This week, Toronto Public Health warned that a young adult in the city had the measles, after getting it while travelling. These stories are no longer uncommon; there have been outbreaks of measles in British Columbia, Alberta, Saskatchewan and Ontario in recent years. One, in Quebec, had more than 100 cases.
One reason is because Canada’s vaccination rates are too low. Eighty nine percent of toddlers have been vaccinated for measles, mumps and rubella (MMR) as well as meningococcal diseases, and 91 percent have gotten the polio vaccine. Vaccinations for diphtheria, pertussis, tetanus and chickenpox are lower, with rates in the 70th percentiles. That’s well below the 90 percent needed for herd immunity – where enough children are vaccinated to protect the whole community, including those with allergies or immune conditions that mean they can’t be vaccinated. And even MMR rates differ across the country, so there are pockets with much lower vaccination rates: Most schools in Vancouver have vaccination rates that are too low for herd immunity, with some as low as 15 percent.
Every new vaccination story seems to be used as an opportunity to rail against anti-vaxxers, who are spoken about with the same disdain as flat earthers. Heated debates and pleas to vaccinate are happening everywhere from Facebook to the doctor’s office – but most of those conversations don’t change people’s minds.
Vilifying people who don’t vaccinate doesn’t help the situation, says Joshua Greenberg, director of the School of Journalism and Communication at Carleton University and a researcher in this field. Nor does acting like they’re dumb or misinformed. “One of the misperceptions is that people don’t get their kids immunized because they simply don’t understand,” he says. But people who don’t vaccinate are often more educated than the general public, and better off as well.
The good news is that researchers like Greenberg are looking into how to best talk to people who are reluctant to vaccinate their kids. Though we don’t have definite answers yet, they have unearthed some promising strategies. Here are seven of those techniques.
1. Stop thinking of all people who don’t vaccinate as anti-vaxxers
“The anti-vaxxer is a specter,” says Greenberg. “It’s character in a narrative. We often inflate the degree of that problem.” Instead, researchers separate them into two groups: anti-vaxxers, who make up 1 to 3 percent of the population, and the vaccine hesitant, a category up to 30 percent of Canadians fall into. Anti-vaxxers are very hard, if not impossible, to convince, but the vaccine hesitant do seem to change their minds.
A study led by Greenberg looked at the attitudes of 1,000 Canadians, and found that while 92 percent thought that vaccines were safe and effective, many of them also had concerns. Twenty-seven percent worried that vaccines might cause serious harm to their children, and 33 percent thought that the pharmaceutical industry was responsible for a push towards mandatory vaccination. Twenty-eight percent were worried about a link between autism and vaccines, despite the fact that any link has been disproved.
2. Keep cognitive biases in mind
Worries around the safety of vaccines have existed as long as vaccines themselves, but much of the recent rise in anti-vaccination sentiment can be traced to a study in the Lancet by Andrew Wakefield that connected autism and the MMR vaccine. That research has now been thoroughly debunked – in 2010, the Lancet issued a retraction on Wakefield’s paper, and he lost his medical licence – but once an idea takes hold, it’s difficult to get rid of it.
That’s because your brain is terrible at processing complex information and rare, emotionally-loaded risks, like a serious adverse reaction to a vaccine. Instead, the brain relies on cognitive biases – shortcuts in how we perceive information. For vaccine hesitancy, we can blame confirmation bias – the tendency to only accept facts that fit our existing beliefs; illusion or explanatory depth bias, which makes us believe that we know more about a subject than we do; and causal illusions, which encourage us to see cause-and-effect where there is none, like between getting a MMR shot and the early signs of autism, which both happen at the same age.
3. Call out distortions in the science
Francesca, a new mom in Toronto, met with her doctor three times to discuss her hesitancy around vaccinating her child. Despite that, he “did not accomplish anything in answering questions I had,” she says. “His words were ‘as of right now there is nothing wrong with these vaccinations.’ To me, they said that about smoking at one time. It’s not good enough to me.” Needless to say, he didn’t change her mind.
Her story is similar to that of other parents we spoke to who had refused to vaccinate their children. They said what would be convincing to them was better scientific evidence. One said: “Until science can definitively prove vaccines are safe … [public relations] won’t sway anyone who has actually researched the safety of vaccines.”
Of course, that science exists. But it’s easily distorted. “There are some very common techniques that science deniers use [and parents absorb],” says Cornelia Betsch, a German psychologist who studies why people choose not to vaccinate. “One is false expectations – they demand 100 percent safety, and nothing on earth is 100 percent safe. They also cherry pick: some anti-vaccination people collect evidence from studies, they pick certain things out of the limitation sections of the studies, and they don’t put that into the context. And they omit the big consensus on the research.” A review by Betsch looked at the messaging side of thing and found that when faced with arguments like these, calling out these techniques can be helpful.
Emphasizing the scientific consensus also seems to help. A randomized trial found that telling people that “90 percent of medical scientists agree that vaccines are safe and that all parents should be required to vaccinate their children” significantly reduced their worries about vaccines and belief in a link between vaccines and autism.
4. Work with confirmation bias instead of against it
Explaining how herd immunity works increases people’s willingness to vaccinate. “It adds some extra value,” says Betsch. “If you know about the individual benefits, you should also learn about the social benefits.”
There’s also some evidence that emphasizing the negative impacts of the diseases, instead of the safety of vaccines, might work. A 2015 study found that showing parents pictures of children suffering from mumps, measles or rubella and a parent’s description of a child’s illness worked better than sharing information debunking the idea that vaccines aren’t safe. Derek Powell, one of the authors of that study and a PhD student at the University of California, Los Angeles, explains that it might work because “if you’re skeptical of vaccines, we’re kind of arguing with you if we talk about vaccine safety. But diseases being dangerous basically fits with what you already think.”
The success of that study goes against the results of a 2014 randomized trial that tested four different ways of promoting the MMR vaccine: offering information explaining that there’s no evidence the MMR vaccine causes autism; information about the dangers of the diseases; photos of children who had measles, mumps or rubella; and a story about an infant who almost died of measles. It found that none of the interventions made parents more likely to vaccinate, and in rare cases, offering evidence about the harms of diseases actually increased beliefs in the side-effects of vaccines – possibly because it put parents in a fearful state of mind.
5. Think about telling real people’s stories
The idea of using personal stories to convince parents is also controversial in scientific circles. After all, if you fight anecdote with anecdote, don’t you lose the upper hand? And even if you do, is it the role of doctors to scare people into action? As Betsch says, “You should really make a decision: do you want to inform people, or persuade them? Usually, health organizations want to inform people and take it seriously that it’s a free decision.”
But Greenberg argues it’s necessary. “Physicians and public health scientists tend to work in a world of statistics, but statistics on their own aren’t particularly compelling. Narratives are the ways in which we have communicated about risk from the very beginning, and stories are the way in which we make sense of the world. We need to find a balance between stories and the evidence.”
6. Change the default
If parents are confused about the evidence, a common reaction is to choose to do nothing. (We can blame another bias for that – the omission bias, which gives us the feeling that harm that comes from an action is worse than harm that comes from inaction.) One response, then can be as simple as having doctors use language that assumes patients are going to vaccinate instead of asking if they will.
Another is to make it harder not to vaccinate. States that make it harder to get exemptions to vaccinations for school attendance have significantly fewer parents opt-out than those that don’t. That’s being adopted in Canada, too: Ontario’s Health Minister has tabled legislation that would require parents to take an educational class before being allowed to opt-out of vaccinating. And Manitoba, Ontario and New Brunswick have enacted legislation that requires children to be immunized before attending public school.
7. Tailor the message to build trust
Health care professionals play a key role here: a systematic review that looked at how doctors should talk to their patients about vaccines suggested a tailored approach is important, given that there isn’t enough evidence to know exactly what kind of messages resonate with patients.
The Canadian Pediatric Society’s guidelines around this suggest how to do that in practice. It suggests physicians start with motivational interviewing (MI), a method that’s used to discuss the parents’ concerns in a non-judgmental way and to isolate a parent’s exact concerns. The technique begins with having health care professionals gauge where parents are in their decision-making process and what their specific concerns are. If someone has few concerns, they might be addressed on the spot. But a parent who is very hesitant might respond better to just getting information and time to reflect ahead of any decision.
The technique, which is commonly used to get patients to accept treatment for alcohol abuse, was first researched on vaccines by Arnaud Gagneur, a doctor and professor at Quebec’s Universite de Sherbrooke. His study involved doing motivational interviewing sessions in the maternity wing at a hospital.“The research assistant [did the interviews] and gave information, but using MI techniques: we ask a lot of questions of the parents, then give answers that are adapted to the questions and position of the parents,” he explains.
The meetings took about 20 minutes, and they included 3,300 families in total. Those parents were 15 percent more likely to say they would vaccinate their babies at two months old, and 9 percent more likely to have completed their scheduled vaccinations when their kids were two years old. (This research hasn’t yet been published.) Gagneur is now testing that approach in pilots across the country, and it’s being introduced in all major maternity wards throughout Quebec at the beginning of 2018.
Part of the reason motivational interviewing is successful, he says, is that parents like it, especially vaccine hesitant ones. “They say, it’s the first time that I feel respected about my position with vaccination, this is the first time someone has spoken to me like this,” he says. “One mother [who had just given birth to her third child] said to the research assistant after the intervention, okay, I’m going to vaccinate my child,and all of my other children as well. It’s the first time that I’ve had a discussion like this, and I feel respected, and I trust you.”