Vaccine Hesitancy: The Growing Parent

Abstract

Vast majority of parents continue to immunize their children against deadly infectious diseases. However, of late, growing number of them in both developed and developing nations have refused vaccination forcing the World Health Organization to declare vaccine hesitancy as one of the top ten major threats to global health. This research reviews literature published in the last few years to understand and explain the phenomenon. It identifies 10 reasons for people’s reluctance for vaccination: parental concerns, perceived disease susceptibility, parent–provider relationship, government policies, role of school authorities, weak interpersonal communication (IPC) skills of health workers, religious beliefs, role of media, social media and information on vaccines, and lack of trust. The review categorizes parents who hesitate or refuse vaccination into four categories: obedients, ditherers, doubters and defiants. Finally, it summarizes recommendations and steps that researchers and policy makers have made to stem the growing concerns regarding vaccine hesitancy.

Keywords

Vaccine hesitancy and refusal parental concerns role of school authorities government immunization policies measles rubella polio

Introduction

In the United States, The Centers for Disease Control and Prevention found that the vaccination rate for the measles, mumps and rubella (MMR) injection in kindergartners in the 2017–2018 school year had slipped nationally to 94.3 percent, the third year in a row it dropped (Hoffman, 2019; Mellerson et al., 2018).

Between 2010 and 2017, over half a million French infants didn’t receive a first dose of the measles vaccine. And last year, France was among the ten countries with the highest year-on-year increases in measles, with confirmed cases jumping from just over 500 in 2017 to nearly 3,000 in 2018 (Whiting, 2019).

The 2014 Joint Reporting Format (JRF) data from India reported 83% MCV1 coverage at the national level as against the current global target of 95% at the national level as well as state-district. Although it has been more than 2 years post introduction of measles-containing vaccine second dose (MCV2) across the country, the HMIS administrative reported national average for MCV2 is ~66% (in 2014), whereas routine immunization monitoring data show the MCV2 coverage to be ~40%, which is far below the expected 95% in an elimination setting (Ministry of Health and Family Welfare Government of India, 2017).

Nations, big or small, developed or developing, have been found wanting in immunizing their children. A major reason is publics’ or parents’ doubts about or reluctance to vaccination. Vaccine hesitancy, a relatively new term coined to explain reluctance, is recognized as a global issue. The Lancet Child and Adolescent Health (2019) states that the phenomenon has been reported in more than 90 percent of the countries in the world (The Lancet Child and Adolescent Health, 2019). The World Health Organization says that reluctance or refusal to vaccinate is one of the top 10 major threats to global health. It defines vaccine hesitancy as a ‘delay in acceptance or refusal of vaccines despite availability of vaccination services’ (WHO, 2014). Other definitions have explained vaccine hesitancy in behavioural terms: ‘[It] is a set of beliefs, attitudes and behaviours or combination of them exhibited by lay people in regard to their own or their children’s immunization’ (Peretti-Watel, Larson, Ward, Schulz, & Verger, 2015). Policy makers and public health experts agree that vaccine hesitancy is complex and context specific and varies across time, place and vaccines (MacDonald et al., 2015; WHO, 2014).

This research commentary attempts to address a seemingly simple question, ‘why do parents (or individuals) hesitate or refuse to vaccinate their children?’ We first review some of the recent research material on the subject to highlight people’s reasons and motivations for refusal. In addition, the article refers to vaccination campaigns conducted in different countries at different times and documents their insights and experiences. We also fall back on our research experience in the field in India. The second part of the article briefly summarizes the recommendations made by research studies to address vaccine hesitancy. Although the literature deals with a wide range of disease domains, we confine ourselves to three infectious diseases: polio, measles and measles-rubella (MR).

Box: Polio, Measles and Rubella

Polio is a highly infectious disease caused by a virus. It invades the nervous system and can cause total paralysis in a matter of hours. The virus is transmitted by person-to-person spread mainly through the faecal–oral route and multiplies in the intestine. According to WHO if a single child remains infected, children in all countries are at risk of contracting polio.

Measles is a highly infectious disease and a major cause of morbidity and mortality among children below 5 years of age. According to literature, if the disease is introduced to a virgin community, more than 90 percent of the community can get infected. Although rare in industrialized countries, it remains common in many developing countries (Park, 2017). Approximately 89,780 children died from measles in the year 2016 (WHO, 2018).

Rubella, on the other hand, is a viral disease that can cause severe congenital defects, such as blindness, deafness and heart defects, in newborns when an unimmunized woman is infected with the virus during early pregnancy. Known as congenital rubella syndrome (CRS), the disease can result in huge health burden to the family, society and nation. As per WHO data, globally 100,000 babies are born with CRS every year and nearly half the cases (48%) occur in South East Asia region (Dewan & Gupta, 2012).

Polio, measles and rubella are preventable.

Source: Authors.

Methodology

We followed a five-step procedure to review literature on vaccine hesitancy. At step one, we identified research articles that appeared on the subject since 2013 in peer-reviewed journals and retrieved them from Google Scholar, PubMed and other sites. At step 2, we screened their abstracts to make initial assessment about their relevance to the main purpose of the study. Next, we critically appraised the research articles and selected 20 of them for abstraction. Additionally, we searched Google to find relevant and more recent updates of development in countries that have shown marked resistance to vaccination. We then created a template to capture issues pertaining to vaccine hesitancy and measures that nations or organizations have taken to tackle it. Finally, we synthesized the main points and findings from the research articles.

The literature on vaccination or vaccine hesitancy deals with various factors that affect patients or parents’ decision to administer or not administer a particular vaccine. We deal with some of the major ones here: parental concerns, perceived disease susceptibility, parent–provider relationship, government policies, role of school authorities, weak interpersonal communication (IPC) skills of health workers, religious beliefs, role of media, social media and information on vaccines, and lack of trust.

Parental Concerns

Parents show discomfort when new vaccines are introduced due to unfamiliarity and concerns about safety. There are a number of reasons parents give to justify their decision to not immunize their children. First, parents are concerned about increasingly crowded vaccination schedules, which might result in ‘immune overload’ in their children’s bodies, eventually weakening their immune system (Leask, Willaby, & Kaufman, 2014). In fact, in Switzerland, non-paediatric physicians delayed or denied measles, mumps and rubella (MMR) and diphtheria, tetanus toxoids and pertussis (DPT) vaccines for their children (Kumar, Chandra, Mathur, Samdariya, & Kapoor, 2016). Second, parents often fear that the adverse effects (rash, swelling, pain, etc.) associated with vaccines are more harmful than the diseases they are designed to eliminate (Callender, 2016). Third, they desire that their children develop natural immunity to diseases rather than have it artificially induced in their body (Kumar et al., 2016). Lastly, as indicated above, country-specific conditions affect vaccine uptake. While in some countries factors, such as high costs, quality of vaccines, ability of vaccinators and stock-outs, dissuade parents, in others, infeasible travelling to longer distances to reach immunization clinics, cleanliness of government health centres among others hamper their ability to get their children vaccinated (Manthiram, Edwards, & Hassan, 2014). In Myanmar, for instance, children in rural areas, children of mothers with lower educational achievement, children from poorer families and children in some states or regions are much less likely to receive their basic vaccinations. Boys are more likely to be covered than girls in the country (58% to 51%) (UNICEF, 2019).

Perceived Disease Susceptibility

At times, parents do not perceive vulnerability of their child or severity of disease to affect the child, so they do not insist medical providers for administering vaccinations (Dubé, Gagnon, Zhou, & Deceuninck, 2016). This could be due to their lack of information or possession of inaccurate information. For example, many parents in India believe that boys are not at risk of incidence of Human Papilloma Virus infection due to contradictory information about HPV on the Internet (Patel & Berenson, 2013). Parents in Israel perceive new vaccine-preventable diseases (VPDs)—Chickenpox and Gastroenteritis—to be mild (Kumar et al., 2016). Disease susceptibility often is related to lack of specific knowledge about risks associated with non-immunization rather than to parents’ general level of education.

Parent–Provider Relationship

An important reason for vaccine hesitancy is parent’s relationship with health providers. In countries such as India, gender, age, literacy and socio-economic status differentiate frontline health workers from those belonging to urban, educated class. The latter therefore have little confidence in their skill and ability and hardly avail of opportunities to interact with them.

Generally speaking, parents tend to be hyper-vigilant in relation to children and risk, especially when providers fail to address their misconceptions and encourage vaccination uptake (Leask et al., 2014). Parents also question the information received from providers and are reluctant to act on their advice due to trust issues with vaccine or providers (Peretti-Watel et al., 2015). In fact, healthcare workers are often hesitant to promote vaccination due to conflicting recommendations of health authorities and their own expertise (Velan, 2016a). Health professionals lack first-hand knowledge of risk of diseases. Therefore, there have been cases when they were unable to break misunderstandings about association of MMR vaccine with autism (UK), Hepatitis B vaccine with multiple sclerosis (France), H1N1 influenza vaccine with Guillain–Barre syndrome (a recalcitrant paralysis) and Oral Polio vaccine with impotency in males (India) (Kumar et al., 2016; Patel & Berenson, 2013; Ramanadhan, Galarce, Xuan, Alexander-Molloy, & Viswanath, 2015).

Although not as widely studied, providers of healthcare information and services have difficulties dealing with parents or caregivers. A quantitative study on community health workers in Myanmar found that key barriers encountered by community health workers included a lack of health awareness among the people they serve, low education among clients and low health literacy among primarily female caregivers (Sommanustweechai et al., 2016). The literature shows that sociocultural background and differential level of understanding of disease affect parent–provider relationship.

Government Policies

Government policies of several countries comprise of expanded programmes of immunization and short bursts of intensive immunization campaigns. The programmes and campaigns usually bring together a diverse group of organizations across the public and private sectors and draw on the expertise of organizations, such as WHO, UNICEF, the Centers for Disease Control and Prevention, the World Bank, civil society and vaccine manufacturers. They deal with an integrated set of activities including high-level political commitment, logistics, cold chain and vaccine management, management of adverse events following immunization (AEFI), communication and social mobilization, training and monitoring and evaluation. Strict policies for compliance with vaccine recommendations send unambiguous messages to parents regarding providers’ belief in the importance of on-time and complete vaccination (Schwartz, 2013).

However, in an era of globalization and revenue generation, increasingly consumerist orientation to healthcare has led to an overall negative attitude towards vaccination. In USA, certain states have exempted school entry mandates; this implies risk exposure for children and outbreak of VPDs (Kestenbaum & Feemster, 2016). There is lack of trust from school management and education department in informing parents about vaccination benefits and requirements (Kumar et al., 2016). In India, government operational guidelines on measles rubella (MR) recommend vaccinating a child second time even though s/he had received the same vaccine at a private health facility earlier. Parents could not grasp the logic of second vaccination and frontline health workers were at a loss to explain the benefit of second MR vaccination.

Conflicts or disasters pose special difficulties to implement vaccination policies as children are most affected by them. Pakistan’s relatively calm province of Punjab achieved elimination of maternal and child tetanus in 2016, but the country is struggling to meet its key goals of polio and measles elimination. According to WHO, Pakistan is third among countries with the most unvaccinated and under-vaccinated children. Similarly, deteriorating security situation in Afghanistan has made access to health services difficult (WHO, 2019). The grimness of the situation can be gauged by the fact that of the three types of wild polioviruses, two have been eliminated globally, but the third remains in circulation in two countries, Pakistan and Afghanistan (Global Commission for the Certification of Poliomyelitis Eradication, 2019). The Hindu, an Indian daily, reported that as of 23 October 2019 ‘there were 18 cases of polio caused by wild virus type 1 in Afghanistan and 76 polio cases in Pakistan this year. While the number of cases reported this year from Afghanistan is quite close to the 21 reported last year, there has been over six-fold increase in the number of cases in Pakistan’ (The Hindu, 2019).

Role of School Authorities

Schools are an important site for administration of vaccine to children. The month-long MR vaccination drive in India, which required vaccinating children of age 9 months to 15 years, depended on active and voluntary participation of school authorities. However, it was not so in the city of Hyderabad that has over 3,500 schools. A local daily reported the programme officer of the state health department saying that about 120 schools in the Old City have sent letters of refusal to health authorities. She added, ‘[O]f the 3,639 schools 2,090 have been covered so far. In 30 percent of these 2,000-odd schools, nearly 60 percent of children have refused vaccination in the Old City area.’

In Vancouver, Canada, health authorities linked measles outbreak among staff, students and family members to French schools. In USA, 1,250 individual cases of measles were confirmed between January and October 2019 in 31 states, which led the Center for Disease Control to update these data monthly. More importantly, the CDC said more than 75 percent of these cases in 2019 were from New York (CDC, 2019). This forced the lawmakers to eliminate religious exemptions for school vaccines for children. In March this year, Italy made vaccination for MMR, chickenpox and polio compulsory for children attending school. In Germany and France too, the ‘No jab, no school’ policy has been made mandatory (Wilson, 2019).

Weak Interpersonal Communication (IPC) Skills of Health Workers

An important barrier to effective implementation of vaccination policies is the ability of ground level health workers to persuade parents to immunize their children. Health workers are required to mobilize the community, interact and counsel them. Not all health workers have the skill and competence to do so. For example, a mixed methods study among healthcare workers in Nigeria found that despite having received training, quality of counselling was inconsistent, unstructured and did not include the use of any information, education and communication materials (Adeyemi & Oyewole, 2014). Another mixed methods study in the same country found that only 18 percent of healthcare workers assessed the child’s vaccination status, 5 percent of treatments were appropriate and that counselling of mothers and caretakers by healthcare workers needed improvement (Oladele et al., 2012). Lack of orientation of health workers on how to develop IPC skills and cultivate relationships with influential sections of community affects their counselling skills to respond to queries and dispel apprehensions.

Religious Beliefs

People belong to different cultures and conform to strong religious beliefs along with conventional trust of natural and artificial medicines. For example, several vaccines constitute bovine serum or bovine derived viruses, or pork gelatine, consumption of which is prohibited in Jewish and Muslim religions (Domachowske & Suryadevara, 2013; Kumar et al., 2016).

Role of Media

The 1998 issue of Lancet carried an article by Dr Andrew Wakefield that linked MMR with autism. The publication caused public consternation. Later, Wakefield’s research was found to be false. Twelve years down the line, the journal retracted the article and the authorities revoked Wakefield’s medical licence (Eggertson, 2010). However, by then the general media, affected parents and advocacy groups had kicked up a storm of controversy. The publication had sown doubts about the vaccine and to this day anti-vaccine groups cite Wakefield’s article.

A day before the MR campaign was to be launched in the southern Indian state of Telangana in August 2017, a local English daily carried a multi-column headline story on the front page which read: ‘Girl dies after measles vaccine; Telangana, Andhra Pradesh get notice’ (Deccan Chronicle, 2017). The girl had died 12 hours after vaccination and there was no immediate evidence to link her death to MR vaccine. But the newspaper story had affected the offtake of the MR campaign.

Media play a critical role in shaping people’s behaviours. Media enable audiences to use news frames to create coherent understanding of illnesses (Andreas, Abraham, Naik, Street, & Sharf, 2010). Of late, there is low coverage of pro-vaccine movements, and parents are greatly influenced by negative stories about vaccine safety in news and on television, or delivery of anti-vaccine messages via digital networks (e.g., YouTube vaccination videos oppose reference standards) or by influential figures (Kestenbaum & Feemster, 2016). Inconsistent messages often put parents in a dilemma, which results in irrational, emotional and ill-informed attitudes and refrainment from vaccinations. In Quebec (Canada), parents refused to get HPV shots to their children due to negative media coverage around the HPV safety and its usefulness (Dubé et al., 2016). Miscommunication from public health agencies is another issue of concern. For example, in the USA, the Federal Drug Administration (FDA) removed thimerosal from majority of vaccines due to theoretical risk of mercury toxicity, resulting in refusal of all vaccines containing thimerosal as a preservative (Kestenbaum & Feemster, 2016).

Social Media and Information on Vaccines

Social media have distorted the vaccination scenario. Parents, who would once hear from health workers, opinion leaders or mass media are now bombarded with barrage of information, some correct, but others often mischievous or misleading. The ‘sources’ of information on vaccination have multiplied, the amount of information received has grown and the frequency and speed with which it comes has created confusion. The net result is vaccine hesitancy. ‘There’s a lot of pretty negative, discouraging, and sometimes quite frightening material about immunization on websites’, says Heidi Larson, director of the Vaccine Confidence Project and a professor of anthropology at the London School of Hygiene & Tropical Medicine, and aluminium ‘is the big scary bogeyman for France’.¹ O’Connor at the WHO says it is an issue that medical professionals are battling worldwide. ‘The fervent or militant resistors are very loud on social media and other forums. People pick that up and then they have lots of questions.’ (Whiting, 2019).

Do vaccine refusers tend to cluster together? Social network analysis conducted in India showed that vaccine-refusing households had fewer outgoing ties than vaccine-accepting households did. It concluded, ‘Vaccine refusing households had 93 percent more nominations to other vaccine-refusing households compared to vaccine-accepting households, revealing that vaccine-refusing households cluster in the social network. Since roughly half of all ties connect households within neighbourhoods, vaccine-refusing clusters lie in spatially localized ‘pockets’,’ the study concluded (Onnela et al., 2016).

Lack of Trust

The fundamental issue with immunization is lack of trust. Four parts describe the construct. The first, and perhaps foremost, is lack of trust of the government. France is a good example of it. Over the years, the French government has mismanaged issues related to public health. First, it was blood transfusion. Hundreds of people were given blood contaminated with HIV, many of whom died. The blood transfusion scandal, as the media called it, led to conviction of a former health minister. Then came an unfounded report that medical professionals had contacted multiple sclerosis after receiving the Hepatitis B vaccine. Later a controversy broke over spending millions of euros on H1N1 flu vaccine fearing a pandemic that never came about. More recently, the Info Vaccins France website has documented stories of parents alleging death and suffering of their children because of routine inoculations (Info Vaccins France, n.d.). The result is that one in three French people disagree that vaccines are safe (Wellcome Global Monitor, 2018).

Lack of trust extends to vaccines as well. The literature on the subject identifies at least four reasons for it. The first is the intrusive nature of vaccines. Unlike polio drops, several of them are injected into the body. While young children may not object or contest, parents fear side effects, such as fever and swelling. Second, mandatory or forced nature of vaccination could lead to hesitancy, if not lack of trust. Third, those who espouse alternative medicine believe that the immune system builds itself up and vaccines somehow interrupt or break that process and make it complicated. But silence over the ill-effects of vaccine is perhaps a critical factor leading to hesitancy and lack of trust. Finally, in several countries, a small number of doctors openly propagate against vaccination. All these lead to vaccine-avoidance behaviour or the vaccination schedule.

Overlapping with the second but analytically separate is the third part of lack of trust: the pharmaceutical industry. Many people see it as a profit-seeking behemoth bent upon selling an ever-growing list of its products. Dr Marcia Angell was fired from her long-held job as executive editor of New England Journal of Medicine because of an editorial that she wrote criticizing the pharmaceutical industry. Her book The Truth About the Drug Companies: How They Deceive Us and What to Do About It, which she wrote later, continued with her criticism of Big Pharma companies. Epstein, another author, pointed out that most medical journals receive a substantial part of their income from such companies’ advertising and reprint orders. Many other journals are owned by medical publishers, such as Wolters Kluwer. Marcia Angell and Helen Epstein’s criticism gained greater public acceptance when well-known pharmaceutical companies, such as GalxoSmithKline in 2012 pled guilty to criminal charges and paid $3 billion—the largest healthcare fraud settlement in US history, to resolve fraud allegations and failure to report safety data (Global Research, 2016).

The fourth and final part of the construct is lack of trust towards public (government) hospitals and staff—a phenomenon we found in our research in India. In the case of H1N1, suspect cases first visited private hospitals, despite government’s repeated announcement that they should visit government hospitals. When H1N1 was confirmed, the patients shifted to public hospitals where, because of delay, they died. The media reported deaths at public hospitals, which reinforced public’s fears that these hospitals were not trustworthy (Krishnatray & Gadekar, 2013). Data show that a combination of factors, including mistrust, forces even poorer patients to seek private health care (Indiaspend, 2019).

Strategies to Tackle Vaccine Hesitancy

Next, we briefly describe the strategies employed or recommended in the reviewed articles to tackle the challenges listed above.

Policy Level

The literature on vaccination refers to dealing with hesitancy at the population level by including transparency in policy-making decisions and providing updated information regarding vaccines to the public and health providers (Kumar et al., 2016). It recommends identifying mechanisms and opportunities to shape social norms regarding immunization attitudes and behaviour and re-envisioning the role of institutions, such as schools and universities (Opel & Marcuse, 2013). Vaccination must be sufficiently covered in university curriculum and continuing education (Leask et al., 2014). Adverse events following immunization, a critical component of immunization programme, should be carefully handled because parents weigh the risk of AEFI with vaccination against the risk of not immunizing a child (Chitkara, Thacker, Vashishtha, Bansal, & Gupta, 2013). Provision of sustained grants to promote highest standard of medical research on adverse events following vaccination can help combat vaccine hesitancy (Callender, 2016).

Literature also suggests that public health laws that make certain immunizations mandatory for school admissions can improve (Domachowske & Suryadevara, 2013) by allowing only medically recommended exemptions (Gowda & Dempsey, 2013; Kestenbaum & Feemster, 2016). However, others suggest that policies should be based on enhanced understanding of the root cause of vaccine hesitancy rather than those that invoke compulsion (Opel & Marcuse, 2013).

India’s polio situation is a good example of what policy level changes can accomplish. Not too long ago, the country harboured the largest number of polio-affected persons in the world. Despite availability of medicines and a vast network of health workers who visited every corner of the country, the debilitating disease refused to go away. This led The Polio Global Eradication Initiative to state,

Given India’s vast population, tropical climate in many parts of the country, and other environmental challenges, it would be easy to imagine that if polio couldn’t be stopped, India would be the place to fail…After all, India constituted over 60% of all global polio cases as recently as 2009. (Global Polio Eradication Initiative [GEPI], 2018)

In 1988, the World Health Assembly adopted polio eradication as a global goal. At that time, India had 23,800 cases of polio. In 2014, the WHO declared India polio free. Since then not a single case of polio has been detected in the country. Schaffer (2012) credits policy level initiatives that brought this about (Schaffer, 2012). This included setting up a chain of surveillance laboratories, the formation of the National Polio Surveillance Programme (NPSP) with support of Denmark’s development agency in 1977, conducting multiple rounds of immunization days, identification of problem states and blocks, zeroing in on micro-communities to isolate the disease, guarding against imported infection, assured financial allocation and high level of political commitment. The Indian government’s immunization efforts continue to receive active support from WHO, UNICEF, Centres for Disease Control (USA), Melinda and Gates Foundation and Rotary International.

Parent–Provider Relationship

Studies listed here focus on dialogue and IPC between providers and parents. A study suggests that open and frank discussions with hesitant parents can assist in improving their understanding of vaccines. Maintaining and sharing authoritative, evidence-based information about vaccines by health professionals and establishing relationships with patients and their parents that are based on trust can minimize the impact of vaccine hesitancy (Domachowske & Suryadevara, 2013). Velan (2016) recommends that communicating the risks of vaccination and respecting vaccine-hesitant individuals’ viewpoints, even if their judgment to decide is imperfect, could pave a way to interact, explain and convince the hesitant public about the advantages of vaccination (Velan, 2016).

Another paper refers to the utilization of new media by local health units (LHUs) to establish a novel, interactive dialogue with residents in their territories (Rosselli, Martini, & Bragazzi, 2016). The Italian Scientific Society of Paediatricians had launched Hermes Project where paediatricians underwent a step-by-step course on how to open a Twitter account and dynamically interact and communicate with children’s families so that they could address their concerns or doubts about vaccination (Rosselli et al., 2016). An Italian website ‘VaccinarSi’ enabled workers in public health to exercise their role of advocacy on the Internet. In the same country, a mobile-based app ‘Pneumo Rischio’ aims to increase public awareness of invasive pneumococcal disease and its prevention. Utilization of such technology can help empower lay people and increase their health literacy (Rosselli et al., 2016).

Literature also suggests that physicians and public health professionals must inform parents not only about changes to vaccine schedules but also why these new recommendations are being adopted so as to provide an opportunity for newly arising concerns to be discussed (Gowda & Dempsey, 2013). Physician–patient discussions should aim to discuss vaccine risks and benefits contextually instead of largely focussing on intended vaccine benefits (Gowda, Schaffer, Kopec, Markel, & Dempsey, 2013). Other studies suggest that parents’ decisions regarding vaccine acceptance are influenced by a larger context of beliefs and personal experiences about child’s health, perceived societal norms and trust in health systems and professional providers at individual, family and societal levels (Benin, Wisler-Scher, Colson, Shapiro, & Holmboe, 2006)

Communication Campaigns

Communication campaigns should focus on reaching large audiences through intervention strategies. Campaigns to engage communities in dialogue through local opinion leaders or peer groups have the potential to build community support and advocacy for the benefits of vaccination (Leask et al., 2014). Targeted and authoritative information must be accompanied by awareness campaigns and school interventions. Educational campaigns must focus on parents’ understanding about vaccination.

A study that focussed on combating anti-vaccine misinformation emphasized the importance of using storytelling as a method of message dissemination among parents and patients. The study suggests that stories have the potential to motivate parents more than scientific communication (Shelby & Ernst, 2013). Campaigns have used celebrities to heighten awareness about vaccination-preventable diseases. For example, the mass media campaign for eradication of Poliomyelitis in India used celebrities and role models for promoting immunization and engagement of vaccine-hesitant families with community mobilizers for counselling (John & Vashishtha, 2013; Manthiram et al., 2014).

Studies suggest that tailoring information (materials/messages) could help mitigate the effect of negative messages and individual influences. ‘Tailoring’ is a method for creating communication tools individualized for receivers, with the expectation that individualization will lead to larger intended effects of such communication. Development of tailored materials target unique experiences of individuals about vaccination and result in a perception that the information provided is more trustworthy, relevant and influential. Tailored materials should also be regularly updated and, if needed, be strengthened with arguments to address rumours (Hawkins et al., 2008; Gowda & Dempsey, 2013). Another exploratory study on parental vaccine hesitancy found that vaccine-specific concerns have varying salience for parents based on their vaccination intention. Thus, educational programmes should tailor messages based on the degree of vaccine hesitancy expressed in their target populations in order to improve their overall effectiveness. For example, some parents may respond better to information about the general safety of vaccines, whereas others may need more information about the vaccine (Gowda et al., 2013).

Capacity Strengthening

There are at least two ways to strengthen the capacity of health workers. One, the conventional way, is to train them periodically and upgrade their skills by providing technology or new content. The second is to complement their capacity with additional human resources. In India, the UNICEF-managed Social Mobilization Network (SMNet) played an important role in polio elimination. As part of a community engagement strategy, the network employed over 7,000 frontline social mobilizers at national, district and community level to advocate for vaccination in some of the most underserved, marginalized and at-risk communities across the country. It supported over 2.4 million volunteers and 150,000 vaccine administration supervisors to administer the oral polio vaccine to 170 million children under 5 years of age on two nationwide immunization days each year. The mobilizers focussed on generating demand for polio vaccination and clearing doubts. In doing so, the SMNet strengthened the capacity of the health system (Deutsch, Singh, Singh, Curtis, & Siddique, 2017). In other instances, efforts have aimed at building the capacity of general practitioners for improving skills for communicating with vaccine-hesitant patients and educating medical providers on ways to counter arguments regarding vaccines at a level that patients will understand (Verger et al., 2015).

Discussion

How Infections Spread

There is an unwritten rule among journalists that says, ‘When in doubt leave out.’ This applies to the immunization context as well. When the efficacy of vaccine is in doubt parents would prefer to err on the side of caution and avoid immunizing their children. Often, the intent of those who spread misinformation is to sow doubt and anxiety to achieve their purpose. When 5 percent or more parents do not vaccinate their children, the purpose of misinformation is achieved. Why is this so? It is important here to understand the concept of herd immunity. In a hypothetical world of 10 persons, if nine were vaccinated for a certain infection, then the last person, who is not vaccinated, would be immune from that infection. That is because the infection will no longer circulate. Following this logic, greater the proportion of a population that is immune (or immunized) or less susceptible to a disease, the lower the probability that an unvaccinated person would be exposed to an infectious person and, therefore, less likely to contract the infectious disease. Hence, for highly infectious diseases such as measles, public health policies prescribe that vaccination should cover 95 percent of the population so that it indirectly protects the remaining 5 percent who for some reason are not (or cannot be) vaccinated. In simple terms, what herd immunity means is that there are so few unvaccinated people left in the population that if one person brings in the disease from elsewhere, they are unlikely to encounter anyone they can pass it on to.

The problem arises when sufficiently large number of people refuse vaccines. Daniel Salmon, the director of the Johns Hopkins Institute for Vaccine Safety, explained it to The New York Times thus, ‘The story with measles for the past 20 years is that it starts among refusers, it spreads predominately among refusers, and along the way it picks off other kids.’ He then added, ‘Up until now, we have been able to put a stop to it. But I’m nervous. I’m afraid what happened in Europe is going to happen in the U.S.’ (The New York Times, 2019).

The challenge is to remain on guard. Governments often frame policies, strategies and guidelines based on cumulative experience thought through scenarios or known factors. But such scenarios cannot anticipate sudden or unforeseen developments or the swiftness of anti-vaccine response. Two challenges that have threatened large-scale vaccination initiatives are the role of technology and mistrust. Earlier, pockets of vaccine resistance were confined to some neighbourhoods, certain types of schools or communities, nomadic groups or hard to reach places. Immunization programmes took this to account and planned activities accordingly. They worked through agencies, institutions and influential local leaders to address local concerns and succeeded to varying degrees. More recently, however, end-to-end encryption technology such as WhatsApp has ensured that resistance is no longer bound by space. Communities of resistance have acquired a relational, not just spatial, dimension and the rapid dissemination of (mis)information has posed unique challenges to health workers and policy makers. A sensible approach to tackle such a challenge would be to drown out misinformation with correct message(s), celebrity endorsement and success stories than to be reactive and counter it.

Mistrust is a bigger, multidimensional challenge. Sometimes it acquires a political hue when elected representatives speak out against certain communities (as in India) or against vaccination (as in USA). It becomes a credibility issue when well-off sections of society perceive public hospitals and health staff as less competent. It gets an ideological edge when anti-vaccine movements attribute unfounded motives to immunization programmes and accuse pharmaceutical industry of profiteering. Finally, mistrust leads to fear and death when extremist groups kill health workers (as in Pakistan and Afghanistan). To some extent, this is a public relations disaster because governments have neglected to communicate with increasingly independent, aggressive but ill-informed communities.

Social media play a critical role in campaigns. They have the potential to defeat or contribute to the success of a campaign. Several gaps and uncertainties contributed to a spread of misinformation and rumours on social media during the campaigns. Various studies have indicated that the amount of information parents usually get regarding vaccine is inadequate. With parents who are hesitant and want more information, the amount of information the parents wanted to receive and the source they felt could be trusted appeared to be linked to the acceptance of the vaccine. They usually found it difficult to decide which information source to trust (Ames, Glenton, & Lewin, 2017). In this context, involvement of religious leaders and influencers to determine the precise concerns can help to reach out to resistant minority communities across all states (Marti, de Cola, MacDonald, Dumolard, & Duclos, 2017). With the growing importance and penetration of information and communication technologies (ITCs), the new media can be harnessed to track anti-vaccine messages and lay people’s perceptions of vaccination in real time. This will in turn enable policy makers to plan communication strategy, design interventions to address negative media stories and health providers to engage communities in the right course of action (Ames et al., 2017; Rosselli et al., 2016).

The review of published material on vaccine hesitancy shows that a community’s response to vaccination initiatives varies and is often perplexing. However, closer examination reveals a pattern in the multitude of responses. The pattern is made of four strands or categories, understanding of which could provide a platform to launch action programmes against anti-vaccination myths and misconceptions. We describe the four categories from a developing country perspective.²

Obey: This category constitutes the largest chunk of people but is a silent majority. They readily accept vaccination, but are poor, belong to lower middle class and live in outreach, peri-urban and hard to reach areas. Their children mostly study in government and government-aided schools, and their faith in the government health system is implicit, if not intact. Neither the parents nor the school children have enough information or in-depth understanding about the vaccine, but they accept it anyway. There is little or no persuasion required for motivating parents to vaccinate their children. We call such people, the obedients.

Dither: This category of people comprises of the fence sitters. They have heard of rumours, have no viable means of confirming their authenticity, and uncertain about vaccinating their children. They prefer to wait to see the result of vaccination (to others), require assurance and are late to accept it. Some of them are actually ‘caught’ during the final or mop-up phase of the vaccination drive. Because of their wait-and-see behaviour, we call them the fence sitters or ditherers.

Doubt: This category of people may appear to be similar to the ditherers but is qualitatively different. Unlike ditherers, parents belonging to this category raise questions, pick arguments and defend their decisions. For example, during the MR campaign in India, some parents asked, ‘If my child has received MMR (from private practitioners) injection, why should s/he receive the MR vaccine again from government sources?’ They genuinely do not feel the need for vaccination and counter arguments do not persuade them. They have a poor opinion of government health services and rely exclusively on private practitioners for their health needs. Given their proclivities, we call this group of people, the doubters.

Defy: This is a small but vocal minority of people who either espouse an alternative medical philosophy or attribute ulterior motive to the campaigns. Ultra-Orthodox Jews in New York City, the modern-day Nation of Islam in USA, and the Ayurveda doctors and naturopaths in the Indian state of Kerala share a worldview and a medical ideology that disregards vaccination as an antidote. Parents who hew to non-traditional philosophies or subscribe to alternative science oppose vaccination and contend that vaccinations are not fool proof. On the other hand, some see a grand design to curtail minority populations, make (male) children impotent or benefit foreign pharmaceutical companies and commercial interests. They draw their inspiration and energy from deep-seated mistrust of government. Technology-savvy, urban, outspoken and better organized, their opposition to the campaigns occurs in small pockets but is intense and often finds prominence on social and mass media platforms. Whatever be their motivations, they reject vaccination. We call them the defiants.

Vaccine-hesitant parents (or community) largely belong to the ditherer category. Effective social mobilization approach is necessary to transform this category to become obedients; not doing so could make them defiants. Although the ditherers are not very vocal about their vaccine concerns (Smith, 2017), their shifting to the defiant category could make them vaccine rejecters and thus vocal. Vaccine rejecters have the potential to amplify myths and misinformation about vaccination that can influence the general public to pull away from vaccine acceptance (Leask et al., 2012).

Limitations of the Research

This review is not a comprehensive review of all published material on immunization. The purpose of this review was to examine select literature published in the last few years in order to highlight the growing concern with regard to vaccine hesitancy across different regions of the world. We chose three health domains that have encountered hesitancy or refusal. We sought to explain reasons for refusal or hesitancy and the steps that policy makers and public health specialists have adopted to address it. We acknowledge our own biases in selecting these health domains.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Notes

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Vaccine Hesitancy: The Growing Parent–Provider Divide

Abstract

Keywords

Introduction

Box: Polio, Measles and Rubella

Methodology

Parental Concerns

Perceived Disease Susceptibility

Parent–Provider Relationship

Government Policies

Role of School Authorities

Weak Interpersonal Communication (IPC) Skills of Health Workers

Religious Beliefs

Role of Media

Social Media and Information on Vaccines

Lack of Trust

Strategies to Tackle Vaccine Hesitancy

Policy Level

Parent–Provider Relationship

Communication Campaigns

Capacity Strengthening

Discussion

How Infections Spread

Limitations of the Research

Footnotes

Declaration of Conflicting Interests

Funding

Notes

References