Challenging Dogma - Spring 2011

Sunday, May 15, 2011

Re-evaluating The Pro-Vaccination Message In Light Of Recent Controversy And Preventable Outbreaks– Kathryn Kinzel

Routine childhood vaccinations are regarded as one of the best public health campaigns in history (1, 2, 10, 21). Since the beginning of the 1900s, the United States has witnessed the worldwide elimination of smallpox, as well as drastic reductions in polio, measles, diphtheria, mumps, rubella, tetanus, and pertussis, along with several other diseases. Today, vaccinations are relatively safe and effective and have saved millions of lives (2, 13).

Over the past ten years, however, vaccine coverage for children has decreased (2, 10, 13). More and more states are allowing exemptions from otherwise legally mandated vaccine schedules due to philosophical reasons, or because the parent simply doesn’t believe in the full safety of the vaccine (2, 3, 14, 21, 22). Sparked by a now debunked study, parents began to worry over the potential effects vaccines may have on the developing child, including connecting vaccines to autism and other behavioral changes (5, 16). Ironically, because the vaccines had been so effective at reducing disease prevalence, parents began to believe that the potential risk of having their child develop autism was worse than the risk of getting the disease the vaccines were preventing. A common saying remarks: “vaccines are the victims of their own success” (6).

With decreasing vaccination rates comes the threat of disease re-emergence. Over the last several years, there have been pertussis outbreaks in several areas in California, along with sporadic outbreaks of measles among unvaccinated populations (2, 9). Despite having reported numbers of concerned parents deciding not to vaccinate their children, and seeing the effects played out in disease outbreaks, the greater public health community has not launched any campaign to attempt to reverse the current trend. Instead, public health officials are relying on the power of the physicians and rational behavior, even when it is clear that the old standbys are no longer functioning like they once were. If members of the public health community wish to raise rates of childhood vaccinations, they must take action using new techniques, which will address the following problems and ideally lead to an effective new campaign.

The Problem With Relying on Logic and the Health Beliefs Model

The first problem with the way the public health community has been approaching the vaccine issue is that officials appear to be using a rational version of the Health Beliefs Model to try to convince parents to vaccinate their children. The Health Beliefs Model relies on an individual weighing “pros” and “cons” to a particular problem, and use rational decision making to make the best decision with the various factors involved. Using this model, the medical community sees very few “cons” with the delivery of the vaccines, with the exception of very rare adverse effects (1). The “pros”, meanwhile, include being immune to numerous diseases that can be serious if contracted, and with so much weight on the “pro” side, the expected outcome is to vaccinate (2, 14).

However, parents do not necessarily think like the medical professionals, and may not make a rational decision regarding vaccinations, instead choosing to favor a protective decision for their family. Doctors and public health officials frequently cite the benefits of vaccination on those who are immunocompromised, or who cannot receive the vaccinations themselves, as reasons for children to be routinely vaccinated, creating the herd immunity effect (14). However generous and altruistic the person, when it comes to the family most parents will choose the health and safety of their children over that of other susceptible people (4). Anti-vaccination proponents have jumped at this information, and routinely state in their messages that the public health officials do not care about each child, but rather the population as a whole – even if that means the injury to some, at least the rest of the population is better off (18). This message plays to the irrationality and fears of parents, and essentially dooms the logical message from the medical community.

“Because I say so”: Unintentionally Triggering Psychological Reactance

Doctors do not have a lot of time to spend with patients – it is estimated that the average pediatric visit lasts approximately eighteen minutes (4). Considering that a full physical exam is usually completed during these visits, which often lasts longer for children than for adults, any resistance or questioning by parents concerning vaccine safety can come across as disruptive (23). While doctors may wish to have the time to fully explain the benefits of vaccinations, the allotted time for patient visits does not permit it (4, 10). As a result, doctors can only answer so many questions before the exam is over, which may make it difficult to convince parents of the safety of vaccinations and/or to answer in detail the various questions they may have.

As a result, doctors appear to take a “my way or the highway” response when it comes to routine vaccinations. Due to the time constraints of the visit, a doctor may not find time to adequately answer concerns and thus needs to push to get the vaccinations completed. This then gives the parents a sense of inferiority and a loss of control over the situation, which triggers a form of psychological reactance and will actually move that parent MORE towards non-vaccination, or at the very least towards a distrust of the doctor (4, 22). Additionally, doctors are more likely to dismiss patients from their practice or suggest they find another provider when parents question or refuse vaccinations (10). Many doctors do this because of the severe conflicts between what the doctor believes is right for the child and what the parent will give consent to do. This can be problematic, however, because some parents will change their minds on the issue, sometimes years later, and will come back to the doctor to have the child caught up on his or her vaccinations (20, 24). If the doctor dismisses a family from the practice, this catch-up event is much less likely to happen, because the parents have lost faith in the doctor.

Reliance on Antiquated Message Delivery Systems

As discussed above, the primary means of information transmission regarding vaccination recommendations and vaccine safety is largely limited to using members of the medical community, and when safety is in the news, limited news coverage. As an extension of the Health Beliefs Model, and also on the theory of reasoned behavior, the medical community relies on getting information out to the public purely through official routes (4, 14). Many of these official pathways of information are passive, requiring the individual to seek out the information and to know where to get this information.

Even in the aftermath of anti-vaccination campaigns and disease outbreaks, public health officials do not change their method of delivery. This is in stark contrast to the anti-vaccination groups, who use social media and emotional campaigns to deliver their message (18, 19). On one such occasion, Jenny McCarthy, a staunch anti-MMR vaccine celebrity, appeared on the popular talk show Oprah to discuss her experiences and her beliefs on the link between vaccines and autism. After her emotional discussion, Oprah read the response from the Centers for Disease Control and Prevention from an index card, which was the standard, scientific, completely unemotional response that public health officials have relied on. The audience was unimpressed by the CDC’s answer, and was swayed to support Ms. McCarthy (17). The incredible non-response from the government over the last several years has allowed the anti-vaccination group effective control over the public perception of messages, and urgently needs to be addressed.

Proposed Initial Intervention

With a matter as emotionally charged as the safety of vaccines, it will be a difficult task to win over the trust of suspicious parents across the country and to have the overall vaccination rates rise to levels they once were. As a critical first step, the public health community needs to revamp the message that is being delivered on an everyday basis, making it more accessible to worried parents and cutting down on any arguments the anti-vaccination groups might raise in objection. A part of this new informational campaign must include known behavioral tendencies, particularly those that do not follow the logical pathways that medical officials are used to following. The campaign should also focus on both an individual and a population level, so that the message can reach all corners of the country and be able to make an additional impact on a personal level. Ideally, this model will 1) be able to take advantage of the traditional Health Beliefs Model 2) allow for personable conversations that avoid psychological reactance and 3) completely reframe the way the issue is presented nationally.

The New Campaign Modifies the Health Beliefs Model

There are a couple of options when it comes to modifying the model used to convey health information. It could be entirely possible to disregard the Health Beliefs Model altogether, and replace it with another model that predicts behavior. However, taking into consideration the relative static nature of medical education in this country, and how current practitioners may be resistant to changing fundamental approaches to the way they deliver information, a modification to the current model might be better received. In this case, perception becomes a major factor. It has been shown that vaccination rates are higher in groups of people that perceive a higher threat to themselves, versus those that do not feel that the disease in question poses a threat (7). The law of small numbers supports this finding; if given a population statistic for risk of getting a certain vaccine-preventable disease, which is low to begin with, an individual might think that the statistic is true, but may associate the low risk with a projected personal outcome of not getting the disease. This fallacy certainly drives the worried parents’ decision in two ways – first, they perceive little personal threat from the various diseases the vaccines protect against, while simultaneously perceiving an increased threat from a behavioral illness, even though there is no scientific association between the two (2-6, 12-14, 18, 21-22).

The new Health Beliefs Model must then take both of these facts into account in order for potential change to occur. Doctors need to be able to convey a sense of danger without being overly dramatic, in an attempt to increase the perceived risks to each individual parent. Relating stories about recent and nearby outbreaks of preventable diseases can help elevate the threat level, as does a full explanation of disease symptoms (21). Most parents today have had no personal experience with the diseases these vaccines now control, and therefore may have a skewed sense of danger when it comes to how severe the disease is for a child; many parents may believe that these diseases are not severe at all (6). Once a parent gets this new information from a trusted source, risk perception should change in such a way that the parent no longer holds an optimistic bias of their child never getting the diseases in question, and would take the protective measure of having their child vaccinated. The medical professionals have a chance to educate the public on this regard, and should start to do so at the first opportunity.

The New Campaign Frames and Provides Support at the Individual Level

Accepting that doctors do not necessarily have all the time that they would like to have with patients, and that modifying the way they are delivering information as outlined above may take up the remaining time they allow in routine visits, it would be difficult to introduce a completely new, additional way to get doctors to modify parents’ perceptions. It has been shown that when parents feel that their concerns about vaccine safety are being acknowledged, they are more likely to trust the doctor and be more likely to allow the vaccination (4, 10, 22). There are a couple of ways to implement this system of trust, but both will rely on the principles of basic communication theory. First, as in the study above, the doctor must be a sympathetic point, in order to allow a sense of familiarity with the patient and to reduce any psychological reactance (11). In this situation, the doctor must be able to put aside the agenda for the visit and be able to take the time to listen to the parent and make sure that concerns are acknowledged, so that the parent feels some semblance of control of the situation. This will run contrary to the current practice, where doctors are more likely to dismiss the parent entirely by not only disregarding their concerns, but also by referring the parent to a completely different doctor (10). In response, the doctor would need to present the vaccinations within a frame that supports security in both health and with the family.

A nurse or other trained staff member can also do this in the doctor’s office. Should the doctor feel that too much time is being taken as is, and will not be able to fit a small discussion into the visit, a staff member can meet with the parent in the waiting room or in the exam room before the doctor arrives. This is usually considered to be downtime for the parent, who might otherwise feel that time is being wasted and/or out of their control (11). Instead, the staff member can act as the relatable, trustworthy person who can hear the concerns of the parent, and can be the one to deliver the framed message promoting vaccines (15). However, this may lead to a disconnection between the parent and the doctor, because the doctor does not hear the concerns firsthand. If the parent believes that the doctor either does not know of his/her concerns, or does not receive the acknowledgement from the doctor as they did with the other staff member, there may still be distrust present in the doctor-parent relationship, even if vaccinations are more likely to occur (10, 14). If this particular approach is to be implemented, care must be taken to make sure that the staff member delivering the message is able to carry over the sense of trust to the doctor in the exam room, either with physical presence or with another positive communication method (e.g. making a note in the patient’s chart).

The New Campaign Fights Back with Population Level Framing

One of the major reasons why the anti-vaccination movement has been so successful is the appearance and propagation of celebrity endorsements and alternative medical practices (18, 19). In order to have any chance to combat these elements, public health professionals must think like these celebrities, and try to be as relatable to the people as possible. Cut and dry statistics from the Department of Health and Human Services do nothing to convince emotionally charged parents that vaccines are safe. People will irrationally have more faith in an argument that is emotional and relevant to that individual’s life, a point that is used to great success in advertising theory (19). Additionally, arguments that claim to give support and provide key values, such as security and family cohesion, will resonate much more strongly than arguments that do not contain these values. Public health officials will take a major step forward by incorporating some of these themes into their public announcement and educational materials.

In order to get their message across that vaccines are safe and not linked to autism or other behavioral changes, officials need to be able to reframe their stance, in order to make their message more appealing. By using spokespeople that are relatable instead of finding a seasoned doctor to deliver the message, the recipients will automatically be more apt to listen to the message, and the campaign will be much more effective (8). One paper suggested using other celebrities to combat the anti-vaccination celebrity movement (19), but the attractiveness of the celebrity is likely relates to the resources they have to fight for what they believe in. On face value, the celebrity is a relatable person, with some connection to the same fight normal everyday parents are struggling with. As long as the messenger shares the same commitment of care and security that comes with raising children, parents should be able to relate and be more likely to pay attention to the message (19).

The power of vaccinations has been demonstrated throughout the last several decades, with many diseases falling by the wayside and leading to healthier childhoods. Vaccines have almost worked too well, and are now under threat from many who claim that they are the cause of new neurological diseases. Decreasing vaccination rates have led to outbreaks of these preventable diseases, posing a risk to the health of the community. The process to reverse the trend will be long and ongoing, but can be put on the right track by modifying the messages being sent by the public health and medical communities. By adapting the current Health Beliefs Model used by physicians, the risks of disease can be elevated relative to the non-risks of developing behavioral changes and will encourage more parents to decide to vaccinate. Additionally, allowing the message to be broadcast to the public on both an individual level at the doctor’s office and on a national level by using ad campaigns with relatable messengers, the public health officials will be able to counter the arguments made by the anti-vaccination groups that have been left unchecked for too long. Provided that changes can begin to be made, vaccination rates will not drop much farther, and outbreaks of preventable diseases might begin to lessen; an impact that will be welcomed by all.


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