Vaccine Hesitancy: The Growing Parent-Provider Divide

A growing number of parents in both developed and developing nations have refused vaccination. This paper reviews some literature published in the last few years to understand and explain the phenomenon of vaccine hesitancy. It identifies 10 reasons for refusal and categorises parents who hesitate or refuse vaccination into 4 types, from a developing country perspective. Throughout, the article refers to vaccination campaigns conducted in different countries at different times and documents their insights and experiences, with a focus on the authors' own experience in the field in India. Finally, the paper briefly summarises the recommendations made by research studies to address vaccine hesitancy.

A search of research articles on vaccine hesitancy since 2013 in peer-reviewed journals revealed these themes/factors:

• Parental concerns, such as discomfort when new vaccines are introduced due to unfamiliarity and concerns about safety.
• Perceived disease susceptibility, which is related to lack of specific knowledge about risks associated with non-immunisation rather than to parents' general level of education.
• Parent–provider relationship, which can be affected by sociocultural background and differential level of understanding of disease.
• Government policies - For example, in India, government operational guidelines on measles rubella (MR) recommend vaccinating a child second time even though s/he had received the same vaccine at a private health facility earlier. Parents could not grasp the logic of second vaccination, and frontline health workers were at a loss to explain the benefit of second MR vaccination.
• Role of school authorities - For example, a month-long MR vaccination drive in India, which required vaccinating children of age 9 months to 15 years, depended on active and voluntary participation of school authorities. However, there were high rates of parental refusal in some schools in the city of Hyderabad.
• Weak interpersonal communication (IPC) skills of health workers, which can manifest itself in counselling that is inconsistent, unstructured, and does not include the use of any information, education, and communication materials (IEC).
• Religious beliefs - For example, several vaccines include bovine serum or bovine-derived viruses, or pork gelatine, consumption of which is prohibited in Muslim and Jewish religions.
• Role of media in shaping people's behaviours - For example, parents can be influenced by negative stories about vaccine safety in news and on television, or delivery of anti-vaccine messages via digital networks or by influential figures.
• Social media and information on vaccines - Earlier, pockets of vaccine resistance were confined to some neighbourhoods, certain types of schools or communities, nomadic groups, or hard-to-reach places. Immunisation programmes took this to account and planned activities accordingly. For instance, they worked through influential local leaders to address local concerns. More recently, however, due to information and communication technologies (ICTs), communities of resistance have acquired a relational, not just spatial, dimension. "Sources" of information on vaccination have multiplied, the amount of information received has grown, and the frequency and speed with which it comes has created confusion.
• Lack of trust, which is a multidimensional challenge that can manifest itself mistrust in the government, in vaccines themselves, in the pharmaceutical industry, and in public (government) hospitals and staff (e.g., when well-off sections of society perceive public hospitals and health staff as less competent). Mistrust leads to fear and death when extremist groups kill health workers (as in Pakistan and Afghanistan).

The review of published material on vaccine hesitancy shows that a community's response to vaccination initiatives includes 4 strands or categories, understanding of which could provide a platform to launch action programmes against anti-vaccination myths and misconceptions:

1. Obedients - "This category constitutes the largest chunk of people but is a silent majority. They readily accept vaccination, but are poor, belong to lower middle class and live in outreach, peri-urban and hard to reach areas. Their children mostly study in government and government-aided schools, and their faith in the government health system is implicit, if not intact. Neither the parents nor the school children have enough information or in-depth understanding about the vaccine, but they accept it anyway. There is little or no persuasion required for motivating parents to vaccinate their children."
2. Ditherers - These fence sitters may have heard rumours but have no viable means of confirming their authenticity. They prefer to wait to see the result of vaccination (to others), require assurance, and are late to accept it. Vaccine-hesitant parents largely belong to this category; effective social mobilisation is necessary to transform this category to become obedients.
3. Doubters - They genuinely do not feel the need for vaccination, and counter-arguments do not persuade them. They have a poor opinion of government health services and rely exclusively on private practitioners for their health needs.
4. Defiants - "They draw their inspiration and energy from deep-seated mistrust of government. Technology-savvy, urban, outspoken and better organized, their opposition to the campaigns occurs in small pockets but is intense and often finds prominence on social and mass media platforms."

Although the ditherers are not very vocal about their vaccine concerns, their shifting to the defiant category could make them vaccine rejecters and thus vocal. Vaccine rejecters have the potential to amplify myths and misinformation about vaccination that can influence the general public to pull away from vaccine acceptance.

Some of the strategies identified in the literature to address the challenges and categories of people, to the end of preventing the spread of vaccine hesitancy, include:

• Policy/population level - e.g., including transparency in policy-making decisions and providing updated information regarding vaccines to the public and health providers. "India's polio situation is a good example of what policy level changes can accomplish....In 1988, the World Health Assembly adopted polio eradication as a global goal. At that time, India had 23,800 cases of polio. In 2014, the WHO [World Health Organization] declared India polio free."
• Parent–provider relationship - Studies explored here focus on dialogue and IPC between providers and parents. For instance, one of them suggests that open and frank discussions with hesitant parents can assist in improving their understanding of vaccines. Maintaining and sharing authoritative, evidence-based information about vaccines by health professionals and establishing relationships with patients and their parents that are based on trust can minimise the impact of vaccine hesitancy. Other studies suggest that parents' decisions regarding vaccine acceptance are influenced by a larger context of beliefs and personal experiences about childre's health, perceived societal norms, and trust in health systems and professional providers at individual, family, and societal levels.
• Communication campaigns - By engaging communities in dialogue through local opinion leaders or peer groups, such campaigns have the potential to build community support and advocacy for the benefits of vaccination. A study that focused on combating anti-vaccine misinformation emphasised the importance of using storytelling as a method of message dissemination among parents and patients. Some campaigns have used celebrities to heighten awareness about vaccination-preventable diseases. It is recommended that educational programmes tailor messages based on the degree of vaccine hesitancy expressed in their target populations in order to improve their overall effectiveness. For example, some parents may respond better to information about the general safety of vaccines, whereas others may need more information about the vaccine.
• Capacity strengthening - There are at least two ways to strengthen the capacity of health workers. One, the conventional way, is to train them periodically and upgrade their skills by providing technology or new content. The second is to complement their capacity with additional human resources. In India, the United Nations Children's Fund (UNICEF)-managed Social Mobilization Network (SMNet) played an important role in polio elimination. As part of a community engagement strategy, the network trained over 7,000 frontline social mobilisers at national, district, and community level to advocate for vaccination in some of the most underserved, marginalised, and at-risk communities across the country. The mobilisers focussed on generating demand for polio vaccination and clearing doubts. In doing so, the SMNet strengthened the capacity of the health system.

In conclusion: "The challenge is to remain on guard. Governments often frame policies, strategies and guidelines based on cumulative experience thought through scenarios or known factors. But such scenarios cannot anticipate sudden or unforeseen developments or the swiftness of anti-vaccine response....[N]ew media can be harnessed to track anti-vaccine messages and lay people’s perceptions of vaccination in real time. This will in turn enable policy makers to plan communication strategy, design interventions to address negative media stories and health providers to engage communities in the right course of action..."