A World With(out) Polio: A Critique of the Polio Eradication Campaign in Nigeria – Alix M. Wilson

For much of the western world the crippling effects of polio remain only as a mere memory from the lives of our ancestors. We categorize poliomyelitis as a disease of the past, yet polio remains a serious concern in other areas of the world. The virus remains active in four endemic countries including India, Afghanistan, Pakistan, and Nigeria (3). As of 2010 these countries accounted for 85% of all new polio cases worldwide (7). Although significant progress has been made, there is still much work to be done in areas where poliovirus still infects populations. As the World Health Assembly turned their attention and energy to eradicating polio, they were committed to global eradication by the year 2000 (6). Today, exactly one decade later polio has not disappeared from the global agenda. However, more than any other endemic area, Nigeria’s eradication movement has demonstrated the dangerous effects and setbacks that can come of a failed campaign. The lessons learned in Nigeria are of grave importance for future efforts towards polio eradication. Without careful examination and remediation of Nigeria’s campaign, a world without polio will remain out of reach.

Although the effects of poliomyelitis had been known throughout the 20th century, the virus gained worldwide attention in 1955 with the announcement of the first vaccine against polio by Dr. Jonas Salk (6). During the early 1900’s polio was being referred to as the most serious and most frightening public health problem of the postwar era. (14). By 1952, polio was responsible for killing more children than any other disease at the time worldwide (15). The symptoms of the disease are often not fatal, however polio is an acute viral disease that is highly contagious and frequently passed through the fecal-oral route (7). Most commonly, people acquire the infection from ingesting contaminated food or water. Infection with poliovirus may result in different outcomes. In most cases, polio infections are asymptomatic. However, in 1% of cases, the virus enters the central nervous system and selectively destroys motor neurons resulting in paralysis, permanent loss of limb function, and often death (7). Furthermore, once paralytic damage has occurred there is no treatment to reverse the polio paralysis (6). This muscle paralysis can sometimes result in permanent skeletal deformities, joint tightness, clubfoot, and severe movement disability (14).

As Salk’s announcement to the world brought hope and optimism into the picture of despair created by polio, nations were in dire need of vaccination campaigns. With polio spreading among populations in developing nations where sanitation was lacking, the devastation was even more evident. Finally, in 1988 as the World Health Organization (WHO) launched the global eradication program, Nigeria became one of many countries flooded with health care workers bringing Salk’s vaccine to stop the spread of a disease that had claimed thousand of innocent lives (9). The eradication endeavor around most of the world was achieved, but by the year 2000 Nigeria remained one of four countries still endemic with poliovirus. With success having been achieved in a multitude of different cultures and among all sects of governments around the world one has to ask – why did the campaign falter in Nigeria?

The failure of the public health intervention to eradicate polio in Nigeria can be attributed to three distinct factors. First and most importantly, health workers were not prepared on how to effectively address resistance to vaccination stemming from a lack of perceived susceptibility and unfounded beliefs surrounding the treatment. Second, the campaign efforts failed to fully take into account the viewpoints and core values of Nigerian citizens. Lastly, in conjunction with sociopolitical context, the approach to vaccinate children was too reliant on a top down, vertical strategy with little to no community involvement. Each of these setbacks presented unique challenges and extended the initial deadline past its goal set for the year 2000.

Propelled by the incredible success of smallpox eradication, the case for polio eradication seemed the next feasible step in a global effort to limit infectious disease. The donor world gave billions of dollars to scale up polio eradication efforts, just as it had done previously for smallpox (20). As health workers were sent to Nigeria to scale up vaccination efforts as a part of the global polio eradication campaign, they had one goal in mind: to eradicate polio through vaccination by the year 2000. However they were quickly met with increasing resistance that they were not prepared to resolve. As vaccination campaigns spread throughout Nigeria there was an increasing resistance encountered to accepting the vaccination (21). Without adequate knowledge or any perceived susceptibility, parents were unwilling to allow health care workers to administer the vaccine to their children. As the Health Belief Model indicates, people who have a low perceived susceptibility to a disease or fail to understand the consequences of being infected with a particular disease will be highly unlikely to adopt any behavior targeted to prevent infection (5). Unlike smallpox, the majority of those infected with poliovirus were unaware they had the infection. In fact, polio only results in paralysis in 1 in every 200 of the people who are infected (8). Consequently, if one person is discovered to have polio after displaying signs of paralysis, they have likely already passed along the infection to others who can remain asymptomatic (10). These victims are the most dangerous in the realm of public health. They pass along the disease unknowingly and simultaneously increase the notion of low perceived severity.

The detrimental impacts of perceived susceptibility and perceived severity as defined by the Health Belief Model were extremely underestimated in the vaccine campaigns designed to eradicate polio in Nigeria. In a study conducted in Gombe State, Nigeria, a total of 216 parents out of 422 of those interviewed believed that their children were not susceptible to poliovirus (15). In other words, less than half of these parents had any degree of perceived susceptibility. Moreover, 55.7% of these respondents did not know the route of transmission for poliomyelitis (15). Furthermore, misconceptions about the vaccine’s safety were rampant throughout much of Nigeria (15). In Between 2003 and 2004, the oral polio vaccine was withdrawn from use in the State of Kano due to strong beliefs that the polio vaccine was more harmful than beneficial (16). These barriers are defined in the Health Belief Model as perceived benefits of taking action (5). If parents do not believe there are any perceived benefits to taking action, or worse yet, those results will be harmful, they will be highly unlikely to take up the behavior (5). Without proper evaluation of the low levels of perceived susceptibility, severity, and or benefits to taking action that existed in Nigeria, health care workers were fighting a loosing battle from the very beginning of the campaign. Regardless of the access to and availability of the vaccine for children in this area, immunization days were unsuccessful in vaccinating a large percentage of children (11). Research that led to the development of the Health Belief Model in the 1950’s was based around findings similar to these. At the time free tuberculosis screenings were being offered, but despite easy access turnout was extremely low. Investigation by Hochbaum and his collegues led them to the conclusion that people are more likely to engage in a preventive behavior if they thought they were at risk and believed they would benefit from that behavior (5). These findings are congruent with those in Nigeria. Regardless of whether the other components of the Health Belief Model were addressed, without any perceived susceptibility or need to change their behaviors, parents in Nigeria were not motivated to adopt the behavior being promoted by the vaccine campaigns. Although the Health Belief Model may not be the entire story behind the breakdown of the eradication campaign, it certainly points out the failure in addressing the populations’ attitudes and beliefs regarding vaccination.

However, not all parents were unaware of the serious consequences polio infection or of the intended benefits vaccination could bring to their child and thousands of others. In fact, despite those who were not motivated to participate and remained passive to the campaign, there was a large outcry against the vaccine campaign as well (11). As the polio vaccine eradication went into full swing in Nigeria, people began to question Westerner’s intentions. With a country still suffering from a multitude of preventable diseases, such as diphtheria, pertussis, typhoid fever, and hepatitis B, polio is just one of the many challenges remaining in the battle of childhood survival (8). Consequently, when free polio vaccines began pouring into the country, Nigerian citizens began to question the Westerner’s approach of focusing all their efforts on one problem. They were well aware of the ongoing threat of other treatable diseases that were killing even more children than polio. From their perspective, fighting the battle against polio was important, but was only a small piece to improving childhood survival rates (11). As a result, frustrations arose and Nigerians began to actively resist vaccination efforts (17).

As this active resistance increased throughout the country it became clear that the approach being taken by Westerner’s, although good intentioned, was faltering. In 2004, Nigeria’s head of primary health care, Dr. Muhammad Ali Pate expressed concerns that the gains made by polio eradication will never hold without a broader health-care system (8). He shared common beliefs held by many Nigerians that vertical attacks on single diseases are ineffective and ultimately ignore the larger problem of stopping infectious diseases. In public health promotion in developing nations, donors tend to ignore the wants and needs of the population they will be serving (8). The polio eradication campaign in Nigeria did exactly this, falling into the dangerous pattern of formulating public health interventions based around intuition rather than research. Too often in public health, practitioners base their campaigns or interventions on what they feel people should want (18). As marketing theory has demonstrated, public health practitioners can be much more effective in achieving their goals by first identifying what it is the people actually desire before designing their intervention (18). The key to establishing an effective campaign is creating a program that addresses the core values of the target population (18). The polio eradication campaign in Nigeria did not address the main concern of the audience it was trying to serve. Nigerians wanted a broader approach. They wanted to eradicated polio, but not at the expense of allowing other diseases to continue to ravage their population. The eradication campaign failed to address the core values of the audience they were serving. Nigerians shared the same concern of controlling the spread of polio, but what they really wanted was control and autonomy over where efforts were being focused. They watched donor money being poured entirely into the polio fight while their sons, daughters, and grandchildren died of a multitude of other diseases that were entirely preventable. As time went on and polio continued to be a problem, Nigerians became frustrated with the narrow approach underway and became resistant to, what they felt, was a loosing battle.

In addition to the failure of the polio campaign to address the core values and desires of those it was meant to serve, the campaign also lacked community involvement. As a result, Nigerians felt no sense of ownership to the campaign efforts or impacts and thus were not invested in the programs. As the World Health Organization (WHO) developed the implementation strategy for polio eradication efforts in Nigeria they stressed the inclusion of political, community, and religious leaders, but evidence demonstrates that none of these players were involved effectively (11). When WHO was ready to role out the eradication campaign, they met with the Minister of Health, but did not include political or religious leaders in gaining support for immunization programs (11). Consequently, the polio eradication campaign in Nigeria transformed into a top-down approach with little to no involvement of community leaders and influential citizens.

This lack of community involvement likely weekend the campaign efforts. Specific theories address the importance of community involvement and are applicable to public health approaches. As Rothman and Tropman stated in their theory of community organization developed in 1987, community change is most effectively accomplished through the involvement of a broad cross-section of members in the community (1). They expand upon this definition by stating that community change is most likely to occur through consensus building, cooperation, and a coordinated effort by the community to address its own concerns (1). Without a sense of involvement in the campaign efforts, Nigerians became subjects of the intervention rather than agents of change. They were simply being vaccinated to fulfill the eradication goal, rather than participating in making this goal a reality. Moreover, there was no involvement on the part of their influential superiors, both religious and community members, to incite motivation. Lastly, the intervention lacked a key component of community organization theory, which was empowerment. According to the theory, empowerment is defined as a process by which communities gain mastery over their lives by being enabled to effectively transform or change their environments (12). Essentially, individuals gain self-efficacy on the community level and these gained confidences and skills are essential to bring about behavior change on a large scale. However, the lack of empowerment in conjunction with few influential and respected leaders at the helm, Nigerians felt no sense of ownership to the cause. With a top-down approach in full scale, the polio eradication in Nigeria continued to suffer further setbacks.

As the campaign was continuing to face further challenges, it became clear that the original goal set for the year 2000 would have to be pushed back. Many people questioned how smallpox eradication could have been so quick and so effective, while polio was proving to be more challenging as each day of the campaign went on. Although smallpox had encountered challenges along the way, the vertical campaign approach along with compulsory vaccination ultimately proved to be successful when the last case of smallpox was reported in 1979 (20). However, the eradication of polio has proved to be more complicated. With increasing opposition and lack of motivation on the part of Nigerians to comply with polio vaccinations, it will be necessary for the campaign to adopt a new strategy. In order to overcome the variety of obstacles encountered in the Nigerian polio eradication campaign, the intervention approach must be altered. Namely, several health behavior models in combination with marketing theory must be understood and applied to meet the resistance being faced to create a solution, rather than a mandate for compulsory vaccination or a continuation of strict vertical strategies.

First, the campaign must address the issues of perceived susceptibility and severity. By increasing the awareness and knowledge about poliomyelitis, parents will understand the importance of getting their children vaccinated. Furthermore, they will appreciate the potential consequences of this infectious disease for their own child as well as other children. In order to accomplish this goal, the campaign workers should collaborate with community leaders to develop information cards. Information cards have been utilized successfully in childhood nutrition programs through South America, where a lack of knowledge about breastfeeding and complimentary feeding have left thousands of children malnourished (22). These cards contain pictures on the front side depicting the message being relayed, while the backside of the cards contain simple words, guidelines, or messages about the public health intervention. These cards can be carried by health workers and posted throughout the community. In the case for polio, the cards could display a picture of a child suffering from polio on one side with information and pictures on the back indicating how the disease is transmitted, what health effects it causes, and how vaccination prevents transmission and infection. These cards will serve to accomplish barriers identified by the Health Belief Model. Many parents do not know how crippling the effects of polio can be. The picture and listed health effects will serve to increase the parent’s perceived severity. Also, the information on the mode of transmission will influence parents’ perceived susceptibility as they learn how infectious poliovirus is among the population. Lastly, the utilization of pictures in combination with words to display messages about the health effects and transmission of polio makes these cards a quick and easily viewable device that transmits a powerful message. Moreover, even though Nigeria has a 72% literacy rate (13) and most citizens will be able to read the accompanying messages, those who are illiterate will not miss out on the message. As the cards a distributed by health care workers and spread throughout communities, the messages can transform the views concerning perceived susceptibility and severity and break down these harmful barriers to vaccination.

With this first step underway, the Nigerian community can begin to see the benefits of taking action. However, in order to motivate people to act, it will be necessary to address the needs and desires of community members. Many people in Nigeria feel that polio eradication efforts ignore the larger issues concerning health care and childhood diseases rampant in the country (8). In order to better quantify and qualify these concerns, campaign workers should be deployed to hold focus groups in collaboration with influential community members throughout Nigerian states. At these focus groups, citizens can have their voices heard about what issues they feel need to be addressed immediately, where they believe resources should be allocated, and in addition to polio, which diseases they feel are of most importance for donors to address. Once these focus groups have been conducted, community leaders and campaign workers can combine their findings for submission to the donor agencies. Given that polio is the mission of this eradication campaign, citizen feedback will serve to increase multiple vaccination efforts or other sanitation projects that will directly address the desires of the people as an extended portion of the eradication campaign. By recognizing the core values of the Nigerian people, mainly their desire to surmount the multitude of diseases currently affecting them, the campaign can redefine and repackage its goals towards these desires. As marketing theory predicts, if public health practitioners offer programs that the target population values and demands, they can more effectively face the challenges of inciting behavior change (18). Instead of working against the Nigerians to incite change, they will be able to work with them. If donor agencies can adopt this strategy, their implementation of polio eradication will be more well rounded and successful.

To bring the campaign full circle, another component for a successful strategy is to incorporate community members as well as influential political, and religious leaders. The polio eradication campaign is too focused on a top-down strategy that disregarded the importance of involvement and community leadership throughout Nigeria. It has become evident throughout the global campaign that wherever community involvement has been low, vaccination coverage has also remained low, directly resulting in the failure to eradicate polio (9). There is no question as to whether community involvement will be beneficial; the only question remaining is how to implement these strategies.

To incite and propagate community involvement health care workers should seek out influential leaders in the political and religious sectors. Health care workers should seek out many of these leaders in every state to ensure all parts of Nigeria are initiating community leadership and involvement. Moreover, once these relationships are established, responsibilities must be defined and shared between the health care worker and the community advocate. They should not simply serve as a voice, but also an agent of change. Research has indicated that active community leadership and community involvement in planning and implementing your own health care is vital to successful health projects (1). If Nigerians can be incorporated into the eradication campaign strategy, they will have the leverage to encourage their counterparts to do the same. In addition, it is generally accepted that people are more willing to follow the advice of those they feel a connection or similarity with (2). Furthermore, religious leaders can be utilized to dispel misconceptions surrounding the dangers of the polio vaccine that surfaced among religious groups in 2003. Again, those who were influenced by these misconceptions are more likely to listen to their own leaders who share common morals and values, than they are to Westerner’s attempts at dispelling these delusions (2). The involvement at the community level is expected to have drastic implications in inciting behavior change by encouraging Nigerians to take an active part in creating a polio-free world. With the increased awareness being created through cards and media to address perceived susceptibility, they will have the tools and a reason to join the cause. Finally, with attention paid to their own needs in the realm of global health initiatives, they will have a more genuine commitment to the cause.

The set backs that have been encountered in the Nigeria are not by any means entirely avoidable. However, with the proper planning and evaluation through known public health strategies such as the Health Belief Model, Marketing Theory, and Community Organization Theory, these set backs can be overcome in a systematic way. Today the world is a decade past its original goal set for polio eradication. Polio has dodged a 20-year effort to eliminate it along with the disbursement of $8.2 billion dollars supplementing the ongoing human effort worldwide (8). Cleary, a new approach is in order. It is expected that the major leaders in polio eradication including WHO, UNICEF, and the CDC will announce a reorganized plan and strategy to address the failures of campaigns like those in Nigeria this week (8). The world can only hope that these strategies address the roots of the problem, taking into consideration the beliefs and viewpoints of those on the ground and the involvement of community and religious leaders in creating new, effective strategies. If these strategies are implemented effectively the world may finally be free of polio once and for all.


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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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