Challenging Dogma - Spring 2011

Saturday, May 14, 2011

A Critique of the City of Boston Public Health Commission Current Intervention on Promoting the Community to Receive Flu Vaccines and a Proposed . . .

. . . New Intervention – Amira Mithavayani


Each year, there is a new strain of influenza (the flu) that seems to sweep the United States and the world. Unlike other viruses, the vaccine must be changed according to the strain. Possible symptoms of the flu include fever, cough, nasal congestion, body aches, fatigue, headache, irritated eyes, diarrhea and abdominal pain. In order to protect the population from the harmful effects of the flu, it is recommended, that each year, everyone get the flu vaccine. This can be obtained at a doctor’s office or a health clinic. Many times, communities provide the flu vaccine for reduced or no cost to the public in order to everyone to stay healthy and not spread the virus. There have been many interventions created to motivate people to get the flu vaccine in order to protect themselves and those around them from contracting the flu. This paper will critique an existing public health intervention being used to address flu vaccines and will propose an alternative intervention based off of social and behavioral science principles, theory, and research (1).

Current Intervention

An intervention that was presented in 2009 to promote the community to receive their flu vaccine was a public service announcement by the City of Boston’s Public Health Commission. The 30 second video consisted of Dr. Nancy Norman, Medical Director of the Boston Public Health Commission, and another member that is unspecified but assumed to be a part of the Boston Public Health Commission as well. They told viewers why to get the flu vaccine and ways of preventing spreading germs. There were videos of nurses giving vaccines and they said, “The flu vaccine is the most important thing you can do this year” (2).

Critique Argument 1

The first flaw noticed in the public service announcement to promote flu vaccines was the improper use of the Health Belief Model (HBM). The HBM was created in the 1950s by three social psychologists, Godfrey Hochbaum, Irwin Rosenstock and Stephen Kegels that worked for the U.S. Public Health Service. It is an individual health behavior theory since it is used to explain the decision making of one person. The HBM believes that behavior is an outcome of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. Perceived susceptibility can be described as how likely one feels they will acquire a health problem. Perceived severity is how severe one feels the health behavior will be to them self. Perceived benefits are how good the results will be from choosing this health behavior. Perceived barriers are any ‘road blocks’ one feels that would prevent them from adopting the health behavior. Cues to action are outside events that act as a trigger in pushing someone toward the health behavior. Self efficacy is one’s confidence in going through with the health action (3).

Though this model is often times use in public health, it may be flawed. There are several assumptions the HBM makes which include health related behaviors are predictable on an individual level based on European values, learning occurs once the goals are met, and one gains knowledge once the behavior is changed (4). The HBM thus adds to restricted understand and reduction of value of individuals since it emphasizes how much knowledge one has predicts whether they’ll adopt a behavior. The acceptable understanding and knowledge one has is different person to person depending on sex, class, race, as well as many other factors. The HBM pools everyone into one category and seems to expect each person will think like every other individual, which is not the case.

Also, working on the individual level, the HBM does not take into consideration social and environmental factors (3). These can include where you live, where you obtain your knowledge that guides your decisions, your family values, how much support you have from people that influence you, or even access your community provides in adopting a health behavior.

In the public service announcement promoting flu vaccines, they emphasized on the individual level, the severity of the flu and that one is very likely to obtain the flu if they do not receive a vaccine. They also gave contact information for a clinic to lower barriers one may have in getting a flu vaccine. The intervention assumed that everyone watching the video would see the benefits and use this as a cue to action in going out and getting a flu vaccine. It did not take into account the other factors that could lower the likelihood of someone being able to receive a vaccine.

Critique Argument 2

The next flaws that were noticed in the public service announcement were the use of the Precaution Adoption Process Model and Basic Communication Theory. The Precaution Adoption Model (PAPM), another individual level theory, was developed by Weinstein and Sandman to help understand one’s willingness or unwillingness to engage in a behavior. The stages of the PAPM are as follows: Stage One: Unaware of the Issue. This stage declares that if someone is not knowledgeable or aware of an issue, how can they change or adopt a health behavior. Next is Stage Two: Unengaged by the Issue. This stage describes a person who is aware of the issue but is not engaged enough to take action. Stage Three: Deciding About Acting says that a person is knowledgeable and engaged in a health behavior and they begin to make a decision on whether they plan on doing something about it. Stage Four: Deciding Not to Act, is a person’s decision not to do anything about the issue and this ends their involvement in the PAPM. Stage Five: Deciding To Act, one decides to do something but they have not taken action yet. Stage Six: Acting, is one pursuing their decision to take action. Stage Seven: Maintenance; this refers to continuing to go through with the behavior (3).

A major flaw in the Precaution Adoption Process Model is that the proposed stages must occur in order (3). This may not always be the case in life. Many times, people act on a behavior without knowing very much about it.

The Precaution Adoption Process Model is seen in the public service announcement through educating the viewers of the negative effects of getting the flu and telling each person to go out and get a flu shot in order to prevent “feeling awful.” If one was to follow the PAPM, they would get a better understanding of why they should stay healthy and to get a flu shot, decide to act on it, go out and get the flu shot and this would maintain their current good health. Unfortunately, not everyone thinks in this order and implementing this behavior theory in this flu vaccine intervention may not work.

Another flaw in the public service announcement is the use of the Basic Communication Theory. Basic Communication Theory deals with principles and methods by which information is conveyed. The most important factor in this theory is who is making the request. This takes into consideration aspects about the messenger such as the degree one likes the person delivering the message, if they are attractive, believable, authoritative, etc. In addition, with the delivery of the message, the amount one feels familiar with the messenger and if any associations are exposed during communication. For example, if someone is conveying a message to you while they are feeding you, food enhances learning, or if you are listening to music that can enhance an association.

The two main messengers in the public service announcement are a professional woman that appears to be in her 50s or 60s and a man that appears to be in power at the Boston Public Health Commission in the same age bracket. It does not seem likely that the majority of the viewers that are watching this intervention can relate to them because of their age, how they dress, how persuasive they are in having someone going out to get a flu vaccine, and how believable they are that not getting the flu vaccine will be detrimental to their own health. Based on the Basic Communication Theory, this intervention is very flawed.

Critique Argument 3

Additional flaws in the intervention to promote the community to get their flu vaccine are seen in Social (or observational) Learning Theory and Psychological Reactance Theory. Social Learning Theory was formulated by psychologist Albert Bandura and his associates in the 1960s. This theory explains how individuals observe other people’s actions and how they acquire new forms of behavior. Many times, people mimic social life seen in the media. For example, cigarette advertisements in magazines, or pharmaceutical advertisements on television. Based on the Social Learning Theory, if a person imitates a behavior and is successful in coping with a certain issue they may have, they are likely to do it again (5).

In the public service announcement, nurses are seen administering the flu vaccine to those who wanted to prevent getting the flu. Based on Social Learning Theory, people who view this should imitate the behavior. The major flaw that may arise from this theory in explaining this intervention is how they are presenting getting the flu vaccine. If one is to view the needles and the atmosphere the vaccine is given, and is either scared of needles or the environment, they are less likely to get the vaccine no matter how many times they view this campaign.

Adding on is the Psychological Reactance Theory. Psychological reactance is a response to one’s freedoms being threatened. Influencing an individual’s behavior seems to be most effective when it is not threatening these freedoms. This can also be viewed as reverse psychology. The single best way of avoiding reactance is through similarity. This is when the communicator is similar to the recipient. This can be through age, sex, college attended, hometown, cultural background, etc. When a communicator’s similarity to the audience is established, this enhances their integrity and the recipient is more likely to go through with and believe something the communicator tells them (6).

By Dr. Nancy Norman and the other speaker in the intervention telling the viewers to get their flu shot follows the psychological reactance theory since they are threatening viewers’ freedom to choose and make a decision on whether getting a flu shot is the appropriate thing for them to do in order not to get sick. Based on this theory, threats to freedom lower compliance so people would be less likely to get a flu vaccine (6). They seem to actually be conveying the opposite message than what is intended. The communicators do not seem similar to the recipients that will view this intervention and that may not generate the response that they are intending to receive. This is yet another reason why the current intervention that is supposed to convince the community to get their flu vaccine is flawed.

Proposed Intervention

In order to counteract the flaws found in the current flu vaccine intervention, a new intervention has been created that encompasses alternate social and behavior science theories. These theories seem to be more appropriate in motivating the community to get their flu vaccine and will be discussed below.

The proposed intervention that would be presented as an advertisement on television would consist of a dad, mom, grandparents, and two kids in the park on a sunny fall afternoon. They would be playing, having fun, laughing and enjoying each others’ company. The dad would step to the side and tell the viewers how he loves his children and loves spending time with them; he would never want anything to threaten the safety of his family. In order to protect his children and to protect him and his wife, the entire family went to get a flu vaccine. Then, the dad would go back to playing with his kids in the park. The intervention can be replicated with different races and cultures and have it aired on television channels that are targeted toward certain ethnicities.

Addressing the Critiqued Intervention

In order to prove to be an improved intervention, criteria will be given on how a different approach was taken to avoid the flaws of the critiqued intervention. First, in addressing the critique 1 above, this intervention did not utilize the Health Belief Model. Instead of focusing on educating one person on the benefits and risks of getting the flu vaccine, it works as a group level model. Next in critique 2, with the Precaution Adoption Process Model and Basic Communication Theory the intervention does not expect the audience to follow a set amount of stages to determine willingness or unwillingness to go through with the behavior of obtaining a flu vaccine. Also, the person conveying the message is more likely to be received well by the target audience – families. In critique 3 with both the Social (or observational) Learning Theory and Psychological Reactance Theory, the proposed intervention does address them by providing an atmosphere families can relate to and would want to be a part of (being together as a family in the park), and the intervention does not tell the audience to go out and get the flu vaccine. Instead, it shows a happy lifestyle and by getting a flu vaccine, this can be a achieved.

Defense of Intervention Section 1

The first two theories that will be used to support the alternate intervention proposed is Advertising Theory and Social Marketing Theory. Advertising Theory is a group level model that does not sell a product; instead it sells the core values of advertising. It is made up of three aspects – promise, support and core values. Making a large promise of what this product or action can do for people is the soul of an advertisement. The more that is offered in the promise, the stronger and more effective it is. Some examples of promise are a sense of belonging, freedom, sex, youth, rebelliousness, control, autonomy, justice, individualism, work ethic, power, love or acceptance. Support is needed to back up the promise and there must be evidence provided that the promise is true. Support can be provided through imagery, symbols, music, etc. Core values represent universal appeals. These surround the promise and support. Effective advertisements do not tell you what to do instead they show you something you can become a part of.

Social Marketing Theory uses marketing techniques that bring about beneficial social changes in the community. It can create acceptance, rejection, modification, abandonment, or maintenance of certain health behaviors by the target audience (7). Social marketing can be similar to other behavior change theory but its integration of exchange theory, audience segmentation, competition, marketing mix, consumer orientation and continuous monitoring set it apart. Exchange theory aims to influence behavior change by offering an incentive for adopting the behavior. The incentive does not have to be immediate such as a product or service; instead it can be over time and should be something the consumer will value. Audience segmentation divides populations based on values, behaviors, age groups, etc., and targets the behavior change based on the specific group. Competition is constantly happening in marketing when companies are trying to satisfy similar wants or needs with their product to the same group. Marketing mix refers to the four P’s: product, price, place and promotion. Product is the advantage of adopting the behavior. Price is what must be given up or done in order to receive the promised benefits. Place is where the audience can perform the desired behavior. Promotion includes the marketing techniques used to influence an adoption of the behavior. It is essential for a marketing strategy to combine these elements in order for it to be successful. Consumer orientation includes being aware of the audience. By researching who they are, a product or desired behavior can be properly geared toward their lifestyle. Lastly, continuous monitoring evaluates the effectiveness of the intervention in regards to its main consumer group (7).

The alternate intervention that has been proposed to influence more people to receive their flu vaccines uses both Advertising Theory and Social Marketing Theory. Advertising Theory is clearly seen in the intervention with promise, support and core values. The intervention promises that the families that get their flu vaccine will be happy and healthy. This is supported with imagery of the family having fun and playing together. The core values being targeted are family values. Social Marketing Theory is implemented in the intervention as well. The exchange value of receiving a flu shot is being happy and staying healthy during flu season. The audience segmentation is focused mainly on families and children since young children and the elderly are most vulnerable for the flu; along with the immuno-suppressed. The competition would be with other interventions presented to lower the likelihood of contracting the flu such as campaigns that emphasize hang washing, covering of the nose and mouth when sneezing, and not sharing drinking cups. In marketing mix, the product would be keeping good health, the price would be getting a flu vaccine, the place would be a doctor’s office or a health clinic, and promotion would be the television advertisement. Consumer orientation is done by researching families and what it is that they value most. Once that is identified, the behavior would be targeted toward not jeopardizing their family’s health and safety. Continuous monitoring will be done by first showing the intervention to smaller audiences and testing the effectiveness of the marketing strategy. If it works then it can be showcased to a broader audience on television, at health conferences or at jobs.

Defense of Intervention Section 2

The next theory that will be used to support the alternate intervention proposed is Optimistic Bias Theory. Optimistic Bias Theory, proposed by Neil D. Weinstein, suggests that people overestimate positive events are more likely to happen to them and underestimate negative events are less likely to happen to them in relation to their peers (8).

With all the flu facts being presented in the classroom, on the news, in magazines and in flu campaigns, it seems that most people know the risks (which are outweighed by the benefits) associated with not getting a flu vaccine. This intervention targets families’ optimistic bias by demonstrating if an entire family goes out and gets a flu shot, they are guaranteed to be safe and not contract the flu virus. One might not think, this can happen to their family but the intervention will use families of all different ethnic backgrounds which can increase the perception of getting the flu.

Defense of Intervention Section 3

The final theory that is used to support the flu vaccine intervention is the Social Network Theory. This theory is based off the idea that behavior is spread through social networks; such as family and friends (9). For example, according to the Social Network Theory, when living in a college dormitory, your roommate’s grade point average will have a large impact on your own grade point average. This can be due to adopting similar study habits from being in such close quarters to one another.

In relation to promoting families to get their flu vaccine, the Social Network Theory can be very helpful. As with smoking cessation and the spread of obesity, the increased number of people getting the flu vaccine can be attributed to this theory, as well. Once this intervention is aired, families will go out and get the flu vaccine together. As more families get the flu vaccine, other close families may go and get the vaccine. Then, people associated with these families are more likely to get the flu vaccine when they hear of someone they know is protected from the flu and believe in the effectiveness of the vaccine. As more and more networks start getting the flu vaccine, this will lead to a decrease in the spread of the influenza virus for that particular season. As each new flu season comes, this intervention might be required to be adapted depending the target audience.


In summary, the Boston Health Commission’s current flu public service announcement that aims to influence the community to get the flu vaccine is seems to be flawed. This is due to the improper use of the Health Belief Model, Basic Communication Theory, Precaution Adoption Process Model, Social Expectations Theory and Psychological Reactance Theory. By identifying the main areas that have contributed to this, it was possible to create an alternate intervention that targeted the safety and happiness of families in order to increase groups of people to get their flu vaccine. The combined benefits of the Social Marketing Theory, Advertising Theory, Optimistic Bias Theory and Social Network Theory, has lead to the support of an improved and effective intervention. This intervention will increase the participation in the public and cause them to be proactive in getting their flu vaccine. The overall goal, which will always be in clear sight, is to lower the incidence of flu virus and keep the community healthy.


1. Kaiser, Jocelyn. A One-Size-Fits-All Flu Vaccine? Science Magazine 2006; 312(5772):30-32.

2. Flu Shot PSA 2009. Video Library. Boston, MA: Boston Public Health Commission.

3. Edberg, Mark. Individual Health Behavior Theories (pp. 35-49). In Edberg M, ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

4. Thomas, Linda W. A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education. Journal of Professional Nursing 1995; 11(4):236-252.

5. DeFleur, Melvin L. & Sandra L. Ball-Bokeach. Socialization and Theories of Indirect Influence (pp. 202-227). In DeFleur M, ed. Theories of Mass Communication: Fifth Edition. White Plains, NY: Longman Inc, 1989.

6. Silvia, Paul J. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005; 23(3): 277-284.

7. Grier, Sonya & Carol A. Bryant. Social Marketing in Public Health. Annual Reviews Public Health 2005; 26:319-339.

8. Weinstein, Neil D. Unrealistic Optimism About Future Life Events. Journal of Personality and Social Psychology 1980; 39(5):806-820.

9. Christakis, Nicholas A. & James H. Fowler. The Collective Dynamics of Smoking in a Large Social Network. The New England Journal of Medicine 2008; 358(21):2249-2258.

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