Should parents be required to vaccinate their children? (Vanessa Farkas)

Context

Reference to a current Michigan bill or law that relates in some way to your proposal:

The Revised School Code - Act 451 of 1976 (Section 380. 1177) 

Why this proposal will make a difference in the lives of students of all ages across Michigan, or a significant subgroup (by age, background, economic status, and/or region, etc.) of students in Michigan:

This proposal will make a major difference in the lives of students of all ages across Michigan. The reason for this is simple. The more students who have received the proper immunizations at the appropriate time, the less likely it is that there will be an outbreak of a vaccine-preventable, and potentially life threatening, diseases. This will minimize the opportunity for dangerous illnesses to spread, especially among students in their educational institutions. Ultimately, parents who opt out of vaccinating their children to avoid a risk are engaging in much riskier behavior by choosing to do so. 

How and where did you learn about the issues underlying your proposal?

My interest in the declining rates of child vaccinations first sparked in my public health class last semester. I have always been passionate about public health and nutrition, but I was initially introduced to the subject of vaccinations in Public Health 350 with Dr. Matthew Boulton. I found this proposal to be a perfect opportunity to expand my knowledge of the topic.

How has your service activity influenced your thinking about this proposal?

Every Thursday evening, I tutor at Peace Neighborhood Center. I work with the same student every session as we try to improve his math and reading skills or complete his homework. Without question, my service activity has influenced my thinking about my proposal. The majority of families that Peace Neighborhood Center works with are low income families who are struggling financially. I frequently wonder how many of these families are educated on when their children should be receiving vaccines. I am particularly interested in this, given my knowledge that a lack of information on when to receive vaccines is a top six reason for why people are not immunized. I'd bet that vaccine appointments for their young children are not on parents' radars as they are increasingly concerned with working hard in order to put food on the table and make a living. I have kept this in mind as I have worked to draft my proposal. It is important to account for families who fall on every level of the socioeconomic ladder as everyone should be receiving vaccines at the appropriate time. 

Link to your media artifact(s) giving background on the issue:

My podcast: Issues with childhood immunization rates

Consultations

Talk directly with at least 3 real live people who have special knowledge about this topic or the impact your proposal would have, and summarize their comments. These may include people appearing in your media artifact (video, podcast, etc.).

CONSULTATION 1: Abram Wagner

Abram Wagner is an Epidemiologist at the University of Michigan in Ann Arbor. In our meeting, we discussed whether or not parents should be required to vaccinate their children. To be more specific, I asked him how doctors and other health professionals can influence parents' thoughts about vaccines. In his response, Mr. Wagner acknowledges that it is, indeed, very difficult to influence a parent's thoughts about vaccines. However, parents do have a particular allegiance to their own doctor. With that being said, doctors hold immense power in positively impacting parents' pre-existing beliefs regarding vaccines. One method that may be especially effective is letting parents know that vaccines are "the default in their practice." It is also helpful for the doctor to address the questions and concerns of parents early on in the child's life. 

CONSULTATION 2: Dr. Matthew Boulton

Dr. Boulton wears many hats, including the Senior Associate Dean for Global Public Health, Professor of Epidemiology, Professor of Health Management & Policy, Professor of Preventative Medicine, Professor of Internal Medicine, Infectious Disease Division, and Editor-in-Chief of American Journal of Preventative Medicine. To no surprise, Dr. Boulton had many insightful thoughts and feelings regarding my proposal and was more than happy to share them with me.

To begin, Dr. Boulton explained that one problem with a handful of the studies done regarding the effectiveness of text messaging on immunization rates is that they are intervention studies, meaning there is no control group. It is hard for researchers to know whether the intervention is truly effective. In other words, are parents getting their children vaccinated because they received a text message reminder or because they recently saw a commercial on television about vaccines and it informed their thinking? A weak study design poses a problem, but that is not to say that they cannot deliver important information. It means that study results must be interpreted with great caution.

Dr. Boulton further shared with me that the State of Michigan's immunization registry is one of the most highly functional registries in the country. It has had more research done and more information published about it than any other registry. Dr. Boulton encouraged me to capitalize on this point as I continue to develop my proposal. 

One aspect of our conversation that I found particularly thought provoking was when Dr. Boulton asked, "What is your hook?" For instance, people get hundreds of text messages a day. What will get them to read the immunization text message reminder and actually go to the appointment? What is the source of motivation? Is it a movie star? Is it Kid Rock? Is it Tim Allen? How can I call their attention to the text message so they get their children vaccinated? This was a thought that had not crossed my mind prior to our meeting. It was a challenging, yet eye opening discussion that gave me a new wave of creativity for drafting my final proposal. 

When asked if he thinks my proposal represents a feasible solution, Dr. Boulton explained that he believes the text messaging system will be effective. There is evidence that text message reminders are successful in behavioral interventions. However, we need to find out if this approach works best for immunizations. The only way to know its effectiveness is to pour more funding into increased research and exploration.

CONSULTATION 3: Mary Jewel Brown (Mj Brown)

My conversation with Mj was very eye opening. Given the fact that Mj opposes mandatory vaccinations, she offered a unique perspective on the issue. Her two primary concerns with my proposal were habituation and scalability. 

In regards to habituation, Mj pointed out that the more you text someone, the less effective the reminder will be. Effectiveness will continue to increase for some point; however, it will eventually decline. This will inevitably happen because people will get used to receiving reminders. Messages will slowly lose the urgency and importance they initially conveyed. 

Additionally, Mj shared with me the need to make my proposal increasingly scalable. It is inefficient to create a solution that is beneficial solely for West Bloomfield, Michigan and less advantageous for Grosse Pointe, Michigan. It is important that immunization text message reminders will be helpful in improving vaccination rates across the state of Michigan. It needs to work for everyone. It is often difficult to accommodate the needs and requests of larger groups of people.

Overall, Mj's feedback was very helpful because she did not simply agree with my proposal. I received great pushback, which encouraged me to think more critically about my ideas.

Prospectus:

 

Vaccinations have significantly reduced the burden of infectious diseases. This has been especially important in the battle against childhood illnesses, such as measles, mumps, diphtheria and rubella. When speaking about childhood immunization, it is vital to note that parents bare the primary responsibility of ensuring their children receive the proper vaccinations as outlined by the Centers for Disease Control and Prevention. This means children should be receiving vaccines as early as 1-2 months after birth.

Unfortunately, a recent decline in child vaccinations in the state of Michigan has sparked serious concerns. Most parents today have never seen first-hand the destructive consequences that vaccine-preventable diseases may have on a family or community. According to a new study from the American Academy of Pediatrics, an increasing number of parents believe vaccinations are "unnecessary."

It is evident that the decline in vaccinations is a growing problem in Michigan as it was recently reported to be among the nation's worst for vaccination rates. In fact, Michigan ranked fourth worse in the country. More specifically, Washtenaw County has been heavily scrutinized since its public health department noted that it was falling behind state averages. To add to the mix, parents have been struggling to find safe day cares for their children. MLive revealed that three-quarters of children in licensed day cares in Michigan attend a center with vaccination rates below federal guidelines. Low vaccination rates have the capacity to jeopardize the health of the remaining community. 

Without question, this is an alarming problem given the global re-emergence of deadly and infectious diseases. It is our responsibility to address the decline in childhood immunization and encourage parents to take preventative measures.

Sources:

http://abcnews.go.com/Health/parents-vaccinating-kids-study/story?id=41716915

http://www.freep.com/story/news/health/2016/08/24/michigan-worst-vaccination-rates-dtap/89256234/

http://www.mlive.com/news/ann-arbor/index.ssf/2014/08/washtenaw_county_vaccination_r.html

http://www.mlive.com/news/kalamazoo/index.ssf/2015/06/day-care_vaccination_rates_fal.html

Potential Solutions:

Describe three reasonable, feasible potential solutions or approaches that would help address this problem.

SOLUTION 1: Stricter school entry requirements

I propose that we tighten school entry requirements by administering less immunization waiver forms. In Figure 1 of the attached document, you will see the recommended immunization schedule for children and adolescents aged 18 years or younger. This immunization schedule was developed by the Centers for Disease Control and Prevention. I propose that students who fail to fulfill the CDC's immunization schedules, on time, will be denied access to the school of their choice. This is a step up from Michigan's previous rule in which parents had the opportunity to meet with a local health worker and sign a statement of acknowledgment that they understand they may be putting their own children and others at risk by refusing vaccination.

Recently, Michigan experienced a problem in which there were emerging areas where vaccine exemption rates were high. As a result, some areas were more prone to outbreaks of vaccine-preventable diseases. California experienced a similar problem. In order to combat this issue, California passed SB 277. Parents were told by doctors and schools that they would no longer be able to claim a "personal belief exemption" from immunizations if they wanted to enroll their children. This proved to be highly effective. Reports showed, "The percentage of fully vaccinated kindergartners entering the state's schools in 2015-2016 was the highest in a decade: 92.9% up from 90.4% last year. State health officials say the measles outbreak at Disneyland a year ago might have scared a few parents off the vaccination fence, but SB 277, combined with another bill from 2012 that required parents to talk to a pediatrician before obtaining an exemption, had more to do with it." The State of Michigan should strive to replicate a similar bill to that of California's SB 277. 

SOLUTION 2: Financial Incentives

I am proposing a solution similar to one that has proven to be widely successful throughout Australia. To start, I'd like to give you some background information. On January 1, 2016, Australia implemented a campaign known as, "No Jab, No Pay." The idea is that parents who refuse to vaccinate their children are at risk of losing up to $11,000 of welfare benefits per year until they comply with the law. The Australian Prime Minister, Tony Abbott, has noted, "The choice made by families not to immunize their children is not supported by public policy or medical research nor should such action be supported by taxpayers in the form of child care payments." This policy has helped to significantly boost the number of children who are receiving vaccines and staying up to date with them. 

I would like to implement a similar policy in Michigan known as, "Immunization or Declination." The law is simple. Those who choose to opt out of vaccinating their children will lose $1,000 of welfare benefits for each month that they do not comply. This will, ultimately, put individuals at risk of losing up to $12,000 per year. For those who are not as high up on the socioeconomic ladder, this represents a substantial loss in benefits. This provides a major financial incentive for parents, who would otherwise expect to receive taxpayer funded child care benefits. 

SOLUTION 3: Text reminders

Last semester I took Public Health 350. In this class, I learned about the top six reasons why people do not get vaccinated. At the top of this list was "Lack of information on when to have a vaccination." Therefore, I'd like to make a proposal that would effectively solve this issue and ultimately increase compliance among parents in the state of Michigan.

Rutgers University psychology professor Gretchen Chapman studies what pushes people to get seasonal flu vaccines. In her research, Chapman found that more individuals will accept a flu vaccination if they receive a message stating, "A flu shot appointment has already been scheduled." This is a far more effective approach than simply telling an individual how to schedule an appointment, especially if they are unaware of when they should be receiving vaccinations.

This logic appears to work with childhood immunizations as well. A 2013 study published in Pediatrics revealed, "...when parents were told that their child would receive a vaccine at their appointment instead of being asked which vaccines they wanted their kids to receive, more children ended up with their recommended shots." This is most likely because phrasing vaccine decisions as an explicit, decided course gives parents little wiggle room to refuse the vaccination. Finally, this approach eliminates a parent's question of whether or not a child should wait another few months to receive a particular vaccination. Text reminders ensure that parents no longer need to worry about having a lack of information on when to have a vaccination.

 

Reaction or advice from a Topic Coordinator:

You must solicit a critique from a topic coordinator, and explain the impact that advice has had on the final draft of this proposal.

I met with Allie Lisner to discuss my proposal. We spent time discussing my research and how it can be of use in crafting my solutions. Allie encourged me to place more attention on the state of Michigan's declining childhood immunization. Similar to Elijah's note below, Allie felt as though I was speaking of the issue too broadly and failed to incorporate statistics that are directly impacting Michigan's youth. I was very conscious of this feedback as I was completing the prospectus. I will continue to be aware of this as I work on the final draft of my proposal. 

Research process:

Describe your research process — indicate who you talked to (including but not limited to consultants), what you read, what your thinking was, how it changed over time, and how your consultants changed your thinking. This description of your research process definitely could include “dead ends,” or ideas you had that didn’t ultimately bear fruit.  In short, we want to know what you did and how it led to your legislation, and we also want you to give us a window into your thought process.

As I previously mentioned, my interest for the decline in child immunizations was first sparked in my public health class last semester. I was not sure if a proposal regarding vaccinations would be a feasible idea because I was not aware of where Michigan stood in regards to immunization rates. After doing some research, I quickly learned that Michigan ranked fourth worst in the country for its vaccination rates. I considered developing a proposal in which parents would have to meet with a health professional in order to learn about the risks of diseases and the benefits of vaccinations before obtaining a waiver. I later discovered that Michigan already has a system of immunization waivers in place. My plan, therefore, would not work. I had to think of a new idea.

From this point forward, I was very inclined to create a proposal in which the educational system would tighten school entry requirements. As you can see, I did not choose to develop this solution. This is because my research and consultations heavily persuaded me towards further developing my text message reminder system. I found this to be somewhat ironic considering I initially believed it to be my weakest solution of the three. Not only did I come to realize that the text message reminder was the most cost effective solution, but it was the most realistic as well. I came across a vast number of research studies in which it had become clear to me that a text messaging system has immense amounts of potential to be effective. One study, in particular, that helped to inform my thinking was done in Kadoma, Zimbabwe. This study demonstrated that immunization coverage in the intervention group was significantly higher than in the non-intervention group. This overall increase in immunization coverage was attributed directly to the use of short message service (SMS) reminders.

Ultimately, the more I thought about this solution, the more it grew on me. It was a combination of my consultations and research that led me to what is now the final product of my proposal.

Author contributions:

Please delineate--in detail--who made what contributions to the process and to the finished proposal? Who took on which responsibilities in researching ideas, drafting language, etc.?

I worked on my proposal alone. With that being said, I was responsible for researching ideas, drafting language, finding experts to consult with and developing the final piece. I am fortunate to have had the opportunity to speak with three incredibly insightful individuals regarding my topic. Without question, this helped to inform and challenge my thinking.
 

===FORMAL PROPOSAL===

The sections below should comprise your final proposal language, submitted for consideration by your peers and potential inclusion in the MSC Platform.

Preambulatory clauses

These set up the PROBLEM, but not the solution.

WHEREAS, Michigan ranks fourth worst in the country for its vaccination rates; and

WHEREASthree-quarters of children in licensed day cares in Michigan attend a center with vaccination rates below federal guidelines; and

WHEREAS, less than 72% of young children and 63% of Michigan adolescents are fully immunized; and

WHEREAS, more than 3 million people die from vaccine-preventable diseases each year and approximately 1.5 million of these deaths are in children less than 5 years old; and

WHEREAS, non-attendance for immunization appointments remains a challenge to healthcare providers around the world; and 

WHEREAS, a lack of information of when to get vaccinated is one of the top six reasons why people do not get vaccinated.

Operative clauses

These describe in detail, the solution you are proposing (not the problem itself; those should go in the "Whereas" clauses above).

1. THEREFORE, BE IT RESOLVED that the State of Michigan will promote childhood immunization through the implementation of text message reminders; and 

2. THEREFORE, BE IT RESOLVED that parents will no longer obtain information about immunizations for their child at a doctor's appointment or in mailings from their child's doctors office; and 

3. THEREFORE, BE IT RESOLVED that parents will not have to rely on memory cues based on their child's birthday or annual appointment, a common concern expressed by parents involved in a study conducted by the University of Kansas School of Medicine; and

4. THEREFORE, BE IT RESOLVED that Michigan hospitals will have an automated system that will be responsible for sending out 3 text message reminders over the course of 2 months; and

5. THEREFORE, BE IT RESOLVED that text message reminders will follow a strategy of priming, reminding and recalling, in which a text will be sent out exactly 1 month prior to the appointment, 1 day prior to the appointment and 1 week after the appointment. The greater the temporal proximity to the event, often times the more effective the intervention may be. It is important to strike a balance so patients have enough time to prepare as well; and

6. THEREFORE, BE IT RESOLVED that those who choose to opt out of vaccinating their children will lose $1,000 of welfare benefits for each month that they do not comply with the text message reminder system. This will, ultimately, put individuals at risk of losing up to $12,000 per year.

Counter-arguments:

What are three reasonable arguments against this proposal?

1. Text messages are typically limited to 160 characters. This limits the amount of information a physician may convey via SMS. While text message reminders have the ability to further inform parents and their understanding of childhood immunization, they are probably not the most appropriate method of addressing parental attitudes, knowledge and trust regarding vaccines. Mothers may benefit more from large, open discussions with health professionals regarding risks of diseases and benefits of vaccines during prenatal care.

2. In today's day in age, technological hackers are everywhere. Given this circumstance, people have a tendency to automatically delete text messages that come from strange, unknown numbers. I find myself doing this as well. It is incredibly alarming to receive a text message from a number that is not saved in my contact list. Additionally, some people may mistake a message from an unknown number as a phishing expedition. Individuals receiving informative text messages regarding their child's vaccine appointment may immediately delete the message without ever opening it. With that being said, it is difficult to combat this issue due to the fact that vaccine text reminders will likely be sent from an unwanted number. 

3. Text message reminders are becoming increasingly popular in different fields of health. It is very common for individuals to receive text messages in regards to their physical exams, mammograms and dental appointments. Therefore, one issue with this system is that in a world where the use of text messages is growing, how will immunization reminders compete with other forms of health messaging? This creates an even greater need for a unique immunization reminder system that carefully characterizes text messages to patients. These messages need to stick out in order for the system to be an effective intervention approach.

Costs and funding:

What will your proposal cost (in direct expenses, lost tax revenue, lost economic opportunity, and/or non-monetary costs)? How will you pay for your proposed legislation? Where will/could the funding for your proposal come from?  Who might object to dedicating resources to your proposal (competing interests)?  

I believe my proposal is very cost effective. The way I see it being carried out is that when a child is born into a hospital, parents will be charged a fee of $100. This money will be given to the child's primary physician in order to offset the cost of the series of future text messages. In exchange for this money, parents will receive text reminders regarding their child's immunization appointment until he/she is 18 years old. 

Since each physician will be compensated for his/her role in this program, I do not foresee anyone refuting this proposal. On the other hand, for families who may struggle financially, one might argue that this is too much money. To that individual, I would say that $100 is an extremely small cost for a life time of protection. If the down payment were to still pose a problem, parents could take the opportunity to discuss a payment plan where they pay this fee in monthly increments. 

Lastly, families who fail to comply with the text message reminder system will be at risk of losing $1,000 of welfare benefits each month. With this policy in place, parents can potentially lose up to $12,000 per year. This should serve as a significant financial incentive for parents to vaccinate their children. Ultimately, the choice not to immunize your child should not and will not be supported by taxpayers in the form of child care payments.

References:

These can include websites or other information you have found about the issue.

https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf

http://wate.com/2017/01/07/measles-making-comeback-as-parents-opt-out-of-vaccines/

http://www.mlive.com/health/index.ssf/2013/08/michigan_has_high_rate_of_pare.html

http://www.chop.edu/centers-programs/vaccine-education-center/global-immunization/diseases-and-vaccines-world-view

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