- Email: [email protected]
Communicating vaccine benefit and risk – lessons from the medical field
Veterinary Microbiology 117 (2006) 71–74 www.elsevier.com/locate/vetmic
Communicating vaccine benefit and risk – lessons from the medical field Joanne Yarwood * Immunisation Information, Department of Health - Area 506, Wellington House, 133 - 155 Waterloo Road, London SE1 8UG, UK
Abstract The childhood immunisation programme in England aims to achieve and maintain high vaccine coverage so that no child needlessly suffers from a vaccine preventable disease. As part of the programme, parents must have appropriate support from health professionals and have information available to them to make informed decisions about their choices. Even though immunisation is voluntary in England, coverage is generally high. It has been estimated that only 0.33% of parents do not consent to their child being included in a computerised database that schedules immunisation appointments. Parental attitudes, experiences and social grade are influential in determining whether a child receives a vaccine. Personal experience and knowledge of diseases influence parental perceptions about the seriousness of diseases and their likelihood of being affected by it. In societies where immunisation programmes have been successful, the challenge is maintaining high levels of vaccine coverage. In the absence of disease, the threat of that disease rapidly disappears and anxieties about the vaccine’s safety may increase. A fall in vaccine coverage can lead to the return of disease as happened in the UK when rates of pertussis immunisation plummeted in the 1970s. Further perceived threats may also affect vaccine uptake, for example, the MMR controversy dating from 1998. The article outlines the MMR debate in the UK, the communication of risk and benefit and the management of information to the public. It will share lessons learned and examine how they might apply to the veterinary programme. Crown Copyright # 2006 Published by Elsevier B.V. All rights reserved. Keywords: Communication; Audiences; Parental concerns
‘The two public health interventions that have had the greatest impact on the world’s health are clean water and vaccines’. World Health Organization.
* Tel.: +44 20 7972 4298. E-mail address: [email protected].
1. Introduction Parental attitudes, experiences and social grade are influential in determining whether a child receives a vaccine. Personal experience and knowledge of diseases influence parental perceptions about the seriousness of diseases and their likelihood of being affected by it (Keane et al., 1993). In societies where immunisation programmes have been successful, the challenge is maintaining high
0378-1135/$ – see front matter. Crown Copyright # 2006 Published by Elsevier B.V. All rights reserved. doi:10.1016/j.vetmic.2006.04.012
72
J. Yarwood / Veterinary Microbiology 117 (2006) 71–74
levels of vaccine coverage. In the absence of disease, the threat of that disease rapidly disappears and anxieties about the vaccine’s safety may increase. A fall in vaccine coverage can lead to the return of disease as happened in the UK when rates of pertussis immunisation plummeted in the 1970s (Gangarosa et al., 1998). Further perceived threats may also affect vaccine uptake, for example, the MMR (measles/mumps/ rubella) controversy in the UK, dating from 1998. What can the veterinary profession learn from such controversies? By examining the origins of the MMR debate, veterinarians can share the lessons learned and apply them to the communication challenges facing the veterinary profession.
2. The origins of the MMR controversy The MMR controversy has its roots in a range of phenomena –
suspicion of institutions rejection of ‘modern’ medicine history science social change media influence and ‘no smoke without fire’
Fig. 1. Headlines from March/April 1998.
concluding that ‘‘We did not prove an association between measles, mumps and rubella and the syndrome described’’ (Wakefield et al., 1998) headlines such as those shown above in Fig. 1 appeared in the media in the weeks following the release of the paper. This media interest continued over a period of at least 5 years and Fig. 2 shows the clear relationship between peaks of media interest, mothers’ confidence in the vaccine and MMR uptake. The media reporting has affected both coverage and public confidence in the safety of MMR. Ben Goldacre writing in the Guardian in September 2003 shows that at least, in his view, the MMR debate was driven by an agenda outside the remit of
Organised dissent has been a feature of immunisation programmes since the earliest days and examples such as the famous cartoon ‘‘The Cow-Pock or the wonderful effects of the new inoculation’’ by James Gillray, 1802 (see: http://lcweb2.loc.gov/cgi-bin/query/ I?ils:1:./temp/pp_YnhF::displayType=1:m856sd= cph:m856sf=3g03147:@@@il) show the sort of opposition that immunisation has periodically attracted.
3. The MMR debate The most recent challenge to the immunisation programme in the UK, exemplified in the debate over MMR, can be closely linked to the publication of a paper in the Lancet in February 1998 and the subsequent publicity surrounding that paper (Salisbury and Olive, 2004). Despite the authors
Fig. 2. Effect of Media interest on mothers’ confidence in the vaccine and MMR uptake.
J. Yarwood / Veterinary Microbiology 117 (2006) 71–74
scientific enquiry ‘‘Journalists aren’t employed to keep you healthy, or even informed: it is our job to sell readers to advertisers, to entertain you, and experience has taught us that we can do this very effectively with scare stories’’. This view is supported in subsequent work from the Economic and Social Research Council (ESRC; Hargreaves et al., 2003) and the Kings Fund (Harrabin et al., 2003) in their examination of the media debate surrounding MMR. Both of these reports examine the impact of media reporting on health issues, using MMR as one model. They broadly agree that policy experts and scientists need to engage more actively with news makers. However, more importantly, both reports agree that not only do the media have a powerful effect on public understanding and behaviour, but that this effect can, in some cases be damaging to public health. This is well described in the Kings Fund report: ‘Arguably this is a case of media coverage affecting public behaviour in ways that may increase rather than reduce health risks.’ The authors of the ESRC report who describe MMR as ‘the biggest news story of the three [issues they studied].’ found that the media scrutiny ‘of those supporting MMR was not matched by a rigorous examination of the case against it. Our main concern here, however, is what it tells us about the role of the media in public understanding.’ In their press release to promote their study, the authors of this paper went further with a headline: ‘Public duped by media over MMR’ (ESRCInfoCentre, 2003). Pressure groups can also exert a considerable influence. In the minutes from the 2004 annual general meeting of Action Against Autism, a deliberate policy of labelling MMR as controversial is discussed ‘‘. . .just as we managed to place the word ‘controversial’ before MMR till its usage became universal. . .’’ (Anonymous 2004, 2005; http://www.actagainstautism.org.uk/agm.html). A search on just one internet search engine reveals the phrase ‘controversial MMR’ appearing 25,000 times.
4. Understanding your audience It is essential to understand the needs of your audience. The immunisation programme in England is
73
unique in the depth of enquiry it makes into the needs of parents (Yarwood et al., 2005). The results of this survey (and of other work such as targeted pretesting of materials commissioned by the programme) enable the information programme to be tailored to the stated needs of the target audience. From our enquiries, we have learned that parents want:
clarity consistency facts openness range of information/resources
Parents want not just printed materials and other resources but, importantly, someone to talk to. Around 80% of parents that we question in our longitudinal survey say that they discuss immunisation with a health professional before they go ahead and have their children vaccinated. The role of the health professional is very important in influencing the decision that a parent makes about immunising their child. In 1989, the Peckham Report (Peckham, 1989) suggested that parental perceptions of immunisations could be modified by external influences such as health education or advice not just from health professionals but also friends and family. Thus, not only is it important that health professionals are well informed about the role of immunisation but consideration should be given to making sure that the whole community has access to evidence based information that is designed to resonate with its target audience. This may include advertising campaigns that reach a wide audience, ‘traditional’ information materials such as leaflets and posters, articles in both professional and public media and the use of tools such as websites specifically designed to give information in an open and easy to access setting. In answer to this wider demand, the Immunisation team at the Department of Health, London, developed http:// www.mmrthefacts.nhs.uk/ which gives evidencebased information on all aspects of MMR immunisation, points to other websites and sources of factual information and has an interactive question and answer section that members of the public and health professionals can send questions to and get answers from.
74
J. Yarwood / Veterinary Microbiology 117 (2006) 71–74
5. The immunisation process
7. Conclusion
Consideration must also be given to the setting in which immunisation takes place. We know from the regular survey of parental opinion (Yarwood et al., 2005) that overall levels of satisfaction with surgery visits are high. However, the time spent in clinic can affect this and dissatisfaction tends to rise when parents do not feel they are given enough time to discuss the issues or feel unable to ask questions. It is important therefore that health professionals ensure that sufficient time is given to discussion that should include the risks and benefits of immunisation and the side effects that may be expected after immunisation. Once more, having someone to talk to plays an important part in ensuring the success of the immunisation programme.
Controversies are an inevitable part of immunisation programmes, and the users of the programme, whether they are parents or health professionals, have specific information needs that must be addressed. It is important that we share information and make it appropriate to the audience – rigorous pre-testing of this information will help this process. Practitioners must be open and scientifically well informed, must listen to peoples’ concerns and base practice on evidence. It is likely that in exploring the lessons learned in the medical world the veterinary programme will add to the quality and sustainability of the service already offered.
6. Implications for veterinary programmes As the veterinary immunisation programme faces challenges it will be critical to assess all aspects of the immunisation process and put measures in place that allow people to feel that the health of their companion animals is, in great part, ensured by a successful immunisation programme. While it is not possible to draw direct comparisons between the immunisation of children and the immunisation of companion animals it is likely that similar factors come into play, and in particular regarding the decision-making process and role of the professional. We know that people want information about the vaccines recommended for them or their children – this is likely to apply to their pets. In that information people want to see
clarity consistency openness facts
People want information about the risks and benefits of vaccination and they want to be able to discuss this with a professional they know and trust – this may be the vet or the veterinary nurse but it is essential that whoever it is allows people to feel that they have properly explored their concerns.
References Anonymous (2004, 2005) http://www.actagainstautism.org.uk/ agm.html. Peckham (1989) The Peckham Report. National Immunisation Study. Factors influencing immunisation uptake in childhood. Converta Limited, London. ESRCInfoCentre (2003) Economic and Social Research Council http://www.esrcsocietytoday.ac.uk/ESRCInfoCentre/PO/ releases/2003/may/duped.aspx?ComponentId=2109&SourcePageId=1404. Gangarosa, E.J., Galazka, A.M., Wolfe, C.R., Phillips, L.M., Gangarosa, R.E., Miller, E., Chen, R.T., 1998. Impact of anti-vaccine movements on pertussis control: the untold story. The Lancet 351, 356–361. Hargreaves, I., Lewis, J., Speers, T., 2003. Towards a better map: science, the public and the media. Economic and Social Research Council http://www.esrc.ac.uk/ESRCInfoCentre/ index.aspx. Harrabin, R., Coote, A., Allen, J., 2003. Health in the News: Risk, reporting and media influence. King’s Fund ISBN 1857174801. http://www.kingsfund.org.uk/resources/publications/health_in_ the.html. Keane, V., Stanton, B., Horton, L., Aronson, R., Galbraith, J., Hughart, N., 1993. Perceptions of vaccine efficacy, illness and health among inner city parents. Clin. Pediatr. 32, 2–7. Salisbury, D., Olive, J.M., 2004. Immunization in Europe. In: Plotkin, S.A., Orenstein, W.A. (Eds.), Vaccines. 4th ed. Saunders, p. 1399. Wakefield, A.J., Murch, S.H., Anthony, A., Linnell, J., Casson, D.M., Malik, M., et al., 1998. Ileal-lymphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children. Lancet 351 (9103), 637–641. Yarwood, J., et al., 2005. Tracking mothers attitudes to childhood immunisation. Vaccine 23, 5670–5687.
Communicating vaccine benefit and risk – lessons from the medical field Joanne Yarwood * Immunisation Information, Department of Health - Area 506, Wellington House, 133 - 155 Waterloo Road, London SE1 8UG, UK
Abstract The childhood immunisation programme in England aims to achieve and maintain high vaccine coverage so that no child needlessly suffers from a vaccine preventable disease. As part of the programme, parents must have appropriate support from health professionals and have information available to them to make informed decisions about their choices. Even though immunisation is voluntary in England, coverage is generally high. It has been estimated that only 0.33% of parents do not consent to their child being included in a computerised database that schedules immunisation appointments. Parental attitudes, experiences and social grade are influential in determining whether a child receives a vaccine. Personal experience and knowledge of diseases influence parental perceptions about the seriousness of diseases and their likelihood of being affected by it. In societies where immunisation programmes have been successful, the challenge is maintaining high levels of vaccine coverage. In the absence of disease, the threat of that disease rapidly disappears and anxieties about the vaccine’s safety may increase. A fall in vaccine coverage can lead to the return of disease as happened in the UK when rates of pertussis immunisation plummeted in the 1970s. Further perceived threats may also affect vaccine uptake, for example, the MMR controversy dating from 1998. The article outlines the MMR debate in the UK, the communication of risk and benefit and the management of information to the public. It will share lessons learned and examine how they might apply to the veterinary programme. Crown Copyright # 2006 Published by Elsevier B.V. All rights reserved. Keywords: Communication; Audiences; Parental concerns
‘The two public health interventions that have had the greatest impact on the world’s health are clean water and vaccines’. World Health Organization.
* Tel.: +44 20 7972 4298. E-mail address: [email protected].
1. Introduction Parental attitudes, experiences and social grade are influential in determining whether a child receives a vaccine. Personal experience and knowledge of diseases influence parental perceptions about the seriousness of diseases and their likelihood of being affected by it (Keane et al., 1993). In societies where immunisation programmes have been successful, the challenge is maintaining high
0378-1135/$ – see front matter. Crown Copyright # 2006 Published by Elsevier B.V. All rights reserved. doi:10.1016/j.vetmic.2006.04.012
72
J. Yarwood / Veterinary Microbiology 117 (2006) 71–74
levels of vaccine coverage. In the absence of disease, the threat of that disease rapidly disappears and anxieties about the vaccine’s safety may increase. A fall in vaccine coverage can lead to the return of disease as happened in the UK when rates of pertussis immunisation plummeted in the 1970s (Gangarosa et al., 1998). Further perceived threats may also affect vaccine uptake, for example, the MMR (measles/mumps/ rubella) controversy in the UK, dating from 1998. What can the veterinary profession learn from such controversies? By examining the origins of the MMR debate, veterinarians can share the lessons learned and apply them to the communication challenges facing the veterinary profession.
2. The origins of the MMR controversy The MMR controversy has its roots in a range of phenomena –
suspicion of institutions rejection of ‘modern’ medicine history science social change media influence and ‘no smoke without fire’
Fig. 1. Headlines from March/April 1998.
concluding that ‘‘We did not prove an association between measles, mumps and rubella and the syndrome described’’ (Wakefield et al., 1998) headlines such as those shown above in Fig. 1 appeared in the media in the weeks following the release of the paper. This media interest continued over a period of at least 5 years and Fig. 2 shows the clear relationship between peaks of media interest, mothers’ confidence in the vaccine and MMR uptake. The media reporting has affected both coverage and public confidence in the safety of MMR. Ben Goldacre writing in the Guardian in September 2003 shows that at least, in his view, the MMR debate was driven by an agenda outside the remit of
Organised dissent has been a feature of immunisation programmes since the earliest days and examples such as the famous cartoon ‘‘The Cow-Pock or the wonderful effects of the new inoculation’’ by James Gillray, 1802 (see: http://lcweb2.loc.gov/cgi-bin/query/ I?ils:1:./temp/pp_YnhF::displayType=1:m856sd= cph:m856sf=3g03147:@@@il) show the sort of opposition that immunisation has periodically attracted.
3. The MMR debate The most recent challenge to the immunisation programme in the UK, exemplified in the debate over MMR, can be closely linked to the publication of a paper in the Lancet in February 1998 and the subsequent publicity surrounding that paper (Salisbury and Olive, 2004). Despite the authors
Fig. 2. Effect of Media interest on mothers’ confidence in the vaccine and MMR uptake.
J. Yarwood / Veterinary Microbiology 117 (2006) 71–74
scientific enquiry ‘‘Journalists aren’t employed to keep you healthy, or even informed: it is our job to sell readers to advertisers, to entertain you, and experience has taught us that we can do this very effectively with scare stories’’. This view is supported in subsequent work from the Economic and Social Research Council (ESRC; Hargreaves et al., 2003) and the Kings Fund (Harrabin et al., 2003) in their examination of the media debate surrounding MMR. Both of these reports examine the impact of media reporting on health issues, using MMR as one model. They broadly agree that policy experts and scientists need to engage more actively with news makers. However, more importantly, both reports agree that not only do the media have a powerful effect on public understanding and behaviour, but that this effect can, in some cases be damaging to public health. This is well described in the Kings Fund report: ‘Arguably this is a case of media coverage affecting public behaviour in ways that may increase rather than reduce health risks.’ The authors of the ESRC report who describe MMR as ‘the biggest news story of the three [issues they studied].’ found that the media scrutiny ‘of those supporting MMR was not matched by a rigorous examination of the case against it. Our main concern here, however, is what it tells us about the role of the media in public understanding.’ In their press release to promote their study, the authors of this paper went further with a headline: ‘Public duped by media over MMR’ (ESRCInfoCentre, 2003). Pressure groups can also exert a considerable influence. In the minutes from the 2004 annual general meeting of Action Against Autism, a deliberate policy of labelling MMR as controversial is discussed ‘‘. . .just as we managed to place the word ‘controversial’ before MMR till its usage became universal. . .’’ (Anonymous 2004, 2005; http://www.actagainstautism.org.uk/agm.html). A search on just one internet search engine reveals the phrase ‘controversial MMR’ appearing 25,000 times.
4. Understanding your audience It is essential to understand the needs of your audience. The immunisation programme in England is
73
unique in the depth of enquiry it makes into the needs of parents (Yarwood et al., 2005). The results of this survey (and of other work such as targeted pretesting of materials commissioned by the programme) enable the information programme to be tailored to the stated needs of the target audience. From our enquiries, we have learned that parents want:
clarity consistency facts openness range of information/resources
Parents want not just printed materials and other resources but, importantly, someone to talk to. Around 80% of parents that we question in our longitudinal survey say that they discuss immunisation with a health professional before they go ahead and have their children vaccinated. The role of the health professional is very important in influencing the decision that a parent makes about immunising their child. In 1989, the Peckham Report (Peckham, 1989) suggested that parental perceptions of immunisations could be modified by external influences such as health education or advice not just from health professionals but also friends and family. Thus, not only is it important that health professionals are well informed about the role of immunisation but consideration should be given to making sure that the whole community has access to evidence based information that is designed to resonate with its target audience. This may include advertising campaigns that reach a wide audience, ‘traditional’ information materials such as leaflets and posters, articles in both professional and public media and the use of tools such as websites specifically designed to give information in an open and easy to access setting. In answer to this wider demand, the Immunisation team at the Department of Health, London, developed http:// www.mmrthefacts.nhs.uk/ which gives evidencebased information on all aspects of MMR immunisation, points to other websites and sources of factual information and has an interactive question and answer section that members of the public and health professionals can send questions to and get answers from.
74
J. Yarwood / Veterinary Microbiology 117 (2006) 71–74
5. The immunisation process
7. Conclusion
Consideration must also be given to the setting in which immunisation takes place. We know from the regular survey of parental opinion (Yarwood et al., 2005) that overall levels of satisfaction with surgery visits are high. However, the time spent in clinic can affect this and dissatisfaction tends to rise when parents do not feel they are given enough time to discuss the issues or feel unable to ask questions. It is important therefore that health professionals ensure that sufficient time is given to discussion that should include the risks and benefits of immunisation and the side effects that may be expected after immunisation. Once more, having someone to talk to plays an important part in ensuring the success of the immunisation programme.
Controversies are an inevitable part of immunisation programmes, and the users of the programme, whether they are parents or health professionals, have specific information needs that must be addressed. It is important that we share information and make it appropriate to the audience – rigorous pre-testing of this information will help this process. Practitioners must be open and scientifically well informed, must listen to peoples’ concerns and base practice on evidence. It is likely that in exploring the lessons learned in the medical world the veterinary programme will add to the quality and sustainability of the service already offered.
6. Implications for veterinary programmes As the veterinary immunisation programme faces challenges it will be critical to assess all aspects of the immunisation process and put measures in place that allow people to feel that the health of their companion animals is, in great part, ensured by a successful immunisation programme. While it is not possible to draw direct comparisons between the immunisation of children and the immunisation of companion animals it is likely that similar factors come into play, and in particular regarding the decision-making process and role of the professional. We know that people want information about the vaccines recommended for them or their children – this is likely to apply to their pets. In that information people want to see
clarity consistency openness facts
People want information about the risks and benefits of vaccination and they want to be able to discuss this with a professional they know and trust – this may be the vet or the veterinary nurse but it is essential that whoever it is allows people to feel that they have properly explored their concerns.
References Anonymous (2004, 2005) http://www.actagainstautism.org.uk/ agm.html. Peckham (1989) The Peckham Report. National Immunisation Study. Factors influencing immunisation uptake in childhood. Converta Limited, London. ESRCInfoCentre (2003) Economic and Social Research Council http://www.esrcsocietytoday.ac.uk/ESRCInfoCentre/PO/ releases/2003/may/duped.aspx?ComponentId=2109&SourcePageId=1404. Gangarosa, E.J., Galazka, A.M., Wolfe, C.R., Phillips, L.M., Gangarosa, R.E., Miller, E., Chen, R.T., 1998. Impact of anti-vaccine movements on pertussis control: the untold story. The Lancet 351, 356–361. Hargreaves, I., Lewis, J., Speers, T., 2003. Towards a better map: science, the public and the media. Economic and Social Research Council http://www.esrc.ac.uk/ESRCInfoCentre/ index.aspx. Harrabin, R., Coote, A., Allen, J., 2003. Health in the News: Risk, reporting and media influence. King’s Fund ISBN 1857174801. http://www.kingsfund.org.uk/resources/publications/health_in_ the.html. Keane, V., Stanton, B., Horton, L., Aronson, R., Galbraith, J., Hughart, N., 1993. Perceptions of vaccine efficacy, illness and health among inner city parents. Clin. Pediatr. 32, 2–7. Salisbury, D., Olive, J.M., 2004. Immunization in Europe. In: Plotkin, S.A., Orenstein, W.A. (Eds.), Vaccines. 4th ed. Saunders, p. 1399. Wakefield, A.J., Murch, S.H., Anthony, A., Linnell, J., Casson, D.M., Malik, M., et al., 1998. Ileal-lymphoid-nodular hyperplasia, non-specific colitis and pervasive developmental disorder in children. Lancet 351 (9103), 637–641. Yarwood, J., et al., 2005. Tracking mothers attitudes to childhood immunisation. Vaccine 23, 5670–5687.