Vaccination Hesitancy

Vaccination Hesitancy – understand the syndrome, address the cause

During the extraordinary year of 2020, uncertainty and fear came together with with a flood of information and ever-changing regulation to fuel suspicion and mistrust in some vulnerable people. These fears have found fertile soil in the anti-vaccination movement.

For people who have followed the organised anti-vaccination movement over time, this collusion seemed almost inevitable. To understand that, however, requires some general understanding of the different motivations for vaccine “hesitancy” or “refusal”. This article discusses vaccine hesitancy in the model of a new syndrome.

Epidemiology

At one end of the spectrum are genuinely concerned parents of young children who have never experienced what used to be called the “typical childhood infections”. These parents, raised in an era where death or severe disability from infectious diseases are thankfully rare, can develop “spectrum bias”. This is a type of cognitive error in which a risk is mis-estimated by people who have not seen the full spectrum of possible outcomes. In a community where the risk of severe infections is low (due to the high level of vaccine-induced community immunity), it’s easy to under-estimate the risks of the diseases themselves and over-estimate the risks associated with the vaccines that prevent those infections.

The reality is that, for unvaccinated children in a highly-vaccinated community, individual risk of severe infection IS low. The risk, however, is that more and more parents opt out, community immunity wanes, and the unvaccinated are no longer protected. This has already been demonstrated in small pockets of low vaccination, such as Northern Rivers NSW.

Many worried parents understand this logic, but their judgement is coloured by anxiety and distorted risk perception. These people are likely to have thought about this issue at great length and are doing their best to protect their children, in their own assessment.

It’s easy to see, then, how insulting their intelligence or attitudes would not play well. In contrast, they are driven into like-minded communities – often on-line – where they are lauded for “doing their research” and acting to “protect their children”. These people may not be suspicious of government or of expertise in general, but feel that they are capable of an independent assessment of the evidence. They may also be wary of what they see as being too many vested interests in vaccine promotion. Another important group of vaccine-refusers consists of parents who are struggling with their children’s behavioural or developmental issues. It’s very tempting to look for an external locus of blame, rather than accept uncertainty. Even worse, the suggestion that these conditions may be hereditary can be interpreted as blame of the parents – that they have “faulty genes” and therefore are the cause of the problems. Socially, these families may feel disempowered and distant from government, regulatory processes and policy-making through a sense of lack of agency (based, perhaps, on real-life experience).

Many of these people are courted by the organised anti-vaccination movement, who embrace them and validate their concerns. They find a supportive community that “believes” them, while the medical community may be resented for failing to support their claims of “vaccine harm”. These communities share on-line links to studies, videos, books and statements that purport to show the evidence against vaccination, which they believe is being “hidden” by the mainstream media and medical community. They may see their doctors as being beholden to “Big Pharma”, and their governments as some sort of world-wide conspiracy.

Another major group to consider is the organised anti-vaccination movement, also known as “anti-vaxxers”. Now that “anti-vaxxer” has become a pejorative, many reject the term, preferring to call themselves “ex-vax” or “pro-choice”. This can be a deceptive stance, however. Promoting free choice CAN be seen as  anti-vaxx, since community immunity requires a high rate of vaccine uptake to protect those who cannot be vaccinated.

The organised anti-vaccination movement lives mostly on websites and social media. Fund-raising is common. Organisers hold rallies, spread misinformation and do their best to dominate discussion on the media (though less so, these days, as many journalists are alert to ‘false balance’).

There is now a new intersection between the anti-vaxx with the “anti-masker” movement, during the COVID-19 pandemic. The very people who were previously championing public health and hygiene measures as the heroes of public health are now the same people who are now fighting against and refusing to comply with the very same types of strategies. What this suggests is that those attitudes are nothing to do with evidence, but all to do with rejecting authority.

Finally, another new attitude has arisen: those who have always been in favour of vaccination, but feel that the COVID-19 vaccine development and roll-out has been “too rushed”. Lack of prior understanding of the steps in vaccine development, and the stages of testing for new therapeutics, can allow people who hear this myth to be convinced by it.

Pathophysiology

The need to be embraced and validated in our views – especially for emotionally-laden topics like child health – is a very powerful force. Fear is a strong motivator. These forces are much stronger than the need to preserve a logical pathway of evidence, and can lead to both cognitive dissonance (where we maintain a line of argument in the face of contrary evidence) and so-called “motivate reasoning” (where an underlying motivation leads us only to consider evidence that supports that view).

Motivated reasoning can occur in response to a range of different influences. These include the need to maintain a certain belief, the need for attention and sympathy, or the need to maintain one’s position within a community.

Management

Like any clinical syndrome, the management needs to be directed at the underlying cause. Seeking the underlying reasons for unexpected behaviour is the first step to understanding, empathising and then managing the issue.

Empathy does not mean validating misinformation, but it means validating the person’s concern, suffering or anxiety, while providing help and advice that can alleviate those conditions. We are encouraged to allow patients to explain their concerns or experiences, and, where possible, offer useful information without denigrating their stance. Through inter-personal interactions, we should be able to earn more trust than vocal people on the internet.

Once we have determined that the concerns are genuine and well-motivated, our approach should recognise that motivation and approach the hesitant person with respect for their desire to do the best for their children. Sometimes it can be useful to state this openly.

For people who are receptive, it can be useful to discuss phenomena like spectrum bias (when we no longer see the illnesses, we over-interpret the risk of the very factors that prevent them). We can use story-telling, including from our own experience – I like to tell the story about how, in my early training, I was drilled to recognise a potential case of HiB epiglottitis – now it has all but vanished.

Measles also makes for a good story. Many young parents – and young doctors – have never seen measles. Until the 1960s and 70s, however, almost every Australian child got measles, no matter how healthy and active they were. Not only is measles highly transmissible, it was the most severe of the previous “typical childhood infections.” A good story could go something like this: “My mother told me that when she had measles, she had to lie in a dark room for a week, with really bad headaches and fever dreams. When I hear that story now, I realise she probably had viral encephalitis, which was quite common with measles. Almost everyone was OK after a couple of weeks off school, but she told me that she had a friend who was left with hearing impairment”.

For those people who are comfortable with vaccination but hesitant about a new vaccine that they see as being “rushed to market”, it can be helpful to again validate the concern (“I can see why it appears that way, but, luckily, the usual delays in vaccine development have been avoided because of the world-wide interest and funding that allowed multiple teams to collaborate”) but then supply good references or written material.

Disdain for the organised anti-vaxx movement should not cloud the clinical interaction. At the organisational level, however, strong opposition to misinformation (while adhering to professional codes of conduct) can be seen as appropriate population-health promotion response. The organised anti-vaxx and anti-science movements can be clearly called out, including their own conflicts of interest, their areas of hypocrisy and their frank dishonesty. This can include writing factual articles for publication, politely and rationally correcting errors in social media posts and having informative face-to-face conversations with friends and acquaintances.

Finally, a different approach may be needed if one encounters a work colleague is spreading misinformation. Studies from the US have shown a degree of vaccine-hesitancy among health care workers, including for influenza vaccination. The Aged Care workforce is an at-risk area, with staff often isolated from the general health care community. When we encounter people with these views of concerns, in good faith, it’s useful again to validate and explain, and to suggest reputable sources of information. This is particularly important for the “too rushed” or “not tested for long enough” anxieties. As well as explaining that “not delayed” is a better descriptor than “rushed” for this vaccine, we can explore their knowledge of other new therapeutics and how they are introduced and monitored.

Follow-up

Once an important health care message has been addressed, it is generally best to ensure that the message is reinforced. One can provide references and written material, but also suggest follow-up discussions with the family’s GP and/or Paediatrician.

If you learn to approach any complex problem in logical chunks, the method will serve you well for all clinical dilemmas.

I wish you all the best for 2021.

Further reading

• C Raina MacIntyre, Daniel Salmon. Want to boost vaccination? Don’t punish parents, build their trust. The Conversation, 2015
• Holly Seale. It’s crucial we address COVID vaccine hesitancy among health workers. Here’s where to start. The Conversation, 2021
• Archa Fox. Not sure about the Pfizer vaccine, now it’s been approved in Australia? You can scratch these 4 concerns straight off your list. The Conversation, 2021
• Adam Taylor. 4 of our greatest achievements in vaccine science (that led to COVID vaccines). The Conversation, 2021
• National Centre for Immunisation Research and Surveillance (NCIRS) [Resources for physicians, parents and patients]
• Vaccine Education Center. Children’s Hospital of Philadelphia [Comprehensive information site for parents]