Addressing Vaccine Hesitancy to Protect Children and Communities Against Preventable Diseases

This Evidence to Action brief from PolicyLab at the Children's Hospital of Philadelphia (CHOP) summarises research findings around the causes and effects of vaccine hesitancy, a behaviour influenced by issues such as lack of trust in the medical community and concerns about vaccine safety, efficacy, necessity, or convenience. It proposes policy changes that could lead to increased vaccination rates and greater protection for the current and future health of children in the United States (US), where approximately 42,000 adults and 300 children die each year from vaccine-preventable diseases (VPDs) despite availability and routine recommendation of vaccines.

Public health entities such as the World Health Organization (WHO) and the National Vaccine Advisory Committee have focused on better defining vaccine hesitancy to help inform interventions designed to address it. Based largely upon this body of work, PolicyLab has identified 3 primary contributors to vaccine hesitancy and its ability to negatively impact children's and population health in the US:

1. Diminished prioritisation of vaccination - A vaccine successfully eradicated smallpox worldwide in 1977. The US declared the national elimination of polio and measles in 1979 and 2000, respectively. The prevalence of other VPDs, such as diphtheria and rubella, has reached such low levels that most Americans have never experienced or witnessed them. Delays may not be driven by negative attitudes toward vaccines, but demonstrate that barriers to accessing vaccines combined with an underappreciation of the severity and prevalence of preventable diseases can keep children from being fully vaccinated on time. Late vaccine initiation can also be due to a parent's deliberate decision to delay vaccination.
2. Lack of confidence in safety and efficacy - When parents do not see the potential benefit of vaccination, any perceived safety concerns about a specific vaccine may seem like a greater risk than the infection itself. Such vaccine safety concerns are also fueled by a prominent anti-vaccination movement in the US, which is - according to PolicyLab - based on misleading and unsubstantiated claims about vaccine safety, perpetuated in the media and online, and difficult to reverse (e.g., the repetition of inaccurate information during attempts to refute it can have an unintended "backfire effect" - increasing familiarity with and perpetuating the myth).
3. Inadequate state vaccine policies - Evidence shows that the availability and ease of nonmedical exemptions (e.g., religious exemptions) increase exemption rates and decrease vaccination rates.

PolicyLab recommendations include:

• Improve health care providers' ability to make strong vaccine recommendations - Suggested strategies include: Health care educators should place a stronger emphasis on training about vaccine safety, efficacy and communication at all levels of career development; obstetricians should counsel mothers before giving birth about the importance of following the recommended vaccination schedule to make sure their infant will be fully protected; providers should aim to reduce or eliminate the number of patients on alternate vaccination schedules (e.g., address vaccine hesitancy through motivational interviewing, during which providers actively elicit and acknowledge specific concerns from parents to foster open and honest dialogue); states should help to strengthen immunisation information systems (IIS) by requiring all providers who administer vaccines to report doses for children, adolescents, and adults; and States should require third-party payers to provide adequate reimbursement to providers for the full cost of vaccination services.
• Strengthen and enforce vaccine mandates for school entry.
• Improve public vaccine education, awareness, and access - For example, Every Child By Two (ECBT) is a nonprofit organisation that uses a variety of public education campaigns to increase awareness of the importance of timely vaccination. Its messaging materials, which have included billboard campaigns, social media marketing, public education events and public service announcements (PSAs), are designed to direct viewers to credible vaccine information sources. ECBT's Vaccinate Your Baby campaign, which utilised these communication tools, reinforced the safety of vaccines and highlighted the dangers of vaccine refusal and delay through personal stories. This campaign generated significant coverage from news outlets. Various other strategies are outlined, such as that states should increase pharmacists' ability to recommend and administer vaccines to patients of all ages. (Many parents interact with pharmacists on a more regular basis than with a primary health care provider. It is important, per PolicyLab, that pharmacy schools train future pharmacists to counsel patients on vaccine decisions, including how to provide information about vaccine benefits and counter inaccurate statements about vaccine risks.)

In conclusion, PolicyLab outlines actions that specific stakeholders can take to encourage vaccination:

• "Health care networks and educators can work to ensure providers have the training and support they need to make strong vaccine recommendations and adequately address the concerns of hesitant parents.
• Providers can make use of available tools and training to understand major vaccine concerns, and prepare themselves for tough conversations.
• Health plans and insurers can support provider efforts by adequately reimbursing for the entire cost of vaccination...
• Federal legislators can...[allow] payers to use premium differentials within the parameters of the federal law that incentivize use of the recommended vaccine schedule.
• States can enforce existing vaccine mandates, make it more difficult to obtain vaccine exemptions and allow vaccines to be given in more convenient locations such as pharmacies.
• State and local health departments can help to address each cause of vaccine hesitancy through targeted public awareness and education campaigns."

An accompanying social media toolkit [PDF] is designed to help readers communicate the report's recommendations to their networks or for use in vaccine-policy advocacy. It contains hashtags, suggested tweets, and infographics that can be used to disseminate these messages to one's social networks. Also, a March 2017 webinar (see below) summarises the report and its implications for policy.