Infrastructural and Theoretical Challenges to Switching From the “Chit System” To Voluntary Blood Donation in Trinidad and Tobago—Natalya Maharaj

The “Chit System” of Blood Donation in Trinidad and Tobago

Blood donation and potential shortages in the blood supply are issues that are typically undervalued in developed countries like the United States. While developing and transitional countries struggle to meet the 10 donations/1000 population that is necessary to meet the minimum needs of the country, the WHO 2007 Blood Safety Survey, notes that the average donation rate among developed countries is 38.1 donations/1000 population (1). The WHO report implies that the disparity in donation rates between developed nations and developing or transitional nations is attributable to the persistent dependence on family/replacement donations or paid donations in the less developed world (1). While the myth that voluntarily donated blood is safer than blood obtained through other methods has been refuted, reliance on solely family/replacement blood donations is not sufficient to sustain a steady blood supply at the minimally required level (2).

The blood supply in Trinidad and Tobago previously relied on the “chit system,” a derivation of the family/replacement donation method. According to Dr. Anand Chatoorgoon, former Acting Medical Director of one of four major public hospitals in Trinidad and Tobago, medical professionals relied primarily on “blackmailing patients to have their relatives give blood” prior to completing medical procedures (3). Upon donation of blood, family or replacement donors were given a “chit” which could be used to retrieve blood for a patient, when necessary (4). Under this system, donors essentially owned the donated blood and ultimately decided whether a friend or relative received their blood (3). As a result, any unused blood stored in the blood bank, essentially, could not be utilized in emergencies or for other patients. Moreover, Minister of Health Therese Baptiste-Cornelis noted that the chit system “encouraged fraud among nationals” as donors resorted to selling chits for thousands of dollars to those in dire need of blood (2).

In addition to being a system that was inherently unethical and that grew to be exceedingly corrupt, the chit system was repeatedly shown to be inefficient and acquiring the blood necessary for sustaining the range of medical procedures that are performed in Trinidad and Tobago. Sampath et al. note that continuing advances in cardiac surgery, dialysis and oncology lead to an increased demand for blood, but merely 6,000 regular, non-remunerated voluntary blood donors were recorded (4). 87% of the blood donations in Trinidad and Tobago were made as replacements for family or relatives and were insufficient for sustaining the demands of the “rapidly developing health system” (4). Indeed, both Sampath et al. and Charles et al. highlighted that continued reliance on the chit system of blood donation could lead to detrimental effects on patient care in Trinidad and Tobago (4,5)

Abolition of the “Chit System”

Presumably in an effort to bring the health system of Trinidad and Tobago closer to internationally accepted standards of care and procedures, the “chit system” of blood donation quietly transitioned to a completely voluntary blood donation system in January 2011 (6). Inefficient communication of this change to the public, however, ensured that the change in the blood donation system went virtually unrecognized until March 2011. As citizens became increasingly aware that their donated blood went into a general blood bank, and not specifically to their friends or relatives, blood donation in the nation dropped significantly (3). On March 12, 2011, Minister of Health Therese Baptiste-Cornelis indicated that there was no shortage of blood in Trinidad and Tobago’s blood banks (2) but it has become increasingly evident that collections are not at levels similar to those obtained with the chit system and significantly less than optimal levels. Several newspapers reports have noted that daily donations have dropped to single digits (2). Additionally, as recently as April 20, 2011, family members of the ill Allyson Hennessy issued a public announcement calling for donation of O-positive blood, necessary for the patient’s treatment (7).

The transition from the chit system to voluntary blood donation in Trinidad and Tobago has been wrought with problems. As the resultant blood shortage becomes a more urgent issue, governmental efforts have focused on a media campaign calling for increased voluntary blood donations. To facilitate this, the four blood donation centers have remained open for 6 hours on Saturdays throughout the month of April. However, it is becoming increasingly obvious that even these efforts are unsuccessful. The Southwest Regional Health Authority has reported that, while 16 pints of blood were collected on the first Saturday blood donation drive, the daily target remains at 30-40 pints per day(8). It is clear that the government of Trinidad and Tobago cannot rely on ineffective media campaigns and lackadaisical infrastructural improvements to boost voluntary blood donations, as the mounting blood shortage can lead to a major public health problem. Indeed, the combination of the lack of proper infrastructure to facilitate accessible and easy blood donations, flawed usage of the Theory of Reasoned Action and inability to appropriately replace the ownership associated with the chit system by tapping into the sense of altruism that is important for voluntary blood donation (9), has essentially doomed the new blood donation system to failure.

Infrastructural Issues

Maintaining the blood supply in developed nations depends heavily on repeat donors (10-12). As donation rates have fallen in the United States, a number of investigators have undertaken studies to examine the major promoters and deterrents among repeat blood donors (10-12). One of the clearest physical deterrents to donation that has been identified is convenience of donation locations (10). According to Schreiber et al., “not having a convenient place to donate was the most important factor for all donors, regardless of race, ethnicity or donor status” (10). Piliavin and Gillespie et al. have highlighted that convenience is not limited to the location of blood donation sites but extends to economic constraints such as difficulty with transportation and the required time commitment, including the time away from work and length of the donation process (11, 12).

While the government of Trinidad and Tobago has undertaken drastic steps to switch to a completely voluntary blood donation system, only modest infrastructural steps have been taken to ensure the success of the new system. According to the Ministry of Health website, there are currently 4 blood donation centers in Trinidad and Tobago(13)—1 on the island of Tobago to serve the 54,000 residents across the 116 square mile area (14), and 3 on the island of Trinidad to serve approximately 1.3 million residents across a 1,981 square mile area (14). Two of the centers are located within close proximity to each other in northern Trinidad, while the third is located in southern Trinidad. These locations are not optimally accessible for the majority of the population. Indeed, transportation time alone to any of the three Trinidad locations would exceed 1 hour for the majority of the population. In addition to this strong deterrent, the blood donation centers are typically open weekly, between 8am and 4 pm, but donors are not accepted after 3pm. This prevents much of the eligible population from donating since it would require spending significant amounts of time away from work or school.

The current efforts to increase the convenience of voluntary blood donations are meager, at best. While the recent additions of Saturday donation times have the potential to increase accessibility to blood donations, it does not account for the tremendous effort required to travel to blood donation centers. Indeed, if the nation is to meet the minimum daily donation rate required to avoid a critical blood shortage of 30-50 donations per day at each of the donation centers, it is imperative that the blood donation process is made more convenient. The Ministry of Health notes that they have one mobile unit that, currently visits workplaces that have at least 20 willing blood donors (13)

Flawed Application of Theory of Reasoned Action

The Theory of Reasoned Action, first proposed by Ajzen and Fishbein, proposes that actions are a result of behavioral intentions that are based on attitudes towards the behavior and subjective norms, perceptions of the societal expectations regarding one’s actions (14). Like many of the other models traditionally employed in public health interventions, the Theory of Reasoned Action relies on logical, reasoned actions by inherently irrational individuals. Despite its flawed reliance on the expectation that intention leads to behavior, the Theory of Reasoned Action has been utilized effectively in several public health settings. Indeed, it has proven to be especially robust in prediction of repeated behaviors such as contraception usage (15), breast feeding habits (16), and cervical cancer screening (17).

The Theory of Planned Behavior is a revision of the Theory of Reasoned Action that accounts for self efficacy, or an individual’s belief that they are capable of completing an action (18). A wide body of research has indicated that the Theory of Planned Behavior can explain blood donor behavior. Giles and Cairn showed that subjective norms and perceived control accounted for 60.5% of the variance in behavioral intention among undergraduate blood donors (19). Overall, students who believed they lacked the ability to engage in blood donating were unlikely to form behavioral intentions regardless of their attitudes and subjective norms (19). Subsequent studies by Armitage and Conner also indicated that self efficacy was an important predictor of blood-donating intention (20).

While it is unclear whether a concerted effort has been made to design a public health intervention to increase voluntary blood donation, officials in Trinidad and Tobago seem to be relying partially on the Theory of Reasoned Action/Theory of Planned Behavior to appeal to the public. Since the introduction of the voluntary blood donation system in March 2011, the Ministry of Health’s media campaign has focused on two major areas: increasing public awareness of the new blood donation system and altering perceived norms about voluntary blood donation (newspaper articles). Increasing public awareness of the new blood donation system has relied primarily on expounding on the weaknesses of the formerly employed chit system and on the impending blood shortage. In the context of the Theory of Reasoned Action and the Theory of Planned Behavior, this approach is particularly ineffective because it relies on the presumption that presenting clear, rational information about the benefits of the voluntary blood donation system would alter attitudes toward voluntary blood donation.

The efforts to alter perceived norms about voluntary blood donation have been employed slightly more effectively. In combination with the calls for increased donations and weekend hours at donation centers, the media has featured images of prominent politicians, doctors and entertainers donating blood. This partially addresses the subjective norms surrounding voluntary blood donation as it moderately addresses individual’s perceptions of social sanctions of the action. However, politicians, doctors and older entertainers do not reflect the typical citizen of Trinidad and Tobago, and as a result, may ineffectively convey societal attitudes towards voluntary blood donation. An important factor of the Theory of Reasoned Action and the Theory of Planned Behavior that often isn’t accounted for is the significance of other people’s opinions on individual action. In efforts to alter subjective norms, it is therefore important to portray individuals who are from a similar population as the target audience and have a significant amount of influence on individual opinions and actions (21).

As research has shown the self efficacy plays a significant role in determining whether intention to donate blood actually materializes to voluntary donation (18-21). For regular blood donors, it has been suggested that promotional activities that emphasize quality of service including cleanliness of surroundings, efficiency of process and qualifications of staff be emphasized while emphasizing the ease of successfully donating could be effective for first time donors (21). Since the public in Trinidad and Tobago is generally wary of government health initiatives, especially given current missteps in several public hospitals (22-25), it is likely that self-efficacy among the population eligible for blood donation is low. It is therefore practical for the Ministry of Health to make a concerted effort to improve self efficacy by incorporating both suggestions for regular blood donors and first time donors in order to successfully increase voluntary donation rates.

“Ownership” of Blood

As Dan Ariely notes in Predictably Irrational, human beings are inherently irrational (26). One of the major features of irrationality in human beings is the “high price of ownership (26).” As Ariely shows, we tend to overvalue that which we own—Duke students who have received coveted tickets to an important basketball games selling price is 14 times the price that students who did not receive tickets would offer and perhaps due to cognitive dissonance, upon taking ownership of an idea, we “prize it more than it is worth” (26).

The chit system of blood donation that was previously employed in Trinidad and Tobago fostered a strong sense of ownership among blood donors. As recounted previously, family or replacement donors were given a “chit” which could be used to retrieve blood for a patient (4). The issuance of the “chit” essentially meant that the donor owned the donated blood, and as a result, would demand a high price to sacrifice it to another individual. Indeed, much of the criticism of the change to the voluntary blood donation system came from citizens who were concerned about not retaining the “right” to choose who received their donated blood (27).

Ignoring the “high price of ownership” and expecting that the transition to the voluntary blood donation could be done effortlessly with a weak media campaign probably resulted in the drastic decline in blood donations in the months subsequent to the switch. Despite the fact that the instated voluntary blood donation system would lead to a safer, more stable blood supply (2-5), the perceived threat to blood ownership over-rode the rational arguments of government officials. As a result of the strong sentiment against the threat to ownership, it is unlikely that any strong infrastructural changes and public information efforts would have increased blood donations. Indeed, the strong effect of psychological reactance (28) means that without compensating for the sacrifice of ownership, it is unlikely that any efforts to alter the blood donation system would succeed.

Proposal

In order for the voluntary blood donation system to be effectively implemented in Trinidad and Tobago, a comprehensive effort needs to be made to correct the infrastructural problems, to successfully market the new system to citizens, and to simultaneously appeal to citizens’ sense of altruism and to compensate for the loss of “ownership.”

Infrastructural Improvements

A wide body of research has indicated that the ease of blood donation—especially related to location of donation centers and the required time commitment, including the time away from work and length of the donation process—is one of the major determinants of whether first time and repeat blood donors continue to donate blood (10-12). While improving the facilities available for blood donation in Trinidad and Tobago alone does not ensure the success of the voluntary blood donation system, it is important to address these physical deterrents if blood is to be collected safely and efficiently.

Though there are currently only four blood donation centers at the major general hospitals in the two island state, there are 84 regional health centers in Trinidad and 18 regional health centers in Tobago (29). These regional health centers provide a range of primary care and preventive care services to a large portion of the population (29). Unlike the major hospitals, these health centers are more easily accessible to the general public and should be recognized as prime areas for boosting blood donations. Having a location that is more convenient to homes and workplaces could serve as a significant encouragement for citizens to donate blood. However, like many of the public health institutions in Trinidad and Tobago, health centers are open only during working hours. Increasing hours at these centers on several days during the week and on weekends , coupled with comprehensive outreach efforts, could lead to increases in blood donation.

While extending blood donation facilities to regional health centers addresses some of the issues regarding the physical barriers to blood donation in Trinidad and Tobago, the challenges of sacrificing a significant amount of time for blood donation still remain. Employing mobile blood banks in a wider range of functions is one of the best ways of efficiently and effectively increasing blood donations. Clearly, the single mobile blood bank currently in use in Trinidad and Tobago is not sufficient to serve the needs of the nation’s health system. In order to efficiently and effectively collect needed blood, it would be wise to employ the mobile blood bank in a wider range of functions and to invest in mobile blood banks for regional health authorities. Investment in multiple mobile blood banks for the six regional health administrations would help to make blood donation less of a time-costly task. Multiple mobile blood banks can easily be utilized to visit large University and high school campuses, government workplaces, or even centralized entertainment areas. The increase in blood donations that would correspond with more resourceful utilization of this resource is easily foreseeable.

Combating Negative Subjective Norms: Diffusion of Innovations Theory and Marketing Theory

The Theory of Reasoned Action/Planned Action has proven to be an accurate predictor of many health behaviors including blood donation patterns (14-20). It is clear from this body of research that self-efficacy and subjective norms about blood donation play a significant role in determining whether an individual ultimately donates blood (14-20). While current publicity efforts by the Health Ministry of Trinidad and Tobago has focused on rational explanations for the switch to the voluntary donation system and some efforts to convey altered norms, without clear direction and target audiences, it will be difficult for actual changes in norms to hold and lead to more approval for the change in the system.

While it is important that the new voluntary blood donation system is accepted by the majority of citizens of Trinidad and Tobago, developing a media campaign that effectively targets all sectors of the population may be difficult. The diffusion of innovations theory suggests that for an innovation to be adopted in a self-sustaining manner, it must first reach a critical mass of adoption (30). Since young adults are more likely to fit the characteristics of healthy donors, have been shown to be more prone to identify with behaviors synonymous with morality, altruism and civic responsibility (31) and are likely to have wider social networks, they seem to be an appropriate population to target a strong marketing campaign. Indeed, assuming that the diffusion of innovations theory can be applied to this situation, effectively eliciting change in behavior in young adults—and consequently, others in their social circle—could lead to redefinition of social norms surrounding voluntary blood donation.

Relying on the diffusion of innovations theory, however, depends on effectively marketing the intervention to the early-adopters (30). Social marketing is a group level model that has been successfully employed in “broad-based behavior change programs”, especially at the community level (32). The Pawtucket Heart Health Program and the Stanford Five Cities Project have been cited as two of the most successful applications of social marketing to the planning, implementation, and analysis of public health interventions (32). Social marketing has proven to be effective at the community level due to two major factors of the model: the reliance on consumer orientation and audience analysis and the integration of the “marketing mix” of blending “product, price, place and promotion” into public health interventions (32).

As Scholz notes, Generation Y—individuals born between 1981 and 2001—have been shown to have incorporated general values such as “collectivism, positivity, moralism, confidence and civic-mindedness” into their vision of the world and the roles they might play in it (31). As a result, younger adults tend to value altruism as a trait in themselves and in their social environment very highly (31). Translating that altruism to the act of donating blood, however, relies on the partially on “relevant norms” that are implied in their immediate society.

Notable social marketing campaigns with young adults in the Caribbean have succeeded in altering perceived norms about sexual health issues and HIV testing (33). One of the most prominent of these campaigns is the popular “Live Up: Love, Respect, Protect” media campaign (33). This effort has rebranded sexual health to not only make it less taboo in the community but also successfully tore down social mores that might have restricted safe sexual health practices. Indeed, the effort has combined this rebranding with appropriate use of television campaigns to make it seem ‘cool’ and ‘normal’ for any regular young adult to participate in HIV testing. Adopting a similar approach to rebranding and marketing voluntary blood donation could be similarly effective among the same demographic that the Live Up campaign targets. First, voluntary blood donation could be rebranded as “3:1”, representing the number of lives that can be saved with one pint of blood (34). Subsequent advertisements will then focus on ‘cool’, ‘normal’ young adults engaging in fun activities, but who convey clearly that they enjoy donating blood because of the easy contribution to society. The rebranding and media campaign should then be paired with social networking sites to develop a community among young adult, voluntary blood donors. Provided that infrastructural improvements are made to in fact make blood donation easy, it is probable that the combination of these efforts could successfully lead to changes in behavior, and consequently norms, within young adults. Diffusion of innovations and the social networking aspect could then be relied on to lead to behavioral changes among other sectors of society.

Rewards for Donation

The sense of ownership that the chit system fostered is one of the strongest factors against public acceptance of the voluntary blood donation system and needs to be properly countered if the voluntary blood donation system is to succeed. In addition to effectively using the described marketing strategy to appeal to citizens’ sense of altruism, tangible incentives need to be provided to encourage sustained voluntary blood donations.
The American Red Cross collects approximately half of the donated blood in the United States (35). Indeed, through effective marketing and branding, the American Red Cross has succeeded in both appealing to altruism among donors and making blood donation a “movement” by labeling donors as “members for life” (34). Recent efforts by the organization have focused on developing diverse ways to thank repeat donors (34). The most recent development includes an online “Red Cross Rewards: Your Link to Life” store (34). Voluntary blood donors collect points under a membership number and are able to redeem those points for a variety of merchandise (34). Utilizing a similar model of rewards for voluntary blood donors in Trinidad and Tobago would be a strong incentive to encourage voluntary blood donation and would reinforce the idea of a “movement” to donate blood expressed by marketing strategies. The concept of ownership of donated blood will persist in Trinidad and Tobago until norms targeted in the marketing campaign take firm hold in the society. However, by pairing incentives with the idea of a voluntary blood donation movement, behaviors may be more likely to be altered and result in a gradual acceptance of the voluntary blood donation system.

Recent Developments

On April 28, 2011, Minister of Health Therese Baptiste-Cornelis reported that the chit system of blood donation had been reinstated temporarily as the new voluntary blood donation system had “not given desired results”(36). In an effort to avert the blood shortages and declines in blood donation rates that occurred upon the first attempt to implement the voluntary blood donation system, “six mobile blood units were purchased for each of the six regional authorities”( 36). While this investment is necessary to ensure the eventual success of the voluntary blood donation system in Trinidad and Tobago, the Ministry of Health needs to realize that infrastructural improvements must be complemented with a comprehensive public health intervention in order for voluntary blood donations to sustain the long term needs of the country.

REFERENCES

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13. Trinidad and Tobago Ministry of Health. National Blood Transfusion Unit. Port of Spain. Trinidad and Tobago Ministry of Health. http://www.health.gov.tt/sitepages/default.aspx?id=184

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21. Abraham, C., Wight, D. and Scott, S. (2002) Encouraging safer sex behaviours: development of a share sex education programme. In Rutter, D. and Quine, L. (eds), Changing Health Behaviours. Open University Press, Buckingham, pp. 28–48.

22. Pickford-Gordon, Lara. (2011, March 29). Panel probing Chrystal’s death can get more time. Trinidad and Tobago Newsday. http://newsday.co.tt/news/0,137977.html

23. Staff. (2011, March 31). Suspended Doctors in the Dark. Trinidad and Tobago Newsday. http://www.newsday.co.tt/news/0,138088.html

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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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