Dr Nighat Nadeem, from South West London and St George’s Mental Health NHS Trust, discusses the crisis in paediatric vaccination, which has resulted in the re-emergence of vaccine-preventable diseases.
Paediatric vaccination is a vital public health intervention, but is now experiencing the ‘vaccine paradox’ as it is a victim of its own success.1 The recent re-emergence of vaccine preventable diseases (VPD) is a result of decreased herd immunity, and even a small decrease in vaccine uptake can leave all children in the community vulnerable to VPDs. Doctors and medical students now have decreased exposure to VPDs and this, combined with the media’s negative portrayal of vaccines, may cause misconceptions and misinformation.
This study explored the beliefs of doctors and medical students in the UK of the main barriers to children’s vaccination. 169 participants from two hospitals, General Practitioner’s from four London boroughs and students from three medical schools completed an anonymous, self-administered, cross-sectional survey. This study was approved by King’s College Research Ethics Committee, and highlighted that the main barriers to children’s vaccination in developed countries are believed to relate to parental factors, the media and the healthcare system.
Parental factors, including disorganisation, apathy, over-protectiveness, laziness and misguided beliefs about vaccinations, all form barriers. Vaccinations may be viewed by some parents as unnecessary or dangerous, leading to parental refusal/reluctance to vaccinate their children, which results in decreased vaccine uptake.2 In turn, this leads to the concept of ‘vaccine hesitancy’ (Figure 1). Since the incidence of VPDs has plummeted in the global north, they are not perceived as a significant threat anymore.
Some anxious parents may rely on herd immunity assuming and hoping that other children will be vaccinated so that their own child can remain unvaccinated and be protected from potential adverse effects of vaccines. This individual incentive to avoid vaccination and gain indirect benefit from the herd immunity was described by participants as ‘selfishness’ on the part of parents. It has also been described in the literature as elitism of a group of people who believe they should not risk vaccinating their child if enough other children are vaccinated.3
Parents may also prefer alternative therapies, and a ‘nature is best’ attitude in some sub-groups of society forms a barrier to vaccination. The social norms of some sub-groups may create a trend or fad resulting in a herd effect in negative attitudes towards vaccinations. Such barriers to vaccination must be understood and addressed in a respectful manner. Although parents are genuinely concerned for their child, they may be misinformed and misguided, and at a time when vaccine uptake is sub-optimal, healthcare professionals (HCPs) may also develop elements of ‘vaccine hesitancy’. The media has a significant role to play in influencing the attitudes of both parents and HCPs.
Media misinformation, fearmongering and poor quality reporting of risks can form barriers to vaccination directly via the anti-vaccination movement or indirectly by affecting parents and HCPs’ beliefs of vaccinations.
The media has a key role to play in disseminating and sensationalising vaccine objections. The ‘anti-vaccination movement’ propagates the myth that vaccines are ineffective, useless or dangerous by confusing scientific evidence and portraying opinions emotionally.4 The media can also orchestrate paranoia by promoting ideas such as ‘stuff your doctor won’t tell you’.
Anti-vaccination campaigns tend to promote a mistrust of government and vaccine manufacturers, as well as promoting conspiracies and reasoning flaws substituting emotional anecdotes for scientific data.5
As parents now have easy access to a large amount of information, it can be difficult for parents to assess the reliability of the source. Social media allows vaccine information to be easily shared, while forums and blogs have allowed the formation of virtual communities across wide geographical areas.3 The sharing of unverified anecdotes and rumours forms a major modern day barrier to vaccination.
HCPs and the healthcare system can form barriers to vaccination, including difficulties obtaining appointments and long waiting lists. Reminder/recall (RR) interventions have been widely used to improve vaccination rates. These are conducted by postal letters or telephone calls and modern technologies including text messages and social media show considerable potential.6 Smartphone applications can also be used effectively as a RR intervention.7 However, conducting RR has its own barriers including staff time, training and cost.8,9
The decreased incidence of VPDs has resulted in HCPs giving VPDs less attention, which subsequently leads to less effective communication with parents regarding children’s vaccinations,10 and research suggests that HCPs poor communication skills can impede high immunisation rates.11 As HCPs have a powerful relationship with parents, they can influence parental vaccination decisions.12,13 Counselling parents who refuse vaccinations poses an ethical dilemma for HCPs, as they have to respect the parents’ right to decide, as well as to consider what is in the best interest of the child and the community.14
Insufficient time during consultations to effectively discuss these matters may form a barrier to vaccine uptake. The negotiation between a HCP and a vaccine-hesitant parent can be an uphill battle, as parents may come to HCPs armed with information they have collated from various sources, including the media.
In this way, the three main barriers to vaccination interlink and impact on each other making it all the more difficult to overcome.
Compulsory vaccination may be used to overcome the barriers to vaccination. Vaccinations are currently not mandatory by law in UK. As unvaccinated children pose a risk to the community, compulsory vaccination may be one solution as it ensures equity.15 One argument against compulsory vaccination is that it is not necessary as herd immunity does not require 100% vaccination coverage, and many countries – including the UK – achieve vaccination rates of more than 90%.16
Compulsory vaccination does not automatically guarantee full vaccine coverage and is fraught with ethical and moral issues. Suggestions have been made that parents who refuse vaccination are essentially ‘free-riding’ on the immunity of others,17 and one of the issues with compulsory vaccination is its infringement on individual autonomy. Vaccination against parental wishes may lead to resentment, which would not set a good foundation for future relations with the medical profession and in the long term may prove detrimental to children’s health. Compulsory vaccination diverts resources away from education17 and a policy of targeted education empowers parents, enhances public trust and is likely to be more successful than coercion.18
VPDs are becoming increasingly common worldwide, and it is our collective responsibility to maintain herd immunity as it has implications on a global scale. The implications of vaccine-related decisions reach beyond the child and affect the whole community and each unvaccinated child increases a community’s vulnerability to VPDs. It is vital to determine the barriers to vaccination and overcome them. Gaining parental trust, parental education and effective communication are all vital, and no professional group can single-handedly reverse the loss of public confidence in vaccines.
As no single strategy is sufficient, a multi-angle, multi-faceted approach is required; communication, dialogue and engagement are needed across all professionals involved in children’s healthcare. It would be a tragedy if the decades of progress in vaccinations were to be slowed or reversed by misinformation, misunderstanding and false propaganda.