At Lakota middle school in Federal Way, about 30 percent of the children who attended last year didn’t receive all of their required vaccinations. The rate was similar at Lynnwood High School in the Edmonds School District. In fact, throughout King County, many schools have rates below 90 percent, which is the percentage that is considered high enough to provide “herd immunity” (preventing outbreaks of disease) to the overall population.

State law requires children to be immunized (although there are exemptions), and there have been ongoing efforts to improve vaccination rates. But vaccine hesitancy—the term for delaying or skipping immunizations, usually based on a decision made by parents who wonder whether vaccines are safe or necessary—has not abated, despite these efforts. 

And because of low vaccination rates in some areas, there have been outbreaks of diseases once considered virtually wiped out, such as whooping cough, measles, polio, mumps Haemophilus influenzae and meningitis.

“These things are still around and can hurt people,” says John B. Dunn, M.D., MPH, a pediatrician who is the cochair of the immunization team at Kaiser Permanente in Seattle, and an adjunct researcher with Kaiser Permanente Washington Health Research Institute (KPWHRI).

The risk of outbreaks of vaccine-preventable diseases is a concern shared by Jessica Booth, a Kirkland-area mother and educator. While many efforts by health workers and officials to educate parents about the importance of vaccines haven’t had a discernable impact, a Washington state–based strategy that Booth has been involved in is showing promise. 

In 2013, Booth worked as a parent advocate for Vax Northwest in support of childhood vaccinations. This public-private partnership of health organizations, which includes the Washington State Department of Health, Seattle Children’s and Kaiser Permanente (formerly Group Health), is working on ways to encourage people to vaccinate their children against preventable diseases. 

Booth’s volunteer job was to find positive ways to share information about vaccinations with the parents of a toddler group in which her daughter was enrolled. First, Booth attended a half-day training session to learn more about vaccines and gather ideas for how to have upbeat conversations on the topic. Then, she spent much of her volunteer year as a sounding board for the parents in the toddler group, and any other friend who wanted information. 

“I’d listen to their concerns…and then answer questions or support them in any way that they were feeling,” she says. “Sometimes I think what is best is just listening, rather than jamming a belief down someone’s throat.”

It turns out that the kind of gentle, peer-to-peer communication style Booth used to support childhood vaccinations in her community may be a winning strategy for overcoming vaccine hesitancy. That’s one of the main findings of a three-year Kaiser Permanente study that measured changes in community attitudes toward vaccines after parents, including Booth, in selected Northshore and Bellingham preschools and child care centers, engaged with their peers in person and through social media to talk positively about vaccinations. 

The idea was to create what is called an “immunity community” of parents who support vaccinations. “We had suggestions about what might work well and what might not, but the parent advocates know their community, schools and friends and families the best, so we looked to them for guidance as well,” says Mackenzie Melton, immunization coordinator at WithinReach (an organization that connects people in the state to health care resources), which coordinated the project.

“We hadn’t heard of any other project that is doing this type of approach, of using parents to spread positive messages,” says Clarissa Hsu, Ph.D., of KPWHRI’s Center for Community Health and Evaluation, a principal investigator for the study. “The exciting thing about the immunity community is that it was a successful proof of concept: You can activate parents to talk to peers about childhood vaccinations in positive ways.”

The results of the study were published in April 2017 in the paper “The Immunity Community: A Community Engagement Strategy for Reducing Vaccine Hesitancy,” in the medical journal Health Promotion Practice. 

Based on the results of a survey before and after the three-year intervention, changes in parent attitudes were encouraging. During the time frame:

• Parents became more concerned about other parents not having their children vaccinated, a number that rose from 81 percent to 89 percent.

• The percentage of parents calling themselves “vaccine-hesitant” fell from 23 percent to 14 percent.

• Fewer parents believed that children were receiving vaccines at too young an age, and more parents were confident that vaccinating their children was a good decision.

More parents also knew the vaccination rates at their children’s child care or school, because the parent advocates collected information on the percentage of vaccinated children at the day cares and schools where they were volunteering, and the numbers were made public. “I think that was a really successful strategy,” said Hsu. 

That’s because, while some parents are vaccine-hesitant, in the end, overall vaccination rates remain fairly high, a message not all parents were getting. “While our coverage rates are not where we’d like them to be for children or for teens, the majority of parents in Washington (nearly 9 out of 10) do vaccinate their children,” says Danielle Koenig, immunization health promotion supervisor for the Washington State Department of Health. Many schools and child care centers don’t enforce or monitor vaccinations. Through the project, Vax Northwest was able to create policy change in some publicly run day cares in Washington state to ensure that vaccine information about students is collected and monitored. 

Pediatrician Dunn says he and colleagues were “thrilled” by the results of the immunity community study. “This is a different approach to the problem than the model we’ve traditionally used,” he says. In the past, he says, it was assumed that parents would understand the need for immunization. If a parent was hesitant, “the concept then was to bring them data and they will come. Lecture until they capitulate.” Dunn says that approach to vaccination hesitancy isn’t effective now. “In my personal experience, families look for another doctor that isn’t going to give them a hard time about it,” he says.

Dunn compared the immunity community concept to the effort to reduce rates of smoking. “There was really a resetting of the community standard, of the community norm.”

Other research has shown that parents are influenced in vaccine decisions by far more than messages from doctors or scientific research. A study published in 2013 by anthropologist Emily K. Brunson, MPH, Ph.D., at Texas State University that looked at the vaccination decisions and influences on first-time parents in King County, Washington, found that social networks, “particularly parents’ people networks,” were a very important part of parents’ decision making regarding vaccinations.

The immunity community engagement formally ended in 2014, but many parents have continued their involvement, and resources and materials became available earlier this fall online (immunitycommunitywa.org) for other communities that would like to start programs. 

Parent advocate Booth says she understands hesitancy. “I definitely felt as a parent that the number of vaccinations can seem overwhelming and scary,” she says. But what she learned through Vax Northwest helped her feel even more secure in her belief in the value of vaccines. “It was rewarding to support something I believed in, and to hopefully do it in a way that is supportive of other people,” she says. 

Outbreaks
The consequences of vaccine hesitancy
In 2015, a Washington resident suffered the first measles-related death in our state in a dozen years. During another U.S. measles outbreak, in 2014, 36 people came down with measles traced to visits to Disneyland. Whooping cough, or pertussis (it’s the “P” in the childhood DTaP vaccine, which also vaccinates against diphtheria and tetanus), has flared up several times in recent years, including more than 2,000 cases in Washington state in 2012, and 587 cases in 2016, when nine infants younger than 1 year were hospitalized in Washington. Last spring, the state saw its largest outbreak of mumps in a decade.