How to convince a person to get vaccinated. Achieving a high rate of child immunisation acceptance depends on establishing strong relationships of trust with family doctors and socio-medical teams in the field, who interact directly and at the same time cover the social ground, information, and counseling of parents.
This is just one of the conclusions of a recently published research study entitled „Parents’ reluctance to vaccinate children in the perception of socio-medical workers„, conducted by George Valentin Roman, PhD student at the Faculty of Sociology and Social Work, University of Bucharest.
PRESShub spoke with George Valentin Roman about the results of his research, in a context in which, even before the COVID-19 pandemic, Romanians’ reluctance towards other vaccines was growing. Thus, in 2018-2019, Romania experienced a measles epidemic, which mainly affected children, in a context where the vaccination rate fell below the immunological minimum of 95%.
PRESShub: First of all, we would like, Mr. George Roman, to put your research in context, in order to see what is the situation in Romania in terms of attitudes towards vaccination and which segments you have looked at in particular.
George Valentin Roman: We should separate the discussion, talking first about the attitude of parents or authorities towards the obligation to respect the national vaccination calendar for children and voluntary vaccination for other threats, such as COVID-19 or other preventable diseases, such as HPV. Vaccinations that are not mandatory but voluntary.
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From this point of view, there are not the same difficulties as in the situation concerning voluntary vaccination, meaning that vaccination coverage exceeds 80% for most vaccines.
But even this does not allow us to say that it is enough. For example, to prevent a measles epidemic, we need 95-97% coverage. We know how contagious this disease is.
But when we talk about reluctance, we need to expand the discussion to other areas, such as access to health care, accessibility of vaccines and social assistance, the problems that families face in ensuring an income so that they can have a decent life or be able to cope with everyday needs.
In your report, you specify a very important point: ‘according to Eurobarometer 488, two situations facing the health system in Romania are illustrative: the measles epidemic and the high level of parental rejection/reluctance to the HPV vaccine’.
I find this significant, but also a paradox: we are talking about the measles epidemic, when we have had the measles vaccine tested for many years and vaccination has been carried out for many years, and about HPV vaccination, which is relatively more recent. The two have in common increased reluctance.
Do you have an explanation?
Yes, indeed, the trust rate of the Romanian population is lower than in other countries.
We have about 72% trust rate, according to the same Eurobarometer 488 document, while the European the average is 85%. When we talk about anti-HPV, the situation is even more dramatic.
For example, in the period immediately after the introduction of this vaccine, we had a vaccination coverage of 3%, compared to other countries such as Portugal (84%) or Slovenia (55%). But vaccine resistance is a very complex concept.
We cannot approach the issue in such a simple way, trying to draw up a list of factors that determine this reluctance, unless we widen the discussion to include social backgrounds, how the community reacts, social expectations, the binding nature of mandatory vaccination, how it is received and how it is supported in action by local authorities.
All these things, in fact, ultimately determine an attitude of acceptance or unwillingness towards vaccines.
It is what sociologists call a „social construction” of the attitude of acceptance, which is in fact a type of reporting to reality, to the real situation with regard to vaccination, which may or may not be in line with reality. For this reason, interventions are needed from several directions.
What are those directions?
First, in our analysis of parents’ reluctance to vaccinate their children, we used a conceptual model proposed by a working group at the World Health Organization that measured or explained vaccine reluctance by three factors: the first was trust, the second was accessibility, and the third was vaccine compliance.
These three concepts branched out according to certain social conditions or parents’ understanding of vaccination.
For example, lack of confidence, obviously meant, that attitude towards the capacity of vaccines to protect, but also in the medical or political system. It is the political system that decides whether or not a population should vaccinate, or encourages the population to do so.
What builds trust in the vaccine
But when we talk about confidence, we also have to think about what are the vectors that may or may not increase confidence in the act of vaccination. And I am thinking of family doctors, epidemiologists, paediatricians. Have you looked at social workers who are somehow „closer to the grass roots”, so to speak?
Not just social workers, but community nurses. The approach has to be taken from this perspective, of teams of medico-social workers, which can mean teams of social workers, nurses, health mediators, including school mediators, people who intervene in the community for different social problems that the population is facing.
What came out of the analysis is that the trust factor was determined by certain aspects. First of all, trust in the medical staff, the way they communicate, the attitude of the staff towards the mandatory nature of the children’s vaccination scheme, whether they are firm or permissive, in the sense that they can accept refusals without insisting too much on the parents’ decision.
In the field, we know very well how important the commitments that health professionals make to parents are, and not only in regard to vaccination in general, but also in regard to their medical care, to interventions for children’s health.
Medical staff also have a role to play in encouraging parents to make decisions that are always in their children’s best interests, but sometimes this needs to be explained.
A second factor determining trust is also the impact that interventions have, whether indeed the interventions of social workers or health professionals can be extended to other needs of the population, such as social care or legal aid needs, monitoring their ongoing health, repeat information and counselling.
Sometimes it is important to encourage parents’ positive motivations on an ongoing basis.
Last but not least, the cultural or social aspects of vaccination, because what is called social expectation operates in the community, i.e. the belief that other parents in the community also vaccinate their children.
It’s important to set a positive example of others, especially those who have some authority in the community, such as the mayor, the priest, the policeman, the teacher. These things become decisive for a parent who is faced with a dilemma and does not know what to hold on to or how to be proactive about vaccinating their children.
At the beginning you ask me about the differences in vaccine coverage on the mandatory scheme and on anti-HPV. It’s also important how the vaccine is perceived by parents: when it’s on the mandatory schedule, it’s supposed to be tested, it’s known, it’s safe for the population, but when it’s new, it raises questions.
The positive effect is not well understood, there are not many examples in the community, people have not heard of the vaccine and this allows for conspiracy theories that circulate in direct discussions between community members, are picked up from the online environment or other community members announce that there is information about negative effects in the online environment, as we encountered in interviews.
Obviously false information, but that can only be fought through direct communication by the medico-social teams, especially the GP, who seems to have the most authority in this area.
All vaccines are clinically tested
This is really also about the type of information that reaches the community and the fact that the information may not reach the community. There was the first HPV vaccination campaign in Romania in 2008 which was, as has been said, a failed campaign because of the poor way in which the information was provided.
On the other hand, the HPV vaccine is a vaccine that has been tested for enough years in other countries that this concern that it is untested is not valid as an argument. Perhaps the information campaign should be thought of differently.
That’s right. All vaccines are clinically tested, very safe and the benefits far outweigh any risk we discuss. This information has not been passed on to the community, the role of GPs has not been so emphasised or supported by the authorities and the campaign has been conducted from somewhere far above society.
Someone would come and tell them that it’s good to vaccinate children. This information should have been accompanied by an information campaign on various aspects and by direct involvement of social services.
In an isolated community, we don’t have many referral people for support other than the social worker.
But there are around 2-3000 localities that do not have professional social workers either at the moment, they just have some people employed with social work duties and who have neither the means, the tools nor the skills to provide social work interventions in the community.
And this has been reflected in the massive pushback from parents and the unbridled penetration of conspiracy theories especially in environments where the level of education does not allow, that’s the word, parents additional information and finding scientifically valid reliable sources.
And to be provided comprehensively, not separately. In my opinion, in these communities where information flows more slowly and access to professional medical services is more difficult, there is a need to combine social work and health care activities.
It is very hard to believe that we can achieve medium and long-term results by acting in isolation.
Teams need to be multidisciplinary, especially as resources are also limited in the community, and municipalities or local authorities develop very few social services or lack them altogether.
This means that the teams formed by these few professionals work together and support is given to these people on several levels. We can also mention the teachers or nursery educators, who can also play an important role.
However, it is also a question of what type of information the chosen vector transmits. There were also some doctors who did not believe and do not believe in the usefulness of HPV vaccination, for example.
Yes, it’s a complex discussion about health professionals. However, there are exceptions.However, there are exceptions. In our experience, all the staff we have met, communicated and cooperated with have not had problems of this kind, but the difficulty arises when these characters are vocal.
But also the reaction of the authorities should be firm towards these people, because they basically violate all the medical commitment, all the medical responsibilities that they took on when they decided they had to be doctors.
When the right to free expression is invoked
On the other hand, you know very well that the right to free expression is also invoked, we have the right to express ourselves.
From a legal perspective, the right to free expression is limited when your expression is within the spectrum of your professional responsibilities. Like an airplane pilot saying that he could run the plane on diesel.
When we talk about free speech, we must also consider the legal and professional responsibilities we have.
And for that reason, when we express ourselves from the position of a doctor, we have to be careful that the information is scientifically valid and does not cause negative consequences in the field in which we work.
So, I do not think that the idea of the right of expression for doctors, who in fact deny the knowledge they have acquired during their training and do not take into account the danger that they create for patients they are supposed to care for, stands up.
Back to your research for a moment. You worked with 12 socio-medical workers, as you called them, 11 women and one man, aged between 29 and 62, from rural areas in 8 counties: Brașov, Dolj, Caraș-Severin, Constanța, Hunedoara, Iași, Neamț and Vaslui.
There are counties, such as Dolj, where you have one nurse, one community health nurse and one social worker. There are counties, such as Vaslui, which have a programme manager. What’s the difference between a nurse and a community health worker?
The community health nurse works in the town hall, in a specific department, alongside the social worker. The medical assistant is a professional working in the family doctor’s offices, in our case, and the programme manager was a person who coordinated the work of a socio-medical team and who could support the family doctor’s offices in the area where the programme was being run, having a very good field experience.
The relation between parents and doctors is vital
Field experience means that these people go and talk directly to the parents, to the people they have to advise, to inform them about vaccination. Does the confidence of these parents increase when a professional in this category comes and promotes vaccination to them?
Yes, it’s very important, in fact outreach work is crucial to establish a good relationship between parents and the medical system.
And in terms of vaccination, at least in socially and economically disadvantaged communities, it seems to be the solution to achieve a high uptake of vaccination. Because such a team not only talks about the mandatory vaccination scheme, but solves many other problems.
Interactions are direct, psychosocial surveys can reveal other problems that can be solved, either by using legal provisions, or simply by supporting the family or involving other professionals, such as those in the education system, or material support to access social and medical services.
If we were to supplement health services in these rural communities, parents would have direct access to information on how they, in turn, access social and medical services.
In addition to trust in the healthcare system, there is also the factor of geographical accessibility of healthcare services.
The transport infrastructure does not always allow parents to go to the doctor. When talking about trust, one social worker stated that when there are strong relationships, people are close to the doctor’s office on all levels, both children and parents.
This means that they will go whenever they feel the need for a check-up on their or their children’s health. There is another interesting statement also from a social worker: if you can vaccinate a certain population that is more neglected, you have to go to them, go from door to door, to do consultations with children.
And, as far as possible, this vaccination process should be done outside, sometimes with the support of a nurse or family doctor, in front of the house or even in the house.
I’ve had a lot of statements about the relationship with the doctor, which can make a difference. And here I quote a nurse: „For mothers in these disadvantaged communities, what the educator says is as important as what the doctor says.”
A psychologist involved in counselling and outreach to mothers who regularly come to information sessions on general health issues, not just vaccination, said she was initially turned away in one community on religious grounds.
„There we were lucky that the lady doctor knew how to do it, this is where she deserves credit, because she knew how to handle the situation.”
The biggest contribution is made by the family doctor, who is the main pawn in the community.
There are also statements that refer to the importance of the position of the religious leader in that community, especially if we are talking about neo-Protestant religious orientations, where we can encounter certain biblically motivated refusals.
But the religious leader gives his congregants the best interpretation, appealing to religious principles that talk about health, about the role of parents for the health of children, about the vulnerability of children. And then the obstacles can be easily overcome, and parents can more easily accept coming to the doctor’s office for vaccination.
From the analysis, it doesn’t appear that there is a problem with religious reasons for refusal, there are very few cases. And anyway, at least for the population that is not so religiously committed, is not so present from this perspective, the medico-social teams have not encountered very many cases.
Accessibility is another problem
Let’s also talk very briefly about accessibility. What is meant by accessibility to vaccines, to the act of vaccination, to the vaccine itself. Have you looked at how the state ensures that we have enough vaccines? Have you even considered the fact that people may not be able to get to the vaccination centres or the dispensary?
The easiest way to see the extent to which this factor matters is how the vaccination process was carried out to prevent the measles outbreak. It affected more than 20,000 people in 2015-2020, with nearly 60 deaths among children.
Socio-medical workers blamed the accessibility in this situation, the lack of proper geographical distribution of family doctor’s offices in villages and communes, for example, the fact that many children were not registered with their family doctor.
There were also situations where families from ethnic minorities were neglected, ignored by medical staff, even though cases of illness were registered there.
Another important issue, which I understand they have also resolved in the last two years, during the pandemic, is that in the past communication between family doctors and public health directorates was not one of the happiest.
Family doctors travelled specifically to provide vaccination doses and either did not receive enough or were delayed and thus could not even respond to parents’ requests.
I remember one of the examples of the socio-medical workers, when they had brought 20 mothers with children to a doctor’s surgery and there were only 3-4 doses. Then they made a selection so that the most vulnerable or those who came from far away were vaccinated.
This situation can create a problem in creating what we used to call a fundamental relationship of trust between parents and health services.
Then there were statements showing that doctors were not always treated properly at the DSP ( Public Health Department).
Waiting in the hallways, wasting time. One social worker told us that the DSP’s hidden message was somehow that „you will need us anyway, even if we don’t treat you properly, you will come back to the DSP”.
I don’t know to what extent these things still exist today, but it is clear that the Public Health Department must prioritise any action by GPs when it comes to newborn care.
One of the conclusions of this study, quoting social health nurses, is that the message to people needs to be based on scientific evidence. Therefore, a scientific content must exist in this message, of course not complicated, it must be accessible as information.
Also, Mr George Roman, your research overlapped with the beginning of the pandemic and from this point of view we were all faced with a completely new situation, including from the perspective of the SARS Cov 2 vaccine. How was the vaccination campaign perceived, the intention to vaccinate against SARS Cov 2? Because we are also talking about, on the one hand, a very new vaccine, but at the same time, in an extremely new context, a disease with some consequences that everybody could see.
Yes, it is true that regardless of education level, people need scientific information.
It’s important how we deliver these messages, how we explain, how often we take certain information. They pay a lot of attention to scientific arguments, each with their own capacity to understand.
It’s true that they always have to be communicated by those who are trusted. For this reason, perhaps the campaigns or articles that appear in various publications or on social media are not convincing, because they do not come from people from who there are expectations of seriousness, responsibility and above all who are known to be able to provide help.
With regard to the COVID 19 vaccines, at least from the social workers’ statements, it appears that communication with families is not enough and that other ways should perhaps be found. Or combined efforts.
Only socio-medical workers cannot convince the population and for this reason I think that family doctors and positive examples in the community have counted a lot.
Most of the time, confidence in the Covid-19 vaccine is very strongly correlated with the human development index. This is measured by GDP per capita, life expectancy and education level.
The correlation is very strong. The higher a state’s Human Development Index, the higher the compliance with Covid vaccination.
This is quite a complex situation and it remains to be seen what other communication methods and contexts can provide positive results in this regard, Romania being the country with the lowest coverage.
Probably only we and the Bulgarians have around 55% of the population vaccinated with at least 2 doses of SARS-cov-2 at the moment.
Confidence in this vaccine is about the same level, 55%. Refusal has been quite general.
At least the families that have accepted the childhood vaccines without reluctance have not accepted the COVID-19 vaccine at all.
I think the anti-vaccination discourse that was circulating at the time was also very important; the news was full of demonstrations by those who were against vaccination or denied the existence of the virus.
The denial of the existence of pathogens is quite present especially in the population with a low level of education, because nobody gave them the basic information about bacteria, viruses and the differences between viruses.
For this reason, perhaps, we also have this kind of self-treatment that people give themselves for any virus, with antibiotics, not really understanding what the difference is between the two types of illness.
We need to expand health services in rural areas
The research results or one of the most important findings of this research, is that outreach „is proving to be the first important segment of parents’ relationship with the health care system”.
Therefore, we should somehow rethink the public health area.
Yes. But for this to happen, we need to expand health services in rural areas, and perhaps also bring other professions into the community, such as midwives, who can train pregnant women and inform expectant mothers in advance about how to care for their newborn babies and how important vaccination is for young children.
Likewise, any vaccine information activity must be combined with social welfare interventions. There are also many social barriers for families.
Last but not least, a multi-stage national communication strategy is needed, involving all those who can reach these isolated communities. And here I refer to family doctors and nurses.
However, the overall conclusion is that we cannot speak of a phenomenon of reluctance of parents to vaccinate, but rather of a complex situation with multiple difficulties.
Compliance is also conditional on accessibility, and access to health services is probably the first step in ensuring compliance with the mandatory vaccination scheme for newborns and limiting infant mortality from preventable causes.
Citește versiunea în limba română: PODCAST | Cum convingi un om să se vaccineze
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