Stop what you’re doing to read this The New England Journal of Medicine perspective by Dr. Doug Diekema. It’s about vaccines, opportunities for health, and physician obligation. Written for physicians, it also speaks loudly to parents and includes a few very essential points. The whole time I read the article, my thoughts kept leaping to our imminent opportunities. Today, in 2012, we can harness the tools of social media and technology to solve many of these problems. It’s time. HPV vaccine? Varicella vaccine? Remember your yearly flu shot? I really think there could an app for that.
Let me explain.
Dr. Diekema opens describing a scene very typical in Seattle.
Recently, the mother of a young child confessed to me that she didn’t know any parents who were following the recommended immunization schedule for their children. She said that when she told her pediatrician she’d like to follow an alternative schedule, the physician had simply acquiesced, leading her to assume that the recommended schedule had no advantage over the one she suggested.
Yes, the physician obliged her desired schedule for many reasons, I suspect: time restraints/desiring a partnership/a hope for future opportunities to provide education and update immunizations for the child. In a state (Washington) that leads the nation in vaccine exemptions, we encounter patients daily who prefer a delayed or personal schedule. I’ve written about parents and alternative schedules and physicians’ conditional comfort with alternative vaccine schedules. But when Dr Diekema mentions this family, he highlights what many pediatricians and family physicians realize: families may be clustered together in vaccine-hesitancy. Friends of friends instruct each about vaccine schedules and share beliefs about safety. We know that 40% of parents who use an alternative schedule create it themselves.
Family members persuade my patients not to get immunized. Even in the midst of a pertussis outbreak in the county in which I practice, grandparents and relatives of newborns refuse the Tdap vaccine. My patients are bombarded with advice and naysayers. Who we love (friends and family) and who we trust (friends and family) certainly affect what we do. My patients get confused. And most of health (care) conversations happen outside the exam room. Therefore, hesitancy clusters in neighborhoods naturally and poses regional risk. What if we had real time information about our schools? About our neighborhood? What if Google mapped our rates of protection from vaccinations? What if we had a smart phone app that provided us yearly data on school immunization/exemption rates when we selected a kindergarten? Why not an app for that?
So what if we gave new parents the tools to help educate Aunt Judy who refuses the Tdap shot. What if we handed her a You Tube video to share with Grandpa Bob while he rocked the newborn. Grandpa isn’t refusing a vaccine out of cruelty; he’s refusing it out of fear or possibly confusion. Why not give him the shot at the ped’s office too? Let our patients educate while cocooning and protecting their babies.
Data from the Pew Internet and American Life Project finds that 80% of Internet users look up health information, but more, Internet users want to use what they learn to help others. Many patients join disease-specific groups to crowd-source and share information about medical conditions/medication side effects/doctor visits. Most of us search for health information on behalf of someone else. Susannah Fox calls this learning and sharing Peer-to-Peer-Healthcare. She says the leading edge of health care is when patients say, “I know and I want to share my knowledge.” They use their mobile device to inform friends and family. New parents are learning how and why to protect newborns for pertussis in my clinic. What if we offered them a link with a video to share with relatives? Or an application of up-to-date infection numbers. Peer-to-peer health care is real and these new parents are strong, wise, and fierce protectors of their children. Why don’t doctors help them outside exam room walls? Young parents are savvy and already tracking the number of poopy diapers on their iPhone, so why are we not making a vaccine app?
In actuality, an alternative or delayed vaccination schedule only increases risk. All vaccines carry risk and waiting to get vaccinated only elevates risk by creating more time for a child to remain susceptible for infection, while still acquiring the small risk of the delayed vaccine. So these delays and these clusters of missed vaccinations become problematic. The Pacific Northwest is one example.
In Washington State’s San Juan County, for example, 72% of kindergartners and 89% of sixth graders are either non-compliant with or exempt from vaccination requirements for school entry. Only 52.5% of kindergartners and 4% of sixth graders were adequately immunized against pertussis for the 2010–2011 school year. Not surprisingly, the county also has one of the state’s highest incidence rates of pertussis.
It’s challenging to keep up with the immunization schedule. The 2012 schedule was just released and reflects new changes but it’s difficult to navigate. Why don’t we help remove barriers in our own lives and in patients’ lives? Often children aren’t up-to-date on their shots not out of refusal, but out of inconvenience or parental misconception. Why not provide text reminders when the booster for HPV is due? Why don’t clinics tweet or text times for flu shot clinics to all patients who need a flu shot (kids 6 months to 18 years of age)? Why not share doctors’ opinions through the smart phone? Why not make an app for that?
First, socioeconomic barriers and disincentives to vaccination should be eliminated. Even small copayments or administration fees pose substantial barriers for some families. Referral to a public health clinic is one option, but attending such clinics requires extra effort, travel, and time away from work — all disincentives to following through. Removing barriers to vaccination is an obvious first step to improving coverage. Some countries, such as Australia, have gone further, offering incentives for vaccinating children on time. Incentives can take several forms, including reduced insurance rates, tax rebates, or direct payments.
We have an opportunity to harness the tools of social media to affect real change and deconstruct barriers. Patients don’t only want more credible science, they want the truth from a trusted partner. The real story, the real facts. We patients want access to why/what/how to protect our children. Doctors need to be communicating online as a part of their day. We already know that parents trust the pediatrician more than anyone else when it comes to questions about vaccine safety. And we’ve known this for a long time. Dr. Diekema hints at online opportunity here:
Fourth, clinicians, health care organizations, and public health departments must learn to use the tools of persuasion effectively. In The Art of Rhetoric, Aristotle argued that persuasion requires not only a reasonable argument and supporting data, but also a messenger who is trustworthy and attentive to the audience and a message that engages the audience emotionally. Data and facts, no matter how strongly supportive of vaccination, will not be sufficient to compete with the opposition’s emotional appeals.
There is a race to make a number of apps in health care. And I’m working hard to help. But we need an app now facilitating credible information on vaccines and personalized information in the palm of parents’ hands. I’m waiting for the day when we say, “Yes, we have an app for that.”
Wendy Sue Swanson is a pediatrician who blogs at Seattle Mama Doc.
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