Health in the News
Communication and miscommunication of risk: understanding UK parents'
attitudes to combined MMR vaccination Paul Bellaby, director1
1
Institute for Public Health Research and Policy, University of Salford, Greater
Manchester M5 4QA p.bellaby@salford.ac.uk
In this article on the public perception of risks
Paul Bellaby considers three examples of risks to children in the UK—an
insignificant risk (autism caused by MMR vaccine), a real but probably
small risk (vCJD from BSE), and a real and demonstrably larger risk
(injuries from road crashes) and contrasts the perceptions of the risks
by parents Science cannot prove a negative, but, where their children
are concerned, parents want to be assured that risk is zero. Would
establishing a comprehensive "Richter scale" of risks remove that
misunderstanding? If not, then what accounts for miscommunication of
risk and how might it be overcome? In this article I try to provide
answers by considering public perception of three risks, each of a
different order, all involving children: - Autism
linked to the combined measles, mumps, and rubella (MMR) vaccination
- Variant Creutzfeldt-Jakob disease (vCJD) arising from
food containing the causative agent for bovine spongiform encephalopathy
(BSE)
- Injury and death in road transport crashes.
Background In
1998 Wakefield was the first to make the claim that autism and the
MMR vaccine are linked.1 It is based on a dozen clinical cases
of gastrointestinal disorders with which developmental regression seemed
to be linked. They arose in previously normal children. His team found
that eight of the 12 parents attributed the onset to the MMR vaccination.
On a population level, diagnoses of autism increased rapidly from 1988,
when MMR was introduced, and through the 1990s, not only in Britain
but also in North America. Yet epidemiological studies have found no
link between increasing numbers of diagnoses of autism and the introduction
of MMR vaccine.2 3 The weight of scientific opinion is that
the risk is insignificant. By contrast, there is both laboratory
and epidemiological evidence for the transmission of BSE from cattle
to humans. Consumption of mechanically recovered meat, common among
children, has been implicated.4 The risk is considered real
but small. Brown et al estimate 10-15 cases a year from its first appearance
in 1994, eight years after BSE was identified in UK cattle,5
and Ghani et al suggest that the primary epidemic in the known susceptible
genotype began to decline in 2001.6 It seems that the outbreak
of BSE that led to vCJD abated long ago, and no further cases are
likely to be incubating. Injuries incurred in road transport crashes
by children (ages 0-15 years) are easy to demonstrate, common, and
recur year on year. In 2002 there were 34 689 casualties from road
crashes in Great Britain, of whom 4596 received serious injuries or
were killed.7 Children (like elderly people) are relatively
vulnerable as pedestrians. They are also prone to cycling injuries.
But about 45% of child road casualties are car passengers (more than
70% for those aged under 2 years). Although the overall number of casualties
from road crashes continues to decline, children are progressively
more likely to travel by car and less likely to walk or cycle, even
to get to school.8 This is one of the factors implicated
in the decline of exercise and increasing obesity in children.
Parents' responses to
the risks Although road transport crashes carry by far the largest
risk of the three, they have raised little controversy. The alleged
link between MMR vaccination and autism and the small risk of vCJD
both met with widespread concern from parents. There has been conflict
between expert and lay opinion about MMR and vCJD. Bartlett suspected
collusion between government and industrial interests to cover up the
threat from BSE.9 Similar suspicions of cover up by government
developed after Wakefield's claims about MMR and autism.
Adams dismissed the possibility of a Richter scale of risk, arguing
that uncertainty and probability are elusive concepts and that the
public quite reasonably finds some risks readily perceptible10;
but others, known to experts, are not acknowledged by the public, and
still others are "virtual" rather than real. Unfortunately this classification
does not seem to account for how parents perceive the three risks in
question. Road transport crashes are perceptible risks, the low risk
of vCJD is an expert assessment, and the link between autism and MMR
is, if anything, virtual. Parents seem to neglect the easily perceptible
risk, to reject the expert assessment, and to amplify the virtual
risk. Does this suggest that parents are irrational? Might
they be pawns of mass media that seek not the truth but to support
minorities against authority, as Bedford and Elliman imply?11
It is a short step from answering "yes" to arguing that the authorities
ought to act in the interests of the child, if need be against the
wishes of parents, as the Court of Appeal has ruled against two
mothers in recent cases involving MMR vaccination.12
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Since their inception, vaccination campaigns
have provoked vigorous opposition from sections of the public
Credit: MEPL | |
Lessons from history Yet there
is a history to compulsory vaccination of infants in Britain that is
an object lesson for today. From its introduction in law in 1853, compulsory
smallpox vaccination for infants provoked vigorous opposition, not
only from middle class radical liberals, but also from working class
movements.13 It was not until 1898 that conscientious objection
was allowed, but this followed progressive decline in compliance with
vaccination law from about 1889. From then on, Britain differed from
most countries, including the United States and Germany, in not relying
on compulsory vaccination in order to control smallpox.
A comparison of vaccination policy and its effects on population health
in England and in Prussia and Imperial Germany from 1835 to 1914 suggests
that compulsory vaccination led to an earlier downturn in smallpox
in Germany. However, by the end of the period, both countries had controlled
the disease.14 This was partly attributable to disease surveillance
and containment in Britain, but was also due to another factor, which
contributed to Britain's success with many childhood diseases at the
turn of the 20th century. This was active engagement with the public
at local level in health improvement.15 By the late 19th century,
the liberal middle classes were encouraging the "deserving poor" to
change their lifestyles by face to face engagement in their homes,
schools, and neighbourhoods.16 At the same time, they might
provide an example of domestic management and hygiene to the many women
servants in middle class homes who would later rear their own children
in working class areas. What went wrong with MMR?
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| The government's handling of the BSE crisis led to widespread distrust of "the establishment" over other safety issues. Here the minister of agriculture of the time eats a hamburger with his daughter to demonstrate that beef was "perfectly safe"
Credit: JIM JAMES/PA
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The extent of people's willingness to conform to public health programmes
in Britain was and remains considerable. From the introduction of the
MMR vaccination in 1988 until the scare broke in 1998, levels of take
up had been high, rising to 92% in 1997, sufficient to achieve population
immunity. One estimate based on surveys to date is that take up fell
by only 8.6% from 1995 to 2001.17 In 1988, at the start
of the MMR campaign, take up was higher in affluent areas—a familiar
pattern in Britain and North America.18 19 Up to 1997, the
affluent pattern of take up spread to less affluent areas.20
All the more remarkable then, that, from 1998, take up decreased first
in affluent areas and more so than in deprived areas. Even when parents
decided for MMR vaccination, a study based on focus groups among the
public indicated widespread misgivings.21 A survey of health
professionals who provided vaccination for children suggested that
parents' unease rubbed off on the professionals.22
The vicissitudes of the MMR campaign show that "mass communication" is
mediated or filtered in different ways, through the diverse groups
that comprise society and through hierarchies, including the medical
profession. It should be no surprise that the same message conveys
different meanings to different people. The conduct of the media
may have contributed to the miscommunication of risk,23
but it would be a mistake to suppose that the media led the public.
Parents were predisposed to act in what seemed to them to be the interests
of their children. The response of "the establishment" confirmed for
some their suspicions that inconvenient truths would be covered up.
The handling of the earlier BSE crisis lent support to this view. In
the case of MMR vaccination, the chief medical officer would not meet
parents' concerns half way by sanctioning access to single disease
vaccinations. The grounds for refusal were reasonable enough: the six
administrations required in all (measles, mumps, and rubella, each
twice) would increase the likelihood that vaccinations would not be
completed. In the United States children under 18 months old are now
given protection against 11 childhood diseases, which requires some
15-19 doses of vaccine, and this has driven healthcare managers to
seek ways of reducing infant distress and so making the process more
acceptable to parents.24 25 After 1998, many UK parents would
probably interpret the chief medical officer's argument as insulting,
both to their conviction that they were acting in their children's
interests and to their competence as responsible parents to ensure
that individual vaccination courses were completed. In spite of
appearances to the contrary, one can argue that parents have behaved
rationally, not only with respect to MMR vaccination, but also in relation
to vCJD and road transport crashes. The case evokes cultural and social
context rather than "economic man." True, as the economic man argument
suggests, parents who refuse vaccination may "free ride" on the compliance
of the majority in order to secure the benefit of herd immunity for
their child. But, taken together, responses to the three risks we have
reviewed suggest that parents are acting conscientiously as norms dictate,
not selfishly. They act in what they perceive to be the interests of
their children. If there seems to be any risk to their child, responsible
parents will avoid it. Thus, they avoid beef products, and they question
the safety of the MMR vaccination. Even though taking children to school
and elsewhere by car may have unintended consequences for their health
and safety, it is interpreted as a way of protecting them from greater
dangers on the streets from other road users and abduction by strangers.26
Changing parents' perceptions Vaccination
has a heroic history in the control of communicable diseases. However,
collective provision that is taken for granted today in Britain—not
just vaccination, but also sewerage, clean water supply, and food safety—had
to be fought for. In the mass mobilisation wars of the 20th century,
several public health plans that had foundered for lack of public support
in peace time came to seem necessary for the war effort. But mass
mobilisation is not a normal state in healthy democracies. A consequence
of peace is that public health measures that have not become part of
infrastructure have often been challenged. For example, when rationing
of food was lifted in 1954, nutritional standards and their rough equality
achieved during the second world war were sacrificed for the sake of
choice.27 The case of public reaction to MMR vaccination should
be viewed in this broader historical context. Any attempt to restore
the compulsion that failed in the late 19th century would almost
certainly fail again. Instead, public health professionals and scientists
should consider the lessons that experience with MMR offers and apply
it in the future. The first is that challenge to authority, including
the authority of science, should be expected in a healthy democracy.
The second is that the establishment should disseminate evidence to
the public in a transparent way that is sensitive to the ways of understanding
of diverse groups. The third lesson is that communicating risk effectively
to the so called masses, and so priming people to act appropriately,
is about much more than providing even the best of information: it
is a matter of two way communication and obtaining agreement. Concordance
has to be the aim if compliance is to fall into place.28
Summary points
- The size of a risk does not necessarily relate to the controversy
it causes
- Parents seem to neglect the most obvious risks to
their children (such as road crashes), reject expert assessment (as
over BSE), and amplify a virtually non-existent risk (autism from vaccination)
-
Yet public willingness to conform to public health programmes remains
high, and parents' behaviour is not necessarily irrational
-
Parents' behaviour is understandable if they are seen as acting to
protect their children within a particular social context
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Competing interests: None declared. References
- Wakefield AJ,
Murch SH, Anthony A, Linnell J, Casson DM, Malik M, et al. Ileal-lymphoid-nodular
hyperplasia, non-specific colitis, and pervasive developmental disorder in children.
Lancet 1998;351: 637-41.
- Kaye JA, Melero-Montes
M, Jick H. Mumps, measles, and rubella vaccine and the incidence of autism recorded
by general practitioners: a time trend analysis. BMJ 2001;322: 460-3.
-
Taylor B, Miller E, Lingam R, Andrews N, Simmons A, Stowe J. Measles,
mumps, and rubella vaccination and bowel problems or developmental regression
in children with autism: population study. BMJ 2002;324: 393-6.
-
Cousens S, Everington D, Ward HJT, Will RG, Smith PG. The geographical
distribution of variant Creutzfeldt-Jakob disease cases in the UK: what can we
learn from it? Stat Methods Med Res 2003;12: 235-46.
-
Brown P, Will RG, Bradley R, Asher DM, Detwiler L. Bovine spongiform encephalopathy
and variant Creutzfeldt-Jakob disease: background, evolution, and current concerns.
Emerg Infect Dis 2001;7: 6-16.
- Ghani AC, Donnelly
CA, Ferguson NM, Anderson RM. Updated projections of future vCJD deaths in the
UK. BMC Infect Dis 2003;3: 4.
- Office of National
Statistics. Road accident casualties: by road user type and severity 1991-2001.
Annual Abstract of Statistics 2003.
- DiGuiseppi
C, Roberts I, Li L. Influence of changing travel patterns on child death rates
from injury: trend analysis. BMJ 1997;314: 710-3.
- Bartlett
DMC. Mad cows and democratic governance: BSE and the construction of a `free market'
in the UK. Crime, Law and Social Change 1998;30: 237-57.
-
Adams J. A `Richter scale for risk'? Scientific management of uncertainty
versus management of scientific uncertainty. Interdiscip Sci Rev 1998;23:
146-55.
- Bedford H, Elliman D. Press: MMR: the onslaught
continues. BMJ 2003;326: 718.
- Independent
2003 Jul 31: 4, 16.
- Durbach N. `They might as well brand
us': working class resistance to compulsory vaccination in Victorian England.
Soc Hist Med 2000;13: 45-62.
- Hennock EP. Vaccination
policy against smallpox, 1835-1914: a comparison of England with Prussia and Imperial
Germany. Soc Hist Med 1998;11: 49-71.
- Szreter
S. The importance of social intervention in Britain's mortality decline c 1815-1914:
a reinterpretation of the role of public health. Soc Hist Med 1988;1: 1-39
- Marks L. Metropolitan maternity: maternal and infant
welfare services in early twentieth century London. Amsterdam: Rodopi, 1996.
(Wellcome Institute series in the history of medicine.)
- Ramsay
ME, Yarwood J, Lewis D, Campbell H, White J. Parental confidence in measles, mumps
and rubella vaccine. Br J Gen Pract 2002;52: 912-6.
-
Boulianne N, Deveuninck G, Lavoie F, Dionne M, Carley J, Valiquette L, et
al. Why some 2-year old children are not completely immunized. Can J Public
Health 2003;94: 218-23.
- Bobo JK, Gale JL, Thapa
PB, Wassilak SGF. Risk-factors for delayed immunization in a random sample of
1163 children from Oregon and Washington Pediatrics 1993;91: 308-14.
-
Middleton E, Baker D. Comparison of social distribution of immunisation
with measles, mumps, and rubella vaccine, England, 1991-2001. BMJ 2003;326:
854.
- Evans M, Stoddart H, Condon L, Freeman E, Grizzell
M, Mullen R. Parents' perspectives on the MMR immunisation: a focus group study.
Br J Gen Pract 2001;51: 904-10.
- Petrovic M, Roberts
R, Ramsay M. Second dose of measles, mumps, and rubella vaccine: questionnaire
survey of health professionals. BMJ 2001;322: 82-5.
-
Lutwick SM. Pediatric vaccine
compliance. Pediatr Clin North Am 2000;47: 427-34.
-
Mullany L. Considerations for implementing a new combination vaccine into
managed care. Am J Manag Care 2003;9(1 suppl): S23-9.
-
Hillman M, Adams J, Whitelegg J. One false move... a study of children's
independent mobility. London: PSI Publishing, 1990.
- Huxley
RR, Lloyd BB, Goldacre M, Neil HA. Nutritional research in World War 2: the Oxford
nutrition survey and its research potential 50 years later. Br J Nutr 2000;84:
247-51.
- Vernon JG. Immunisation policy: from
compliance to concordance? Br J Gen Pract 2003;53: 399-404.
Dated: : 27.09.03Back to the News
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