How routine mammography of women under 50 diverts attention from cancer prevention and environmental factors - Lynn Rosenbaum

Setting the stage
Breast cancer in the United States is a highly prevalent and dangerous disease for women. According to the Breast Cancer Fund, a woman has a one in eight chance of getting breast cancer in her lifetime, and more women between the ages of 20 and 59 die from breast cancer than from any other cancer. From the 1930’s to the end of the 1990’s, a woman’s risk of breast cancer continually increased, and between 1973 and 1998 alone, increased by 40%. [1] In the last decade, we have finally seen a decrease in both incidence and mortality for women; however, the research is unclear as to whether these positive results were only relevant to women over age 50 [1,2]. Many sources agree that the decline was probably due mainly to the decrease in post-menopausal hormone replacement therapy which, in 2002, was found to be associated with an increased risk for breast cancer[1].
So what is the most effective way to prevent breast cancer? And what exactly do we mean by prevention? One of the most prevalent public health strategies to address breast cancer is screening through the use of mammograms. According to The American Cancer Society “Getting a mammogram is one of the best things a woman can do to protect her health.” They recommend, “Women age 40 and older should have a mammogram every year and should continue to do so for as long as they are in good health. While mammograms can miss some cancers, they are still a very good way to find breast cancer.” [3]
But does screening mammography truly prevent breast cancer? In this paper I will argue that an emphasis on routine screening mammography among average risk women under 50 is neither safe nor effective; it directs attention and resources to secondary rather than primary prevention; and it results in minimizing the links between environmental toxins and breast cancer.

Mammograms can be unsafe and ineffective
Although regular mammograms have been shown to offer benefits to post menopausal women, mammograms carry associated risks, and are not proven to offer the same benefits to healthy women under age 50. The first risk of routine mammography screening in premenopausal women is unnecessarily exposing them to radiation, which is potentially dangerous. Although many experts believe that this low-dose exposure radiation is of low risk (perhaps causing 1 additional breast cancer death per 10,000 women) [4], other researchers have argued that the risk has been underestimated and cannot adequately be predicted by models based on higher doses or radiation [1]. It has also been found that “young women with the very mutations that lead them to begin mammography screenings at earlier ages are actually more vulnerable to the cancer-inducing effects of early and repeated exposures to mammograms.” [1]
The second risk of routine mammography is that it may lead to unnecessary medical interventions. Mammograms, particularly for younger women whose breast tissue tends to be more dense and less likely to yield accurate results, can lead to both false positives and false negatives. As a result of false positives, women may end up getting dangerous and unnecessary surgeries and radiation treatments. “It is estimated that a woman who has yearly mammograms between ages 40 and 49 has about a 30 percent chance of having a false-positive mammogram at some point in that decade and about a 7 percent to 8 percent chance of having a breast biopsy within the 10-year period.”[5]
In the 1980-1990’s, according to a study by Horner 2009, rates of diagnosis of the non-invasive condition ductal carcinoma in situ (DCIS) increased by 4 times, mostly due to the greater use of mammogram screenings. [1] Because, current medical science cannot tell us which cases of DCIS will end up actually leading to cancer and, in fact, most do not [4], many women have been unnecessarily subjected to the risks of subsequent surgical biopsies, radiation and Tamoxifen.
There is very minimal evidence of benefits to outweigh the above risks. Some research has shown that for women between 40-49, after a seven year follow-up, there was no effect on mortality, and in order to even extend one life, it is estimated that 2500 women would have to be screened regularly. [4]
In 2009, the U.S. Preventive Services Task Force (USPSTF) published a controversial revision to its policies. It weighed the potential benefits (reduced chance of dying from breast cancer) and potential harms (for example, false-positive results and unnecessary biopsies) and then concluded that “there is moderate evidence that the net benefit is small for women aged 40 to 49 years.”
It recommended biennial mammograms to women age 50 and over, rather than annual screenings to women 40 and over, and for women of average risk, age 40-49, it recommended against routine screening. [6]
Despite this report and the evidence cited above, The American Cancer Society, National Cancer Institute, Susan B. Komen and others continue to recommend regular screening mammography for younger women[7], although other organizations such as the Cancer Prevention Coalition and Breast Cancer Action are in accordance with the Task Force’s recommendations in discouraging healthy young women to be screened [8,9]. And then there are those organizations such as the Center for Disease Control which have backed off of any strict recommendations and instead encourage women to talk with their doctors to make an individual decision based on the research and their particular set of conditions [10].
Another problem with a policy of routine mammograms for women under 50 is that women may think that getting a mammogram is all they need to do to avoid getting breast cancer, at the expense of attending to important lifestyle and environmental factors. Women are subject to the “illusion of control,” which refers to the expectation that one has more control over a situation than is objectively warranted by probability. This illusion is enhanced when one is involved or takes action in the situation at hand. [11] So in this case, young healthy women who take a specific action by getting mammogram screenings may feel more in control of preventing the likelihood of their getting breast cancer, even though the mammogram is a tool to potentially detect existing cancer rather than to prevent it and, as argued above, has questionable benefits. In order to truly prevent cancer, that is, address its underlying causes, young women should be encouraged to focus on controllable lifestyle factors, such as diet, exercise and alcohol consumption and perhaps more importantly, on environmental factors, such as toxins which permeate our food, air, water, and consumer products.

Primary versus secondary prevention
An emphasis on mammogram screening directs focus and resources at secondary prevention, that is, researching and promoting how to detect cancer early enough to treat it, instead of at true primary prevention, which identifies and eliminates preventable causes of the disease. The way in which a problem is framed determines what is seen as important. “Elements left out of the story are outside the frame and are thought to be unimportant.” [12] The framing of a medical problem in this way is not limited to breast cancer. “The dominant focus in epidemiology and perhaps the American culture in general is on individually-based risk factors that lie relatively close to disease in a causal chain.” [13] Thus the medical establishment has framed the issue such that both doctors and patients tend to approach breast cancer prevention as an individual level problem – it’s up to individual women to make sure they get regular mammograms and to monitor their individual risk level and their behavior around diet, exercise, and alcohol consumption.
Framing is very important in determining what types of interventions are used to address the problem. The medical establishment tends to frame breast cancer in such a way that leads to “downstream” solutions rather than “upstream” solutions. The money, research, and attention focused on detection, treatment, and finding a cure, greatly outweigh addressing causal factors, such as environmental toxins, which are contributing to the development of the disease in the first place.
The predominant frame described above is reinforced by both public health campaigns and the media. According to Agenda Setting Theory [14], how much the news media covers a particular issue directly affects how important people think the issue is. The media not only reflects the news agenda, but shapes it as well. The media emphasizes mammogram screenings, and to a lesser degree, diet and lifestyle, and thus encourages women to value these same issues. One recent analysis by Michigan State University of news stories covering breast cancer found that 31% focused on treatment, while just 18% addressed prevention [15]. Newspapers, television and advertising offer widespread coverage and promotion of fundraising walks such as the Avon Walk for Breast Cancer and the Susan B. Komen Race for the Cure, which are corporate sponsored and raise money mostly for screening, treatment and finding a cure, while spending very little on primary prevention [7,16].

Environmental factors
One major consequence of the framing of breast cancer as a downstream rather than an upstream issue, is that environmental factors of breast cancer are minimized and under funded. According to researchers at Cornell University, “Because established risk factors for breast cancer account for less than half of all cases, scientists believe environment may play a role in this disease.” [17] And despite the fact that breast cancer research is the most funded of all cancers [18] over the last decade, only a small percentage is spent on environmental links to the disease.
When underlying environmental toxins are addressed, they often point to large corporations, which are responsible for producing harmful chemicals in almost every area of life. These corporations often have a vested interest in continuing to produce these chemicals because of the profits they bring in. The close financial and political ties between large pharmaceutical/chemical corporations and some cancer organizations influence the “anti-cancer” agenda that is promoted. Several progressive organizations such as the Cancer Prevention Coalition, have pointed out that Breast Cancer Awareness Month is completely controlled by Astra/Zeneca, a multimillion dollar donor to the American Cancer Society. Astra/Zeneca is one of the world’s top ten largest pharmaceutical companies, formerly a part of Imperial Chemical Industries, and the producer of Tamoxifen, a drug used in breast cancer treatment and prevention. AstraZeneca retains the right to oversee all of the promotional materials of the awareness campaign and heavily promotes mammograms and treatment – including Tamoxifen – while ignoring links between industrial toxins and breast cancer [19].
Despite the relative lack of funding for research on links between environmental toxins and breast cancer, there is still much that we do know and need to be concerned about. “There are over 85,000 synthetic chemicals on the market, and fewer then 10 percent have been tested for their effects on our health.” [20] The harmful effects of toxins are particularly relevant to breast cancer because many toxins are concentrated in fat and thus breast tissue. And according to the Center for Disease Control and the Environmental Working Group, over 200 chemicals have been found in our body fluids. Furthermore, studies reveal 216 chemicals associated with increased mammary gland tumors in animals [21].
Harmful chemicals reach into virtually every aspect of our lives including our food, air, water, and consumer products. We ingest pesticides and additives in the foods we eat, are exposed to chemicals used in food packaging and production, and are subject to synthetic hormones in milk and meat. For example, recombinant bovine growth hormone (rBGH ) which is given to cows to increase their milk production, has been shown in several studies to contribute to links to increased risk of breast cancer, and has been banned in Europe, Canada and elsewhere. [21]
Plastics, which are used extensively in household products, toys, and electronics, contain many chemicals of concern, such as styrene, bisphenol A (BPA), and phtalates. For example some baby products such as bottles are particularly concerning because they contain a combination of carcinogens, such as vinyl chloride, and several endocrine-disrupting compounds, namely, BPA and phtalates. Cosmetics, including makeup, soap, and sunscreen, are rife with harmful chemicals which may affect our hormonal systems and affect breast development. Some of the chemicals have already been banned in European nations, but are still permitted in the United States. [21]
In sum, young healthy women do not need to undergo routine mammograms and take on their associated risks and resulting unnecessary interventions, all in the name of prevention. Instead, we must address the underlying root causes of the disease, particularly environmental toxins in our daily lives. We need to fund more research on links between environmental toxins and breast cancer, persuade corporations to use more caution in putting untested chemicals into our lives, and demand that our government increase its testing and regulation of harmful chemicals.

An Alternative Approach
So what is a truly effective way to prevent breast cancer among young healthy women? We can focus on changing corporate and governmental practices to remove from our daily lives the environmental toxins that put people at risk for breast cancer. We need to involve and empower young women and others in the population to bring about these changes. It is not enough to recommend that people individually try to avoid toxic chemicals by buying certain consumer products; this is not always possible to do, especially for those with limited income and accessibility. Furthermore, we all deserve to live in a society where we are not exposed to toxins which are known or suspected to increase risk for cancer.
One organization that advocates for this approach is Breast Cancer Action (BCA), a small non-profit organization which often works as part of larger coalitions to make social change. Despite its limited size and budget, it has succeeded in several of its campaigns to change policies. For example, in 2008, BCA’s “Think Before you Pink” campaign, successfully persuaded Yoplait yogurt to change its practices. Yoplait, which is manufactured by General Mills and touted as a “pink” company because it donates money to breast cancer treatment and sponsors the Susan B. Komen Race for the Cure, was producing yogurt from cows treated with rGBH, a suspected cancer-causing hormone. Through an online campaign in which thousands of consumers contacted General Mills in protest, BCA was able to exert enough public pressure to convince the company to commit to sourcing its dairy products from cows not treated with rGBH. After this victory, Dannon yogurt, a competitor, followed suit [22].
Unlike mammography screening, a campaign such as this was safe and effective : there were no medical risks involved for women (though speaking out against the status quo often involves other types of political/social risks.) Women were empowered by taking action, and unlike with mammography, were exerting real control in taking a step to reduce breast cancer risk as opposed to just the illusion of control; the campaign resulted in the actual elimination of the suspected cancer causing hormone from the source of the dairy products.
The Yoplait campaign took a group level approach which enabled change to happen quickly on a large scale, affecting thousands of consumers simultaneously. The campaign also framed the issue as one of primary prevention – targeting the company producing the yogurt, rather than targeting individuals’ buying or eating habits. This is an example of an effective upstream approach.
Finally, by focusing on rGBH, the Yoplait campaign raised awareness of environmental toxins, which not only affected Yoplait, but Dannon as well. Given that these 2 companies represent two thirds of America’s dairy products, it is likely that their change will also affect the practices of farmers, since they will no longer be able to supply these companies with milk unless they stop injecting their cows with the harmful hormone.
We need to continue to launch and expand upon policy campaigns such as the Yoplait example. A current environmental campaign which is in the works and is supported by a coalition of nearly 300 environmental health organizations is the proposed reform of the Toxic Substances Control Act of 1976 [23]. One way to motivate people to join a campaign for changing policy is to emphasize the ways in which women’s freedoms are being threatened by corporations and governmental agencies. According to the theory of psychological reactance, developed by Jack W. Brehm in 1966, as human beings we all need to feel in control of influencing our own environment. When we feel that our ability to be in control is threatened, we will experience “reactance” and resist against whatever is threatening us [24].
We can use this understanding of human psychology to our advantage in crafting a public health campaign. For example, the “Think Before you Pink” campaign used a form of psychological reactance by highlighting the hypocrisy of Yoplait in its giving money to breast cancer organizations while at the same time manufacturing a product thought to increase breast cancer risk. When women learned that they were being used in this way, they likely felt a threat to their sense of control and fairness and were motivated to write to General Mills in protest.
We need to deliver promotional messages to women that show how corporations who market harmful products are taking advantage of the public by profiting off of the chemicals which they produce and similarly, how governmental agencies who design environmental policies are failing to enforce them. As women learn about the way their freedoms are being squashed, they are likely to be motivated to fight back and join a campaign to restore those freedoms. In other words, if women feel like they are being duped, they are likely to take action.
We can make campaigns most effective by using tools honed by the advertising industry, which include making large promises to meet the needs of our target population, supporting these promises and appealing to universal core values [25]. This approach was used very successfully in the late 1990’s by the anti-tobacco Truth Campaign, which significantly reduced smoking rates among Florida youth. The campaign designed commercials, among other tools, aimed at the core value of rebelliousness among youth. They showed young people how they were being manipulated and lied to by big tobacco companies. The campaign promised them the “truth” and opportunities to rebel against the tobacco industry. Youth responded by joining in community activities directed against the tobacco industry and ultimately deterring more young people from starting to smoke [26].
Simon Sinek, a leader from the advertising industry, explains how to create an effective message that will inspire people to action. He describes the “golden circle” of three rings in which the message should start in the center with “why,” your purpose or cause. The “why” relates to universal core values, such as freedom and fairness. (Unfortunately “health” is not as important a core value to most people.) The next outer ring in the golden circle is “how,” the specific actions to take. And the final ring is “what,” the actual results [27].
So, for example, these tools could be applied to the campaign to reform the Toxic Substances Control Act (TSCA). The messages should emphasize the ways in which we are being duped by the law – we have been lead to believe that products brought to market have been tested and are safe, when it fact this is not the case. Thousands of chemicals in the marketplace have never been tested. The message should first introduce the “why” - we want our control back! We don’t want to be manipulated – and joining this campaign will allow all of us to do that. The “how” is to take concrete steps such as contacting legislators, garnering media attention, and raising money. Finally, the “what” is the result that we will all have healthier lives and less risk of breast cancer and other diseases.
In conclusion, in order to prevent breast cancer among young healthy women, we must bring more attention and action to the production, distribution and regulation of environmental toxins in our daily lives. In order to do so we need to inspire the public to put pressure on corporations and governmental agencies which are responsible for the manufacturing and regulation of chemicals. By using lessons learned from the social sciences and advertising, we can effectively mobilize the public to participate in campaigns which are safe and effective and ultimately change policies.

REFERENCES

1. Gray, Janet. State of the Evidence: The Connection Between Breast Cancer and the Environment, 6th Ed, Breast Cancer Fund, 2010.
2. American Cancer Society. Cancer Facts and Figures 2010. Atlanta: American Cancer Society, 2010.
3. American Cancer Society. “Mammograms Matter” 9/14/2010. http://www.cancer.org/Healthy/ToolsandCalculators/Videos/mammograms-matter-video
4. Love, Susan. Dr. Susan Love’s Breast Book, 4th Ed. Cambridge, MA: Da Capo Press, 2005.
5. Edison Imaging Associates. 2009. http://www.njradiology.net/what-is-mammography/
6. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2009;151:716-726.
7. Susan B. Komen for the Cure. http://ww5.komen.org
8. Cancer Prevention Coalition. http://www.preventcancer.com/
9. Breast Cancer Action. http://bcaction.org/
10. Center for Disease Control. http://www.cdc.gov/cancer/breast/
11. Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975;32:311-328.
12. Dorfman, Lori, Lawrence Wallace, and Katie Woodruff. More than a message:Framing public health advocacy to change corporate practices. Health Education & Behavior, Vol. 32 (3): June 2005; 320-336. DOI: 10.1177/1090198105275046
13. Link,BG and Phelan, J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995;35(extra issue):80-94.
14. McCombs, Maxwell.The Agenda-Setting Function of the Press (Chapter 9). In: Overholser, Geneva and Jamieson, Kathleen Hall, eds. Institutions of American Democracy: The Press. Oxford: Oxford Press, 2006.
15. Michigan State University (2008, April 15). Media Coverage of Breast Cancer Focuses Too Little on Prevention, Study Suggest. Science Daily. http://www.sciencedaily.com/releases/2008/04/080415111718.htm
16. Avon Walk for Breast Cancer. www.avonwalk.org
17. Program on Breast Cancer and environmental Risk Factors. Cornell University. 2010. http://envirocancer.cornell.edu/learning/basics.cfm
18. National Cancer Institute. Funded Research Portfolio http://fundedresearch.cancer.gov/search/funded;jsessionid=BC78DC94EFAEDA27F675478235BDB811?action=full&fy=PUB2009&type=site
19. Epstein, Samuel and Liza Gross, “The High Stakes of Cancer Prevention.” Tikkun Magazine, Nov/Dec 2000.
20. Breast Cancer Action http://fundedresearch.cancer.gov/search/funded;jsessionid=BC78DC94EFAEDA27F675478235BDB811?action=full&fy=PUB2009&type=site

21 Nudelman, Janet and Connie Engel. State of the Evidence: From Science to Action. Breast Cancer Fund, 2010
22. Breast Cancer Fund. http://thinkbeforeyoupink.org/?page_id=10
23. Safer Chemicals, Healthy Families. www.saferchemicals.org
24. Dillard, Price James and Michael Pfau. The Persuasion Handbook: Developments in Theory and Practice. Thousand Oaks, CA: Sage Publications, 2002.
25. Siegel, M. and Lotenberg, LD. Chapter 3 in Marketing Social Change: An Opportunity for the Public Health Practitioner, 2nd Ed . Sudbury, MA: Jones and Bartlett, 2007.
26. Bauer, U.E., Johnson, T.M., Hopkins, R.S., and Brooks, R.G. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 2000; 284:723-728.
27. Simek, Simon. http://www.startwithwhy.com/What/TheBook.aspx

Mitigating Climate Change: How Can Public Health Change Behavior When the Public Health Approach Refuses to Change? – Shanta Shepherd

A. Introduction
Evidence clearly illustrates that within the past 5 decades, global climate change has been due to human activity (1). Since industrialization began to take off in the late 18th century and early 19th century, there has been a 29% increase in atmospheric carbon dioxide (CO2), for which developed countries are largely responsible (2). However, even among developed nations, the levels of Co2 emission vary greatly. The average American puts out five tons CO2/year compared to the average Swedish counterpart, who puts out only 1.5 (3). These numbers therefore reflect waste and over usage, not wealth or standards of living. However, with the exception of the successful deleading of gasoline beginning in the 1970s (4), the public health community has yet to influence the public to make any of the widespread modifications necessary to mitigate the potentially impending crisis we are collectively inducing (1, 3). The fact is that many people still, despite the recent disastrous effects that climate change is starting to have on local communities (e.g. Hurricane Katrina, exponential increase in flooding in Norfolk, VA, recent tornadoes in the Midwest), do not believe in the existence of climate change, or are simply apathetic and just do not care (5, 6).
A recent climate change advertisement for the UK’s Climate Challenge intervention aptly stated, “If we could see the gases, the causes of the problem would be obvious to everyone…and if you could see the effects we are having on our planet, you’d do something about it (2).” Unfortunately, we cannot see the gases being produced, and the effects are gradual and far removed, such as in the ocean, or in distant communities. This makes the issue of climate change particularly important and the delivery of public health messages extremely difficult. While many public health interventions have addressed climate change, several components of the current public health approach to climate change serve as major barriers to adaptation, resulting in few successful interventions (7-9).
The United Nations Framework Convention on Climate Change (UNFCCC), a global summit of countries that works to curtail the effects of climate change, has attempted to create plans of action, such as the Kyoto Protocol, in order to control and reduce greenhouse gas emission (1, 4, 8). While this treaty was a step in the right direction, the fact that the US did not ratify it sent two strong messages to the world. First, the Kyoto Protocol put the economic burden of reducing emissions on developed nations, while allowing developing countries, particularly large ones like China and India, to continue to heavily pollute (4). Secondly, the steps required to mitigate climate change were rejected as economically unviable and unsustainable due to heavy dependence on fossil fuels (4). Unfortunately, the US’s stance also set the tone for public response to climate change: people have difficulty making small, yet seemingly expensive, changes in their daily lives, particularly when they will not see benefits from the changes, economic or otherwise, over a long period of time (5, 6, 10). Present savings is a stronger driver than potential gain in the future (5).
Unfortunately, many interventions currently use reducing greenhouse gas emissions as the basis for mitigating climate change and promoting behavior change (1, 3, 4). However, if much of the public has already rejected the idea that green house gases cause climate change, dismissed the relevance of this argument, any intervention with greenhouse gas emissions as a focus will likely be ineffective (1, 5). Moreover, conflict between theories concerning climate change amongst the expert scientists in the field has caused the public to grow skeptical of assertions made by the public health community as a whole (3, 11, 12). As a result, climate change campaigns have been dismissed as erroneous, and the public has continued to use the controversies as a way of rationalizing and validating their current behavior (5, 11). This paper will attempt to explain the reasons why the public health community has been largely unable to effectively influence the public, by presents a brief background of the current state of climate change interventions, three common barriers to the successful delivery of climate change messages within the current public health approach, and an alternative framework consisting of three key components.
B. Background
Models of Human Behavior and Current Interventions
Current public health interventions are generally based on classical theories of human behavior (7, 13). Theories such as the Health Belief Model, Theory of Reasoned Action, and Social Cognitive Theory have long been the archetype for public health interventions (5, 7, 13). These theories fundamentally assume that a person is rational, and that knowledge followed by intention must always precede behavior (5, 7, 13). However, the literature has shown that these theories are largely ineffective in promoting and accurately predicting patterns of behavior and behavior changes in the general population (1, 5, 7, 8, 13).This is due to the fact that these theories are inappropriately applied (1) – promoting behavior change among the population requires a different approach than promoting it among individuals (7, 13).
An example of the inappropriate use of behavioral theories is in the difficulty the public health community has had getting people to stop smoking. The vast majority of smokers are aware of the health risks associated with smoking tobacco, and yet many still do (14). This is largely due to classic cognitive dissonance, in which there is a conflict between beliefs about tobacco and their actions (smoking) (7, 13). As a result of this conflict, they then rationalize their behavior by changing their attitude toward tobacco use – they either focus on the immediate positive results of smoking, change their perception of self risk, or both (7, 13). Thus, interventions that depend on the human mind to make rational decisions will almost always be ineffective, because the very act of rationalizing is irrational (1, 7, 13).
Few public health professionals have ventured from the classical models to innovative alternatives, but with each passing year, more and more do (5-7, 9, 13). Alternative models such as Advertising and Marketing theories, Diffusion of Innovations Theory, and Theory of Hierarchy of Needs, are being used with increased frequency, but still make up the minority of current interventions (7). Evidence has shown these models to be more effective in understanding collective human behavior, thus promoting sustained behavior change amongst populations (5-7, 13). This is because these models work at the group level; they are based on the understanding that human behavior is not always rational, and in fact, it is chiefly irrational – knowledge and intent rarely precede behavior (5, 7, 13).These notions allow the interventions to take advantage of cognitive dissonance by changing behavior first, which forces people to subsequently change their attitude about the behavior, making the intervention a sustained one (7, 13).
Climate Change and the Public’s Mindset
There are many reasons why climate change interventions have been ineffective in mitigating widespread changes amongst the world’s population (1, 4, 15). Some include the feasibility and affordability of their solutions, but for the most part, the limiting factors are in the communication between the public health community and the public (1, 8, 15).The public’s perception of climate change and the way public health messages are framed to the public are major obstacles to the success of interventions (5, 6, 10).
The public’s lack of motivation regarding climate change can be explained in part by the Theory of Hierarchy of Needs, in which there are several levels of need required for personal growth and survival (7, 9, 16). These needs range from physiological basics such as food and shelter, to security and social status, to the highest level, which is self actualization (9, 16). Therefore, people who are concerned with putting the next meal on the table or paying their rent or mortgage do not have the luxury to worry about the effect of human behavior on the planet (16). It simply is remiss for public health practitioners to not take this into consideration.
The fact that the effects of climate change are far removed from the public’s everyday lives further exacerbates people’s lack of motivation to change their behavior (1, 3, 8). The Theory of the Tragedy of the Commons, in which “common spaces” deteriorate as a result of no one wanting to take responsibility for them (5, 7, 13), exemplifies the current stance people have taken today with regard to issues such as rising sea levels resulting from glacial melts. Even people who care about environmental issues use cognitive dissonance to rationalize their lack of response, with the notion that there is nothing they alone can do to mitigate the problems (1, 3, 10).
C. Barriers to Successful Delivery
The public’s skepticism of climate change, and its resistance to behavioral changes, is only potentiated by public health community’s inability to effectively communicate with the public (1). Despite consistent evidence of the ineffectiveness of classical behavioral theories in population-based interventions, the public health community has been largely resistant to changing its own methods and behavior (7). While there are various flaws in the current public health approach to climate change, this paper will focus on three: the concept of climate change is a man-made consequence, the use of fear or alarmism, and the mixed messages being sent out to the public by experts regarding the specific causes and effects of climate change.
The Concept of Man-Made Climate Change
Core values are the ideas or beliefs that people hold dear; they are the basis of all that we do and how we experience, and understand our realities (13). They are how we give meaning to life. These values range from family to freedom and autonomy, love and belonging to fairness and justice, power and youth to rebelliousness (5, 6, 13). While there may be slight differences amongst people in different parts of the world, overall these values transcend cultures fabricating the essence of what it means to live (13).
The belief in man-made climate change is complex. It requires first the belief that climate change exists, and then that human beings are responsible for it. Current public health interventions require audiences to buy into this two-fold belief system in order to be effective (10). This is crucial because there may be, and probably is, a cohort that believes in climate change, but not in the man-made component of the argument, and thus dismiss the message altogether (10). As a result, the only people the message reaches, and for whom the message is effective, are people who already share the common belief in man-made climate change (10, 13). These are the same people who are most likely to be already engaging in environmentally friendly behavior. Because the message may interfere with their core values – their beliefs – many people who could benefit from changing their behavior may outright dismiss the intervention (6, 7, 13).
Public health professionals today often miss this key idea of addressing core values when creating and implementing interventions (13). This is evidenced by the “Above the Influence” campaign, particularly in the early years of the intervention, in which data showed that not only was the campaign ineffective in mitigating attitudes toward marijuana and usage, but that it may have had a boomerang effect, and caused an increase in usage (14, 17). The ineffectiveness of the campaign can be explained by the fact that people who value freedom, a value particularly important during adolescence, will reject messages that take away their freedom to make their own decisions (6, 7, 10). Psychological reactance, which occurs when their freedom is threatened to a larger degree (7), causes them to actively pursue the activity they were urged against as a result of their freedom being so threatened.
The Theory of Hierarchy of Needs also demonstrates that even if a person finds the issue of climate change to be important, more imminent issues such as everyday survival will take precedence (16). If the message does not convey that the behavior change will help in the fulfillment of immediate needs, the public will likely ignore the message (6). This is why public health professionals have such difficulty getting people of lower socioeconomic status to eat healthier – they are not providing a solution that will allow people to work the required two or three jobs needed to make ends meet while getting dinner on the table quickly enough to feed their families (5- 7, 10, 13, 16).
Fear and Alarmism
Classical theories such as the Health Belief Model, upon which the majority of current public health interventions are built, have numerous flaws when applied to mass audiences (7, 13). The first is the assumption that behavior results from very deliberate and rational processes, which take place within an individual’s mind (7, 13). There are various perceived benefits and perceived barriers of a particular behavior, which are then weighed to create the intention of the person, and ultimately lead to a behavior that reflects the intention (7). Factors that contribute to the perceived benefits of a behavior include ones perceived susceptibility to the harms associated with the behavior, as well as ones perceived severity of the associated harms (7). Public health interventions often use fear to capitalize on and increase perceived susceptibility and severity in order to deter individuals from certain behaviors (6, 7, 10).
A recent, yet classic, example of the use of fear to drive behavior change was the H1N1 influenza outbreak. Normally public health professionals struggle to get the public vaccinated. This issue has become so commonplace that hospitals have had to mandate vaccination among their employees. However, when H1N1 first appeared, it was a new and seemingly deadly virus unlike any influenza virus before it, and the field of public health was able to capitalize on the fears held by the public of the severity and susceptibility of the disease that schools closed; shortages of the vaccine put people into a panic. Months later, when the public realized that H1N1 was not as virulent as projected, the resulting decreased perceived severity caused few people lined up for vaccines the following season, setting the stage for a potentially deadly outbreak of a similar strain in the future.
The blowback, or unforeseen damages, of using fear or alarmism can mean the difference between life and death in public health (10). If there is no compelling evidence to support a message, coupled with conflicting messages being sent to the population in the case of climate change, the public health community may be faced with an enormous task of regaining a desensitized public’s trust in them and in the issue at hand (6, 10). The use of fear tactics also tends to drive psychological reactance amongst the population once the realization that the public health community has lied to them occurs, making the job of public health professionals that much harder (10).
Mixed Messages
Despite the fact that the general public still has many incorrect ideas about the science of climate change and that evidence clearly shows that education does not result in behavior change, the public health community still attempts to use education about climate change as a driver for behavior change (6, 7, 13). Details regarding the science of climate change are insignificant with regard to the public (5). While most scientists agree on that man-made climate change exists, many disagree on the details of climate change (3, 11). Outward discussion of the details amongst scientists is crucial for the development of science and technology (3, 6, 10).
Scientists are at odds about whether the planet is warming or cooling (2, 6, 11). They are unsure whether CO2 is the gas most responsible for climate change or if there are others (2, 6, 11). They also cannot agree on the effects of climate change, when they are going to occur, how fast, and to what magnitude (6, 11). This constant argument and lack of leadership makes the field unreliable, and as a result leaves the public unwilling to take seriously, any of the messages (6, 11). However, when public health professionals use the detailed arguments in their messages, and then their arguments are proved wrong by a new theory, the entire field gets discredited (6). At present, “Climategate.com,” amongst other organizations, make a mockery out of climate change experts, and serve as resources to the public (11). Climategate.com provides extensive information and research on the contradicting ideas and messages the public health community has put out regarding climate change since the advent of industrialization (11).
It may very well be that the public is simply looking for any way to discredit climate change messages due to preconceived notions (6). However, where the field of public health goes wrong, is that we focus our attention on the minutia of the issue, rather than on tangible actions, which can only mitigate the problems, whatever they may be (5, 6). The fact is that we are uncertain about the details regarding climate change. Despite false perceptions and uncertainties, the main focus of the public health interventions needs to be the behavior change (6-8).
D. A Framework for a New Approach
Applying Advertising Theory to Public Health
The current public health approach to climate change neglects people’s core values, relies on ineffective tactics such as alarmism to promote change, and frequently sends the public mixed messages about the causes and effects of climate change (5). Advertising Theory is an alternative behavioral theory that has been proven on countless occasions to be effective in promoting behavioral change (7, 13).
Advertising Theory sells the product or idea to the target audience by promising the audience something, which is of desire (13). This desire can be fulfilled through the product. Unlike traditional public health theories, Advertising Theory does not tell the audience to purchase the product; it does not tell the audience what to do (7, 13). Rather, it makes the product something that the audience wants to do, and the packaging around this promise is the audience’s core values (13).
Advertising Theory uses the core values of the target audience to lure them into the message, while simultaneously avoiding psychological reactance (13). In this way, Advertising Theory is proactive, instead of reactive like most classical behavioral theories in public health. Therefore, this theory will make up the basis of the proposed framework to a new public health approach. This framework requires public health professionals to take three major actions: to send out a single coherent message rather than multiple conflicting messages, to understand their target audience using core values, and to ensure sustained behavior change through the use of compelling evidence. These components will help to transform the way the public views issues of climate change by using concrete, solution-centered approaches.
A Single Coherent Message
Conflict among public health professionals has rendered the climate change experts discredited in the eyes of the public (6). These inconsistencies, coupled with alarmist notions that are rarely backed by supporting evidence, not only keep people from engaging in environmentally friendly behavior, but can drive them to engage in increasingly detrimental behavior (5, 6, 10).
Public health campaigns often do a good job of letting the public know expressing the gravity of a situation (7, 8). However, they are unable to provide a clear solution to the problem while giving the public any incentive to do something about it (6, 7, 13). Data shows that people care most about family and future generations and the effect climate change will have on them, which is another source of a framing angle (5, 6).
In focusing on positive solutions, the field will no longer further destroy its reputation among the public by constantly reinforcing preconceptions about the controversies surrounding climate change (6). As a result, the effectiveness of the public health message will no longer depend on changing people’s attitudes about climate change. Rather, the message will directly change their behavior, which is the goal of public health interventions. Once people change their behavior, cognitive dissonance will kick in, and they will change their attitude regarding that behavior, and the change will be sustained. The important thing is that the public health field shifts their focus from anything of uncertainty to only things of certainty (6, 10).
Understanding the Target Audience
Messages that emphasize man-made climate change, make predictions in trends and outcomes of climate change, and speculate as to the exact causes of climate change, have for the most part been unsuccessful (1, 3). Further, the people generally responsive to current climate change messages tend to have already bought into the idea of climate change, and are likely to already be engaging in environmentally friendly behavior (5, 8). This counter-intuitive effect is because traditional climate change messages have tried to impose the public health community’s beliefs on the audience, rather than taking the time to understand the beliefs of the audience, and then appealing to it (13).
Many public health professionals may counter the use of advertising theory in public health campaigns, with the idea that public health messages should not have to be packaged, nor should they be framed to appeal to the audience; people should intrinsically want to mitigate climate change (1, 6). However altruistic this assumption, it is not realistic. The fact is that people respond to messages that align with their beliefs (13). If a person does not believe in the notion of man-made climate change, he will not be responsive to a message with requiring belief in man-made climate change as the core value.
In understanding the target audience, public health professionals will be able to use appropriate values to frame their messages in various ways, giving the messages universal appeal (7, 8, 13, 16). Each message can then be framed in multiple ways. For example, public health professionals selling the use of alternative energy sources can frame their message as either being an opportunity to free the US from oil dependence, for those who value patriotism and freedom, or they could emphasize the importance of legacy and longevity, for those who value family (5, 6, 10). Another option is to take advantage of psychological reactance by deliberately inducing it in the target audience (6, 7, 13). In understanding that people do not like feeling deceived, using psychological reactance can serve as a viable way to get the audience to rebel against a harmful industry.
Ensuring Change with Compelling Evidence
Statistical evidence is generally ineffective in interventions not only because knowledge rarely leads to behavior change, but more importantly the supporting statistical evidence of climate change is bleak and negative (5, 6). When the promise of a message is then supported by evidence, not statistical evidence, but visible and tangible proof that the promise is real, behavior change is likely to be sustained (6).
Effective messages make people feel good (13). Supporting evidence will also show the audience that in buying into the message, the audience will be joining a group of people who also have been able to attain the same goals – the audience joins a movement (6). These movements can grow to influence policy and ultimately change social norms (6).
Having tapped into the audiences’ core values, the only supporting evidence that is required is the proof that the intervention will help them attain their core values (6, 13). This can be conveyed in something as simple as a story. One person or one community’s story, with whom the target audience can relate, can be exponentially more powerful than any statistical evidence (6).
E. Concluding Remarks
There are various approaches to behavior change, each with its own strengths and weaknesses (7). The current public health approach to climate change, however, is ineffective. The climate is changing quickly, and we have adapted too slowly and ineffectively (3).
In order to successfully get the public to buy into the public health message, the public health community must stop trying to force people to change their behavior (6). Environmental health experts must understand and tap into the ideas and beliefs of their target audiences – the audiences’ core values (6, 13).
People want to be a part of something larger than them, and using advertising theory is an effective way to do that (6, 13). In combination with other behavioral theories and approaches, the public health community can facilitate the creation of new social norms. Climate change campaigns can have little to do with climate change, yet induce behavior changes that will ultimately address the issues of climate change (6, 9, 13). Conveying messages to the public is a very delicate matter; one that can easily fail if handled incorrectly. The responsibility of mitigating climate change rests on the shoulders of today’s public health professionals.
 
References
1. Ebi, K. L. (2009). Public health responses to the risks of climate variability and change in the united states Journal of Occupational and Environmental Medicine / American College of Occupational and Environmental Medicine, 51(1), 4-12.
2. Directgov. Environment and greener living. www.direct.gov.uk/en/Environmentandgreenerliving/Thewiderenvironment/Climatechange/index.htm.
3. Donohoe, M. (2008). Roles and responsibilities of health care professionals in combating environmental degradation and social injustice: Education and activism Monash Bioethics Review, 27(1-2), 65-82.
4. Ballester, F., Diaz, J., & Moreno, J. M. (2006). Climatic change and public health: Scenarios after the coming into force of the kyoto protocol. Gaceta Sanitaria / S.E.S.P.A.S, 20 Suppl 1, 160-174.
5. Maibach, E. W., Nisbet, M., Baldwin, P., Akerlof, K., & Diao, G. (2010). Reframing climate change as a public health issue: An exploratory study of public reactions BMC Public Health, 10, 299.
6. Maibach, E. W., Roser-Renouf, C., & Leiserowitz, A. (2008). Communication and marketing as climate change-intervention assets a public health perspective American Journal of Preventive Medicine, 35(5), 488-500.
7. Airhihenbuwa, C. O., & Obregon, R. (2000). A critical assessment of theories/models used in health communication for HIV/AIDS Journal of Health Communication, 5 Suppl, 5-15.
8. Ebi, K. L., & Semenza, J. C. (2008). Community-based adaptation to the health impacts of climate change American Journal of Preventive Medicine, 35(5), 501-507.
9. Evans, W. D., & McCormack, L. (2008). Applying social marketing in health care: Communicating evidence to change consumer behavior Medical Decision Making : An International Journal of the Society for Medical Decision Making, 28(5), 781-792.
10. Moser, S. C., & Ekstrom, J. A. (2010). A framework to diagnose barriers to climate change adaptation Proceedings of the National Academy of Sciences of the United States of America, 107(51), 22026-22031.
11. Climategate. Anthropogenic Global Warming, history's biggest scam. www.climategate.com.
12. Folster, S., & Nystrom, J. (2010). Climate policy to defeat the green paradox Ambio, 39(3), 223-235.
13. Guttman, N. (1997). Beyond strategic research: A value-centered approach to health communication interventions Communication Theory, 7(2), 95-124.
14. Carpenter, C. S., & Pechmann, C. (2011). Exposure to the above the influence antidrug advertisements and adolescent marijuana use in the united states, 2006-2008 American Journal of Public Health, 101(5), 948-954.
15. Ebi, K. L., Balbus, J., Kinney, P. L., Lipp, E., Mills, D., O'Neill, M. S., & Wilson, M. L. (2009). U.S. funding is insufficient to address the human health impacts of and public health responses to climate variability and change Environmental Health Perspectives, 117(6), 857-862.
16. Benson, S. G., & Dundis, S. P. (2003). Understanding and motivating health care employees: integrating Maslow’s hierarchy of needs, training and technology. Journal of Nursing Management, 11(5), 315-320.
17. Hornik, R., Jacobsohn, L., Orwin, R., Piesse, A., & Kalton, G. (2008). Effects of the national youth anti-drug media campaign on youths American Journal of Public Health, 98(12), 2229-2236.

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.

References

1 - Abramson, J.S., Pickering, L.K. US Immunization Policy. JAMA 2002; 287(4):505-509.

2 - Calandrillo, S.P. Vanishing Vaccinations: Why Are So Many Americans Opting Out of Vaccinating Their Children? University of Michigan Journal of Law Reform 2003; 37(2):353-440.

3 - Campion, E.W. Suspicions About the Safety of Vaccines. New England Journal of Medicine 2002; 347(19):1474-1475.

4 - Casiday, R.E. Children’s Health and the Social Theory of Risk: Insights from the British Measles, Mumps and Rubella (MMR) Controversy. Social Science & Medicine 2007; 65:1059-1070.

5 - Chez, M.G., Chin, K., Hung, P.C. Immunizations, Immunology, and Autism. Seminars in Pediatric Neurology 2004; 11:214-217.

6 - Cooper, L.Z., Larson, H.J., Katz, S.L. Protecting Public Trust in Immunization. Pediatrics 2008; 122:149-153.

7 - de Wit, J.B.F., Vet, R., Schutten, M., van Steenbergen, J. Social-Cognitive Determinants of Vaccination Behavior Against Hepatitis B: An Assessment Among Men Who Have Sex With Men. Preventive Medicine 2005; 40:795-802.

8 - Evans, W.D. How Social Marketing Works in Health Care. BMJ 2006; 332(7551):1207-1210.

9 - Feikin, D.R., Lezotte, D.C., Hamman, R.F., Salmon, D.A., Chen, R.T., Hoffman, R.E. Individual and Community Risks of Measles and Pertussis Associated With Personal Exemptions to Immunization. JAMA 2000; 284:3145-3150.

10 - Flanagan-Klygis, E.A., Sharp, L., Frader, J.E. Dismissing the Family Who Refuses Vaccines. Archives of Pediatrics and Adolescent Medicine 2005; 159:929-934.

11 - Fogarty, J.S. Reactance Theory and Patient Noncompliance. Social Science & Medicine 1997; 45(8):1277-1288.

12 - Hughes, V. A Shot of Fear. Nature Medicine 2006; 12(11):1228-1229.

13 - Kennedy, L.H., Pruitt, R., Smith, K., Garrell, R.F. Closing the Immunization Gap. The Nurse Practitioner Journal 2011; 36(3):39-45.

14 - May, T. Public Communication, Risk Perception, and the Viability of Preventive Vaccination Against Communicable Diseases. Bioethics 2005; 19(4):407-421.

15 - Newman, T.B. The Power of Stories Over Statistics. BMJ 2003; 327:1424-1427.

16 - Offit, P.A. Vaccines and Autism Revisited – The Hannah Poling Case. New England Journal of Medicine 2008; 358(20):208-210.

17 – Offit, Paul. Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure. New York: Columbia University Press, 2008.

18 - Offit, P.A., Moser, C.A. The Problem With Dr Bob’s Alternative Vaccine Schedule. Pediatrics 2009; 123:e164-e169.

19 - Opel, D.J., Diekema, D.S., Lee, N.R., Marcuse, E.K. Social Marketing as a Strategy to Increase Immunization Rates. Archives of Pediatrics and Adolescent Medicine 2009; 163(5):432-437.

20 - Pinker, S. Physicians May Have to “Sell” Benefits of Immunization to Sceptical Parents. CMAJ 1999; 161(6):737-738.

21 - Reluga, T.C., Bauch, C.T., Galvani, A.P. Evolving Public Perceptions and Stability in Vaccine Uptake. Mathematical Biosciences 2006; 204:185-198.

22 - Salmon, D.A., Moulton, L.H., Omer, S.B. Factors Associated With Refusal of Childhood Vaccines Among Parents of School-aged Children. Archives of Pediatrics and Adolescent Medicine 2005; 159:470-476.

23 - Street, L.M. Occupational Therapists Views and Beliefs Regarding the Risks and Benefits of Childhood Vaccinations. Occupational Therapy In Health Care 2011; 25(1):65-76.

24 - Wilson, T.R., Fishbein, D.B., Ellis, P.A., Edlavitch, S.A. The Impact of a School Entry Law on Adolescent Immunization Rates. Journal of Adolescent Health 2005; 37:511-516.