Communication and miscommunication of risk: understanding UK parents' attitudes to combined MMR vaccination

It seems to me that the comparisons being made in ‘Parents responses
to the risks’ do not involve risks of the same order.

Parents can take care or otherwise when they are driving, but they
cannot control the behaviour of other road users. If public transport is
being used then there is very little control that either parent or child
can exert positively.

With regard to vCJD, parents can be concerned but in practice I
believe that they do not see the current risk of contracting this
condition to be great and, of course, there is no way of telling if any
particular action will produce a reaction.

When it comes to the MMR vaccine, the order changes in as much that
it is not the vaccine that may be at fault but that it might be their
child who may be susceptible to adverse reactions. The factor that
produces the risk reaction is that the parents have no way of knowing if
there child is a reactor or not. So it is in reality a sort of Russian
roulette in reverse. Not, will my child find the bullet, but will my
child’s system fire the gun.

The real motivator to decline vaccination is the potential ‘guilt
factor’ that enters the equation. It is the parent and not the child who
makes the decision whether or not to vaccinate. Those who have had
children who are brain damaged by vaccination know only too well how heavy
this burden is to carry. Unfortunately it is not a factor that is
considered by epidemiologists, vaccinating doctors and researchers who
tell us that, “authorities ought to act in the interests of the child”.

What has not been thought through here is the possibility that if a
vaccination was imposed by dint of law, who would be responsible if the
child was adversely affected by the vaccination? If the answer is that the
matter is covered by the Vaccine Damage Payments Act 1979, then think
again. No mother would willingly bargain their child’s life and wellbeing
for the rest of its life in payment of £100,000.

Competing interests:
Father of a vaccine damaged daughter.

EDITOR--Thank you for devoting an issue of the BMJ to the important
topic of communication and public perception of risk. As a Public Health
Physician, whose daily thoughts are shaped by probability, other
statistical methods and epidemiology, I have long pondered and puzzled
over the apparent dissonance between statistical and public interpretation
of risk. Not just the unknown mass public, but even my friends and
family. In fact those avoiding or declining minimum risk activities and
health interventions are more frequently from the sector of society which
is apparently better informed and more highly educated, as pointed out by
Bellaby1 in relation to the drop in MMR uptake post Wakefield’s claim in
1998.2

Bellaby takes us through the complexities of how scientific findings
and probability are transformed in the public’s mind, via politicians and
the media, into perceptions, beliefs and actions. In general, I agree
with the points he makes. However, three thoughts occurred to me which I
feel need further consideration:

Bellaby argues that in a post-war democracy, like Britain, compulsion
cannot work and concordance through two-way communication (presumably with
each person on an individual basis) is the only way forward. This is time
-consuming. Whilst concordance is preferable, there is one example where
arguably compulsion worked well: seat belt legislation. Post introduction
in 1988, this compulsory health measure for all vehicle drivers and
passengers, did not generate riots or failed compliance.3 The rate of
fatalities and serious accidents has not substantially increased since,
despite a huge increase in traffic-miles travelled.4 I acknowledge the
contribution of better car design, road engineering and slower speeds in
urban areas due to congestion.5

There is another factor which could influence reaction to risk, that
is whether the risk is within an individual’s control or imposed upon
them. Risk imposed by others may be less acceptable. In the three
examples covered by Bellamy, the injuries sustained by children as
passengers, presumably largely driven by their parents, could be perceived
by parents as under their own control and their responsibility.
Measles, mumps, and rubella (MMR) vaccination is imposed by the health
service and by the Government. Variant Creutzfeldt-Jakob disease (vCJD)
could be perceived as being imposed by the agriculture and food
industries. Two risks, which I like to compare, are those of death from
smoking and air travel. The statistics tell us that air travel is
incredibly safe and that tobacco smoking is not. I suggest that not many
disasters hit the headlines or produce more public fear than a plane crash
and yet approximately 340 jumbo jets would have to crash in one year to
equal the toll from smoking in the UK. I argue that those who smoke feel
that smoking is under their personal control and the fate of an aircraft
in flight is not.

This example brings me to my third point, the media and hence the
public, seem more interested and frightened by unusual and immediate
events. Smoking is an every day occurrence plane crashes are not.
Smoking takes many years to kill, a plane crash happens in a matter of
hours after take off.

So in addition to Bellamy’s well-made points, I would add the
suggestion that the above points are worthy of further research both as to
whether they are relevant to the public’s assessment and perception of
risk and how the findings can help the implementation of effective Public
Health programmes, through better communication, in today’s Britain.

References

1. Bellaby P. Communication and miscommunication of risk:
understanding UK parents’ attitudes to combined MMR vaccination. BMJ
2003;327:725-728.

2. Wakefield A, Murch S, Anthony A, Linnell J, Casson D, Malik B,
Dhillon A, harvey P, Walker-Smith J. Ileal-lymphoid hyperplasia,
non-specific colitis, and pervasive developmental disorder in children.
Lancet 1998 Feb 28; 351 (9103):637-41.

3. Mackay M. Seat belt legislation on Britain. J Trauma 1987 Jul;
27(7):759-62.

4. MacCarthy M. The Benefit of seat belt legislation in UK. J
Epidemiology Community Health. 1989 Sep; 43(3):218-22.

5. Crandall CS, Olson LM, Sklar DP. Mortality reduction with air bag and
seat belt use in head-on passenger car collisions. Am J Epidemiol. 2001
1;153(3):219-24

Dr. Rosemary J. Geller

Director of Health Strategy

Shropshire and Staffordshire Health Authority

NB the views expressed here are those of the author and do not
necessarily represent the views or policies of Shropshire and
Staffordshire Health Authority.

Competing interests:
None declared

Justin suggests in the mildest tones what would be a major change in
British doctor-patient relations.

Firstly, it is not true that vaccination is compulsory in the USA.
Rather, admission to public schools without vaccination certification is
disallowed. But parents are allowed not to have their children
vaccinated.

I do not want to vaccinate a child, whilst her parents are held in
temporary police custody. Parents (all those I have known) do try to make
the right choice for their children given their experience, knowledge,
fears and concerns. I well remember 25 years ago, having to take my baby
daughter for vaccination, because I was embarking for a new job in
Nigeria. My tiny daughter needed to have BCG, Triple Vacc, etc all in a
'crash course'. I agonised about other risks too - but we decided to give
her a Measles vaccine ( single measles vacc was available then ! ), but
after much heart-searching !! And who holds the child while the jabs are
given ? How many needles can you stick in your child ? It is an emotional
business, I can tell you - I held her while my wife looked away.

Justin's analogy seems reasonable - the Law requires the wearing of
seatbelts, designed only to protect that individual, not 'society' - so
why not pass a Law to vaccinate children ? Yet many individuals object
to seat belts in principle, and many simply ignore the Law ( I am not
'immune' ! ). Policemen respond according to their mood , or the Chief
Constable's need for convictions 'targets'. I am regularly asked for
'Seat-Belt exemption' certificates - sometimes for the most bizarre of
reasons.

We in the UK can achieve high immunisation rates, AND a reasonably
tolerant liberal approach to 'parental rights'. All we need to do is
listen to concerns, try to persuade - and OFFER SINGLE VACCINES where
parents persist in refusing MMR. How do I know this ? Because it is
exactly what we did with triple DPT vaccine through the dark years of the
'Pertussis and Brain Damage' debate - when mass refusal to accept
Pertussis vaccine led to a major upsurge in Whooping cough morbidity and
mortality. But after due discussion we would give DT vacc and not add
Diphtheria and Tetanus epidemics to our problems!

But Dr Pat Troop and the Public Health establishment have taken on a
Stalinist policy... how times change !

Competing interests:  
doing good vs. avoiding harm

The introduction of compulsory use of a seat belt belt in the UK is
an interesting comparison to make in support of the suggestion of
compulsory vaccination as an method of achieving herd immunity.

Even with a well fitted, self adjusting seatbelt, one size does not
fit all, hence the use of baby & booster seats etc to avoid damage
from the seatbelt per se and maximise it's benefits.

I wonder, would Justin Daniels advocate a similar "tailoring" of his
proposal regarding compulsory vaccination policy based on appropriate
screening of individual suitability and family health history?

MCF

Competing interests:  
In favour of the use of appropriately fitted & tested seatbelts in all road vehicles........