Oregon health officials are trying to determine why a 5-year-old law that was supposed to make it harder for parents to claim nonmedical exemptions to the school vaccination mandate has not seemed to have an effect on immunization rates.
The law took effect for the 2014-15 school year, requiring parents who claimed religious or philosophical exemptions to undergo an educational program — either from their doctors or by watching an online video module — about vaccines and the diseases they prevent.
But data released by the state last month showed that while nonmedical exemption rates for kindergartners dropped from 7 percent to 5.8 percent the first year, rates have risen steadily since then, to 6.2 percent in 2016, 6.5 percent in 2017, and 7.5 percent in 2018.
“We really don’t have enough information right now, to really be able to tell the reason,” said Stacy de Assis Matthews, immunization school law coordinator with the Oregon Health Authority. “We did see the initial decrease in the nonmedical exemptions, and it’s possible without the module we could have an even higher exemption rate.”
Some 95 percent of parents claiming nonmedical exemptions met the requirements by watching the online video, and last year the agency commissioned a review of the feedback provided by those parents.
About 41 percent of the parents who completed a survey were satisfied with the material, and 83 percent said the information was easy to understand. Slightly less than half commented in an open-ended question.
“The responses ranged widely in length from a single word or few words to several paragraphs, complete with statistics and web links,” the review authors wrote. “The emotional tone of the responses varied widely, as well, from positive through neutral, to angry and even raging.”
About 17 percent appreciated the video, while 19 percent complained of technical difficulties. State officials have already made changes to address some of those technical concerns.
More than half of the comments were objections, either based on religious or ideological grounds or based on concerns about vaccine safety. Some parents complained about the tone of the video, describing it as condescending or patronizing, while others felt it was biased or lacking in data. Many expressed their distrust in the government and in vaccine research.
“With one module that’s aimed at the whole audience of exemptors who may have different reasons for exemptions, it is a challenge to address everyone’s concerns,” Matthews said.
The agency plans to review the comments again this summer and to update the online video with the latest data and responses to the questions and concerns that parents expressed. Matthews said the agency was challenged to complete a video in the eight-month time frame set out in the law, and was hamstrung by limited funding.
“It’s a good product for meeting the requirement of the law,” she said. “But we’ve all seen really amazing interactive products on the internet that with enough financial resources could be more engaging to parents.”
The agency relied primarily on existing stakeholder groups of parents and providers to test the online video. Those included some parents who were hesitant about vaccines, but it was not the majority of the group.
“In public health, an intervention like this specifically doesn’t have enough information to be recommended to increase immunization rates,” Matthews said. “Not that it won’t work, but it’s fairly new and there’s not enough information.”
That’s in part because states have only recently had to address the question of nonmedical exemptions. The vast majority of parents, upward of 90 percent nationwide, vaccinate their children. As exemption rates have ticked up, putting various pockets of the country at higher risk for disease outbreaks, states like Oregon have tried to tighten up loopholes that allow parents to opt out. But the research in how to convince parents to do so has lagged behind.
“Just giving people the facts isn’t always going to work,” said Diane Peterson, associate director for immunization projects at the Immunization Action Coalition. “In fact, it’s not a good way to approach it.”
Several studies have backed that notion.
“We need to test videos like Oregon’s to see what effect they have,” said Brendan Nyhan, a professor of government at Dartmouth University. “But I’m skeptical that a mandatory video is going to have much of an effect on people.”
In 2014, Nyhan and his colleagues surveyed parents with kids at home under age 18, randomly assigning them one of four messages promoting vaccination: a debunking of the myth that the measles, mumps and rubella vaccine causes autism; information about the risks of those diseases; images of children affected by those conditions or a narrative about a sick child.
None of the messages seemed to sway parents toward vaccination, and the corrective message about vaccines and autism actually had the opposite effect among parents who were most skeptical about vaccines. Those parents came away from the message even more entrenched against vaccination.
“We actually did find that parents were persuaded by the corrective information in terms of their factual belief,” Nyhan said. “It just didn’t seem to change their behavioral intent.”
The researchers weren’t able to track whether parents actually vaccinated their kids or not, but the study mirrors the findings of other research that simply providing accurate information has little effect on intent. But that’s primarily how public health officials have tried to combat vaccine exemptions. Most messages, Nyhan said, focus one of three approaches: emphasizing the dangers of vaccine preventable diseases, addressing specific objections to vaccination, and trying to strengthen norms around vaccines. But none of those approaches has been systematically tested for effectiveness, he said.
A study published last year in the journal Nature Human Behavior, may explain why that traditional approach has fallen short. Researchers at Emory University applied a method traditionally used in psychology and political science work to the question of vaccine hesitancy.
“The idea with this moral foundations theory is there may be underlying values that guide the development of attitudes,” said Dr. Robert Bednarczyk, an assistant professor at Emory University and a co-author of the study. “The lens through which we see things or the taste buds through which we taste things, may influence how we process some of that information and ultimately, develop those attitudes.”
The researchers found parents didn’t differ much in how important they considered notions of care, harm, fairness or quality, typically stressed in public health messaging.
“They are equally important to everybody,” Bednarczyk said. “Parents love their children; they want to do what’s best for their children.”
But parents with higher levels of vaccine hesitancy were more likely to have strong feelings about values like purity and freedom. That could explain why those parents could hold concerns about the ingredients in vaccines or reject vaccine mandates.
The researchers are now working on ways to express pro-vaccine messaging in a way that speaks to those values and resonates with skeptical parents.
“You’re still getting to the same point,” Bednarczyk said. “But the way you direct the message can very different.”
It’s early in the process for developing and testing such messaging, but public health researchers say Oregon could take other steps to reduce nonmedical exemptions.
“Oregon’s law is one of the more relaxed immunization laws in the country,” said Tony Yang, a health policy professor at George Mason University. “You still have religious exemptions; you still have philosophical exemptions. There are some components that can make it harder, and Oregon doesn’t have that.”
Those could include requiring notarized exemptions, establishing a review process by health departments or school districts or having officials investigate the legitimacy of religious exemptions.
“Are you seriously part of a religious group that has those kinds of beliefs, or are you just taking the loophole, claiming a religious exemption but you don’t even go to church?” Yang said.
States could also require parents renew their exemptions each year or as students start middle school and high school. All of those administrative hurdles might not change parents’ attitudes towards vaccines, but it could make the process much harder than just watching a short video.
“(Exemption) policies in general have not appropriately struck the balance between the health care needs of the community and the respect for personal autonomy,” Nyhan said. “In some cases, it’s easier to get an exemption than to prove your child was vaccinated, which is totally backwards.”
— Reporter: 541-633-2162, firstname.lastname@example.org