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For some parents, the decision to vaccinate requires more than just objective evidence. rocketboom/flickr , CC BY-NC-SA

Australians’ attitudes to vaccination are more complex than a simple ‘pro’ or ‘anti’ label

Reading the headlines, it would be easy to believe childhood vaccination rates are declining in Australia, due to an increasing trend towards distrust of vaccines among parents.

In fact, vaccination rates in Australia have been high and stable, hovering between 91% and 93% since 2003. Only 7% of children living in Australia are not fully vaccinated. This includes children who are not vaccinated at all and those who are partially vaccinated.

Among the 7% of children who are not or not fully vaccinated across Australia, more than half have been prevented from accessing vaccination by some practical barrier. Perhaps the family can’t afford to register or repair the car this month, or has recently arrived from overseas and needs to start a complex schedule of catch-ups.

Less than half of that 7% are not fully-vaccinated because their parents are so worried about the safety of vaccination, they reject some or all vaccines.

Concern about incomplete vaccination

Although the numbers are small, there are good reasons to be concerned about parents who don’t vaccinate their children, or who delay getting their children’s vaccinations.

First, the national target for vaccination coverage is 95%. Plateauing at 93% isn’t good enough: more needs to be done.

Second, the parents who reject vaccines tend to cluster in certain regions. This can result in small communities having very low vaccine coverage. In these communities babies who are too young to be vaccinated, older people whose immunity has waned, and people whose immune systems are compromised by a medical condition are more vulnerable during outbreaks.

Children who aren’t fully vaccinated are not protected if there is an outbreak of disease. Outbreaks of measles, meningococcal disease, and whooping cough capture wide public attention because they spread easily and can cause very serious illness. However the current childhood vaccination schedule is designed to prevent at least 12 diseases, and even more for children, teens and adults who are more likely to get serious complications from vaccine-preventable diseases.

Third, under-vaccination is especially dangerous for some groups of children. Only 18% of children at risk of severe flu, including Aboriginal and Torres Islander children and those with some medical conditions, are estimated to receive their recommended influenza vaccines each year.

Fourth, many new parents have questions, or even concerns, about vaccination. Is it safe? Is it really necessary? Despite their concerns, almost all of these parents have their children vaccinated on time.

Confidence in vaccine safety

Vaccine scares, whether rumours or theories about vaccines being harmful, or genuine safety issues, can undermine parents’ confidence in the safety of vaccination.

When parents who are scared turn to other parents (in their social networks, or through social media) for reassurance, they often encounter people who are convinced vaccines are unsafe, or that it is safer to avoid vaccination.

The MMR-autism scare led to a national outbreak of measles in 2013 in the UK. The ripple effects from this scare, which has repeatedly been shown to be unfounded, continue to undermine parents’ confidence in vaccines around the world.

We suspect the reason there is so much talk about parents who choose not to vaccinate is because we don’t yet know how to prevent or reverse vaccine rejection. The evidence we do have mostly tells us what not to do. Throwing more facts at sceptical parents rarely changes their minds, and often makes them more entrenched.

When the MMR vaccine scare was at its height in the UK, there was little useful evidence to guide a public health response. Ultimately, it took years for vaccination rates to recover. Today in many countries the public conversation about vaccination has become mired in an aggressive argument, which characterises parents as either “pro-vax” (responsible) or “anti-vax” (irresponsible). Most ordinary parents just want to do what’s best for their children.

A spectrum of confidence

Our research, and that of others, suggests parents’ confidence in the safety and need for vaccination is best described as spectrum, ranging through unquestioning acceptance; cautious acceptance; hesitance; delaying or selective vaccinators; to those who decline all vaccines. Within that group of decliners, only a handful are the noisy “anti-vaccination” activists.

Australian attitudes to vaccination fall into a spectrum comprised of five unfixed groups. Adapted from Leask et al (2012); Benin et al (2009), Author provided

Parents often move from one position on this spectrum to another, and not always sequentially. A parent may not have thought much about vaccination and simply accepted it as ordinary. Then a bad experience with the health care system triggers mistrust, they revise their position, and begin “declining all vaccines”.

It is the hesitant parents - those sitting on the fence - who are most likely to change their positions. These parents can be reassured, or their concerns can be amplified. Many times, a hesitant parent will bring their concerns to a health professional who skilfully addresses their concerns, and the parent decides to vaccinate the child.

Sometimes the discussion leads to conflict and the parent leaves with a firmer sense that vaccination is unsafe. That health professional might also have had bad experiences trying to convince parents who have already decided not to vaccinate to change their minds. After a few of these experiences they no longer try to reassure those questioning parents, preferring to move on quickly to the presenting clinical problem and avoid the conflict-ridden vaccination topic.

Sharing knowledge about immunisation

Because these encounters are so influential and often difficult, we are investigating health professionals’ and parents’ communication needs during vaccination consultations. Health professionals have told us they need information they can give to parents about vaccination, and strategies to help them avoid arguments and reassure parents.

In our recent qualitative study, parents told us they want more information about vaccination from sources they can trust, before the first appointment. This finding is also supported by other evidence, as shown in a recent review. Parents also want to be invited to ask questions.

Parents at the more hesitant point on the spectrum told us being offered more detailed information about vaccine safety reassured them nothing was being hidden from them and increased their trust. However, parents on the more accepting end found too much information overwhelming, reducing their confidence.

Parents who felt conflicted wanted their health professional to help them make a decision that was aligned with their parenting values.

Parents also told us they felt more trust for health professionals who admit they can’t answer a question and refer them to someone who can.

In response, we have developed a package of communication support and information for parents about vaccination, called SKAI: Sharing Knowledge About Immunisation. The first of these is a series of question and answer sheets that address five questions parents commonly ask about vaccination.

We will test the rest of the package, designed for use during vaccination consultations, later in 2017. SKAI will help health professionals tailor their consultations to meet parents’ needs - wherever they are on the spectrum of confidence in vaccination.

Parents are all different. It makes sense to respond to them differently.

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