It should concern every American that measles, a disease declared eliminated in the United States in the year 2000, is now back with a vengeance. Since June 2019, more than 1000 cases have been reported to the US Centers for Disease Control and Prevention (CDC) by local, state, and territorial health agencies.1 The outbreak has been fueled primarily by infected overseas travelers who then spread measles to others upon visiting or returning to the United States. The consequences of contracting measles for young children and/or individuals with compromised immune systems are especially serious and potentially fatal. Media attention to the outbreaks has raised the issue to the forefront of policymakers' agenda. Since the recent outbreak started, several states have enacted legislation to limit philosophical exemptions to vaccination and changed existing state laws to make it harder for parents to avoid vaccinating their children for nonmedical reasons.
While public support for vaccination remains high, parents continue to have questions and concerns.2,3 A national Poll of Parents conducted by the CDC in 2016 found that 86% of parents indicated their child received all recommended vaccines and 1.6% refused all vaccines.3 In between were vaccine-hesitant parents with concerns or who delayed vaccination. Most commonly, these concerns centered on the ingredients in vaccines and quantity of vaccines administered at a single visit. Pediatricians or other health care providers were the most influential factor in changing a vaccine-hesitant parent's mind to vaccinate his or her child (44.5%),3 as was more time to consider vaccination (38.6%), state legal requirements (20.7%), convenience/not wanting to have to come back for a vaccine at another appointment (10%), and influence of family and/or friends (7.5%).3 Also, 24% of parents surveyed used the Internet as one of their top 3 sources of information about vaccines in addition to other trusted sources, including family members and scientific medical journals.3
As concerns have increased about vaccine safety, there has also been a decrease in public opinion regarding the importance of vaccines to the health of our society. A public opinion survey commissioned by Research!America and the American Society of Microbiology in 2018 found a 10% decline in the percentage of people who believed vaccination is very important to the health of a society and a 11% decrease in the percentage of people who strongly believed parents should vaccinate their children since a 2008 survey that asked the same questions.4 Americans are also less likely to believe they have personally benefited from vaccines over the last 50 years: in 2008, 75% of survey respondents strongly believed that they have “personally benefited from the development of vaccines over the last 50 years” and 59% strongly believed they benefited in 2018.4 In sum, national data show that while vaccine acceptance remains high, in the last 10 years there has been eroding confidence in the benefits of vaccines, rising concerns about vaccine safety and schedule, and a decreasing belief in the importance that parents should vaccinate their children (82% in 2008 compared with 71% in 2018).4
The decision not to vaccinate one's child counters the conventional thinking of most public health practitioners and health care providers. Why would a parent decline to protect the health of his or her child, and the health of others' children, when time and time again scientific studies of vaccine safety have concluded, beyond any reasonable doubt, that vaccines are safe for all but the tiniest fraction of children? In response to these declines in confidence and increased concern, public health leaders and health care providers have provided accurate information about the safety and efficacy of current vaccines and stressed that the facts concerning vaccines demonstrate the safety of vaccines with very few exceptions.
Therein lies the problem. Relying solely upon sharing accurate information to counter “misinformation” is a rational argument that appeals to the rational decision-making part of our brains. It does not, however, appeal to the more emotional or irrational part of our brains (I don't care what science says; I'm not chancing it with my child) that drives hesitancy. To more effectively counter hesitancy, public health leaders have to appeal to both rational (“head”) as well as irrational (“heart”) decision making used by parents to delay or refuse to vaccinate their children. Why? A vaccine-hesitant parent is most likely experiencing cognitive dissonance: Do I believe my pediatrician or my public health agency who assure me the science is sound, or do I believe the family member or friend who says vaccines are unsafe? Should I believe the Web site that says vaccines contain toxins, or that requiring vaccination for school entry is part of a large pharmaceutical industry-government conspiracy to exploit me and potentially harm my child? Both rational and irrational factors go into weighing the risks and benefits of vaccination, and parents give different weight to existing beliefs and scientific facts.
Sharing accurate information about vaccination is an important rational strategy and the dominant one for public health experts: present the facts, share the data, prove efficacy. But that strategy does not address the “heart”-based arguments that lead to dissonance around vaccination, specifically concerns about how vaccines are made, how they are tested, and how they are scheduled for administration during childhood and young adulthood. A 2012 ASTHO report based on focus groups with mothers and a survey of 1278 parents and guardians about vaccine refusal found that most vaccine hesitancy was not due to a misunderstanding of the basic facts about vaccination but rather due to unanswered questions about the ingredients in vaccines.2 In addition, vaccine-hesitant parents and guardians delayed vaccination because they felt that too many vaccines were given to their child at the same time and they wanted to know more about why. The report confirms what many public health leaders already know from practice: vaccine-hesitant parents are not necessarily making decisions based solely on misinformation or lack of facts.2 Rather, they do not feel right about vaccinating their child because they are worried, scared, or concerned enough to decline or delay. These seemingly irrational “heart” arguments can be countered by moving the conversation from a scientific frame (“let's review the facts”) to complementary, more emotional frames (“tell me more about why you are worried about vaccines, and let me share why I am worried that your child is not vaccinated”). Some potential considerations to combine these head and heart arguments are described as follows:
Use empathy and focus on the hesitant and delayers, not total refusers. First and foremost, public health leaders can express empathy and work to understand rather than dismiss the fears or concerns of vaccine-hesitant parents. National survey data illustrate that there is a continuum of parental support for vaccination ranging from complete acceptance to total refusal.2–4 In between these ends of this continuum are parents with concerns about the ingredients in vaccines, parents who want to know more about how vaccines are monitored for safety, the relationship between vaccines and developmental disorders, or why multiple vaccines are given in a single visit. In the ASTHO report cited earlier, 16% of parents had refused a vaccine for their child but not all vaccines for their child, which could mean that, in fact, a parent may be very well informed (or, more likely, very well misinformed) about particular vaccines, such as the popular but untrue “fact” that the measles-mumps-rubella (MMR) vaccines should be avoided because they contain thimerosal (they never did).2,5 While trying to change the minds of those on the total refusal end of the continuum is most likely an exercise in futility, focused efforts to identify and compassionately address the concerns of vaccine-hesitant parents hold the most promise. Vaccine facts can be a starting point for conversations about the emotional side of the issue and that includes more empathetic discussions of fear, worry, timing, safety, composition, and ways to follow-up with further questions.
Understand the importance of social networks and leverage them. Public health practitioners are accustomed to identifying social networks as part of case finding and contract tracking when investigating how infectious diseases are spread within certain populations. Similarly, it is important to assess how social networks may spread information and opinions about health decisions, especially in dense social networks. For example, the outbreak of measles among the ultra-Orthodox Jewish population in New York was not due to religious prohibitions on vaccination. Rather, the spread of measles within that community was due to shared beliefs among a tight network of individuals in that community who shared information about vaccines with each other through close friendship groups based on trusting relationships. Similar vaccine hesitancy and refusal were common at non-Jewish private and parochial schools where families have similar dense networks, including bible-centered Christian schools, Catholic schools, Waldorf schools, and schools serving special needs children.6 These beliefs are often long-standing, spanning years or generations within a faith community, group of parents, or other networks.
Information sharing among dense social networks has played out in prior measles outbreaks, such as the 2016 outbreak among the Somali American population in Minnesota where the belief of a link between vaccines and autism spread widely among families in that community.7 Why would a parent in these networks trust a public health worker or health care provider over a sister or friend who has shared information and advice about childrearing with him or her for years? Just a few key influencers with a dense social network can impact the entire network's decision making on a multitude of domains, including health and wellness. In Minnesota, New York, and other states, working with faith leaders to talk about child development and address fears and concerns was successful in increasing vaccinations postoutbreak most likely because faith leaders were trusted voices in the community and could pastorally address concerns in addition to sharing facts. Public health can leverage these social networks to change beliefs by enlisting the support of key influencers and learning how specific beliefs about health are shared and spread within a community. Governmental public health leaders have effectively worked with faith leaders on increasing influenza vaccination, and similar approaches can be applied to measles and other vaccine-preventable diseases, an approach being used by local health officials in New York and other states to address the current measles outbreaks.8,9
Counter public health complacency and bolster community connectedness. Eliminating vaccine-preventable diseases is one of CDC's “ten great public health achievements” of the last 100 years.10 With that success, however, comes less urgency to adequately convey the risk of the reemergence of diseases that have not been seen in the United States for decades. Disease outbreaks, such as the recent measles outbreak, remind us of the need for public health to continually educate and inform the public on the need for vaccinations, especially in areas where vaccination rates are declining. In addition to educating and informing, however, public health professionals can work to foster connectedness in communities. Just as “anti-vaxers” have spread misinformation via social media to exploit the fears of vaccine-hesitant parents, public health agencies can harness the power of social media to connect more intently to share information within communities and address concerns and worries at the community level.11 Increasing connectedness between public health leaders and community members through authentic dialogue and meaningful engagement has led to successful health improvement in many areas. ASTHO's President's Challenge to build healthy and resilient communities is one approach that could be used to listen to community concerns and address them collaboratively.12
Hesitancy is not the only problem. While rising hesitancy and the rapid spread of misinformation are alarming, so too is declining public opinion regarding the importance of vaccines for societal health that were identified in 2 of the surveys cited earlier.3,4 This decline in perceptions of social benefit may be part of the growing disconnection that has been noted as leading to “diseases of despair,” as well as increasing lack of confidence in the government's abilities to solve problems. A community that cares about the health and well-being of all its members would emphasize the importance of vaccination not just to a single child but the protective factor that herd immunity plays for the entire community and reinforce the societal value of vaccines. Public health's role in promoting well-being and ensuring the conditions for optimal health for all involves addressing community resilience and connectedness, taking the best of science and medicine and combining it with compassionate, empathetic, and locally led efforts to improve at the community level. Not only do public health leaders have to address the concerns of individual parents and address these at the individual or family level, but they also have to develop and sustain community-level approaches to health that promote collective commitment to community well-being and health equity.
Addressing the growing trend in vaccine hesitancy is tough work and relies upon more than sharing facts. Using appeals to both heart and head arguments provides a comprehensive way to empathetically understand and discuss concerns that lead to vaccine hesitancy, delay, and refusal. Getting to know social networks and opinion leaders within various communities at the local level takes time and effort but is really the only way to sustain health improvement across a number of public health priorities, including this one. Finally, the current measles outbreak reminds us that engaging communities in authentic conversations about health concerns should be the first step, never the last step, when addressing myriad public health priorities, including vaccine hesitancy.