June 1997
WASHINGTON, D.C. — With the plethora of anti-vaccine literature available in bookstores and on the Internet, vaccine benefits are sometimes obscured. Acknowledging parents' concerns about vaccine safety is an important first step toward good risk communication.
Communicating vaccine risk and safety to parents must be handled carefully, a point heavily stressed during a recent workshop entitled, "I Don't Want My Child Immunized," held here at the Pediatric Academic Societies' 1997 Annual Meeting.
In this era when the visibility of vaccine-preventable diseases is decreasing and the visibility of adverse events following immunizations is increasing, it is a challenge for vaccine providers to discuss with parents why vaccination is still necessary, according to panel participant Michele Puryear, MD, PhD, National Vaccine Injury Compensation Program
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Nine Ways to Lose Trust and Credibility | |
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Not involving people in decisions that directly affect their lives |
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Not providing information people want |
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Ignoring parents' or patient's feelings or saying they are irrelevant or irrational |
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Not following up with patient/parent concerns |
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Denying a mistake |
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Pretending to know the answer |
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Not speaking plainly |
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Presenting yourself as superior |
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Not coordinating and collaborating with other credible sources |
The difference between parental and medical perceptions of vaccine risks and benefits often causes conflict which leads to confusion and distrust among parents and physicians. In some countries, rising concern about vaccine adverse effects has led to decreases in immunization coverage and may ultimately lead to epidemics, according to Sharon Humiston, MD, who also participated in the panel.
Providers must learn to comfortably communicate the benefits and risks and answer questions about when the vaccine is preferred and when is it contraindicated, Puryear said.
"Difficulty in communication often arises when the provider is hurried and the parent has a perception of risk with a vaccination," said Beth Hibbs, RN, MPH, from the Centers for Disease Control and Prevention (CDC) Vaccine Safety and Development Activity division.
"There is an added dilemma that parents may accept a death caused by a vaccine-preventable disease over a death caused by the vaccine. In contrast, a physician may regard death due to a vaccine-preventable disease as worse. So, when confronted by parents with questions, the physician must be prepared to answer knowledgeably, dealing with both of these dilemmas," Puryear added.
Humiston, of the University of Rochester, said there are three chief reasons physicians avoid discussing the risks associated with vaccines:
Informational sources to aid communication include the Advisory Committee on Immunization Practices, the American Academy of Pediatrics Red Book, the Vaccine Information Statements, the Standards for Immunization Practices, Six Common Misconceptions about Vaccination and How to Respond to Them and the CDC National Immunization Program hotline and website, but these tools are not being used. Puryear said.
"Providers are failing to recognize that parents come with their own knowledge and perceptions about vaccine risks," she stressed.
Gina Terracciano, DO, also from the CDC Vaccine Safety and Development Activity Division, used methods from the book Responding to Community Outrage to explain why some parents become distressed about childhood immunization. She described risk as a combination of hazard and outrage. Hazard was defined as the result of magnitude and probability, and outrage as all things people are worried about, but experts ignore. "Certain risks are perceived to be more dangerous than others, regardless of the magnitude of the hazard," she said.
She also described the 12 components of parent outrage applied to vaccination, one of which is choice: risks voluntarily taken are more acceptable than imposed risks. Most people feel less at risk when it is their choice.
"Consider the difference between being pushed down a mountain on a pair of slippery sticks and deciding to go skiing," she said.
A related outrage factor deals with control. The perceived risk is much less when a person is in control of their own actions, as opposed to being controlled by others. Terracciano said, for example, the composition of the vaccine is not controlled by the parent and therefore, they feel at risk.
"People feel much more comfortable when they are driving a car than when they are sitting in the passenger seat," she explained.
Natural risks seem to be more acceptable then man-made risks. Vaccines are manufactured and contain "dangerous" additives like mercury, preservatives and aluminum, and some naturalists believe it is healthier for the immune system to contract the disease, rather than preventing the disease with a man-made vaccine.
"In a recent study, 77% of homeopaths believed that contracting measles infection actually strengthened a child's immune system," Terracciano said.
Familiarity also plays a part because familiar risks and surroundings diminish outrage. Childhood vaccines are familiar to most parents, however, new vaccines or situations involving vaccines may be perceived as exotic, according to Teracciano.
Memorable incidents and images of risk exacerbate outrage, and vaccination is usually a memorable experience. Many parents don't recognize many of the vaccine-preventable diseases and don't have a memory of them, yet they remember their child crying after receiving the first series of immunizations.
"As a consequence, many parents will attribute subsequent illness to the most recent round of vaccination," she said.
An event or risk that is unexplainable or explainable only by experts is less acceptable than a risk that is generally understood. Components of this theory include uncertainty, and expert disagreement which all confuse the parents because the so-called experts now include people other than physicians.
Dreading a situation can intensify a perceived risk, and risks that affect children are especially dreaded, Terracciano said. Media dramatizations can also worsen the problem by providing statistics for the risk of vaccine-associated paralytic polio (VAPP), but not showing the number of vaccine-prevented polio cases.
As vaccine-preventable diseases disappear, people no longer dread the diseases, only the vaccines, she said.
Chronic vs. catastrophic outcomes are also components of outrage. Risks that can lead to catastrophic outcomes like seizure disorders or VAPP are less accepted than risks leading to outcomes with a long latency.
"With a catastrophic event, there is no time to prepare or to become accustomed to the risk or the outcome," Terracciano explained. "Although some of the seizure disorders in children that can occur following vaccination are really an unmasking of an underlying illness, the disorder is blamed on the vaccine."
Fair distribution is also important, she said. Risks that appear fairly distributed are more acceptable than risks perceived as unfairly distributed. The benefits of vaccines are fair because there is no discrimination of who receives the vaccines, but the risks of the vaccines are often perceived as unfair.
Studies have identified some of those at an increased risk for vaccine-associated adverse events, but unexplainable cases have occurred.
An especially challenging outrage factor involves individual patient morals, Terracciano said, because some people believe vaccination can not only cause harm, but is morally wrong.
"It's moral relevance that makes the arguments of cost benefit or risk benefit trade-offs seem callous," she explained. "Some religious groups even hold that vaccines are counter to their beliefs."
The challenge is often insurmountable because these anti-vaccine beliefs are not easily changed. People who are opposed to animal testing make be opposed to a vaccine that was developed and tested in animals.
Seven risk communication pointers | |
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Emphasize and provide choices |
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Candidly discuss risks and benefits for the child |
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Empathize with parents' concerns |
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Be aware of anti-vaccine arguments |
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Vaccination policies are based on recommendations from non-governmental sources |
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Vaccines generate immunity through natural response |
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Be careful with risk comparisons |
Risks generated by trusted sources like health care professionals are generally accepted as opposed to risks from untrustworthy sources such as government officials, insurance companies and vaccine manufacturers.
"Obviously industry has a financial interest and so people are distrustful of them. Government is in a situation of both promoting vaccines and monitoring vaccine safety, which can be viewed as a conflict of interest," Terracciano explained.
However, opponents of vaccination can also have an economic interest; if people promote alternative medicine practices, they are actually supporting their organization.
"It's critical that concerns be dealt with courteously and responsively and not with arrogance, defensiveness or 'techno-babble' that people cannot understand," she said.
Being responsive includes openness, acknowledgment and concern; courtesy, helpfulness and compassion.
"Being responsive is the role of everyone that is involved in providing care or overseeing care. This includes the health professional, the government and industry," she said.
The meeting was sponsored by the American Pediatric Society, the Society for Pediatric Research and the Ambulatory Pediatric Association. For more information on communication tools, call the CDC National Immunization Program hotline at 800-232-2522 (English), 800-232-0233 (Spanish) or visit the CDC website at http://www.cdc.gov/nip/.
For more information:
- Sandman P. Responding to community outrage: Strategies for effective risk communication. 1993.
- Colley F, Hass M. Attitudes on immunization: a survey of American chiropractors. J Manipulative and Physiological Therapeutics 1994;17:584-590.
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