A few months ago I described three major epidemics around child health in Canada today, when there are in fact four. I failed to mention the equally important epidemic of misinformation, which has been described well here and while this is certainly applicable to the issue of vaccine hesitancy, it doesn't describe the entire picture.
There is some overlap between vaccine-hesitant parents, who may be mistrusting of vaccines, and those who have been disappointed by regulations around chemicals in child products. For instance, BPA and triclosan are two examples of common ingredients that were deemed safe by regulators for years, but have only recently come under fire for harms related to children's health in particular. There has since been more in-depth monitoring and research around these risks. Some parents might not be aware that the regulations around environmental safety can be quite different from the policies, research, and regulations around vaccine safety -- this could be one reason behind the mistrust around vaccine safety.
The good news is that leaders in pediatric medicine are taking note. Very recently, the Canadian Pediatric Society (CPS) issued a statement to encourage ways in which pediatricians can continue to engage parents around their concerns around vaccines and provide accurate information in plain, easy to understand language. Yet, as I have described in part 1 of this discussion, this is only one part of the puzzle.
I was never great at math, but equations are slightly more attractive than puzzles, so here is my personal attempt to explain the key factors behind whether a parent may or may not be likely to perceive benefit with a health intervention for their child. Perceived benefit is linked to the likelihood of adopting the health intervention. [∝ refers to "proportional to"]
Likelihood of perceived benefit of pediatric intervention ∝ (direct social network/community perceptions of intervention) x (relationship with MD) x (access to accurate information around intervention) x (1/perceived risk of pediatric intervention) x (1/relationship with non-endorsing providers)
Using "vaccines" as the intervention, we see that parents are more likely to choose to vaccinate if their social network values vaccination, their relationship with their doctor is positive (non-judgmental, trusting, with open discussion), they have good access to accurate sources of information, they have an ability to appropriately evaluate risks of vaccination (compared to risks of contracting measles), and their relationship with a health provider who does not endorse vaccines is less influential. Of note, I have left out the issue of "time," -- it is unclear whether early counselling might be helpful for parents, so for the sake of argument, and from anecdotal accounts, I will assume that more time to weigh the information provided can be beneficial for the parent and the patient.
From my depiction above, we recognize that physicians have some control over the "what" -- in terms of providing access to accurate information. This is the basis from which most of the media coverage, op-eds and the like are derived from -- the assumption that "anti-vaxxers" just lack accurate information. Yet it's clear that this is only one part of the issue.
The good news is that by identifying this complex interplay of factors, we see that what emerges is an innovative approach to addressing the issue of vaccine hesitancy. By approaching it with the "when," "how," and the "whom," a better relationship between the patient and their doctor can also be fostered, which may help address concerns the issue of vaccinate hesitancy.
WHEN: While some physicians counsel parents about vaccination at the newborn visit, many discuss it immediately before the child's first vaccine -- this is generally right before the two-month visit. However, this might not leave enough time for some parents -- who may have done their own research, spoken with their social network, and/or discussed vaccines with unconventional providers -- to make an informed decision. So, it might be beneficial to begin counselling early, during pregnancy perhaps, or to encourage this discussion during all newborn visits. During other visits that occur before a vaccine is due, providers might continue to establish rapport with the parent, identify any preconceived notions or fears around specific treatments, and, as the CPS statement alludes to, provide a compassionate ear for the parent regardless of their concerns.
HOW: While op-eds around vaccine hesitancy can be helpful, they are usually one-sided and many parents who have questions may be hesitant to publicly post comments or engage in an online discussion. Even op-eds by parents themselves, while certainly emotive, but not convince parents, many of whom may be on the defensive already, to choose to vaccinate their children. Most of us have come to realize that guilt is not a powerful long-term motivator; if anything, it can be disempowering and very unlikely to lead to sustainable behaviour change.
Instead, articles that provide a balanced view with factual information and a nonjudgmental tone (this is a great example) might be more powerful. Other mediums to encourage discussion between vaccine advocates and parents include workshops or town-hall meetings where physicians and public health leaders respectfully field questions. There they could suggest ways in which a parent might accurately evaluate risk (related to the vaccine or the disease) for their child and for the community of children that may be in contact with their child. Physicians should also continue to recommend valid sources of information that are updated often, written concisely, and presented plain language. The CDC and the Hospital for Sick Children are two examples.
WHO: The "who" might be the most important component to consider when engaging vaccine-hesitant parents. First, it is crucial that physicians engage other "non-conventional" health providers (who provide some care to up to 75 per cent of children) around public health threats such as vaccine-preventable diseases. These alternative providers are not a homogenous group -- there are naturopaths, nutritionists, and homeopaths that endorse vaccination for instance.
Historically, the medical community notoriously used less palatable methods to silence these providers. Now, instead of simply engaging in investigation-style media coverage or vicious social media rants, it might be worth considering formal discussions with leaders in these alternative health communities around issues such as vaccine hesitancy. One day this could even lead joint position statements between alternative health regulatory bodies and the medical community around specific preventative health interventions, in an attempt to balance benefits with forseeable harms.
Indeed, consistent, collaborative messaging between various health providers is something that is crucial and missing in our health system, and my teams with the mobile health app Kidzie hopes to allow for medical doctors, nutritionists and dieticians, psychologists, yoga/mindfulness instructors, and naturopaths to work together on health tips and strategies for parents that are evidence informed. While this type of collaboration is unlikely thing to be adopted universally right now, given the various ongoing debates and regulatory policies, this is certainly something to look forward to in the future, which could be groundbreaking for child healthcare.
Further, the medical profession might be able to learn from these providers, many of whom may have had training in motivational interviewing and other counseling approaches related to preventative medicine (e.g. nutrition, mindfulness). As recently described, due primarily to stress, lack of time, burnout, physicians may benefit from other strategies to better engage patients/parents (e.g. active listening), which provides a good foundation for discussing concerns around health interventions.
And there you have it -- a possible approach to vaccine hesitant parents that might just work. The challenge now is when do we start; how do we begin to engage with all types of child health providers and all types of parents. With the measles outbreak is taking its toll, now seems like the right time.
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