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Childhood immunisation: acceptance and advocacy

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Lecture for elective on Vaccines in Public Health, 22 August 2013

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Childhood immunisation: acceptance and advocacy

  1. 1. Vaccines in Public Health 21 Aug 2013 Julie Leask Twitter: @JulieLeask Social Science Unit, NCIRS Associate Professor, School of Public Health, University of Sydney Public acceptance of vaccination in Australia
  2. 2. This session  Public acceptance of vaccination in Australia  Advocacy and risk communication
  3. 3. True or False? 1. Organised opposition to vaccination began in the late 1700’s. 2. Among 4 year-olds, vaccination rates in Australia are increasing. 3. Rates of registered conscientious objection to vaccination have risen by 1.41% in absolute terms. 4. In Australia, most under-vaccination is a result of barriers to access
  4. 4. Anti-vaccination sentiment is as old as vaccination The Cow-Pock—or—the Wonderful Effects of the New Inoculation! (James Gillray, 1802) 1. Organised opposition to vaccination began in the late 1700’s.
  5. 5. OUR VACCINATION RATES
  6. 6. 2) Among 4 year-olds, vaccination rates in Australia are increasing Source: Hull et al 2013, Comm Dis Intell
  7. 7. 0.23 0.41 0.55 0.67 0.77 0.86 0.94 1.03 1.1 1.2 1.3 1.36 1.41 1.44 0 10 20 30 40 50 60 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Percentage of parents recording Conscientious Objection to vaccination in Australia, 1999-2012 3) Rates of registered conscientious objection to vaccination have risen by 1.41% in absolute terms. Source: http://www.health.gov.au/internet/main/publishing.nsf/content/E80E195CFBCE77CBCA2578790017413 B/%24File/202-1213%20Documents%20released.pdf
  8. 8. Refusers Late / Selective Hesitant Cautious Acceptance Unquestioning Acceptance I didn’t want to put anything unnatural in him As a Mama I practice breastfeeding, baby sign, selective, and delayed vaccinating. ―I was in two minds. I did get Leo vaccinated within the recommended time frame‖ 47% 38% 6% 6% 2% Parental Orientations Sources: Leask et al, BMC Pediatrics 2012 and Benin et al., Pediatrics, 2006
  9. 9. What prevents full and timely vaccination of children?
  10. 10. Access / Logistics A – B – C ‘s Influences on vaccination uptake Class exercise: Work in pairs: write down 2-3 things in each category
  11. 11. Socio-demographic factors ACCESS/LOGISTICS GROUP  poorer  single parents  larger families  children born overseas  Indigenous children (timeliness) WORRIED ABOUT VACCINES GROUP •tertiary educated •older •intensive parenting •“alternative lifestylers”
  12. 12. 0 10 20 30 40 50 60 70 80 90 100 Actual coverage Access Acceptance Optimal coverage 2) In Australia, most under-vaccination is the result of barriers to access Graph concept: Angus Thomson
  13. 13. Increasing coverage in children: what works?  „Education‟ when teamed with multicomponent strategies  Recalls/reminder  Routinely checking immunisation status  Home visits  Incentives  Catch up plans  Provider record audits  Clinical decision support systems  Standing orders  School entry linkage Ward et al, ANZJPH 2012 Briss et al http://www.thecommunityguide.org/vaccines/index.html
  14. 14. Can we be complacent about immunisation acceptance? NO Three reasons
  15. 15. Proportion of conscientious objectors in Australia by Statistical Division, 2008 1. Vaccine refusing communities cluster
  16. 16. Source: NSW Health Survey/NCIRS (unpublished) Graph by Maria Chow 81.3 79.7 75.5 64.8 15.4 16.5 18.0 28.3 1.0 1.8 2.6 4.9 1.7 1.1 2.1 1.4 0.0 0.9 0.7 0.5 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 2001 (n=3,459) 2004 (n=739) 2007 (n=1,045) 2010 (n=642) Percentage Support immunisation by year (weighted) Strongly support Generally support Neither support nor oppose Generally oppose Strongly oppose 2. Vaccine hesitancy may be on the increase
  17. 17. MMR coverage at 24 months in the UK and laboratory confirmed cases of measles for all ages (England and Wales), 1995-2010. 3. Sometimes, vaccine scares can catch fire Wakefield paper
  18. 18. VACCINE SCARES Part 2
  19. 19. Exercise  Google “vaccination” or “immunisation”  Jenny McCarthy on CNN http://www.youtube.com/watch?v=DsRSgWUifo8
  20. 20. The Australian Vaccination Network
  21. 21. ADVOCACY AND RISK COMMUNICATION
  22. 22. Principles of risk communication  accept and involve the public  plan and evaluate efforts  listen and be responsive to specific public concerns  be honest, frank and open  work with other credible sources  meet the needs of the media  speak clearly and with compassion Covello 1988
  23. 23. Understand multiple audiences and their concerns  Class discussion: Imagine you are working in a government department responsible for vaccination programs. What are some of the ways you can understand your audiences?
  24. 24. Maintain trust as a priority Trust is made up of: 1. Perceived competence – technical expertise 2. Objectivity – lack of bias 3. Fairness – represents all points of view 4. Consistency – predictability of arguments and behaviour 5. Faith – perception of good will in composing information 6. Empathy – degree of understanding and solidarity (Renn and Levine in Communicating Risks to the Public 1991) People invest enormous trust in the system when they present for vaccination The MMR scare was underpinned by eroded trust in UK health authorities Source: SMH
  25. 25. Maintaining trust  Use trusted spokespersons  Be honest, frank and transparent  Err on the side of disclosure “There is new evidence from Australian and overseas studies suggesting a small increased risk of intussusception in infants following rotavirus vaccination”
  26. 26. DOES TALKING ABOUT VACCINE RISK PUT PEOPLE OFF VACCINATING? Not if done well. It may increase willingness to vaccinate among hesitant http://www.ncirs.edu.au/immunisation/education/mm r-decision/index.php
  27. 27. Sydney study ―Leaning towards MMR immunisation‖ 39% to 55% Leeds study (unpublished – data removed for public version)
  28. 28. PLAY THE ISSUE, NOT THE OPPONENT
  29. 29. One way to play the issue and not the opponent Re-frame debates ―There is sufficient anxiety in my own mind for the long term safety of the polyvalent vaccine—that is, the MMR vaccination in combination—that I think it should be suspended in favour of the single vaccines,‖ Andrew Wakefield Interview 4 Feb, 1998 Source: http://briandeer.com/solved/bmj-wakefield-2-2.htm
  30. 30. Core issue Parental autonomy Healthy childre Manifest argument “Separate vaccines are safer” Reframing Reframed argument “Children need protection from measles” “Consider the choices of children: six needles versus two.” Manifest argument “Separate vaccines are safer and the government should provide them.” Core argument Parental choice Healthy children
  31. 31. Support health professionals in communicating Parental position Key indicators Goal Strategies* Unquestioning acceptor Tailored strategies informed by: Motivational interviewing Principles of valid consent Avoiding the „righting reflex‟ Cautious acceptor The hesitant Late or selective vaccinator Refuser Source: Julie Leask, Paul Kinnersley, Cath Jackson, Francine Cheater, Helen E Bedford, Greg Rowles 2012 BMC Pediatrics
  32. 32. Prioritise special risk groups  listen then share with communities the information needed  localise, personalise and humourise  avoid paternalism, tokenism and „Aboriginalising‟  Consider social media for targeted communication An example… Pandemic project with Indigenous communities From: Massey PM et al Health Policy 2011;103:184-90 Australian Aboriginal and Torres Strait Islander communities and the development of pandemic influenza containment strategies: community voices and community control.
  33. 33. Consider social media as a way of engaging
  34. 34. Don’t ignore the other factors 1. The social determinants of vaccination 2. Strong infrastructure 3. Good record keeping 4. Carrots and sticks 5. Reminders 6. Support health professionals 7. Planned campaigns
  35. 35. Summary  Most of the under-vaccinated face genuine barriers, amenable to systemic change  Around 2-3% parents in industrialised countries actively refuse vaccines. They often cluster in regions  But most parents with concerns about vaccines still immunise  Vaccine scares arise within specific geopolitical contexts and are usually amplified by a doctor  Organised opposition to vaccination will remain  Good communication involves: • recognising the contexts in which a vaccine scare arises • understanding multiple audiences and their concerns • include communication with multiple stakeholders • address the needs of health professionals • targeting efforts accordingly • ensure countries have „well oiled‟ systems

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