In April 2017, a measles outbreak occurred in Minneapolis, Minnesota. The outbreak ended in August 2017 with 79 confirmed cases, 65 of these cases were children of Somali descent. This outbreak was the result of a slow decline in MMR vaccination in the Somali community due to vaccine hesitancy, fears that the MMR vaccine causes autism, and specific targeting of the community by anti-vaccine activists.
Understanding what has led the Somali community to be wary of the MMR vaccine is critical to knowing how to approach the conversation in the clinic setting. In 2004, Minnesota Department of Health reported that 92% of Somali American children were vaccinated with MMR. Since that time, the rate of vaccination has fallen 5-7% per year. In 2014, only 45% of Somali American children were vaccinated with MMR in Minnesota. This decline was due to one concern: autism.
Concerns about autism arose in the Somali community in Minnesota when, in 2008, parents noticed that there was a disproportionate number of Somali preschoolers who were receiving special education services for autism. Since there is no single word for autism in the Somali language, the community was concerned about this “new” condition. Autism is often described by the symptoms that children exhibit. Around the same time, Andrew Wakefield, discredited medical researcher whose fraudulent paper linked MMR vaccine and autism (Wakefield, 1998) (Rao, 2011), visited Minnesota and anti-vaccine groups targeted the Somali community’s new concerns and fears by spreading misinformation about the link between MMR and autism.
An autism prevalence project was done in 2013 by the University of Minnesota’s Institute on Community Integration. This project estimated that 1 in 32 Somali children ages 7-9 where identified as having autism spectrum disorder (ASD). Although this prevalence was the same in White children in Minnesota, this rate was higher than the Black and Hispanic populations there. Additionally, the project found that Somali children with ASD were more likely to have intellectual disability when compared to other groups. Alarm bells went off in the community. Soon, given the Somali community’s close ties and oral communications, concerns about autism and MMR vaccine spread rapidly nationwide.
Knowing this background is fundamental in facilitating a conversation about the MMR vaccine, particularly in vaccine hesitant parents. Although techniques regarding how to discuss vaccines with vaccine hesitant parents as described in the literature remain relevant, there are additional considerations in the Somali community. Both of these approaches are included in the following recommendations regarding how to approach this conversation:
- Focus on the disease: When discussing vaccines, meeting misconceptions with facts can lead to backfire described in the literature as the “boomerang effect”. Experts recommend that instead of directly correcting a wrong statement, change the conversation to the disease itself. Perceived seriousness of the disease being discussed has been shown to be a stronger predictor of vaccinating than the probability of getting sick. The perception of disease severity relies on the symptoms presented by the physician.
- Keep “myth busting” concise: There are times when directly addressing the myth surrounding a vaccine is inevitable. In these instances, keep it short and mention only key facts. Too many facts will be overwhelming. Do not forget to directly mention why the myth is wrong.
- Don’t shy away from the discussion: The Somali community looks to physicians and medical providers as authority. They trust the advice of their providers, especially those with whom they have built a relationship. Given this dynamic, the community places a significance on how physicians address certain topics. When the topic of vaccines come up, the way that this is approached sets the stage for how the family perceives the importance of the vaccine. For example, if a parent states that they do not want a vaccine and this is met with little resistance or discussion from the provider, patients will assume that the vaccine is not very important since the physician, a person who is seen as an authority figure, did not strongly disagree with or discuss the decision being made. In these instances, state your position firmly and with confidence. Although shared decision making is important, having a soft stance on vaccines only hurts your message.
- Don’t make the issue a contentious one: Parents will avoid having conversations that they believe upset the physician. Trust can be eroded if the parents feel that the physician only wants to change their minds or they become concerned that the physician is being paid to promote vaccines. Focus on what is important to both you and the parent: the health and well-being of the child. Agree to discuss further at the next visit or another time.
- Address the elephant in the room: Whether parents in the Somali community freely bring up this topic or shy away from it, autism is the elephant in the room when MMR is being discussed. Be ready to discuss this issue. When autism comes up, do not say “we don’t know what causes autism”; this leaves vaccines as an easy target. Instead mention what we have learned through research. Statements such as “Vaccines do not cause autism. So far, we have learned that certain exposures during pregnancy have been linked to autism …” clearly shows that this topic is being studied and reinforces that fact that vaccines have not been linked to autism.
- Focus on an education campaign not a vaccination campaign: The focus of any conversation about vaccines should be educating the parents so that they can make an informed decision about vaccinating their child. Although we encourage physicians to make strong statements in support of vaccines, an attack on the parents’ point of view can have negative consequences including reinforcing their beliefs. Parents have voiced concerns that physicians who are not open to conversations about vaccines are running a strict vaccine campaign and wonder if they have ulterior motives. In a community where messages are spread rapidly through oral tradition a few negative interactions can have a rippling effect.
Rao, T. S. S., & Andrade, C. (2011). The MMR vaccine and autism: Sensation, refutation, retraction, and fraud. Indian Journal of Psychiatry, 53(2), 95–96. http://doi.org/10.4103/0019-5545.82529
Wakefield, A. (1998). RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. The Lancet., 351(9103), 637-641.
Measles facts in Somali: Factsheet in Somali language from Public Health-Seattle & King County
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