Why Emergency Contraception has Failed to Decrease Unintended Pregnancy Rates – Is There a Better Solution? – Danielle Roncari

Introduction

Unintended pregnancies, including those that are mistimed, are a significant maternal and child health problem and comprise 49% of all pregnancies in the United States (1). Women with unintended pregnancies are more likely to recognize their pregnancies late, delay the start of prenatal care, and have unhealthy behaviors during their pregnancy (2). Consequences may also extend to the woman’s own health and socioeconomic status and to that of her family. To this end, family planning public health professionals have piloted many interventions to decrease the rate of unintended pregnancy. Programs ranging from comprehensive sexual education, in-depth contraceptive counseling, availability of emergency contraception (EC), increased contraceptive availability and increased use of long-acting reversible contraceptives (LARC) have all been advocated as potential solutions. Success, however, has been mixed. In particular, improved access to EC including over the counter status and advanced provision, has had little effect on decreasing rates of unintended pregnancy. While increasing the use of LARC may be a promising intervention to decrease these rates. Current use of LARC is extremely low and an effective public health intervention to increase use has yet been proposed.

In understanding why EC has met with such little success, it is important to understand how the method works. There are currently two methods of EC available in the United States, levonorgestrel and ulipristal acetate. Each method works most likely by preventing ovulation. As such, these medications are extremely time sensitive. If they are taken too remote from an episode of unprotected intercourse or after ovulation has already occurred, the potential window to prevent a pregnancy is lost. The levonorgestrel method is most effective within 72 hours of unprotected intercourse, but can be used up to 120 hours and ulipristal acetate can be used up to 120 hours (3 and 4).

In attempting to decrease unintended pregnancies, public health and medical professionals have developed many interventions to increase the use of emergency contraception. Among these interventions, have been advanced provision of emergency contraception and a policy change allowing the levonorgestrel method to be available over the counter to people age 17 and over with a picture ID. Both of these interventions have potentially increased access to the medication but have done little to actually decrease unintended pregnancy rates.

In a Cochrane Review of 11 randomized controlled trials of advanced provision of EC, pregnancy rates were unchanged with the intervention (5). While these results are disappointing, it is interesting to note that these studies did not show an increase in STI rates or frequency of unprotected intercourse among participants who had advanced provision of EC.

Emergency Contraception and the Health Belief Model

So why has improved EC access not decreased unintended pregnancy rates? The methods are effective, with efficacy ranging from 60% to 94% depending on when in the cycle it’s taken (3). One reason for its lack of effect is that EC was never designed to be a long-term method of birth control. It was intended to be a “back-up” method, something to be used for those times when a primary method either wasn’t available or had failed. Public health and family planning experts believed that EC could be a solution to a large number of unplanned pregnancies. However, in order for EC to prevent a large percentage of unintended pregnancies, improved access was necessary because of the time sensitive nature of the medication. Past efforts to improve this access have focused on obtaining over the counter status for EC as well as “advanced prescription” - providing patients with prescriptions or actual boxes of the medication at routine annual exams so it’s available “just in case.” The idea behind these interventions was that it was a lack of access that was preventing the widespread use of EC and hampering its ability to decrease unintended pregnancy rates.

Policies and programs to improve EC access can be attributed to adoption of the health belief model. At the core of the health belief model are the following principles: 1. An individual has a perceived susceptibility to a condition 2. An individual has a perceived severity of a condition and its potential consequences 3. There are perceived barriers by the individual to adopting a particular health behavior 4. There are perceived benefits for the individual to adopt a certain health behavior 5. The individual has confidence in his or her ability to take action and 6. The individual is exposed to factors that prompt action (6). Underlying these principles is the assumption that people behave rationally and are able to weigh the costs and benefits of a behavior in order to choose the appropriate course of action. For EC, this would mean that an individual would understand the negative consequences of unprotected intercourse, would understand the benefit of using EC and the minimal cost to using such a medication and would therefore choose to take the medication. The model also assumes that the individual after using EC would recognize that unprotected intercourse can lead to unintended pregnancy and thus after using EC would obtain more reliable contraception or abstain in the future to avoid this consequence.

We know, however, that EC has not had an effect on unintended pregnancy. It would appear that individuals have not used EC when needed and/or they have not followed up its use with a more long-acting method of contraception. There may be several reasons for this failure, both medical and behavioral. Focusing on behavioral patterns, the health belief model may be a poor choice to determine decision-making surrounding EC and may help explain why improved access interventions have not led to the desired outcomes.

The primary reason that the health belief model has poorly influenced EC use is people are not rational and do not make rational decisions, particularly when it comes to sexual intercourse. Inherent to this model, the individual must understand herself to be at risk of unintended pregnancy. Traditionally, unintended pregnancies are those that are unwanted or mistimed while intended pregnancies refer to those that occur at the “right time” or later than desired (7). These pregnancies, therefore, are caused by a behavior, sexual intercourse that by its very nature is often an unplanned, unintended, or unexpected event. Surveys of college and adolescent students corroborate this view.

College students report a high incidence of unplanned intercourse. In a survey of college students in 1991, 40.9% used either no contraception or withdrawal at first intercourse with 10.1% reporting they did not use contraception because they were not prepared (8). Results among adolescents are similar with 30-38% of adolescents reporting inconsistent contraceptive use (9). Furthermore, we know that 40% of unintended pregnancies are a result of inconsistent or incorrect use of a contraceptive method (10).

These results affirm that intercourse is often unplanned and to expect that people will plan to prevent the outcome of a very behavior that was not intended is unrealistic. And what we know about EC is that it only works if taken immediately after intercourse (or at the very least up to 120 hours after unprotected intercourse). EC is also only effective for a single act of unprotected intercourse; multiple acts will not be prevented by a single course of EC. Some degree of planning is therefore needed even with EC.

A second reason why the health belief model has not been an appropriate model for EC is the individual may have a perceived susceptibility to becoming pregnant that is not in line with scientific principles - the idea that “it won’t happen to me.” We know that EC only works for a single episode of unprotected intercourse. In reality, in a given cycle people may have many such episodes. However, the individual may take EC for one of those episodes and think that they are either protected or not susceptible with subsequent acts. They never follow through after the first episode and obtain more reliable contraception because they do not see the need or the risk in not doing so. In a randomized controlled trial of advanced provision of emergency contraception compared to no advanced provision, adolescent mothers in the intervention group were no more likely to begin another more effective method of birth control at 6 or 12 months (11).

Another reason that the health belief model has failed to be a successful model to predict behavior regarding use of EC is that while unintended pregnancy is something to be avoided by most public health professionals, individuals may not see avoiding this as a beneficial outcome. We know that for some people unintended pregnancy does not mean unwanted and about half of women with an unintended pregnancy choose to continue the pregnancy. Results from the NSFG report that among women who had an unintended pregnancy due to a contraceptive failure, 59% were unhappy or very unhappy about the pregnancy while 25% were happy or very happy (12). Trussell et al suggests that for some women: 1. Planning or intending to become pregnant may be different than wanting to be pregnant: 2. The concept of planning pregnancy may not have the same meaning for all women: and 3. Ambivalence towards pregnancy may lead to contraceptive failure (13).

And while finally, certainly improved access has decreased barriers to EC use, Many individuals may still perceive barriers to using it properly particularly because it has such a short window of action. For example, teenagers under age 17 still need a prescription to obtain EC, an individual may use her one pack of advanced provision and then never keep a second pack available and many pharmacies may refuse on moral objections to stock a medicine despite its over the counter status (14).

In summary, EC has failed as a public health intervention to decrease unintended pregnancies. There are many reasons for this failure and in particular, trying to promote the use of EC with the health belief model is particularly flawed because of the following faulty assumptions:

1. Sexual intercourse is a planned event and done rationally.

2. People have only 1 episode of unprotected sex per cycle and if they have greater than 1 episode, they will begin more effective contraception after using EC.

3. People recognize the negative health consequences of unprotected intercourse and because of these health consequences and their perceived susceptibility to pregnancy make the decision to take EC.

4. With over the counter status and advanced provision policies, individuals no longer face barriers to appropriate use.

Alternative Model to Decrease Unintended Pregnancy

Given that we know sexual intercourse to be an inherently irrational, unplanned behavior, an acceptable model to change behavior would not rely on the rationality of individuals. It would also make use of technologies that don’t require planning with each act of intercourse. LARC, in particular the Mirena and Paragard intrauterine contraceptives (IUCs) and the Implanon contraceptive implant, provide highly effective, temporary birth control that is not coitally dependent and is safe for most users. While technology has developed these highly effective, safe methods of birth control, they have not been widely accepted. New policies need to be developed to promote their use. Social network theory can provide a framework for improving utilization of these devices. Such an intervention based on this theory could use new social media such as Facebook and Twitter along with carefully designed advertisements tailored to at-risk populations that air both during network television shows that are popular with young adults and are printed in magazines read by young adults. This is in stark contrast to current media around these devices which typically depict women in their mid 30s with a family, certainly not the demographic most at risk of unintended pregnancy. These concerted media and online efforts would help spread the message through various social networks that these methods are safe and effective. As a result, use of LARC would increase.

Why hasn’t LARC been widely accepted? According to the National Survey of Family Growth, only 4.9% of reproductive aged women were using an IUC and only 0.08% of women were using an implant (15). Yet LARC is an excellent method of birth control in that it’s safe, doesn’t require the user to remember anything, and has very few contraindications.

In part, this low rate of use is secondary to myths surrounding these methods. Many reproductive aged women or their family members still remember an earlier IUC, the Dalkon Shield, which had higher failure rates than some of its predecessors, unacceptably high rates of septic abortion, hospitalization from severe pelvic inflammatory disease, resultant sterility and even death (16). Implanon conjures up images of Norplant, the preceding long-acting contraceptive implant that was introduced in the early 1990s. Norplant was immediately targeted to low-income women through the work of the Norplant Foundation, which provided 2.8 million Norplant devices a year to these women. Many states targeted low-income women and offered them financial incentives to use Norplant. In Kentucky, women were given $500 and an additional $50 a year for each year they continued to use Norplant. Louisiana paid women $100 per year to use the device. At the same time, women were not told about all of the side effects of the drug (17).

In order to combat some of the myths and fears surrounding LARC and gain more widespread acceptance, social networking theory may be an appropriate behavioral model to frame public health interventions. The theory takes advantage of the interconnectedness of individuals on many levels. In 1954, J.A. Barnes first proposed the concept of the “social network, ” which he described as patterns of connection including bounded groups (e.g. families, tribes) and social categories (e.g. race/ethnicity, gender) (18). This theory has been used to explain many behaviors including contraceptive use, alcohol consumption, obesity, and smoking. In a study assessing the prevalence of smoking of a 30+ year period among Framingham Heart Study participants, smoking cessation appeared relevant to one’s social network with smoking behaviors found more commonly among subjects interconnected by both close and distant social relationships. Furthermore, smoking cessation was more common among participants who had a sibling, spouse, friend, or coworker who had also quit smoking (19).

Today these connections have expanded to include online media such as Facebook, Twitter and MySpace, which have proven to be powerful tools to promulgate ideas and promote behaviors and products. Healthcare is just starting to use this media as well. As an example, one primary care practice in Brooklyn, called Hello Health, uses social media to take the place of many traditional health care roles. Patients can IM a question to the doctor, get an online “visit” for a problem and even read the physicians’ biographies on Facebook (20). In addition, peer-peer education is already occurring on many of these social networking sites. One study on the number of breast cancer groups on Facebook found 620 such groups with activities related to fundraising, awareness, service promotion, and patient/caregiver support. The support groups were the most popular sites on Facebook with the greatest number of posts (21). There remains tremendous opportunity to capitalize on the success of these media outlets to promote health behaviors.

Contraceptive use is particularly prone to influence by one’s social network. Often misconceptions, misperceptions as well as personal stories, dissatisfaction or satisfaction with a particular method are shared among people in the same social network (22). In some social networks, individuals may consider the advice regarding contraceptive effectiveness, side effects, safety and instructions for use to be more reliable coming from those in their network than from health care professionals. In a qualitative study of Latina females on their concerns about contraceptive side effects, women in the focus groups tended to value anecdotal information from peers over that of providers (23). In another qualitative study among a group of postpartum African American and Latina young women, the authors similarly found that the social network played a large role in family planning decision-making. Women often reported that while providers gave accurate information, the stories and experiences of women in their social circle had a more direct impact on their contraceptive choice (22). However, this information from their social network was also used in a positive way to encourage women to choose a more reliable method.

Given the influence that one’s social network has on contraceptive use and knowledge, this network could be exploited by public health professionals to increase use of LARC. If LARC were more commonly used, many of the reasons that improved EC access failed to decrease unintended pregnancy rates could be avoided. First, sexual intercourse is unplanned and often done irrationally. LARC, however, because it is long-acting does not require an individual to plan for each act of intercourse. It’s already in place even during unexpected sexual encounters. Second, EC only works with a single episode of unprotected intercourse. LARC is good for multiple acts without requiring any additional effort on the part of the user. Third, many people perhaps do not use EC because they do not believe in their own susceptibility to pregnancy or do not believe in the negative health consequences of unintended pregnancy. Likely, women’s belief in their susceptibility to pregnancy and their feelings regarding how a pregnancy may positively or negatively affect their lives may change several times during their reproductive life. With LARC, an individual needs to only recognize at one point in time that she is at risk of an unintended pregnancy and that this is not a desired outcome and subsequently visit a provider for a device. After this initial insertion, she needs to then consciously make a decision that an unintended pregnancy would not be a negative consequence and visit a health care professional for removal. In fact, in a study looking at interest in intrauterine contraception among seekers of emergency contraception or pregnancy testing, presumably a population that at the time of their clinic visit recognized the importance of avoiding pregnancy, 85% reported an interest in same-day insertion of an IUC (24). The challenge thus is to capture this group of patients at their most vulnerable time. And finally as compared to EC, while LARC may have a high upfront cost, once the device is inserted or implanted, there are no additional barriers. An individual does not need to visit a pharmacy, see a health care provider or pay any additional cost for effective contraception. In a research setting that eliminated many of these barriers to use of more effective methods, including provider misinformation and cost, 67% of subjects chose a LARC device (25).

LARC has many inherent advantages as a contraceptive method to decrease unintended pregnancy rates. It is safe, highly effective, doesn’t require repeated effort once in place and has no additional barriers to use once it is inserted. This is in contrast to EC, which is user-dependent and less effective. LARC, however, is infrequently used in the United States. The challenge to public health professionals is to develop innovative ways to increase utilization of these methods. Given the inherent unpredictability of sexual intercourse, constantly changing attitudes and emotions surrounding pregnancy, and a lack of understanding of the negative health consequences of unintended pregnancy, an intervention for increasing utilization based on the health belief model would be ineffectual. Furthermore, given that beliefs about fertility, childbearing and contraception are often tied to one’s cultural and social beliefs, social network theory may provide a more appropriate framework for an intervention to improve LARC uptake among at risk populations which would and thus decrease unintended pregnancy rates.

References

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Every Child By Two Campaign: The Failure of Individual-Level Behavior Change – Lauren Kleimola

Rosalynn Carter and Betty Bumpers founded Every Child By Two (ECBT) in 1991 in reaction to the measles outbreaks in the United States between 1989-1991 (1-2). The goal of ECBT is to raise awareness of the need for timely immunizations and provide support for every child in the United States to be immunized by age two. The primary method for achieving nationwide immunization is through education of different sectors of the population. Parents, elected officials, and healthcare providers constitute the three focus areas for the campaign. ECBT also helps to secure funding for programs providing vaccinations to uninsured and underinsured children. Further, ECBT assists the implementation of electronic vaccination registries throughout the country. The objective of the campaign’s approaches is to persuade all parents’ of the critical importance of vaccinations and offer the means to achieve timely and complete immunization. Unfortunately, ECBT is unsuccessful as a behavior change campaign because it does not address the true motivators of and barriers to human behavior. The campaign will not result in nationwide immunization of children without a deeper understanding of the factors that shape parents’ decisions to vaccinate or not vaccinate their children.

Assumes that behavior is rational

The ECBT campaign relies on the Health Belief Model (HBM) to persuade caretakers to vaccinate their children. The HBM theorizes that when individuals make health-related decisions they weigh the threat of the disease and the benefits of an action against the barriers to taking action (3). If the perceived threat of disease and benefits of action are greater than the perceived barriers to the action then the individual will engage in the health behavior, according to the theory (4). Perceived susceptibility and perceived severity are two components of the HBM theorized to determine the degree to which individuals assess the threat of a given disease (5). ECBT attempts to increase the number of parents choosing to vaccinate their children by both amplifying the perceived threat of vaccine-preventable diseases and by decreasing the barriers to vaccination. The campaign increases perceived threat of disease in two ways, increasing perceived susceptibility to and perceived severity of disease. Using the HBM to create behavior change assumes that people logically evaluate risks and benefits before taking an action. Unfortunately, people do not use reasoned thought in order to make rational decisions (6). Therefore, the ECBT campaign relies on the flawed assumption that human behavior is rational when it utilizes the HBM to improve childhood immunization rates.

The campaign increases perceived threat of disease in two ways, increasing perceived susceptibility to and perceived severity of disease. On the ECBT website, a public service announcement titled “Timely Immunizations” uses images to increase caretakers’ perception of children’s susceptibility to disease and audio to increase caretakers’ perception of the severity of the diseases (7). Images of young children covered with the names of diseases, such as mumps and whooping cough, play during the video (7). Visuals that associate children with disease relay the message that children are at risk for, or are susceptible to, these diseases. At the same time, Rosalynn Carter tells listeners that “children still die and suffer from vaccine-preventable diseases,” increasing the perceived severity of disease (7). Attempting to change caretakers’ behavior by amplifying the threat of disease assumes that caretakers are currently unaware of these threats and that once they are better informed, they will make the decision to vaccinate their children.

The campaign also models the HBM by decreasing the barriers to immunization. ECBT minimizes barriers in two ways: helping to secure funding for vaccines and promoting efficient organization of vaccine registries. ECBT funds programs that help make vaccines readily available to uninsured or underinsured children. In doing so, ECBT reduces or eliminates financial burden as a barrier to childhood vaccination. The campaign also provides support to implement electronic vaccination registries in healthcare facilities. Electronic registries of vaccines help healthcare workers to keep track of children’s immunization histories. Improving organization within healthcare facilities promotes timely and complete immunization, reducing inadequate healthcare services as a barrier to vaccination. ECBT employs multiple strategies taken from the HBM to improve childhood vaccination rates, concurrently decreasing barriers to vaccination and amplifying the threat of disease. By creating a campaign based on the HBM, ECBT relies on the assumption that parents will weigh the benefits of vaccination against the barriers to vaccination and make a decision based on the outcome.

The assumption that providing information and increasing access to vaccines will lead to improved immunization coverage is flawed because individuals do not engage in objective and logical thought processing to come to rational decisions (5). A rational decision is one that an individual would make repeatedly, regardless of how a question or situation is presented, or framed (8). However, situational factors interfere with rational thought and consequently alter people’s behavior (9-11). Far from objective, emotion, impulse, and instinct shape human decisions (9-11). Amplifying perceived threat of disease and reducing barriers to immunization are behavior change methods, taken from the HBM, that assume reasoned thought will guide behavior. The ECBT campaign, grounded in the flawed assumption that human behavior is rational, fails to effectively intervene in caretakers’ decision-making processes. Without impacting caretakers’ behaviors regarding immunizations, the campaign will not achieve its goal of increasing childhood vaccination rates.

Frames vaccination using health as a core value

Framing theory suggests that an issue can be viewed from multiple perspectives (12). The perspective with which one views an issue determines the values one associates with the issue and the opinions one forms (13). Therefore, the way in which an issue is framed has a profound impact on the values an individual assigns to the issue and these values will determine individuals’ opinions and behaviors (14). It seems intuitive then that an effective campaign first determines the core values of its target audience, along with its needs and wants, and then frames the campaign according to those values, needs, and wants (15). The Truth campaign, for example, successfully reduced cigarette smoking among teenagers by appealing to teens’ desires for independence and rebellion (16). The success of this program was in stark contrast to the failure of Just Say No campaigns that preached to adolescents about the dangers of drugs (17). In fact, two of five Just Say No campaigns were significantly less effective at reducing adolescents’ willingness to try drugs and improving their confidence in handling situations involving drugs when tested against a control campaign about video and news production (17). The evaluation of past campaigns shows that understanding the values of an audience before developing and using a campaign is essential, as using the wrong values can result in the opposite effect of the desired outcome.

The ECBT campaign uses health as its core value to encourage parents to vaccinate their children. A written message to parents on the ECBT website states, “it is so important to immunize your child on time, every time. Vaccines have saved millions of lives over the years and prevented hundred of millions of cases of diseases” (18). Also available for parents are sections on vaccine safety and descriptions and images of vaccine-preventable diseases. These messages emphasize the importance of immunization to health, a value that past campaigns show is ineffective at prompting behavior change (15).

Past public health campaigns have overwhelmingly tried to change behavior by using health as a core value (19-24). Despite decades of these campaigns, indicators of public health in the United States, such as exercise rates, consumption of fruits and vegetables, and prevalence of obesity, continue to worsen (25). Research on the association between risk awareness and engaging in risky behavior has helped to illuminate that health does not drive human behavior (26-28). Studies show that individuals engaging in unhealthy behaviors are frequently aware of the health risks associated with those behaviors, so lack of knowledge is not the main cause unhealthy behavior (26-28). Knowledge of health risks among individuals engaging in unhealthy behaviors implies that protection of one’s health is not a strong enough force, or value, to change behavior. Understanding that health is not a core value among many populations explains why campaigns using health as a core value have often failed. ECBT, like past failed campaigns, frames its message using health as a core value. Without shifting the frame of childhood vaccines to appeal to the values, wants, and needs of its audience, ECBT will neither change caretaker behavior nor increase childhood vaccinations.

Ignores the context in which behavior occurs

A final critique of ECBT’s campaign strategy is that it ignores the context in which individuals make their decisions. Previously discussed with the irrationality of human behavior, the context in which a decision is made influences the outcome of that decision (29-30). According to social-ecological theory, evaluating the context in which a decision or behavior occurs recognizes that outcomes result from an interaction between situational and personal factors (31). Therefore, public health professionals cannot attribute behavior entirely to the individual, but must consider factors such as the social, political, and economic circumstances acting on the individual. Yet, many public health campaigns aim to change behavior through altering individual traits (e.g. attitudes and beliefs) without accounting for situational factors (e.g. social norms and access to healthcare) that constrain or assist individuals’ ability to change their behavior (32-33).

When a campaign targets only individual traits, as ECBT does, it overestimates the control the individual has in determining his or her own behavior (34). ECBT includes information relating to vaccine safety on its website (35). The campaign is attempting to change individual traits, specifically attitudes toward vaccination, by providing educational materials, without considering the context in which people make decisions. The campaign relies on each individual to make an informed decision regarding vaccine safety in isolation from external influences. As seen through social-ecological theory, targeting only individual traits and not the broader context in which the individual interacts with his or her surroundings does not provide the necessary means for behavior change (31). In fact, addressing fears surrounding vaccines may hinder the campaign’s goal of increasing childhood vaccination rates by reminding parents of reasons why they should not have their child vaccinated, having the opposite effect of what the campaign is hoping to achieve (36).

Trend in social norms is a defining component of the context within which individuals encounter the issue of childhood vaccination (37). Social norms, a set of rules, customs, and values within a society that determine social behavior, are upheld by the “embarrassment, anxiety, guilt and shame that a person suffers at the prospect of violating them” (38-39). After the release of the article by Wakefield et al. incorrectly linking Autism and the MMR vaccine (40), childhood vaccination rates plummeted, falling from 92% coverage in 1995-96 to 80% in 2003-04 in the United Kingdom (41). The downward trend in vaccination spread across the globe, initiating a shift in social norms toward skepticism of vaccines (37). It is crucial for campaigns aiming to increase immunization coverage to understand societal trends. Broadening the study of behavior from the individual to society offers explanations for irrational behavior and provides an alternative means for behavioral interventions.

ECBT’s narrow focus on individual-level behavior change restricts its effectiveness. Understanding that vaccines do not cause Autism is insufficient to change the behavior of individuals feeling shame at the prospect of violating social norms (42). The campaign will not lead to a rise in childhood immunization coverage unless it acknowledges the context in which individuals make vaccine-related decisions by addressing changes in social norms.

An Alternative: The Live Free Club

I propose an alternative to the Every Child By Two Campaign that targets parents of young children as a group and frames vaccination using freedom as a core value. As opposed to using a campaign strategy, I propose a social club for first-time parents and parents of young children. A social club provides a new context in which parents decide whether or not to vaccinate their children, acknowledging that context plays a vital role in determining parents’ behavior. The club name, Live Free, highlights its focus on parents’ ability to retain freedom, a prominent core value, after a child is born (15). The target audience is parents of young children, with a particular focus on first-time parents, living in the United States. The average age at first birth in the United States is 25 and has been climbing over the past four decades, so the club is centered around the values, needs, and wants of parents ranging from their mid-twenties to early-thirties (43).

Live Free believes in the freedom of parents to lead a fulfilling, well balanced, and happy life. The purpose of the club is to allow parents of young children to regain freedom they may feel they have lost after the birth or adoption of a child, or to avoid that sense of loss altogether (45-46). Freedom and autonomy are therefore the driving values of the club and help define the common beliefs of club members. Live Free accomplishes its purpose by connecting parents who live in the same region and providing different services, activities, and benefits. Services include a list of prescreened babysitters and discussion boards for parents to connect with one another. Activities give parents a chance to meet in person and involve trips to sporting events, museums, and hiking trips. Some trips are for parents and children while others are just for parents, showing that life with children can involve social engagements but also recognizing parents’ desires for the social lives they had before having children (45). Membership also includes discounts to local restaurants, gyms, museums, movie theaters, etc., offering relief from the financial restrictions to freedom that come with having a child.

The club starts in select regions of the United States, using the National Immunization Survey to define target areas with the highest vaccination coverage, and then expands to other regions until reaching nationwide coverage (44). Mass media, including television commercials and magazine ads, will promote Live Free. Advertisements have images of young, happy parents engaged in fun activities that highlight their freedom to enjoy life and fulfill their sense of adventure. The mass media strategy recruits parents through social norms, again addressing the context in which behavior occurs. Membership is for individuals who have had a child within the last five years, creating a cohort and sense of belonging among parents, and commit to having their children fully immunized. While commitment to immunization is a part of membership, it is not the focus of the club.

Recognizes that behavior is irrational

Live Free does not depend on human behavior to be rational in order to improve childhood vaccination rates. Live Free invokes social norms and Cognitive Dissonance Theory to change behavior instead of using logic and reason as the ECBT campaign does. The club improves immunization coverage by first changing parents’ behavior, allowing attitude change to follow behavior change. Changing behavior before attitudes does not require parents to be rational. Instead, it models Cognitive Dissonance Theory by relying on parents to react to discomfort incurred by inconsistencies between behavior and attitudes by adjusting their attitudes (47).

Previously discussed in the section on context, social norms influence individuals’ behavior (48). People are driven by a need for acceptance and consequently behave in ways of which they believe others will approve (48). Further, people model their own behavior after observed social norms (48). Frequent and intense media messages can make behavior or values associated with the advertisements appear normative (49). Thus, a high-intensity media campaign using young parents as spokespeople for Live Free will make membership appear to be a social norm. The establishment of membership as a norm will appeal to individual’s desire to belong and follow socially acceptable behavior by also joining. Concurrently, joining Live Free requires that members commit to fully vaccinating their children, making immunization appear to be a norm as well. As human behavior is guided by social norms, parents will join Live Free and vaccinate their children, leading to an increase in childhood vaccination coverage.

After Live Free changes parents’ behavior, cognitive dissonance will change their opinions and beliefs regarding vaccination. Cognitive Dissonance Theory proposes that it is unpleasant for people when two cognitions (ideas, beliefs, opinions) they hold are inconsistent with one another, or in other words, are dissonant (50). If behaviors (which becomes a cognition, e.g. “I am a smoker”) and beliefs are incompatible, an individual will more frequently change their beliefs over behaviors in order to reduce dissonance (51). Similarly, a person will amplify the positive attributes of a chosen decision and amplify the negative attributes of a forgone option in order to reduce dissonance after making a decision (52). Unlike the HBM, “dissonance theory does not rest upon the assumption that man is a rational animal; rather, it suggests that man is a rationalizing animal – that he attempts to appear rational, both to others and to himself” (52). Live Free uses cognitive dissonance by first getting parents to join and committing to vaccinate one’s children, knowing that parents will reduce any dissonance between membership and their previously held beliefs regarding vaccination through attitude change. Live Free takes advantage of parents’ irrationality by invoking social norms to recruit parents and thereby vaccinate their children, then allowing cognitive dissonance to change attitudes toward vaccination of previously skeptical parents.

Reframes vaccination using freedom and control as core values

The failure of health as a value to motivate behavior change indicates that to successfully change health-related behavior, the issue must be reframed using a higher core value (15). Following successful marketing strategies, new parents’ needs, wants, and values are first identified and then childhood vaccinations are reframed according to the findings (53). Previous research indicates that freedom and control are strong core values of new parents (45-46). New mothers report losses of freedom and independence; time for themselves, their partner, and their friends; and control over one’s life (45). Women also indicate strong desires to regain the freedom and control they feel they have lost (45). Similarly, men associate parenthood with a loss of freedom (46).

Live Free reframes vaccination using freedom and control as core values. In order to effectively market childhood vaccination with these new core values, Live Free makes a promise to parents that fulfills their needs and provides support for that promise (15). The promise of Live Free is that if you become a member, you will live a fulfilling, happy, and balanced life and regain the freedom and control that was lost with the birth of a new child. Immunization of one’s children becomes a part of this promise as commitment to vaccinating one’s children is embedded in membership. Just as being a member of Live Free promises freedom and control, so does immunizing one’s children. The support for this promise comes from advertisements. Ads display new parents engaged in activities that parents feel they lost the freedom to partake in when their child was born, such as social engagements with friends or exercising to take care of oneself. Visual images of peers in control of their lives will appeal to parents’ emotions, encouraging them to join Live Free in order to achieve the same level of freedom and control. Reframing childhood vaccination using freedom and control as core values is a more effective way to increase vaccination coverage than the use of health as a core value because freedom and control appeal to the wants of new parents. Live Free increases immunization rates by making vaccination of one’s children a characteristic of members and also fulfilling parents’ desire for greater freedom and control through membership.

Changes the context in which behavior occurs

A final way in which Live Free succeeds in changing parental behavior toward vaccination where ECBT does not is by changing the context in which parents make their decisions. The release of the Wakefield paper initiated a downward trend in vaccination rates and established a social norm of skepticism toward vaccines (37). Understanding that social norms are driving immunization rates, Live Free changes attitudes and behavior at the societal-level instead of at the individual-level. The majority of new parents are recruited into Live Free through diffusion of innovations and their behaviors and attitudes toward vaccination are changed through this new social network.

Diffusion of Innovations Theory separates society members into early adopters, early majority, late majority, and laggards (54). Early adopters are individuals who are willing to take risks and adopt a new idea before the majority (54). Live Free targets the early adopters by initiating the club in areas of the United States with the highest vaccine coverage. Areas with high vaccine coverage will have the fewest number of parents who refuse to vaccinate their children and therefore the fewest number of parents who have negative opinions of vaccines. Intense campaigning in these regions will accrue a foundation of early adopters. Expansion of the advertising campaign, along with the foundation of early adopters, will lead the early majority to join Live Free. Once membership reaches a threshold level, the vast majority of new parents will follow the behavior of others by joining Live Free (55). The threshold level is the point at which the benefit of joining is greater than the cost of joining for a given individual (55). Cost and benefit of joining Live Free can be seen in terms of the social acceptability of doing so. Joining before others is a risk because the social acceptability of Live Free is not yet established. On the other hand, once Live Free is established as a social norm, individuals benefit from joining by partaking in socially acceptable behavior. Once a certain number of people join Live Free, meaning the threshold is met, the benefit is greater than the cost of joining and the majority of new parents will join. While starting Live Free will require intense advertising and specific targeting of early adopters, less intense advertising will be necessary once membership reaches the threshold level.

Live Free serves as a social network for new parents after recruitment through diffusion of innovations. A social network consists of a group or groups of people that develop a pattern of contacts or connections (56). Behavior and other phenomena spread through social networks using connections between individuals (57-58). As early adopters into Live Free are parents who accept the importance of vaccination, and as vaccinating one’s children is a part of membership, adherence to immunization will spread from early adopters to the majority through connections in this social network.

Live Free acknowledges that individuals’ behavior occurs in a broader context and that context shapes behavior. Enlisting Diffusion of Innovations Theory and Social Network Theory as group-level models to change behavior takes advantage of societal influences by changing the behavior of the entire group at the same time, instead of targeting each individual. Changing the behavior of the group also changes the context in which parents’ make decisions regarding vaccination. In this way, Live Free harnesses the ability of societal trends to change the behavior of an entire group and uses it to achieve nationwide childhood vaccination coverage.

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