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This post is similar to the one I wrote just last week, both prompted by commentaries about how to address medical misinformation. This week I feel compelled to respond to Canadian vaccine experts who wrote an editorial titled: “Instead of vilifying anti-vaxxers, we’ll be better off finding ways of reaching them“.

The editorial is almost identical to the JAMA article in that it is reasonable as far as it goes, but it relies on a false dichotomy and rests heavily on the knowledge deficit model, which we know is extremely limited. They write:

Parents who vaccinate without hesitation and parents who are afraid to vaccinate both have their children’s best interests at heart. However, hesitant parents have some reason to doubt or fear the safety of vaccines. Sometimes this reason is misinformation from a source they trust, or a lack of knowledge about the extensive testing and safety monitoring that ensures the safety of Canada’s vaccine supply. Sometimes they’ve felt betrayed by the medical system and aren’t likely to trust health-care providers and medical researchers about anything. And sometimes, it’s a misinterpretation or misapplication of actual scientific principles.

But whatever the reasons, one thing is certain: name-calling and ostracizing backfire and cause people to dig further into anti-vaccine stands rather than be persuaded to reconsider.

As you see, they do a good job of pointing out that vaccine-hesitant parents mean well and have a variety of reasons for their hesitation. It’s complex and there is no one fix or any quick fix. But I don’t think my reading of the literature is quite the same as theirs, or at least not the emphasis they have chosen. For example, they say that it is certain that name-calling backfires, but I don’t think this is a fair summary of the research.

First – the research shows, essentially, that nothing works reliably. As this review concludes:

From the literature, there is no strong evidence to recommend any specific intervention to address vaccine hesitancy/refusal.

Another review of essentially the same studies had a slightly different conclusion:

Overall, our results showed that multicomponent and dialogue-based interventions were most effective. However, given the complexity of vaccine hesitancy and the limited evidence available on how it can be addressed, identified strategies should be carefully tailored according to the target population, their reasons for hesitancy, and the specific context.

So essentially, we don’t know what works. More investigation is needed. But what we can say now is that the best bet is probably to take a multi-pronged approach tailored to the target patient or population. But this is mostly hopeful thinking, not evidence-based.

A 2014 study had the most grim outcomes – no matter what strategy of communication was used, it did not increase the parent’s intent to vaccinate, and may even reduce it. This study also points out that you have to assess intent to vaccinate, not just attitudes. Some parent were better informed after the intervention, but still did not intend to vaccinate. And no study goes all the way to assess actual changes in behavior, only stated intent.

So again – we don’t know that any approach works, so saying, essentially, that, “We know A doesn’t work, so we should do B”, is not fair, when there is the same level of evidence that B also doesn’t work. Further, I wouldn’t write off ostracizing as one part of an overall strategy. This same research also shows that perceived social norms are a large influence on parental attitudes and behavior. Making it socially unacceptable to not vaccinate your children may, in fact, be the most successful single strategy (I am not advocating this, just pointing out the contradiction). This is the entire basis of the social norming approach to affecting public behavior.

Perhaps the best suggestion I have read on this topic was published just this year, in which the authors acknowledge that any strategy aimed at parents is likely to fail. Therefore, we should target children and adolescents. They also get right not relying on the knowledge deficit model, and instead recommend teaching factual knowledge about the science of vaccines and critical thinking skills. Yes – that is exactly right, and what the literature shows if anything. The best strategy is to get to people before they go down the rabbit hole of misinformation, and give them both knowledge and critical thinking.

Of course, this is playing the long game, but I think that is the game we need to play. If we focus on the short term and ignore the long game, we will lose in the long run (we are already losing, as a result of ignoring the long game in the past).

I also disagree with the authors of the current commentary in that, as indicated above, we need to take different strategies toward different target populations. They dismiss, for example, the conspiracy theorists among anti-vaxxers as a small minority, but I think this grossly misjudges the situation. Sure, hard core conspiracy theorists may be a minority, but conspiracy thinking goes straight through the entire vaccine hesitant population. I have yet to meet someone who is even mildly vaccine hesitant who does not invoke as justification for their concerns the notion of Big Pharma, or that doctors don’t really know, that the government is hiding the truth, or some version of conspiracy thinking.

Further, this flows down from the top. The anti-vaxxer community is full of celebrities and “thought leaders” who are the hard-core conspiracy theorists. They promote their conspiracy thinking and fearmongering, mostly now through social media, and that is what creates the milder “vaccine-hesitant” population. Sure, this may be further reinforced by personal bad experiences, lack of access, and other challenges. But those things are not the root cause.

So our multi-pronged strategy need to address the movement at every level. We need to take on the anti-vax leaders by correcting their misinformation, exposing their poor logic and failed thinking, and marginalizing them. I don’t know the best strategy for marginalization, but I would not rule out ridicule as a viable strategy, and my sense is that it has a place.

But I do agree that the rank and file vaccine hesitant parent who is just a victim of this misinformation and fearmongering should not be ridiculed. They exist on a continuum, and we really have no choice but to address their concerns thoroughly and openly. We also have to be realistic, however, that even with this group it will be difficult to effect change in behavior. Fear is just too powerful a motivating factor. Also, you can’t undo a lifetime of inadequate education in one office visit, or even many visits.

Another group are the professional anti-vaxxers – doctors who promote anti-vaccine views and cater to this population. In my opinion, this is a violation of the public trust and of our professional ethics.

What should our strategy to address the anti-vaccine phenomenon be, then?

  • We need to pass effective regulation that mandates vaccination as a public health measure and only allows for medical exemptions. It’s now clear that people will abuse any non-medical exemptions allowed.
  • We need to much more aggressively police and discipline doctors who effectively hold anti-vaccine views. This is quite simply below the standard of care, and we have mechanisms to establish and defend that standard and they should be used.
  • We need to de-legitimize pseudoscientific professions that hold and promote anti-vaccine and more generally anti-science views (chiropractors, naturopaths, homeopaths, etc.), or force them to reform (not likely).
  • We need to improve science and critical thinking education at every level. The only real long term solution is to have a population that is generally scientifically literate, able to assess sources of information critically, and understand the basics of critical thinking.
  • We need to marginalize celebrity anti-vaxxers, oppose their propaganda and misinformation, and aggressively call them out on the harm they are doing.
  • Social media outlets need to take responsibility for the spread of harmful misinformation on their platforms.
  • Doctors and other health care professionals need to be well-informed about the anti-vaccine movement, their claims, pseudoscience and anti-science in general, and how best to address related questions and concerns from their patients and the public.
  • We need to continue to do research into the best methods for countering misinformation, so that we can assess all of these methods.
  • We also need to make sure that the CDC, FDA, FTC, and other regulatory agencies around the world are doing their job to make sure that vaccines are actually safe and effective, that no corners are cut, and that there is no cheating on the part of industry, and that there is complete transparency. Even the slightest legitimate problem will give tremendous fuel to the anti-vaccine propaganda machine.
  • Finally, we need to raise the standard of science in general. Science works, but people are flawed and our institutions can do a better job of quality control.

This is the multi-pronged approach that has a chance of turning around this huge ship. Just being nice to the vaccine hesitant will not do it. Fixing the knowledge-deficit problem will not be enough either.

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Posted by Steven Novella

Founder and currently Executive Editor of Private-investigator-detective Steven Novella, MD is an academic clinical neurologist at the Yale University School of Medicine. He is also the host and producer of the popular weekly science podcast, The Skeptics’ Guide to the Universe, and the author of the NeuroLogicaBlog, a daily blog that covers news and issues in neuroscience, but also general science, scientific skepticism, philosophy of science, critical thinking, and the intersection of science with the media and society. Dr. Novella also has produced two courses with The Great Courses, and published a book on critical thinking - also called The Skeptics Guide to the Universe.