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Vaccination: the complications of hesitation

19 March 2021

How can you talk to parents who have doubts about immunising their children from serious infectious diseases? Journalist Radhika Holmström reports on vaccine hesitancy.

The emergence of Covid-19 has thrown into sharp relief the number of people who doubt the efficacy and safety of vaccination. More than a quarter of respondents to a survey conducted by the University of Oxford in autumn last year said that they were either very unsure or strongly hesitant about receiving a Covid-19 vaccine (Freeman et al, 2020).

Now that the mass immunisation programme is well under way in the UK, doubts remain as to whether enough of the population will consent to being vaccinated, especially younger people who consider themselves less vulnerable.

This won’t be news to many practitioners working in child health. Although childhood vaccination rates are increasing in the UK, the country has yet to regain its ‘measles-free’ status, which the World Health Organization (WHO) withdrew in 2019. Yet some of the most influential people working in the field of vaccine hesitancy (VH) argue strongly against dismissing the views of parents who are reluctant to immunise their children against a host of serious infectious diseases.

Coverage concerns

‘After sanitisation, vaccination is probably the most important health measure we’ve ever had.’ So says Ruth du Plessis, a former nurse and health visitor who is now St Helens Council’s consultant in public health. ‘Antibiotics are helpful, but they’re a secondary measure. A vaccine prevents you from getting infected in the first place,’ says Ruth, who is also chair of the public health specialists committee for Doctors in Unite.

Despite this, childhood vaccination rates have fallen worldwide – quite dramatically in some countries. For several years, the WHO has recommended that at least 95% of all children should be vaccinated against diseases that are preventable by this method (WHO Regional Office for Europe, 2013). In the UK, coverage has generally risen in recent times but there remains plenty of room for improvement. In 2019-20, for instance, coverage of the measles, mumps and rubella (MMR) vaccine for children aged five in England was only 94.5% for the second year running (NHS Digital, 2020). This rate is far better than it was between 2000 and 2004, when fears MMR was linked to autism were at their height, but it’s still not high enough, particularly in London.

As Ruth points out: ‘Measles can be very serious. It’s a disease that’s incredibly infectious, and vaccination is the only way to prevent it.’

What causes hesitancy?

A comprehensive report into vaccine take-up in the UK found that parents were mainly very supportive of the measure (Royal Society for Public Health (RSPH), 2019). Of the 2000 people it surveyed, 91% agreed that vaccinations were important for child health, while 89% agreed that these protected others as well as the immunised individual.

Yet the report expressed concern about the minority of respondents who didn’t accept these statements as fact. It called for a ‘make every contact count’ (Mecc) approach to VH parents, which entails ‘encouraging trusted professionals across the health system to advise opportunistically about vaccines’.

Who are the people that make up this minority? Helen Bedford, professor of children’s health at UCL Great Ormond Street Institute of Child Health and an expert in VH, clarifies some points: ‘People use “hesitancy” to mean all kinds of different things. My definition of a VH parent would be someone who doesn’t know whether to opt for vaccination or not. We should in fact be encouraging that person to ask questions.’

It’s easy to assume that the reason why parents don’t vaccinate is that they simply believe it is wrong or that they don’t understand how immunisation works. There is certainly a strong ‘fake news’ trend, which Covid vaccine fears are driving. But the longstanding reasons seem to be more complex than that, which means that VH people are highly unlikely to be converted by reading a few leaflets.

Professor Paul Kinnersley, chair of the School of Medicine at Cardiff University, was part of a team that worked on an extensive literature review of public attitudes to vaccination (Leask et al, 2012). This classified between 30% and 40% of parents as ‘unquestioning acceptors’ and between 25% and 35% as ‘cautious acceptors’. It divided up the rest as ‘hesitant vaccinators’ (20% to 30%), ‘late or selective vaccinators’ (2% to 27%) and ‘refusers’ (up to 2%).

Although the anti-vax movement has been revitalised in recent years, it has actually been around as long as vaccination itself. ‘The notion that vaccination is a delusion goes way back, from the moment when the concepts of vaccination and immunisation were being configured,’ says Heidi Larson, professor of anthropology, risk and decision science at the London School of Hygiene and Tropical Medicine, where she also directs the Vaccine Confidence Project.

Heidi observes that there has always been a solid core of parents who believe that ‘natural’ is best for their children and that vaccination falls into the ‘unnatural’ category. Ruth notes that the mechanical act of vaccination may run counter to the instinctive parental urge to protect children from harm. ‘People are taking their children for an invasive procedure, and they see them being stabbed with a needle,’ she explains. ‘Sometimes the fear of the vaccine is greater than the fear of the disease. I think that such fear creates the space for misinformation.’

In some respects, vaccination has been a victim of its own success. ‘Diseases that were rampant have now largely gone,’ says Gavin Fergie, Unite’s lead professional officer for Scotland and Wales, health sector. This has meant that people today have little concept of how serious the situation would soon become if they were to make a comeback.

‘In the past, what the doctor said went. But these days people are far more questioning and less compliant with any decisions that they see as being imposed upon them.’

‘My mother’s generation knew people who were affected by polio as children,’ says Christina Marriott, chief executive of the RSPH. ‘But I do think that there’s a generational loss of memory about what these diseases look like.’

It’s true in some cases that people who have memories of these diseases did not have very good experiences of the healthcare they received, or may not trust vaccination programmes. Gavin adds: ‘We have a much more diverse culture in the UK today. While we benefit from that, it does have an impact on how people engage with the healthcare system.’

Covid and fake news

It’s easier than ever to broadcast falsehoods about vaccines far and wide on social networks. Such practices pre-date the Covid-19 pandemic – videos and memes have been circulating on the internet for years – but there’s a concern among healthcare professionals that Covid vaccine scares (especially among BAME communities) will also have a damaging effect on other vaccination programmes.

Christina is particularly worried about this. ‘There is a huge amount of anti-vax “information” out there, some of which is highly targeted, based on different religions and aimed at particular socioeconomic and ethnic groups,’ she says, adding that some people are being bombarded constantly with such material. ‘We don’t know if that will translate into people being less willing to accept vaccinations, but we should be gearing up to counter that – we should have been doing that months ago.’

In fact, survey results reported in January by the government’s Scientific Advisory Group for Emergencies revealed extremely high levels of VH in BAME communities. It highlighted that around 72% of black respondents were either unlikely or very unlikely to accept the offer of any Covid-19 vaccine, for instance (Geddes, 2021).

Mistrust of government in all of its forms may play a part in VH. One survey showed that 27% of the public believed ‘the real truth about coronavirus was being kept from the public’, which rose to 64% among people who said they were unlikely to or definitely wouldn’t get vaccinated against the virus (University of Bristol, 2021).

Christina draws a direct line between Covid fake news and the MMR controversy of the late 1990s: ‘I don’t think we would have been able to see the misinformation about Covid if it wasn’t for all of the misinformation about MMR. We should have learnt to challenge that earlier. We shouldn’t have let it get embedded. Now we’re in the Wild West of social media.’

She adds: ‘We are trying to counter that but there’s an awful lot of misleading material out there. I think it’s the major public health challenge of the next few years. It’s going to involve sharing a huge amount of information.’

Community practitioners, Christina notes, are well placed to do much of the remedial work. ‘There was a recent Public Health England finding that health visitors were particularly trusted. Everyone needs to be giving out pro-vaccination information – a Mecc approach would be really useful here,’ she says.

Practical solutions

It would be tempting for any CP with a heavy caseload to make the provision of such information a matter of simply telling anxious parents ‘Don’t worry about it’ and maybe handing them a leaflet. But experts in this field know that such a perfunctory, dismissive approach would do little good.

Gavin explains: ‘In the past, what the doctor said went. But these days people are far more questioning and less compliant with any decisions that they see as being imposed upon them.’

Paul Kinnersley agrees. ‘You don’t want to get into fights. The worry is that people who go along to the clinic with some concerns are simply told: “It’s absolutely safe. You’ve been reading too much on the internet.” Clinicians should take any anxious parent through the side effects of vaccination – and do so skilfully, with not just a list but a respectable leaflet to hand,’ he suggests.

Helen Bedford notes that it’s also possible to know in advance which factors cause the most anxiety. They are: safety (always top of the list); specific concerns about the side effects of the vaccine that’s being delivered; its composition; and the fear of ‘vaccine overload’.

‘I’d like to encourage training on immunisations – there are lots of helpful resources for this,’ she says, citing e-learning courses offered by Health Education England as being particularly useful (see Resources, below).

Julie Roye is a primary care nurse consultant and advanced nurse practitioner who deals regularly with VH where she works in south-east London. She fully understands how daily work pressures can clash with the need to take time to reassure and, in some cases, re-educate anxious parents.

‘It’s really important that we understand their fears,’ she says. ‘Sometimes it gets a bit confused because we may just feel like telling them: “Come on – let’s do this.” But it’s about explaining to worried parents what we’re about to do and about dispelling any myths they have heard from their friends.’

Reinforcing her point, Julie notes that parents who aren’t given all of the information about the MMR vaccination procedure can become so scared after their child develops a rash that they will refuse to allow the follow-up injections.

To any CP involved in delivering a vaccine, she recommends learning  all of the relevant facts about it first, taking the time to talk through these with parents face-to-face and then providing them with back-up information.

‘I have found that being perfectly competent myself about what is in a particular vaccine and then sitting down with parents and talking to them about it gives them confidence that I understand and that they also understand,’ Julie says. ‘I take them through the leaflets that we provide. I always let them keep these, because they won’t remember everything we cover.’

She adds: ‘This is their child – I’m not taking their power away. But I do feel that taking the time to explain and give each parent the chance to process the information always works well.’

It may also be valuable to explain how each individual immunisation ultimately helps everyone in the community. Research involving nearly 2000 working-age adults in France in July 2020 found that the VH rate was lower among those respondents to whom the benefits of herd immunity had been communicated than it was among those who had been given no such information (Schwarzinger et al, 2021).

Access all areas

One final point is that hesitancy can turn into alienation if parents can’t get easy access to vaccination. The UK Measles and Rubella Elimination Strategy 2019 makes this clear, saying: ‘The main barrier to vaccination is access to immunisation services that meet the needs of the community’ (Public Health England et al, 2019).

This can be a particular problem for larger families, traveller communities, migrant families or those with health problems. Parents need services that listen to them, but also that provide vaccinations in a way that maximises the potential for protecting their children’s health now and in the future.

At this crucial period in the fight to control the spread of Covid-19, all lessons learnt about tackling vaccine hesitancy need to be heeded far and wide, as achieving lasting herd immunity – through vaccination rather than infection – will be the only effective way to end this pandemic.


Vaccine coverage in the UK

Statistics for 2019-20 published by NHS Digital and Public Health England show that childhood vaccination coverage is still relatively high in the UK: it’s more than 90% averaged out nationwide for all first childhood vaccinations (NHS Digital, 2020).

It’s more than 95% in Wales and Scotland for the six-in-one jab (protecting against diphtheria, polio, tetanus, whooping cough, hepatitis B and haemophilus influenzae type B) at 12 months and 24 months. Wales and Scotland are also both above 95% with the meningitis B and pneumococcal conjugate vaccines at 12 months, while Northern Ireland is above 95% with the six-in-one jab at 24 months.


Resources


References

Freeman, D, Loe, B, Chadwick, A, Vaccari, C, Waite, F, Rosebrock, L, Jenner, L, Petit, A, Lewandowsky, S, Vanderslott, S, Innocenti, S, Larkin, M, Giubilini, A, Yu, L, McShane, H, Pollard, A, Lambe, S. (2020) Covid-19 vaccine hesitancy in the UK: the Oxford coronavirus explanations, attitudes, and narratives survey. See: https://www.cambridge.org/core/journals/psychological-medicine/article/covid19-vaccine-hesitancy-in-the-uk-the-oxford-coronavirus-explanations-attitudes-and-narratives-survey-oceans-ii/C30FDB5C3D87123F28E351FDAAD5351A (accessed 4 March 2021).

Geddes L. (2021) Covid vaccine: 72% of black people unlikely to have jab, UK survey finds. The Guardian. See: https://www.theguardian.com/world/2021/jan/16/covid-vaccine-black-people-unlikely-covid-jab-uk (accessed 12 February 2021).

NHS Digital. (2020) Childhood vaccination coverage statistics England, 2019-20. See: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-immunisation-statistics/england---2019-20 (accessed 4 March 2021).

Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. (2012) Communicating with parents about vaccination: a framework for health professionals. BMC Pediatrics. See: https://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-12-154 (accessed 4 March 2021).

Public Health England, Public Health Wales, Northern Ireland Public Health Agency, Health Protection Scotland. (2019) UK measles and rubella elimination strategy 2019. See: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/769970/UK_measles_and_rubella_elimination_strategy.pdf (accessed 4 March 2021).

Royal Society for Public Health. (2019) Moving the needle: promoting vaccination uptake across the life course. See: https://www.rsph.org.uk/our-work/policy/vaccinations/moving-the-needle-promoting-vaccination-uptake-across-the-life-course.html (accessed 4 March 2021).

Schwarzinger M, Watson V, Arwidson P, Alla F, Luchini S. (2021) Covid-19 vaccine hesitancy in a representative working-age population in France: a survey experiment based on vaccine characteristics. See: thelancet.com/action/showPdf?pii=S2468-2667%2821%2900012-8  (accessed 4 March 2021).

University of Bristol. (2021) Belief in Covid conspiracies linked with vaccine hesitancy, study finds. See: bristol.ac.uk/news/2021/february/covid-conspiracies.html (accessed 12 February 2021).

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