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Messaging Matters: Following the Science Behind Effective Vaccine Recommendations

The Vaccine Hesitancy Continuum

So, as we know, the vaccine hesitancy continuum really is a spectrum. Where we have the most impact is this large area of vaccine hesitancy, right? Those that are – accept, some may be confused, maybe refuse some, etc. This is where we can have the most impact, and the most fluctuation occurs in this area as well.

Factors Contributing to Vaccine Hesitancy

So, two things to address first. We have both misinformation as well as disinformation when it comes to contributing to vaccine hesitancy. So, misinformation - we see both on social media - but misinformation is incorrect information that's spread inadvertently, accidentally, right? We think about maybe a study came out and it has a correlation and it's - it's pushed forward as if that's the cause, or you know, we think about, you know, vaccines that were made from aborted fetal tissue, or mercury and vaccines. That is misinformation, false, inaccurate, and spread inadvertently. Versus the disinformation, which is the deliberate spreading of false information, intentionally trying to deceive the public and discredit vaccines. And we think about this with COVID, with information that it was implanting microchips or with the measles, mumps, and rubella vaccine, that it was a cause of autism. All right.

How to Speak to Vaccine-Hesitant People

So, how to speak to vaccine-hesitant people? So, first of all, we need to make sure that we are taking a presumptive approach where we're framing vaccination as the expected standard of care, and we're assuming parents and patients are ready to vaccinate, right? So, this might be something like your child is due for the hepatitis B vaccine versus would you like to talk about vaccines that are available today.

So, having that presumptive lead in is very- very essential. And it's what's recommended by both the CDC, AAP, NAPNAP, etc., because we know that that's the most impactful for uptake of vaccination. Some other key things, kill them with kindness. We want to listen to their concerns. We want to listen in order to - to understand, not listening to respond. Remembering that convincing may sound coercive, right? We have - we have some history in the medical - in the medical arena and the healthcare arena of unethical type of issues, right. We've got Tuskegee syphilis study and the Willowbrook hepatitis studies. Many people still remember that, right? So, we want to make sure that we are partnering with them as - as experts on pediatric health and vaccination and - and creating that partnership.

If we alienate them, we've lost them, right? We want to work on that malleable middle, that vaccine hesitance. Encourage questions. If they're hesitant. And again, don't - don't give up if they refuse, it's a marathon, not a sprint. They may refuse today, but maybe in a couple of weeks we can get - we can get them vaccinated. And then leading by examples. Behaviors really can change attitudes much faster than attitudes change behaviors. And stare - share stories of vaccines that you've received or why you've received it. My grandfather's two-year-old brother died of influenza, and ever since I learned that as a young child growing up, I always wanted a flu vaccine. So, share those stories of how vaccination or non-vaccination can impact your family - has impacted your family or your patients.

Attention Economy

And so, it's important to examine that attention economy. And we can really see this with social media, right? Attention is limited. It's very valuable. We know it can be captured, studied, traded for profit. We think about all of those influencers that are making multi millions or billions each year by grabbing that attention and remembering that even a short pause on that information on social media or even a dislike is feeding into that algorithm.

So, we do know from psychology that people accept information that supports their pre-existing beliefs, and people also ignore information that contradicts their beliefs. And we can see this when we, you know, our family members, what new station maybe they watch, right, when we think about what's supporting our beliefs.

Attention Economy: Shaping Vaccine Beliefs

So, we know that the attention economy is very influential in shaping those vaccine beliefs. We're going to talk a little bit more about this later in the webinar. But the research shows that there's only about 12 people that originated most of those vaccine hoaxes. They're well known to researchers and social networks alike, including, you know, anti-vaccine activists, alternative health entrepreneurs, and even physicians. Some can often run multiple accounts promoting natural health. Most of them have some type of selling something, you know, being supplements or books, charging exorbitant speaker fees. But what we know above all else is that 90% of our parents do vaccinate their children. However, this disinformation and misinformation may really drown out some of those majority voices.

Attention Economy: Strategies to Support Parents and Caregivers

So, when we're thinking about the attention economy, we know that it rewards emotional, high-click content. We've all seen those posts. It really opens the door to overwhelm individuals. Creates false narratives that stick with them, right? Tugging on their emotions. Provider strategies validate the overwhelm. Ask them what they've seen on social media, what platforms they've gotten information from, ask what they've read online.

Why Behavioral Economics Matter for Vaccination

Now, we know that rational decision-making is what we all claim to base our behaviors on, right? But why do people deviate from that? It's a lot of different factors: emotions, social influences, cognitive biases. All of these can impact why individuals may choose to not vaccinate, even when the rational evidence is in front of them

Behavioral Economics Principles

So, we're going to talk about some behavioral economic principles that influence decision-making, and touch on each of these. What is essential is that we remember empathy, which, with every single interaction we have, that we, the vast majority of our families want to do what's best for their child, but they've been confused, right? There's a lot of information out there, and they've been confused. And often that misinformation, disinformation, is louder than our evidence-based information.

Present Bias

So, present bias is one of those behavioral principles. So, that's when immediate cost and benefits outweigh those occurring in the future. So, now feels bigger than later. We think about this, you know, I'm nervous to get this vaccine because then my child may have a fever tomorrow. I may miss work. I may miss the family reunion, etc, that present bias.

So, overcoming that is making the benefits feel immediate and real. So, saying things like protection begins the moment the vaccine does. And then risk of preventable disease complications far outweighs adverse effects or side effects.

Status Quo Bias

Then we also have the status quo bias. And this is when individuals choose to do what they've done, always done, or choose to do nothing if they have not done that, right? Those of us that have been getting flu vaccines for decades will most likely continue to do that, right? Versus those that have not will most likely continue to do that.

So, overcome the status quo bias by making vaccine acceptance the default or the neutral short choice, right? With that presumptive approach and opt-out type of clauses. So, these are the vaccines that your child is due today, these are the mandatory school vaccines, making opting out more challenging than accepting the vaccines. And then prescheduled appointments that are routinely done. And we have that in pediatrics, right, set up along with our well-child visits.

Availability Bias

And then we have the availability bias. This is when individuals estimate the probability based on examples or stories, right? What they've heard. What they've seen. We all know that individuals are more likely to vaccinate when they've got a personal family friend or neighbor, or they've read something that's concerning, right? And a teenager dies of influenza in our county makes you much more likely to go and get vaccinated and get your kids vaccinated.

So, to overcome that availability bias, using short, relatable stories to anchor that risk, right? So up to one in five children are susceptible to measles due to the age, age gap, or due to the gap in vaccination under the age of three. And measles is one of the most contagious diseases known to man. One in five children who contract measles are hospitalized. These short little soundbites about some of the risks and redefining that

Loss Aversion

And then loss aversion. Again, when people prioritize preventing loss over that equal or greater gain. So again, what if I get an adverse effect - adverse effect. What if a side effect is significant? What if I'm not able to go to work for a few days. Versus that equal or greater gain of vaccinating? So, talking about, you know, don't leave them unprotected. Give them that vaccination so they can walk out safer than they came into the office.

Social Forces

And then social forces. We cannot underestimate this. Peer pressure we know, impacts behavior. And social media can really act as an echo chamber and feed you more and more and more to - to scare you, right? To make you question. So, normalizing vaccination as the community standard. This is what the community does. Most families in our practice vaccinate today. we are a family that vaccinates, etc.

Ensuring Consistent Messaging

And then we think about ensuring consistent messages, right? Getting everyone on the same page, but also involving the entire staff and ensuring consistent communication. So, it would be things like we follow the AAP vaccination schedule that your schedulers that are booking the appointments, if anyone asks about vaccinations, they say, "We follow the AAP vaccination schedule," versus well, when you come in, you can talk to your provider and you can decide which vaccines you want to give your child, right? We need to make sure that the entire practice is on the same page, and that we're having that unified voice.

Also establishing a social presence, right? Putting out that information. Utilizing behavioral nudges. And then using positive framing. I can tell that you are a mother that really cares about the health and keeping your child safe, right? Positively framing that. Emphasizing the benefits over potential risk, and then knowing when to use narratives. Know when statistics are not going to reach that individual, but narratives are much more impactful.

Connect With People's Values

We also want to connect with people's values, right? Those that value well, you know - that value the medical system or authority, you know that the doctors, the nurse practitioners, the nurses that have dedicated their lives to patient care, saying well qualified doctors and nurses - nurses endorse vaccination.

Also thinking about liberty. Appealing to that value of liberty. Take personal control of your family's health. Vaccination can help your child live to be free, live a free and happy, and healthy life. And then values of purity. Boost your child's natural defenses against vaccines. Keep your child pure of infection. Vaccinate. These are all evidence-based messages that can really change behavior.

Micromessages That Stick

And then more micromessages that stick. Short little sentences. Most families choose to vaccinate at this visit. You're in good company. Vaccines are what parents trust. Don't leave them unprotected. Strong kids, strong futures.

Case 1

Patricia Stinchfield: Great, Jen. Thank you so much. That was so good. I really love those last list of soundbites. It's really important. Well, I'm going to take us into a case. This is a real live case from my practice back in 2017. But it really started back in - in the 2008 or so. And this is related to the Somali community in Minneapolis. You may have heard of this. It ended up on the front page of the Washington Post. But there have been a long-standing vaccine hesitancy in this community. It is still a problem today. But in 2008, there were some concerns about Somali kids having a greater rate of autism.

And it was raised initially by the Minneapolis Public Schools. And there was, in fact, a very good researcher, University of Minnesota, who looked at and said, you know, these kids who are coming into kindergarten have never been diagnosed and never had early intervention. And they do have autism, or they do have some delayed learning, and they live in a household that is - in a world that's bilingual. They maybe went for care and said, you know, have the questions we all ask is your child looking at you? Are they babbling? Are they starting to make sounds? Are they starting to talk? And in the Somali community, your child is a gift from Allah. And so, your child is your child. And whatever your child is - is - is not a problem to be sought for specialists or to be given treatment or interventions or whatever. That is just how your child is. And so, many families just would say, my child is fine.

And so, they were noticing this in the schools that the kids were coming far, far, far too late and without early intervention. So in 2017, a measles outbreak occurred in this same community in the Somali Muslim community in Minnesota. We ended up with that case lasting about four, five months, 75 confirmed cases. Almost all of them were in preschoolers. The median age was 21 months. And the main problem was that they just had not had their MMR vaccine.

Vaccination Rates Fell Following the Rise of Misinformation

And so, how and when did this happen? You can see that Somali children initially, back in the early 2000, when they come to the United States, primarily Minnesota, very welcoming state, largest Somali community outside of Somalia, they're highly vaccinated. In fact, look at that. Higher vaccinated than the other children in Hennepin County, which is the county Minneapolis is in.

But you can see that degradation over time. Slowly there was this conversation about, you know, the schools raising some concerns. And then Andrew Wakefield got wind of that and came here twice. And started talking in - interestingly to the imams, the head of the religious communities, and in private closed door, gun bearing person at the door, no one else, no public health allowed to come in, no clinicians allowed, just told the imams, do not vaccinate your children. The vaccines - MMR vaccine causes autism. And so then you could see this plummet over time, dropping from higher than the community of right around 90% all the way down to 42%. And remember, with measles, we need to have vaccine coverage at 95% or greater to prevent outbreaks.

Impact of Measles

So, this is what happens. These are why we don't let a child just walk out the door and say, "Okay, well, I'll see you next time." We have to make sure we keep an image like this in our mind of why we keep having these hard conversations. This is one of the children from one of our measles outbreaks at Children's Minnesota on a ventilator for 15 days. And they were - he was part of a family who travelled to Somalia and back. And all of the family got their travel vaccines except this kiddo. And the mom—he was nine months old—and the mom said, you know, he just fell asleep. I just don't want to wake him up. He'll do. Okay. We'll get it when we get back. And the travel provider really pushed hard, but the mom said no. Got infected. Travelled back to Minnesota, infected on the plane, infectious to the community, and then ended up coming straight to the hospital very sick.

And as I took this picture, she asked me to take this picture, and she said, you know, get all of those pumps in the machines and the wires. Look at how sick he is. You have to show this to people so they know this is what measles can do. And she asked me to take this picture and gave me permission to share it with you. And she said, you know, that fateful decision I made, I didn't want to wake him up that day. And now I stand at his bed, praying that all I want him to do is wake up. So keep this story in mind when you're tired. It's Friday at 4:00, and you don't want to have one more dang immunization conversation. This is what we're trying to prevent.

Working With the Somali Community: Culturally Competent Care

So, what did we do? Well, we worked directly with the Somali community. We - the message is important. The messenger is also important. Not only just that they're coming from that same community, but they are well informed. And so this partnership of clinicians and imams and spiritual leaders and community leaders in the Somali community was really important.

So, I pulled together a dinner of Somali clinicians from all of the hospitals in the Twin Cities area. We had a listening dinner. We had meetings with imams. We had our Somali employee resource group was super helpful. We did a Ramadan Eid meeting and dinner, and were welcomed in and - and did panels with both Somali leaders and clinicians like me who were measles or vaccine experts. And we had some autism experts.

So, it took a lot of intervention to get that vaccine coverage up. But some of the parents would say things like, "I didn't know that M, M, and R, when you said MMR, I didn't know that the M was measles. That's where the listening comes from. Really listening. If I had known it was measles, my sister died of measles in Somalia. I would not have skipped it." And so even simple things like making sure when we don't just whip over MMR, that they know what that stands for.

So, it was a difficult time, and the rates are not where they need to be at 95% in Hennepin County, but we learned a lot from this.

Case 2

And then case two, I'm going to turn it over to you, Jen.

Jennifer Walsh: Thank you. I love that reminder to list out the illnesses that we're hoping to prevent with vaccination. Really excellent. So, case, we've got a first-time mother. Identifies as a crunchy mom. Prioritizes natural living, low-tox choices, homemade remedies. Follows natural health influencers on Instagram and TikTok, and she says to you, "I'm not anti-vax. I just want to make the most informed, natural choice. But every time I look something up, my feed fills with stories of moms whose kids had reactions." I'm wondering what Patsy and Mary Beth think about this.

Mary Koslap-Petraco: Well, first of all, I would ask the mom - I would thank her for sharing that information with me. And then I would ask her specifically, what were the concerns with the parents following the vaccines? And then I would address those one by one. Because the other thing that I always advise folks to do, too, is make sure you tell the parent the baby can get a fever. The baby can be fussy. The things that we - the baby can have a sore red leg. And what I say to parents is when we see these things, what that says to me is your child's immune system is kicking into high gear to protect them. So, I think it's how we approach those - those issues.

And the other thing too is, and Patsy and I are old enough to remember all of these diseases, parents have no recall of the diseases years ago.

And then that one - and that was just so important when Patsy talked about that mom who  says, "I didn't know M was for measles. I would have, because my sister was so sick or my sister died in Somalia from measles," you know, spelling those words out for them. Asking them, what other questions do you have, asking for permission to answer those questions. Patsy, what do you have to think about that?

Patricia Stinchfield: Yeah, I think I like talking to these parents when they are talking about ‘natural’ because it gives me the opportunity to talk about my favorite thing, which is the power of the human immune system. And I'll talk a little bit more about that later. But in this case, I would say I hear you about really wanting to serve your family healthy food and, you know, with as little extra things as possible.

And I think that's the same thing we're doing with vaccines. There's nothing more natural than your body's ability to see, recognize a germ or an antigen, and then build an antibody, store it away in amazing file cabinet that circulates constantly looking for if it ever sees a germ that looks just like this, the measles virus or the pertussis bacteria, that file cabinet is going to open up that those antibodies are like an army and they will come out and protect your child.

It is this beautiful, wonderful, natural way that we are made. And the vaccines are simply the easiest way to give your body a little hint of what those serious diseases are, so that you're well protected in the event that you ever come in contact with that disease. So, it's about as natural as anything I can think of.

Jennifer Walsh: Absolutely. I agree with all of that. I think also reframing the risk for the mother is important as well. In addition to all of these questions. You know, asking her, you know, what - what those reactions were. And as you mentioned, that's our immune system doing what it's designed to do. That's the healthiest way we can protect your child, versus coming in contact with that potentially debilitating, life-changing, potentially fatal disease that has consequences.

Vaccines Are the Safest Way to Acquire Immunity

So, reminding them that vaccine prevent - preventable illnesses can cause serious complications, right? We all know that as providers, but - but they may not know that or may not remember that about the risk of pneumonia with many of our vaccine preventable. Heart muscle damage, liver failure, encephalitis with measles, right? That scares anyone when they think about encephalitis, right?

And then things like deafness or even testicular cancer with mumps infection. And, as Patsy mentioned, vaccines train the immune system to defend against those infectious organisms. So, they don't - they don't risk those illnesses, those long- term complications, those death - deaths. And I love this statistic. I'm a big statistics person that almost 30 years, and we've estimated that vaccines have prevented 508 million illnesses and 1.1 million premature deaths. Like that's just astounding and really shows what a success vaccination is in our world.

Strategies to Overcome Vaccine Fears

So, as we go back to that mom that was concerned about toxic - toxicity and wanting to - to feed healthy foods and whatnot, some of the behavioral economics that are at play are social norms, right? What she's reading in her online groups and then that attention algorithm reinforcement, once she clicks on one of those post about a reaction after a vaccine, she's going to get hundreds more, right? You just see that - that vicious cycle that just revs up.

So, the goals of our interaction are to reduce fear re-anchor risk, and to shift the norm. So, affirming identity as we mentioned. You are obviously a mother who really values the health and safety for your child. I can tell your baby girl is so lucky to have you as a mother. And then making positive norms. This is what most parents do. This is what 90% of parents do. And then reframe that risk.

Case 3

And now I will turn it over, I believe Mary Beth, is this you?

Mary Koslap-Petraco: Okay. I just had a couple of comments though, on that last case that we did. You know, sharing family stories as well. My own sister's immune system was permanently damaged by - by measles. And those very personal stories like Patsy has talked about that - that one mom who talked about her sister not knowing it was measles, those are the things that I have found in so many of us have - have found, which is also backed up by the data are really what makes a difference.

Sometimes, just going over numbers and what can happen. But when you can connect those personal stories - Patsy's got those wonderful stories about those terrific Somali families and how terrible they felt because they just didn't know.

I think it's - they don't know about the diseases because vaccines have been a victim of their own successes. And they also have not had the opportunity for people to explain to them what the vaccines do and how they affect the immune system. That's why Patsy's story is about how the immune system is such a strong and wonderful thing, and couldn't be more natural, are such important stories to - to share with parents and with the children themselves? Okay-

Patricia Stinchfield: Can I add to that about our—is lack of education an issue? I'm going to really agree with that strongly because I think we are lacking in science education from early childhood, all the way through high school, and into to college years and beyond that, having a good appreciation for science, a good understanding of how the human immune system and the human body works.

So, if you read Andrew Wakefield's paper with an N of 12, you know, that you should just not even read one sentence on any study that has such a small N. So I do think science illiteracy is a problem in America. And I think that is feeding into some of our anti-vaccine stuff that we're dealing with.

Mary Koslap-Petraco: Great points Patsy. Those were terrific points. I could not agree with you more.

Okay, let's talk about case three. During a routine office visit for her two-year-old child, a mom states she's confused about the vaccine recommendations from CDC.

She's expecting her second child and believes that the new CDC recommendations mean that her future child will now get fewer shots, which she is very happy about. She's concerned about the recommendations about the hepatitis B vaccine changing and doesn't know who to trust.

Oh wow. Is that a can of worms? So, Jen, you want to open us up with that - discussion with that?

Jennifer Walsh: It is a can of worms, Mary Beth, for sure. It is confusing. I mean, for decades, I would recommend that parents look to the CDC as a reputable source. And that has changed in the past couple of years.

I think it's important to know why the recommendations changed and that it was not based on any science. That the science overwhelmingly supports universal vaccination. And - and so that's why the American Academy of Pediatrics, NAPNAP, etc., all of the medical and nursing organizations support that universal recommendation because that's where the evidence lives about how impactful that vaccination - that hepatitis B vaccine has been.

Changing CDC Recommendations

Mary Koslap-Petraco: Yeah, I think those are very important points. And what we're saying is, regardless of what ACIP is saying, that's not evidence. And we also—what I say to parents too is there has been a stay, or those recommendations are not to be put in place because they were not scientifically based. It's in the court system now. And again, like Patsy says, we need to do that science education. Patsy, do you want to add a word or two before we move forward?

Patricia Stinchfield: No, I just think that we should all keep our eye on the AAP lawsuit and what's happening there. And unfortunately, the people that work at the CDC are kind of held hostage right now. The CDC recommendations are, you know, really not evidence-based. And so, we are leaning on NAPNAP and the American Academy of Pediatrics schedule, which is evidence-based and actually has been being published by AAP for 90 years as opposed to CDC, which has been since the last 60 years.

Mary Koslap-Petraco: Right. Well, when I started my career—and I'm the public health nurse —and when I started my career in public health, we didn't have a harmonized schedule. AAP had their schedule, and ACIP had their own. And then they used science to come together so that everybody was going to be on the same page.

So, I'm just going to move on with this. The shared decision-making is now recommended for vaccines, including the birth dose. We are not following that. That is not the science. And that's what I tell parents all the time. It's very confusing to providers. I'm not sure whether the providers have even heard that the - the - the cases has been found to hold all of those recommendations from ACIP. But the person, again, educating yourself, talking to your provider. And then later on in the talk, we have some really good evidence-based websites for you to use as well.

So, let's move on to the next slide.

isks of Not Vaccinating Against Hep B

So, what are the risks of not vaccinating against hepatitis B? I can tell you a story about that right here in Suffolk County where I live. And when we were taking the thimerosal out of the vaccine, we were holding off on the hospital birth doses. And this is going back many years. And I remember a physician saying to me, "Oh, I'm not worried about that, because I'm so sure all of my mothers are hepatitis B negative." And I said, "But you can't guarantee that." "Oh, yes, I'm so sure." Well, guess what? It was one of the moms from his practice that the baby went on to be hepatitis B positive because we weren't vaccinating the baby. That physician came to me later, and he says, "I should have listened to you."

So, we can never guarantee that the mom is going to be hepatitis B free because she's continuing to have sex. She might be exposed to blood somewhere. We cannot do that. 90% of infants who contract hepatitis B go on to develop chronic hep B. And people with chronic hep B are at a higher risk of liver failure, cirrhosis, and hepatocellular carcinoma. And about 25% of untreated patients with hepatitis B are going to die from liver cancer. This - I sell this vaccine to parents as this is an anti-cancer vaccine.

So, I think we're going to move on now. And Patsy, you're going to take over from here.

Strategies to Overcome Vaccine Confusion

Patricia Stinchfield: Yeah. I'll take it from here. All right. So, what do we do? Strategies to overcome our vaccine confusion. But really and truly it is listening to their concerns first. And as Jen said, listen to understand, not listen to convince, but really stop and listen. So, ask those questions, probing questions, open-ended questions, and make sure they know your expertise as a healthcare provider and your personal experience too. I have two children. They are fully vaccinated. My daughter was one of the first ones to get a COVID vaccine at her pregnancy, right after it became available, I knew the science, and I trusted the science with what we had at the time.

So, vaccinating your child will really prevent long-term consequences of hep B, of COVID, of other things. So it's important to just share and listen.