Issues with Parental Refusal of Vaccinations: Critiques and Recommendations using Social Science Theories -Mary Gaeddert

Introduction
Vaccinations are widely viewed as one of the best preventive measures in public health that have dramatically reduced the burden of disease. However, not everyone shares that opinion, and there is a vocal group of people that openly question and criticize vaccines. As a result of this distrust of vaccines, there has been a growing number of parents who are refusing some or all of the recommended vaccinations for their children.
A large part of this debate is focused around the claim that the MMR (measles-mumps-rubella) vaccine causes autism. This was based on a study published in 1998 by Andrew Wakefield which sparked an international crisis of confidence in the safety of the MMR vaccine. Although this paper has been widely discredited by the scientific community and even retracted by the Lancet (1), the damage has been done to the public perception of vaccine safety.
The refusal of some parents to have their children vaccinated has led to a growing number of children who are susceptible to vaccine-preventable diseases. This has led to weakening of herd immunity and more outbreaks of measles, mumps, and other vaccine-preventable diseases. A current example of this is the outbreak of mumps going on in the New York-New Jersey area; over 1500 cases have been reported since June of 2009, and is the largest mumps outbreak in the US since 2006 (2).
The issue of parental vaccine refusal and outbreaks of disease is a public health problem that had been receiving more recognition from medical and public health professionals recently. One example is a study done looking at a outbreak of measles in San Diego in 2008 in which the authors discuss the role of the intentionally under-vaccinated (3). This paper will critique the existing approach to this public health issue and provide recommendations for an alternative approach focusing on three elements: framing of the issue, comprehensive national response, and the doctor-parent interaction.

Critique 1: Framing the Issue
People often act irrationally, and one example of this irrationality is the concept of “framing”: the way in which the issue is framed, or presented, has a huge effect on how it is viewed and accepted. Two equivalent outcomes of a decision can be presented in either positive or negative terms, and the positively framed messages will be more effective than negatively framed ones for increasing prevention behaviors (4). Framing has been found to have a biological basis, which shows a key role for the emotional part of the brain in mediating decision-making (5).
The way that vaccinations are currently framed by the majority of medical and public health professionals is that vaccines are wonderful, have minimal risks, the benefits far outweigh any risks, and that all children should get every recommended vaccine on schedule from their doctor. However, the anti-vaccine movement frames the issue in a much more negative light. Many parents are focused on the harm posed to their children by vaccines which they do not feel are safe.
A study was done analyzing the growing number of anti-vaccination websites, and reveals the main concerns and arguments. Anti-vaccine groups avoid using the term “immunization” because they do not believe that vaccines provide immunity. Every site reviewed in the study made claims that vaccines are poisonous, cause illness, and weaken the immune system. They assert that vaccine-preventable diseases are trivial, and do not acknowledge the serious complications of these diseases. Alternative and naturopathic medicine are common themes. Claims of conspiracy theories are also common themes. Most of these websites reject the scientific data supporting the safety and efficacy of vaccines, showing an overall lack of trust in the scientific and medical establishments. This lack of trust in published research, rejection of expert opinion, and fear of conspiracies in the system reveal how large the gap is in framing the issue of vaccines (6).
This study also shows how opposition to vaccines has created a counter-culture movement, where the social norm is rejection of vaccination and the traditional medical establishment. Several social-behavioral models, including the Theory of Planned Behavior, used the component of social norms. This can be described as subjective norms that predict whether a certain behavior, like vaccination, will be approved or disapproved by the social group influencing an individual, such a parent (7). This use of social norms accounts for the social context surrounding someone’s decision making. So if a parent is influenced by this anti-vaccination movement, social norms may play a role in predicting whether or not the parent will vaccinate their child. Because this movement frames the medical establishment and doctors in general and not trustworthy, it may have the additional impact of negating any positively framed messages about vaccines that come from the child’s pediatrician (6).

Critique 2: Lack of National Level Response
One of the main criticisms of this paper is that there has not been a coordinated response on the national level that is publicly visible. In general, the topic of vaccination, framed in a positive way from public health groups, is generally not visible. One of the exceptions has been during the H1N1 flu pandemic when a large effort was made to promote flu vaccination to the general public, and was accompanied by reassurances about the safety of the flu vaccine.
The current coordination of vaccination issues is led by the Centers for Disease Control and Prevention, which publishes information and recommendations (www.cdc.gov/vaccines). An example of a current public health effort relating to vaccinations is the “Project Tomorrow” campaign led by the American Academy of Pediatrics; this is a national education awareness campaign designed to promote the importance of vaccines and encourage parents to talk to their doctors.
Outbreaks of vaccine-preventable diseases, such as those mentioned in the introduction (3), are often handled by the local public health departments. The focus in those situations is to control the outbreak immediately, and there may not be funding or resources available to do large-scale educational campaigns. The only public communication about the outbreak may be press releases made after the outbreak has started (2). This approach to situation waits until an outbreak begins, and reacts to it, instead of working more proactively to prevent outbreaks.
In contrast to the relative silence of public health officials on vaccine safety at a national level, the media is constantly reporting the opposite side. The media has an influential role during vaccine scares, and the influence of press coverage has been found to effect parental acceptance or non-acceptance of vaccines (4). A brief glance through news headlines on the topic of vaccines will show that media outlets have picked up on the negative framing of the issue. Most stories talk about controversies in vaccine safety, like how vaccines are dangerous and cause side-effects. Celebrities go on talk shows describing how the MMR vaccine caused autism in their child. These stories are sensational and make strong emotional appeals, and while lacking the rigor of scientific research publications, have a stronger impact on public opinion.
So, as a result of a steady stream of negative information coming from the media, and not very much positive information coming from public health officials, the public associates vaccines more with risks of receiving the vaccine itself than with the benefit of disease prevention. Another factor at work is that many of the diseases prevented by vaccines are no longer common, so many parents today have not seen any active cases of measles or mumps. This leads to an underestimation of the severity of the vaccine-preventable diseases, many of which can be fatal or leave the child with permanent disabilities (8).
There are also social-behavioral factors at play. The availability heuristic describes how people tend to infer general truth from a vivid example. Perceived risk often does not align with actual risks because people judge the likelihood of something happening based on how easily and example of it comes to mind (9). Another piece of irrationality at work is the law of small numbers: people view a small sample randomly drawn from a population as highly representative, and are over-confident that the conclusions based on small samples are valid (10).
This explains why powerful stories that can be easily recalled are more compelling that statistics and data. And why one heart-wrenching story on the news about a child who died after receiving a vaccine seems to be representative of all children at risk for vaccine side-effects. While it would seem rational to present numerous studies on the the safety of vaccines and rarity of severe adverse events, it is hard to counter these few emotional examples with volumes of scientific data. In contrast, stories are not published every time a child is vaccinated and has no side effects, or every time a case of disease is prevented through vaccination, so the numerous benefits are not readily available for people to draw on.

Critique 3: Reliance on doctor-parent education
Currently, the main response to the issue of vaccine refusals is to encourage parents to talk to their doctors when they have any concerns, and for doctors to thoroughly educate parents about the risks and benefits of vaccines (11). This paper argues that too heavy a reliance is place on this as the main solution to vaccine refusals.
As has been already shown, there is a growing anti-vaccine movement that is characterized by mistrust of doctors and the medical profession. Simply telling doctors and parents to talk over the issue without any other guidance is not sufficient.
The theory of psychological reactance may be helpful in understanding the dynamics of the doctor-parent interaction in these situations. This theory explains how individuals value their sense of freedom and self-efficacy, and will react when social pressures threaten this. Experiments supporting this theory have shown that when attempts are made to restrict a person’s freedom, these attempts often result in them doing the opposite behavior; attempts to limit freedom will actually increase the likelihood of someone doing the opposite (9). Applying this theory to the doctor-parent interaction, it can be seen that if a parent feels as if the doctor is pressuring them to accept vaccines for their child, the parent may react with the opposite behavior and refuse vaccination.
Many of the parents who decide to opt-out of recommended vaccines tend to place a high value on “natural living” and alternative medicine, and distrust the “westernized” medical approach. There has been more emphasis on taking a more active role in making health decisions, and parents want to make an active decision about whether or not to vaccinate. This requires more time and involved discussion with the doctor. They are also generally more educated about vaccines and health in general. It is not enough for a doctor to simply tell a parent that they should vaccinate their child because the doctor says so (12). This kind of approach may trigger psychological reactance, resulting in the parent refusing the vaccine, and possibly other health care related messages.
The issue of parents refusing vaccines for their children and refusing the recommendations of their doctors has gone so far that some doctors will dismiss these families from their practice. This raises many legal, ethical, and public health concerns. One of the ethical concerns is in not respecting the autonomy of the parent to make medical decisions for their children. Dismissing such families from an individual medical practice cuts off the lines of communication between the doctor and the parent, and also cuts off any possibility that a solution can be worked out. As a result, parents who are dismissed from practices may become more distrustful of the medical system and drop out of the formal health care system altogether (13).
Another social-behavioral factor that be behind parents’ concern over vaccine safety is omission bias. This is a term used in medical decision-making that describes how people are more likely to accept the risk of passively not doing anything, over the risk of actively choosing an intervention. Experiments have shown that people acting the role of the parent were less likely to choose the active treatment, while those in the role of medical professionals were more likely to choose the active treatment to maximize the patient’s survival. (14). So it may be easy for doctors to objectively weigh the risk and benefits, and recommend vaccination; but from the other perspective it may be more difficult for a parent to actively choose to do something that carries a risk, however small, to their child. Parents will feel responsible for harming their child if the vaccine has side-effects.

Proposed Intervention
The following recommendations are being made to address the problems highlighted in the above critique of the issues surrounding parental refusal of vaccinations. The main goal is to take back control over the issue of vaccinations from the anti-vaccine movement. The public health response has been mainly reacting to criticism in the media and responding to outbreaks caused by falling levels of immunity.
This paper proposed an intervention to take a more proactive role in leading the debate on vaccine safety and effectiveness. Key parts of the intervention will be to reframe the issue, and develop a visible public information campaign specifically designed at addressing the fears of parents that vaccinations will harm their children, especially the MMR-autism link that is so commonly mentioned in the media.

Defense 1: Reframe the issue
In order to restore public confidence in vaccines, the issue needs to be reframed. When a large number of children are intentionally un-vaccinated, they are at risk individually, but they also put all the other children in their school and community at risk due to waning herd immunity. There are some children who are too young to receive immunizations, and others who cannot be vaccinated because of specific medical reasons (3). The reason it is necessary to maintain high immunization levels in the population is to create herd immunity, so that those who are not able to vaccinated will still be protected.
The issue can be re-framed in terms of collective responsibility. American culture is predisposed to individual explanations, and in order to reframe public issues, it is necessary to shift the focus to balance out individual and group outcomes (15). One parent’s decision to vaccinate their child will protect not only their own child, but it will also protect all the children in their classroom. To look at this the other way, one parent’s decision to not vaccinate their child will put all the other children at risk. While a parent may be comfortable making this decision for their own child based on individual beliefs, they may not feel comfortable when those beliefs may be harming other children who are vulnerable.

Defense 2: Develop a Comprehensive national response
The public health sector must actively, and publicly, engage this issue on a national level. Interventions must be developed to address the concerns over vaccine safety on a larger scope than just relying on the individual doctors talking to parents. One way to do this is to launch a national media campaign. This campaign must be more than just simply an educational campaign that warns people about the risks of disease, and tells them they should be vaccinated. As already discussed, this approach may raise psychological reactance, and be drowned out in the media by the sensational stories of side-effects caused by vaccine conspiracies.
A national media campaign should be based on the principles of advertising and marketing theory, creating a public health “brand”. A brand is a set of associations linked to a name and associated with a product or service. Public health brands aim to change health behaviors and knowledge to improve overall health outcomes (16). The brand can be specific to vaccines, or can include other health behaviors, such as other routine prevention measures for children.
The campaign should emphasize the number of children who are vaccinated,and who do not get sick or have any side effects. It should also include the emotional appeal
of saving children's’ lives. This can be done through emotional stories about how much doctors care about health of children because they are parents too, and because they want their children to be healthy, they choose vaccination. The campaign can also appeal to the protective side of parents, by using the reframed issue of vaccinating your child to protect other children who are not able to be vaccinated. Messages on the severity of vaccine-preventable diseases can included, but without over-emphasizing the fear component. For example, parents whose un-vaccinated children were infected during recent outbreaks can talk about how scary it was to see their child fall sick with measles, and how it could have been prevented.

Defense 3: Improve Doctor-Parent Counseling
The doctor-parent interaction is a key part in working with parents who are questioning vaccines, and it is necessary to give doctors better tools to work with. It is important that the doctors have open discussions with parents about vaccinations while respecting their autonomy to make medical decisions for their children. Both the doctor and parent want what is best for the child, and that should be made clear throughout the discussions.
If a parent has refused vaccination for their child, that family should not be dismissed from the practice. As discussed before, this action has a wide range of ethical and legal considerations, and may further push the parents away from communication with the medical establishment (17). However, if the parents are still undecided, it is important to keep an open and respectful dialogue. Reframing the issue, and asking the parents what they would do if they were facing the decision for someone else may be useful (14).
Most parents who question vaccines have already done research of their own, but the doctor must sift through what knowledge they have and clear up any misinformation. Parents need to be empowered to educate themselves in order to make a thoughtful and evidence-based decision (4). The doctor is in a key role to assist by giving the appropriate information on vaccines in general, and answer any questions about specific vaccines or safety concerns, without overwhelming the parents with data.

Conclusion
The issue of parents refusing to vaccinate their children poses a significant risk to public health by weakening herd immunity and leading to new outbreaks of disease. The anti-vaccine movement has been growing in recent years, and similar situations exists in other countries, including England, Ireland, Canada, New Zealand, Australia, Switzerland. When planning interventions for educating parents about immunizations, it is important to keep in mind social behavioral principles, including framing and psychological reactance.
The main public health approach to this issue has been that better education is needed, but most parents refusing vaccines are well-educated. They are getting their information from other sources and are inherently distrustful of anything that comes from the government and research studies, so planning a general education campaign will not be as effective. The issue is more complex than just having experts tell parents what to do, and assuming the public will trust them because they are doctors and experts. Interventions should be designed to clearly and openly address the concerns over the safety of vaccines, dispel any myths about the link to autism, and have an open public dialogue about the best way to protect the health and safety of children.

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