Which bridge would you cross?
Scenario 1: You and a friend are walking in the woods, and you come to two bridges. The one further up the path looks newer and sturdier than the closer bridge. Would you cross the closer bridge or walk a bit further and use the bridge that looks sturdier?
Scenario 2: Another day, you and that friend are walking in the woods, but as you approach the two bridges, you see a mighty large brown bear heading in your direction. The only thing between you and the bear are the two bridges. Would you cross the closer bridge or try to make it to the sturdy bridge even though it means heading closer to the bear?
Chances are in scenario 1, you answered that you would walk a bit further to the more sturdy-looking bridge, but in scenario 2, you answered that you would cross the closer bridge.
This short exercise, based on Macpherson (2008), demonstrates the difference between the concepts of safety and risk. In both scenarios, each bridge was similarly safe (or unsafe as it might be). However, your assessment of safety was evaluated through a lens of risk. In scenario 1, crossing the closer bridge felt like the riskier choice, but in scenario 2, crossing the closer bridge felt like the safer choice.
The same divergence between safety and risk has been seen when it comes to vaccines. In 1998, Andrew Wakefield published his now infamous MMR-autism hypothesis. Very quickly, numerous studies were completed to evaluate his idea; none of them found evidence to support it. By 2004, the Wakefield study was retracted based on a variety of scientific and ethical factors. However, many parents still felt that there may be something to Wakefield’s claims, so some continued to opt out of the MMR vaccine for their children. But, when a measles outbreak started in Disneyland in late 2014 and spread to seven states and two countries, media coverage was widespread. In national surveys, awareness of the outbreak was between 53%-80%, and studies looking for a “Disneyland effect” demonstrated a move toward vaccination. Similar findings have been found locally in areas of vaccine-preventable disease outbreaks, and anecdotal reports from Texas during the 2025 measles outbreak have also suggested increased vaccine acceptance by some who previously opted out. As with the bridge anecdote, the safety of MMR vaccine did not change before and after the Disneyland or other outbreaks; rather, the sense of risk associated with receipt of the vaccine changed.
What these examples demonstrate is that whereas safety is what we measure, risk is how someone feels about those safety measurements. In this way, risk is both relative and subjective. It can change over time and by situation, and it will differ between individuals.
When it comes to vaccine decisions, a family’s risk assessment will be informed by both their sense of risk related to the vaccine and the disease it protects against — leading to the irony of the situation in which we find ourselves. Since vaccines have successfully decreased the prevalence of the diseases they prevent, many people assign a low risk to disease. First, they don’t “see” these diseases, so they can’t foresee a reality in which the disease would affect someone in their family. Second, they aren’t familiar with the potential damage the disease can cause. As such, many families view the choice as that of receiving a vaccine or not receiving a vaccine rather than receiving a vaccine or remaining unprotected against a disease.
This sense of low disease risk is complicated by an information environment rife with vaccine safety conversations. Inaccurate or disproportionate risks of vaccines are regularly heard and seen, particularly on social media, and more recently, in federal messaging. Anecdotes of presumed (or “medically dismissed”) vaccine injuries are easy to find, making it likely that more people have heard of someone who believes they or a family member was injured by a vaccine than having heard of someone injured by the disease it prevents.
The net effect of this skewed sense of risk and the current information environment leaves many families viewing vaccines, rather than the diseases they prevent, as the risk. As Thompson (1999) explained “when a particular activity or course of action is classified as ‘risky’ it is moved into the deliberative realm and singled out for scrutiny.” (p. 498) This means that when vaccine decisions arise, families are more carefully scrutinizing vaccines. This additional scrutiny results in a greater need for information, more questions, and sometimes delays in making a decision at all.
So, what does this mean clinically?
Because healthcare providers continue to be trusted sources of information when it comes to making health-related decisions, vaccine conversations are increasingly common at the point of care. From a clinical perspective, this means figuring out ways to meet patient needs within the constraints of practicing medicine in the current U.S. healthcare system. Some opportunities and suggestions are described below. If you have found ideas that work, we’d love for you to submit them, so we can share them as well.
Provider framing
As providers, expecting questions during all vaccine appointments and viewing parents with questions as doing their “due diligence” in assessing vaccine risks rather than labeling them as “vaccine hesitant” can change the dynamic of these conversations. Parents today are trying to make informed vaccine decisions in an environment in which hypothetical vaccine risks are overshadowing real disease risks and in which they are more likely than not to be seeing and hearing inaccurate information. If we continue to label people with vaccine questions as “hesitant,” we may be arbitrarily leaning into implicit biases that negatively impact these interactions rather than coming across as partners working together to keep their child healthy in a tough information environment. This framing can reduce provider stress because it changes expectations heading into each interaction, and it can improve patient satisfaction because families feel heard and validated rather than dismissed. According to the 2025 Edelman Trust Barometer findings, the number one thing cited by people who reported listening to uncredentialed health voices (i.e., those without a medical degree) was that those individuals displayed empathy that their healthcare provider did not.
Practice environment
Altering processes to have a more consistent and supportive practice-based environment can include:
- Providing a short list of vetted information sources to reinforce the point that your team evaluates vaccine information as well as to help families find answers from reliable sources when they are looking. This can be posted on your website or patient portal, handed out or added to new patient packets, or displayed in waiting or exam rooms.
- Establishing opportunities for vaccine conversations that work within the constraints of appointment times and limited staff availability, such as having vaccine-specific office hours; hosting or providing access to special events, such as webinars, panels or guest speakers; providing a library of information or resources to help in addressing the common questions that arise from your patient population; and ensuring that staff have opportunities to improve their own understanding of vaccine information.
Individual needs
As described in part 1 of this series, people have pre-existing attitude structures, and how they receive messages depends on how those messages fit into that structure. These individual attitude structures also explain why risk is subjective — people with differing attitudes and beliefs will assess safety data through different risk lenses. At the point of care, this means understanding the person’s concerns and addressing those specifically. For example, side effects, vaccine ingredients, and too many vaccines are all examples of vaccine safety concerns, but each requires sharing different information to respond to the concern. Importantly, you don’t have to be prepared to answer every possible question about vaccine safety on the spot, but rather once you determine the person’s informational needs, you can connect them to resources where you know they will find the answers or offer to get back to them once you get the information they need. Not only will this aide in their informational needs, but it can increase the strength of your partnership in caring for their child.
If a parent continues refusing to vaccinate, realize this still comes back to their risk assessment. As described earlier, risk assessments can change based on situations and new information. As such, continue discussing vaccines at each visit. However, in the meantime, your goal, like theirs, continues to be protecting their child. So, while their child remains unvaccinated, you want to share some strategies that they should consider implementing. This includes things like monitoring local disease outbreaks; ensuring that if their child needs to go to the emergency department, the medical team is immediately made aware of the child’s unvaccinated status because they will need to assess the child using different protocols; alerting them to any special office practices you have in place when an unvaccinated patient is coming for a sick visit; etc. The VEC offers a useful sheet that you can share with families in this situation, called Vaccinated or unvaccinated: What you should know (also in Spanish). During subsequent visits, when discussing vaccines, also check in with how these activities are going and whether they have questions. It is important that as vaccine-preventable diseases continue to become more widespread, families with susceptible children are prepared to protect them as much as possible, particularly if they continue to opt out of vaccinations.
References
Machperson JA. Safety, risk acceptability, and morality. 2008. Sci Eng Ethics. 14:377-390.
Doll MK and Correira JW. Revisiting the 2014-15 Disneyland measles outbreak and its influence on pediatric vaccinations. 2021. Hum Vaccin Immunother. 17(11):4210–4215.
Thompson, PB. The Ethics of Truth-Telling and the Problem of Risk. 1999. Sci Eng Ethics. 5(4):489-510.
Edelman Trust Institute. 2025 Edelman Trust Barometer Special Report Trust and Health. 2025.
Contributed by: Lori Handy, MD, MSCE , Charlotte A. Moser, MS
Which bridge would you cross?
Scenario 1: You and a friend are walking in the woods, and you come to two bridges. The one further up the path looks newer and sturdier than the closer bridge. Would you cross the closer bridge or walk a bit further and use the bridge that looks sturdier?
Scenario 2: Another day, you and that friend are walking in the woods, but as you approach the two bridges, you see a mighty large brown bear heading in your direction. The only thing between you and the bear are the two bridges. Would you cross the closer bridge or try to make it to the sturdy bridge even though it means heading closer to the bear?
Chances are in scenario 1, you answered that you would walk a bit further to the more sturdy-looking bridge, but in scenario 2, you answered that you would cross the closer bridge.
This short exercise, based on Macpherson (2008), demonstrates the difference between the concepts of safety and risk. In both scenarios, each bridge was similarly safe (or unsafe as it might be). However, your assessment of safety was evaluated through a lens of risk. In scenario 1, crossing the closer bridge felt like the riskier choice, but in scenario 2, crossing the closer bridge felt like the safer choice.
The same divergence between safety and risk has been seen when it comes to vaccines. In 1998, Andrew Wakefield published his now infamous MMR-autism hypothesis. Very quickly, numerous studies were completed to evaluate his idea; none of them found evidence to support it. By 2004, the Wakefield study was retracted based on a variety of scientific and ethical factors. However, many parents still felt that there may be something to Wakefield’s claims, so some continued to opt out of the MMR vaccine for their children. But, when a measles outbreak started in Disneyland in late 2014 and spread to seven states and two countries, media coverage was widespread. In national surveys, awareness of the outbreak was between 53%-80%, and studies looking for a “Disneyland effect” demonstrated a move toward vaccination. Similar findings have been found locally in areas of vaccine-preventable disease outbreaks, and anecdotal reports from Texas during the 2025 measles outbreak have also suggested increased vaccine acceptance by some who previously opted out. As with the bridge anecdote, the safety of MMR vaccine did not change before and after the Disneyland or other outbreaks; rather, the sense of risk associated with receipt of the vaccine changed.
What these examples demonstrate is that whereas safety is what we measure, risk is how someone feels about those safety measurements. In this way, risk is both relative and subjective. It can change over time and by situation, and it will differ between individuals.
When it comes to vaccine decisions, a family’s risk assessment will be informed by both their sense of risk related to the vaccine and the disease it protects against — leading to the irony of the situation in which we find ourselves. Since vaccines have successfully decreased the prevalence of the diseases they prevent, many people assign a low risk to disease. First, they don’t “see” these diseases, so they can’t foresee a reality in which the disease would affect someone in their family. Second, they aren’t familiar with the potential damage the disease can cause. As such, many families view the choice as that of receiving a vaccine or not receiving a vaccine rather than receiving a vaccine or remaining unprotected against a disease.
This sense of low disease risk is complicated by an information environment rife with vaccine safety conversations. Inaccurate or disproportionate risks of vaccines are regularly heard and seen, particularly on social media, and more recently, in federal messaging. Anecdotes of presumed (or “medically dismissed”) vaccine injuries are easy to find, making it likely that more people have heard of someone who believes they or a family member was injured by a vaccine than having heard of someone injured by the disease it prevents.
The net effect of this skewed sense of risk and the current information environment leaves many families viewing vaccines, rather than the diseases they prevent, as the risk. As Thompson (1999) explained “when a particular activity or course of action is classified as ‘risky’ it is moved into the deliberative realm and singled out for scrutiny.” (p. 498) This means that when vaccine decisions arise, families are more carefully scrutinizing vaccines. This additional scrutiny results in a greater need for information, more questions, and sometimes delays in making a decision at all.
So, what does this mean clinically?
Because healthcare providers continue to be trusted sources of information when it comes to making health-related decisions, vaccine conversations are increasingly common at the point of care. From a clinical perspective, this means figuring out ways to meet patient needs within the constraints of practicing medicine in the current U.S. healthcare system. Some opportunities and suggestions are described below. If you have found ideas that work, we’d love for you to submit them, so we can share them as well.
Provider framing
As providers, expecting questions during all vaccine appointments and viewing parents with questions as doing their “due diligence” in assessing vaccine risks rather than labeling them as “vaccine hesitant” can change the dynamic of these conversations. Parents today are trying to make informed vaccine decisions in an environment in which hypothetical vaccine risks are overshadowing real disease risks and in which they are more likely than not to be seeing and hearing inaccurate information. If we continue to label people with vaccine questions as “hesitant,” we may be arbitrarily leaning into implicit biases that negatively impact these interactions rather than coming across as partners working together to keep their child healthy in a tough information environment. This framing can reduce provider stress because it changes expectations heading into each interaction, and it can improve patient satisfaction because families feel heard and validated rather than dismissed. According to the 2025 Edelman Trust Barometer findings, the number one thing cited by people who reported listening to uncredentialed health voices (i.e., those without a medical degree) was that those individuals displayed empathy that their healthcare provider did not.
Practice environment
Altering processes to have a more consistent and supportive practice-based environment can include:
- Providing a short list of vetted information sources to reinforce the point that your team evaluates vaccine information as well as to help families find answers from reliable sources when they are looking. This can be posted on your website or patient portal, handed out or added to new patient packets, or displayed in waiting or exam rooms.
- Establishing opportunities for vaccine conversations that work within the constraints of appointment times and limited staff availability, such as having vaccine-specific office hours; hosting or providing access to special events, such as webinars, panels or guest speakers; providing a library of information or resources to help in addressing the common questions that arise from your patient population; and ensuring that staff have opportunities to improve their own understanding of vaccine information.
Individual needs
As described in part 1 of this series, people have pre-existing attitude structures, and how they receive messages depends on how those messages fit into that structure. These individual attitude structures also explain why risk is subjective — people with differing attitudes and beliefs will assess safety data through different risk lenses. At the point of care, this means understanding the person’s concerns and addressing those specifically. For example, side effects, vaccine ingredients, and too many vaccines are all examples of vaccine safety concerns, but each requires sharing different information to respond to the concern. Importantly, you don’t have to be prepared to answer every possible question about vaccine safety on the spot, but rather once you determine the person’s informational needs, you can connect them to resources where you know they will find the answers or offer to get back to them once you get the information they need. Not only will this aide in their informational needs, but it can increase the strength of your partnership in caring for their child.
If a parent continues refusing to vaccinate, realize this still comes back to their risk assessment. As described earlier, risk assessments can change based on situations and new information. As such, continue discussing vaccines at each visit. However, in the meantime, your goal, like theirs, continues to be protecting their child. So, while their child remains unvaccinated, you want to share some strategies that they should consider implementing. This includes things like monitoring local disease outbreaks; ensuring that if their child needs to go to the emergency department, the medical team is immediately made aware of the child’s unvaccinated status because they will need to assess the child using different protocols; alerting them to any special office practices you have in place when an unvaccinated patient is coming for a sick visit; etc. The VEC offers a useful sheet that you can share with families in this situation, called Vaccinated or unvaccinated: What you should know (also in Spanish). During subsequent visits, when discussing vaccines, also check in with how these activities are going and whether they have questions. It is important that as vaccine-preventable diseases continue to become more widespread, families with susceptible children are prepared to protect them as much as possible, particularly if they continue to opt out of vaccinations.
References
Machperson JA. Safety, risk acceptability, and morality. 2008. Sci Eng Ethics. 14:377-390.
Doll MK and Correira JW. Revisiting the 2014-15 Disneyland measles outbreak and its influence on pediatric vaccinations. 2021. Hum Vaccin Immunother. 17(11):4210–4215.
Thompson, PB. The Ethics of Truth-Telling and the Problem of Risk. 1999. Sci Eng Ethics. 5(4):489-510.
Edelman Trust Institute. 2025 Edelman Trust Barometer Special Report Trust and Health. 2025.
Contributed by: Lori Handy, MD, MSCE , Charlotte A. Moser, MS