Dr Seuss’ book Green Eggs and Ham is built around the urgings of a weird creature, Sam I Am, who insists the narrator eat the food of its title. When the narrator refuses, Sam issues an ever-widening range of appeals – Would you eat them in a box? Would you eat them with a fox? But Sam’s insistence fails to convince an increasingly vehement narrator.
The story provides a light-hearted analogy to the plight of anyone who has tried to persuade another person to abandon an entrenched position – especially a parent’s decision to not vaccinate their child. In fact, psychologists have found that too much urging can result in a backfire effect, with the person becoming more committed to their beliefs.
When herd immunity hangs by a narrow margin, the decisions taken by a small group of parents matter. With too few children vaccinated, a disease such as measles can easily spread. This impacts on the whole community, including those too young to be vaccinated and those who can’t have a vaccine for medical reasons.
While a measles epidemic cannot be solely blamed on people who actively forgo vaccination – waning immunity in adults also contributes – it can be an important factor. We saw this play out in the United Kingdom in the late 2000s, when the now-debunked theory that the measles, mumps and rubella (MMR) vaccine caused autism drove immunisation rates down to 80%.
Avoiding a disease tragedy
The most important strategy to prevent the avoidable spread of infectious diseases lies on the supply side, with governments maintaining well-oiled systems. Free, easily accessible, safe and effective vaccines need to get to those who actually want them. It’s a tragedy when parents who want to vaccinate their children can’t do so because of external impediments.
The second strategy is to target those who are hesitant about vaccination. People in this group usually vaccinate but might delay or decline a stigmatised vaccine such as MMR or human papillomavirus (HPV).
Australia could do more to meet the needs of these active information seekers. Just this week, the Academy of Science released a high-end publication The Science of Immunisation: Questions and Answers. It sets out to explain the current situation in immunisation science, including where there is consensus in the scientific community and where uncertainties exist.
The third approach to preventing a disease outbreak is to minimise the proportion of people who refuse vaccines. Even though they represent about 2% of Australian parents, they cluster in certain regions where up to 35% may be unvaccinated. An outbreak of whooping cough or measles in those communities would result in a much more sustained spread.
Talking with vaccine refusers
One of the most important times to address this problem is when parents are forming or solidifying their views on vaccination – usually during pregnancy or in the child’s first year. At this time, their family doctor or child health nurse has a crucial role in discussing concerns.
These discussions can be challenging for health professionals. With this in mind, I worked with an international group of clinicians and communication scientists to develop a framework for health professionals in communicating about vaccination. We recognised these health professionals posess a good deal of training, experience and skill in communicating – that they already had a collection of communication tools. The trick is often knowing which tools to use and when.
The framework involves a tailored approach and is informed by evidence in the areas of communication science and motivational interviewing. It begins with a spectrum of parental positions: unquestioning acceptance, cautious acceptance, hesitance, delay/selective vaccination, and refusal. The goals and strategies will differ across these positions.
The common theme is listening and acknowledgement, and, as even Dr Seuss himself inferred, this approach is far more likely to produce a positive result than talking at cross-purposes.
When mum “Kate”, for example, declares her intention to her doctor to give her baby homoeopathic preparations instead of vaccination, he may immediately try to put her right, knowing homeopathy won’t protect the baby at all. This “righting reflex” is the natural response of health professionals to instinctively leap in and “put right” health-care problems.
With parents such as Kate who are often fixed in their views, the discussion can descend into a game of scientific ping-pong, arguing back and forth about the evidence. These discussions are usually time consuming and are likely to further entrench Kate who, feeling cornered, will defensively rehearse and reinforce her arguments.
In this situation, a better goal would be to build a rapport that may have gains further down the track, including further discussion, partial vaccination and, perhaps eventually, full vaccination. This would be done by acknowledging her concerns, asking permission to discuss, encouraging her to explore the pros and cons of her decision, and eliciting her own possible motivations to protect her baby from diseases such as whooping cough, particularly since her decision to use homeopathy has already demonstrated some desire for active protection.
This approach draws from motivational interviewing that uses a guiding style, rather than a directing style, for discussions where there is ambivalence and resistance to change. The method has shown to be effective for a range of health behaviours.
Our framework also sets out strategies for parents who want to delay or select-out some vaccines, are hesitant, or generally accepting of vaccination. Across all such scenarios, it is more effective if professionals build rapport, accept questions and concerns, and facilitate valid consent by discussing both benefits and risks of vaccination.
In Green Eggs and Ham, it’s not until Sam I Am finally acknowledges, “You do not like them, so you say. Try them try them and you may” that the winds of refusal change. The narrator tries the strange dish and, by book’s end, happily declares his love for it, and his gratitude to Sam.
Seuss showed us that a simple acknowledgement and a more respectful plea is part of the art of gentle persuasion.