerns has felt similar the onetime arcade game of "whack-a-mole"—a new concern arises, information technology gets refuted with scientific discipline, and another new business organisation speedily pops upwardly to take its place. It seems like antivaccine groups have been able to exacerbate this bike with the internet and social media.

All of these factors led usa to develop a hybrid intervention approach that combines show-based vaccine information with interactive outlets for parents to discuss vaccine-related topics with physicians, experts, and other parents. This type of spider web-based resource could not only empower parents by encouraging them to ask questions and voice their concerns merely also allow website staff to quickly quash new vaccine-related rumors as they arise. To maintain a respectful environment, the website staff would also take to carefully fact-check the content and moderate the forums. The objective is to plant rapport with parents, build trust, and combat misinformation. Of course, creating such an surroundings poses many challenges, and nosotros are hoping that our intervention volition provide some useful data on its feasibility and effectiveness.

Residue

A child's medical provider is frequently the about trusted source of health data for parents [four]. Our inquiry has shown that even parents who refuse or delay babyhood vaccinations express a loftier level of trust in their doctors' advice on diet, beliefs, and development [fourteen]. However, as expected, these hesitant parents also tend to be skeptical of their doctor'due south communication on vaccines. They further report that their child'due south doctor is much more likely to describe the "pros rather than the cons" of vaccination, and parents limited a desire for more "balanced" information [38]. To some parents, residual likely implies receiving only as much information on the risks as on the benefits of vaccination. To a medical provider, balance should reflect the state of the scientific bear witness, which warrants placing much more emphasis on the benefits than the risks. Nevertheless, when physicians talk over vaccines with parents, it may seem as though they are withholding information on the risks.

It is not entirely clear how to span the gap between parents' and providers' perceptions of balance. Although there is a vast literature on how to communicate risk to patients [39–41], vaccines pose some unique challenges. On the surface, conveying the benefits and risks of vaccination seems like information technology would be straightforward—vaccines are highly effective at preventing serious diseases and severe side furnishings are rare. Even so, because of broad-calibration vaccination, most vaccine-preventable diseases are also very rare in the U.s.. Children are generally at low risk for contracting a vaccine-preventable disease, and quantifying individual adventure is difficult because it depends on numerous factors. A child'south take a chance for disease is often determined by where the family lives, where they travel, who the child plays with, and the child'south immunity. This implies that physicians may have to engage in lengthy, nuanced conversations in club to paint a truly balanced picture for hesitant parents. Such conversations would have to simultaneously comprehend the individual- and customs-level benefits of vaccination and the seriousness of vaccine-preventable diseases, also as the risks of side effects.

Given the complexity of the topic, communication gaps are to exist expected. This complexity argues for additional preparation to help physicians accurately communicate risk data, in addition to trusted educational resources to help parents digest vast amounts of scientific information. One possible communication approach is to merely state the risks of vaccination. Explicitly acknowledging the risks—which are real but rare—may ease the concerns of parents who believe that information is being hidden from them and facilitate trust [38]. Based on our determinative research, for example, parents were adamant that our intervention website prominently brandish and explain the known side furnishings of vaccination. Whether or not such an arroyo is persuasive remains to be formally evaluated in our ongoing intervention trial.

Timing

Determining when parents should receive vaccine information is important to an intervention's success. Our research has shown that virtually vaccine-hesitant parents first to seriously retrieve about vaccines while pregnant [14,42–44]. Other parents told united states that the first time they received vaccine information was at the routine cheque-up visits, in the form of vaccine information statements (VIS) created by the CDC. Parents further stress that receiving this information so shut to the actual vaccination of their child does not give them enough time to fully process the data. Lastly, vaccine-hesitant parents report that their vaccine decisions are constantly evolving over fourth dimension. Some parents who refuse or delay vaccines draw themselves equally existence on "hyper alert," worried that their decisions may be putting their kid at take a chance for infection. These information suggest that parents' immunization behavior are not necessarily entrenched and that interventions should be implemented early during pregnancy and keep throughout the first several years of the infant's life.

Conclusion

Resistance to childhood vaccination is a concerning public health issue. However, in attempting to address vaccine resistance, information technology's important to continue in mind that parents are only trying to exercise what is best for the health of their children. Many parents who worry about the risks of vaccination sift through an immense amount of material on vaccines, and physicians often find themselves having to competition the misinformation during short check-up visits at which there are other important topics to cover. Information technology's clear that nosotros demand improve ways to inform and appoint vaccine-hesitant parents. While interactive web-based technologies represent a promising approach, researchers should continue to experiment with strategies that focus on engaging parents with thoughtfully presented, evidenced-based information. Ultimately, successful interventions volition be those that build trust, reduce concerns about unfounded risks of vaccines, and help parents understand that vaccinating on schedule is in the best interests of everyone, including their ain children.

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