Sunday, June 1, 2014

Critique of Current Public Health Strategies Against the Anti-Vaccine Movement---Cassie Huang


Edward Jenner pioneered the modern vaccine when he developed the smallpox vaccine in 17981. Since then, vaccines have been a cornerstone of public health and the prevention of communicable diseases. The current measles, mumps, and rubella vaccine (MMR) was licensed for use in the United States in 1989 and is administered in countries all over the world, from the U.S. to England to Madagascar.2 Vaccinations have dramatically reduced the burden of disease all over the world and have led to the eradication and near-eradication of two debilitating, fatal diseases smallpox and polio, respectively.
The MMR vaccine should be administered to children at 12 - 15 months and later a second dose at 4 - 6 years.2 The majority of parents comply to these recommendations by the CDC, as it is understood to be beneficial to their children’s overall health. However, there is a small faction of people who refuse or delay the vaccine existing in pockets throughout the United States. This anti-vaccine population is alarmingly growing, and outbreaks of measles have been occurring at greater magnitudes and higher frequencies. There was an outbreak of measles in San Diego in 20083, as well as a current outbreak in New York City5. California is one of 19 states that allow personal beliefs to exempt children from school-required immunizations, and as of April 2014, there has been a staggering 49 cases of measles reported so far this year in California. This number is over 10 times the total number of California cases reported in 2013.4
This decline in vaccinations was sparked in large part by a 1998 study published in the highly regarded British medical journal The Lancet that linked MMR vaccination to autism.6 Although this study was officially retracted in 2010, twelve years after its publication and made headlines for its retraction7, distrust and fear of the MMR vaccine lingers. Parents’ refusal of the vaccine for their children has led to decreases in herd immunity and subsequent outbreaks in communities with highly accessible healthcare options.4 Measles is a highly infectious disease that can lead to fatalities in children and miscarriages in pregnant women and had been considered eradicated in the United States in 2000.4
Despite the leaps and bounds made in this century with the development of vaccines, this increase in vaccine refusals is becoming a concern in the medical community. It is bringing back entirely preventable diseases like measles to countries with accessible healthcare.8 This paper will critique and provide recommendations on three branches of this issue using social and behavioral theories, focusing on the lack of a nation-wide campaign, framing of the issue, and the medical community’s education strategy.  

Critique 1: Lack of a Strong MMR Vaccine Campaign
Although the medical community has debunked the myths and unfounded beliefs purported by anti-vaccine supporters, the media continues to work in the favor of the anti-vaccine campaigners. Because most U.S. citizens generally support vaccines, there lacks a nationally publicized vaccine campaign for common childhood illnesses. There is no public voice backing the MMR vaccine, so it is easier for anti-vaccine anecdotes and examples to be sensationalized.
The anti-vaccine supporters spread their claims by catering to the emotions of people. The media chooses stories that are compelling and attention grabbing. It is not news if a child receives a vaccine and does not get sick; however, it is newsworthy when a child receives a vaccine and has highly negative effects. These repercussions grab attention because they differ from the norm, and it is easy for media outlets to publicize these stories. The law of small numbers is a social science theory that explains the power behind these individual examples.9 People think irrationally when they perceive risk. We tend to view a small sample randomly drawn from a population as representative of the whole. This leads to over-confidence in the validity of conclusions drawn from small sample sizes.9 The facts and statistics that many public health campaigns utilize do not ring as true as an individual story demonstrating an exception to the rule.10 An emotional retelling of a family that was hurt by a vaccine is more compelling than an unemotional, fact-driven explanation of the need for vaccinating children at a young age to prevent illness later.
If parents choose not to vaccinate their children, they are aware that their children may get a disease. Why would parents voluntarily place their child at risk for this? The theory of optimistic bias explains the phenomenon that people tend to think that they are invulnerable.11 We expect others to be victims of misfortune, but not us ourselves.11 Though it is human nature to be optimistic and hopeful, it is partly due to this optimistic bias that leads parents to refuse childhood vaccines for their children. Additionally, the media tends not to cover the deadly symptoms of measles and rather focuses on the potential threats brought on by vaccinations. Most parents in this day and age have never experienced or seen measles, mumps, nor rubella25, so the illnesses are more of an abstract idea than a life-threatening reality. They may underestimate the severity of these childhood diseases. Autism is a more salient focus, as it is a more contemporary, and widely discussed disease than measles.
The illusion of control also plays a role in parents opting out of the recommended vaccinations for their children. This theory defines the phenomenon where people tend to expect a probability of personal success inappropriately higher than the objective probability of success, especially when people are led to believe that personal skill is involved.12 Parents who choose the no-vaccine route are often of higher socioeconomic status and are informed on the perceived risks of the MMR vaccine. However, they choose to refuse the vaccine for their children.13 Because they are making this informed decision themselves, whether after copious research or through hearsay via friends or media outlets, parents feel a sense of control that their children will not get a disease.

Critique 2: Weak Public Health Frame

The way an issue is framed has a profound impact on how it is viewed. A positive frame put in the right context will affect how a person perceives the issue, and a negative frame on the same issue can change the person’s perception of the issue.14 This is actually biologically based, and the changed perception is real.15 In this case, the frames used in the anti-vaccine argument are much more salient and tap into emotion and fear.
Doctors and the rest of the medical community insist that vaccines are safe and well developed, and that every child should receive these vaccinations20. Most medical professionals would agree that the benefits of a receiving a vaccine highly outweigh the risks of getting the disease. The CDC site lists several facts and figures about vaccines, statistics16 that are not as compelling as stories. However, because there does exist minimal risk, it is human nature to fixate on these risks and want to know more about them. The law of small numbers9 supports this idea, and a sensationalized story or two can easily sway people into distrusting vaccines.
The anti-vaccination groups call into question the scientific claims that vaccines are safe. They utilize fear of the unknown and use anecdotal evidence to support their claims against the science. When the study linking autism to the MMR vaccine was published, media outlets framed it as an outrage based upon core values such as freedom, justice, autonomy, and fairness. The media was easily able to induce a loss of trust between patients and authorities on medicine because the frame elicited such fear26. Though health is not a strong core value, the health of loved ones, especially one’s children, ranks much higher.
Many supporters of the anti-vaccine movement invoke naturopathic and homeopathic medicines as well as reasons to distrust the large conglomerate of Western medicine.27 Conspiracy theories are a common tool to incite distrust in the use of vaccines and the doctors who administer them. They use frames that stress people’s autonomy to choose their own paths, and support counter-cultural thinking.
Social norms are very powerful. People who choose not to vaccinate their children often exist in small groups throughout the United States. An outbreak that occurred between March and June 2013 was isolated in a small orthodox Jewish community in Brooklyn. A total of 58 cases of measles were reported, all within this community. Measles was brought in by a teen returning from abroad, and then the disease was propagated in the community by a few extended families that refused MMR vaccination.17 This is an example of how a community group can influence individual thinking and decision making.
In some of these pockets of anti-vaccination, religious reasons are the main basis behind their thinking; however, others are based in counter-cultural thinking. In these counter-culture movements, the social norm is to reject professional opinions and scientific data in favor of forging one’s own path and utilizing alternative medicine in the name of children’s health. In the theory of reasoned action and the theory of planned behavior18, two health behavior models, social norms are pivotal in changing one’s behavior. Opinions of others and how much those opinions matter influence the behavior of one person. If other parents in a preschool or on one’s neighborhood block are also rejecting vaccinations, it is likely that a parent may also decide to go the anti-vaccination route. Social learning theory further supports this phenomenon, in that people behave as they see others behave in their cohort.19 As a result, parents will behave irrationally and reject the advice given by their pediatrician if their communities lean towards anti-vaccine. It is plausible that this kind of social influence is contributing to more and more measles outbreaks in the United States and other countries where MMR vaccines are routinely given.

Critique 3: One-way Communication Regarding Vaccines
When a pediatrician encounters parents that refuse to have their child vaccinated, the main recommendation by the American Academy of Pediatrics is to listen to their concerns and reiterate the benefits and minimal risks of being vaccinated. The pediatricians are encouraged to explain the risks of receiving the vaccine and the risks of being unimmunized in the context of the community.20 As previously described, conveying risk via facts and statistics does not have the effect it rationally should, as people act irrationally.9, 11 We tend to respond to individual stories, which the anti-vaccine supporters use, rather than statistics.9
Parents and doctors perceive vaccines and treatment differently. The general population would rather choose passivity (no vaccination) whereas doctors will choose active treatment for the child.23 This concept of omission bias23 is particularly applicable to vaccine administration. We tend to favor omissions rather than commissions, especially when either one may cause harm.23 We also tend to withhold action when missing information about probabilities is salient, such as whether the child to be vaccinated is in a risk group susceptible to harm from the vaccine. The information cannot be obtained, and this ambiguity prompts inaction.23 Whether influenced by social norms, misinformed research, once parents are fixated on possible risks associated with vaccines, these two theories support their reluctance to follow the doctor’s recommendation.
Furthermore, when parents speak with doctors, they may feel inferior or that the doctor is being condescending. Doctors are discouraged from conveying condescension, but they are an authority figure that can elicit negative feelings in some people. People generally value personal freedoms very highly, and when people think that a freedom is threatened, they experience psychological reactance.21 They react by doing the opposite of what is suggested in order to help them feel as if they have control over the freedom that was threatened.21 In this case, doctors pressuring parents to allow their children the MMR vaccine threatens personal autonomy, and may cause some to reject the doctor’s recommendations.
For some, doctors are not perceived as peers; rather they are perceived as authority figures or perhaps for some, a foe that wants to inflict unnecessary pain and illness upon their children. The anti-vaccine message is spread through the grapevine: from parent to parent, from media figures, even celebrities. Psychological reactance decreases when the message is received from a peer or someone who seems to share commonalities.21 A few celebrities have been in the news during the past decade, supporting and spreading the message against vaccination. Parents are more likely to be open to messages put forth by their peers or someone like Jenny McCarthy, people they can relate to.
If a patient does not take a doctor’s recommendations, the doctor is legally allowed to dismiss the family from the practice. This is considered a last resort.22 However, when a dismissal does occur, this enhances the distrust and reactance the parent had towards the doctor. They are likely to lose even more trust in medical establishments and be pushed more towards the anti-vaccine movement, which is the opposite of what the medical community wants; that is, the best health for the child in question.

Proposed Interventions

In order to turn this vaccination dilemma around and get people back on board with childhood vaccination, we must take back the issue from the anti-vaccine side. We lack an effective, prominent vaccine campaign, whereas the anti-vaccine side has celebrities and media outlets spinning the stories for them. A pro-vaccine frame should be developed and marketed using the same highly core values as the anti-vaccine side used, but using them in our favor. Lastly, doctor-to-patient discussion should be improved in a way that uses fewer statistics and more stories, making it easier for parents to decide to allow vaccines to be administered to their children.

Intervention 1: Create and Publicize an Effective Vaccine Education Campaign

Pro-vaccine messages need to be displayed more in high traffic areas with children and parents, such as schools, preschools, buses, playgrounds, and toy stores. This could promote discussion regarding vaccines from parent to parent, peer to peer, allowing pro-vaccine messages to be spread through the grapevine rather than the anti-vaccine message. The campaign should employ happy images, with smiling children and parents of all kinds. Basic marketing and advertising theory is based on what the consumer wants28: in this case, most parents want their children to be happy and healthy, and getting or not getting vaccinated is just one step towards that. By addressing this fundamental need that parents have and designing a campaign that speaks to it, the campaign may be more successful.
Vivid support and evidence is necessary for a successful campaign – warm, happy colors, depictions of smiling families convey the promise that the MMR vaccine will lead to better health. Too often, public health practitioners and campaign managers follow their Health core-based intuition in what people should want.28 For an effective campaign, the designers must base their strategy on market research and know the audience that they are trying to reach and influence.28 By dropping the core value of health and invoking more effective values like community, autonomy, and justice – similar core values to the anti-vaccination cores – the pro-vaccine campaign could overtake the arguments that those against vaccines use.
Creating a public health “brand” for the campaign would further emphasize the promise that is marketed with getting the MMR vaccine.28 It is essentially an identity concurrent with the core values that people can connect with and associate with the vaccine and the promise of a healthy child and a healthy family.
Employing celebrities and other relatable, respected public figures to bring the pro-vaccine message to the general public would help decrease psychological reactance.21 Asking someone as influential as Oprah Winfrey, Gwyneth Paltrow, or Michelle Obama to support the campaign would garner a lot of interest and discussion, hopefully leading to the social norm of accepting vaccinations rather than rejecting them. Targeting the right audience is extremely important in getting this message across. Many of the pockets of anti-vaccine supporters are of higher socioeconomic status or of certain religious beliefs, and each campaign should be tailored to each group’s needs and wants.28 Having religious leaders support vaccines and promote discussion about the benefits and few risks would be particularly useful for those who decline vaccines due to religious beliefs.
The use of facts has been shown to be less effective than sensationalized stories.9 Individual anecdotes from parents who have had unvaccinated children get the measles would be more effective than listing the many benefits of the MMR vaccine. More information about the severity of the measles disease should be conveyed, but only through stories, so as not to invoke reactance.

Intervention 2: Reframe the Issue and Change Social Norms

Public health interventions often base their frame on the core value of health, but that is not a salient value.28 People respond better to core values of fairness, justice, and community.24 The social contract and social norms within a community are very powerful in influencing people’s behavior, as shown in the social learning theory.19  
Herd immunity is a large reason why vaccines have been so effective in preventing diseases in this century. Even if one child is unimmunized, because every other child is, they are protected because the disease does not exist in that community for the unimmunized child to contract it. Measles outbreaks are commonly sparked by an international traveler inadvertently bringing the disease into the community.17 However, herd immunity only works if almost everyone in the community is vaccinated. By re-framing the issue and taking back the justice frame from the anti-vaccine side, public health practitioners could frame universal vaccines as a form of fairness. It would not be fair for other children to contract measles just because one family decided not to vaccinate their child. Or, phrased another way, it would only be fair for every child to receive the vaccine, and then everyone would be protected and be subjected to the same physical discomfort and payments. This idea of collective responsibility and adhering to the social norm of MMR vaccination can be very powerful in convincing parents to have their children vaccinated.

Intervention 3: Improve Communication
Doctors cannot be seen as the enemy. They should be trained in other social and behavioral persuasion techniques in order to convey their message of vaccination to a more receptive audience. Psychological reactance is a natural human trait that is brought on when someone whom they cannot relate to conveys the message.21 Authority invokes significant reactance, making parents feel as if their autonomy to make decisions is being threatened.21 Doctors and other medical health professionals should deliver their message in a way that is nonthreatening and respectful of parental autonomy and freedom of choice. By providing parents with pamphlets in the waiting room with leading pro-and-con lists for either vaccination side, one could manipulate illusion of control12 and create a feeling of ownership of the decision to vaccinate their child, all before the parent and child see the doctor.
When pediatricians do speak with parents about vaccines, instead of listing off facts and statistics of the benefits of MMR vaccination,20 they could have individual stories of unvaccinated children falling ill and spreading measles to other toddlers in a daycare center, or of a pregnant woman contracting measles and miscarrying.17 These stories would invoke the law of small numbers,9 and help parents visualize repercussions of not receiving the vaccine, and steal focus from the stories used to support the anti-vaccine argument.
Public health practitioners and medical professionals should be able to facilitate discourse about vaccines, and listen to all sides and reasons for and against vaccination. By hearing all the sides and addressing concerns about safety, health, and links toward autism in an open environment, practitioners can decrease reactance and increase trust, thus leading to more immunized, healthy children and communities.


The availability of vaccinations is only increasing in the United States and many other countries in the world. However, in the United States and other countries of similar economic development status like England and Canada, outbreaks of measles and very preventable childhood diseases are becoming more numerous. Global travel aiding the travel and transport of these diseases is exacerbated when children are not immunized against these common childhood diseases. Herd immunity is key to preventing outbreaks, but there exist small communities of people who have decided to refuse the MMR vaccine for their children. In this way, the greater community is placed at risk of disease.
Re-framing the issue, addressing parental concerns, and dispelling the autism myth all while respecting parental freedom is the best public health strategy to prevent further outbreaks of this vein. Encouraging open dialogue between parents and pediatricians and promoting vaccination using marketing with a brand can help sway parents back toward the pro-vaccine side and strengthen the social norm of getting vaccinated as a child.

1. Riedel S. Edward Jenner and the history of smallpox and vaccination. Proceedings (Baylor University Medical Center) 2005; 18(1): 21-25.
2. Centers for Disease Control and Prevention.  Measles: Make sure your child is fully immunized. Atlanta, GA: National Center for Immunization and Respiratory Diseases: Division of Viral Diseases, 2014.
3. Centers for Disease Control and Prevention. Outbreak of measles – San Diego, California, January-February 2008. Morbidity and Mortality Weekly Report 2008; 57(8): 203-206.
4. O’Connor L. California measles outbreak highest since it was declared eradicated, and it’s only April. Huffington Post: Healthy Living, 2014.
5. Associated Press. New measles case confirmed in New York City. ABC News, 2014.
6. Wakefield AJ, Murch SH, Anthony A, Linnell J, et al. Retracted: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. The Lancet 1998; 351(9102): 637-641.
7. Hensley S. Lancet renounces study linking autism and vaccines. National Public Radio: Shots Health News from NPR, 2010.
8. Sugerman DE, Barskey AE, Delea MG, Ortega-Sanchez IR, et al. Measles outbreak in a highly vaccinated population, San Diego, 2008: role of the intentionally undervaccinated. Pediatrics 2010; 125(4) 747-755.
9. Tverskey A, Kahneman D. Belief in the Law of Small Numbers. Psychological Bulletin 1971; 76(2): 105-110.
10. Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. JAMA 1999; 281: 1019-1021.
11. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39: 806-820.
12. Langer EJ. The illusion of control. Journal of Personality and Social Psychology 1975; 32: 311-328.
13. Smith PJ, Hurniston SG, Marcuse EK, et al. Parental delay of refusal of vaccine doses, childhood vaccination coverage at 24 months of age, and the health belief model. Public Health Reports 2011; 126(Suppl 2): 135-146.
14. De Martino B, Kumaran D, Seymour B, Dolan RJ. Frames, biases, and rational decision-making in the human brain. Science 2006; 313: 684-687.
15. Williams LE, Bargh JA. Experiencing physical warmth promotes interpersonal warmth. Science 2008; 322: 606-607.
16. Centers for Disease Control and Prevention. Q&As about vaccination options for preventing measles, mumps, rubella, and varicella. Atlanta, GA: National Center for Immunization and Respiratory Diseases, 2014.
17. Centers for Disease Control and Prevention. Notes from the field: Measles outbreak amoung members of a religious community – Brooklyn, New York, March – June 2013. Morbidity and Mortality Weekly Report 2013; 62(36): 752-753.
18. National Cancer Institute. Theory at a glance: a guide for health promotion practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896).
19. Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1: 7-21.
20. Diekert DS. Responding to parental refusals of immunization of children. Pediatrics 2005; 115(5): 1428-31.
21. Silvia PJ. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27: 277-284.
22. Diekert DS. Provider dismissal of vaccine-hesistant families: misguided policy that fails to benefit children. Human Vaccines and Immunotherapy 2013; 9(12): 2661-2.
23. Ritov I, Baron J. Reluctant to vaccinate: omission bias and ambiguity. Journal of Behavioral Decision Making 1990; 3: 263-277.
24. Menashe CL, Siegel M. The power of a frame: an analysis of newspaper coverage of tobacco issues – United States, 1985-1996. Journal of Health Communication 1998; 3(4): 307-325.
25. Centers for Disease Control and Prevention. Overview of measles disease. Atlanta, GA: National Center for Immunization and Respiratory Diseases, 2014.
26. Flaherty DK. The vaccine-autism connection: a public health crisis caused by unethical medical practices and fraudulent science. The Annals of Pharmacotherapy 2011; 45(10): 1302-04.
27. The Healthy Home Economist. Six reasons to say NO to vaccination., 2010. Retrieved 5 May 2014.

28. Siegel M. (2014, March). Advertising and marketing theory. Social and Behavioral Sciences for Public Health, Spring 2014. Lecture conducted from Boston University School of Public Health, Boston, Massachusetts.

Using Antibiotics to Death: Current Public Health Policy Model Failures and Posed Improvements for Antimicrobial Resistance – Philip Sullivan

Antibiotics were developed and refined at the start of World War II to supply the government with a means of treating wounded soldiers with increasingly dangerous and previously untreatable illnesses (1). As production streamlined, public access increased and thus the first signs of treatment failures and resistances started to appear (2). Antimicrobial resistance is the natural evolution of microorganisms to gain methods of rendering current, effective antimicrobial agents ineffective for the treatment of illness (3). As standard treatments for infection lose effectiveness, diseases are able to spread more widely and aggressively, limiting the variety of safe and effective antimicrobial agents. Importantly, improper use of antimicrobial agents speeds the natural evolution of resistance, spreading it throughout human populations.
Due to the noticeable emergence of resistant microorganisms, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the World Health Organization (WHO), the Institute of Medicine (IOM), and the medical c0mmunity as a whole, began monitoring the type and quantity of ever-increasing resistance bacteria, viruses, fungi and other microbes that humans interact with (3–7). The medical and public health community have increasingly criticized the lack of direction and control around historical antimicrobial application, forcing discussions on responsibility of administering the drugs (8–11). The most vocal critics call the situation a ticking time-bomb (6,12,13).
In response to community outcry and the need for study and policies to slow the spread of resistance, the CDC, WHO, NIH and other governing medical bodies have created programs and initiatives to address the spread of antimicrobial resistance; The CDC created the “Get Smart” Campaign (14), The NIH’s NIAID (National Institute of Allergy and Infectious Diseases) group created the “Antibacterial Resistance Program” (15), The WHO started its Antimicrobial Resistance informative webpage (3). These organizations provide education materials, resource links, surveillance data, and other resources, covering a range of audiences from the general public to governing health officials. A public health plan has also been created by an interagency task force headed by the CDC, FDA and NIH (16,17). This incorporates each agency’s individual measures and provides communication between them for improved reporting. In addition to education initiatives, non-medical applications of antimicrobials have come under increased scrutiny.  The US Food and Drug Administration (FDA) recently increased their involvement in controlling the spread of resistance through newly proposed guidelines for farming and agriculture (18).
The overall goal of public health initiatives is to prevent spreading antimicrobial resistance by lessening unnecessary selective pressure on microorganisms. These efforts will extend the utility of current treatments and allow time for new developments in fighting diseases (3,7). Current efforts are necessary and well intentioned, but significant progress will not be made unless improvements are made in the approach of the medical community’s fight against rapid development of antimicrobial resistance. These arguments are laid out in the remainder of this commentary.

The First Flaw with Current Initiatives
Multiple reports note that programs like the CDC’s Get Smart campaign and the NIH’s Antibacterial Resistance program place most of their focus on the hospital, professional, research, and medical education settings (16). Few resources address the public, and arguably the most important setting, the physician-patient interaction point. Teaching medical students in training, re-educating professionals with continuing education opportunities, and hosting medical society discussions have not done enough to face the growing resistance issue. The medical system is only a portion of the problem.
Historically, the medical system is proficient at changing protocols based on results of scientific studies, but with extremely varied momentum. This variability in time for policy adoption has many factors, some stemming from personal characteristics of healthcare personnel (19–21). These characteristics include individual behaviors and feelings, and their participation in creation of the new policies. While the intentions behind new protocols to face resistance are well understood, the management of medical personnel and patients in an abrupt and authoritative manner leads to psychological reactance (22). Psychological reactance is an individual’s response to perceived loss of freedom. For example, if a new policy that prevents over-prescription of a certain drug is put in effect, a physician who favors that agent for treatments may not agree with the policy and ignore it. Even if the physician understands why he or she is being forced to change prescription habits, the physician may feel some level of agitation and anger with the loss of a choice. This example demonstrates how intentions, even when fully understood, may not translate into directives being followed. Responsibility as a dictated policy creates the perfect environment for non-compliance of procedure.
Instituted stewardship may prevent irresponsible prescription and dispensing of agents, but does not address psychological reactance. Stewardship circumvents reactance and cannot replace guided collaboration. Reactance in professional settings, physician-physician relations or system-physician relations, is one area of concern, but the physician-patient interaction presents a larger reactance opportunity.
During care provider meetings, individuals ask for specific treatments and testing based on previous knowledge gained from commonplace talks, waiting room magazine ads, or Internet based searches. Without sufficient time and energy (23) going to the patient-physician interaction, the way information is relayed to patients changes. For example, quickly instructing or dispensing a sheet of instructions, on why and how to take medication leaves patients with no alternative to a “do as you are told” situation, instigating feelings of reactance. Patients have also been known to ‘doctor shop’ and look for a physician that agrees with their viewpoint and wishes, and provides them with what they ask. Such as situations where sufferers of the common-cold seek out antibiotics, even with known viral infections. This is not to be confused with comfortableness of care; this is the patient seeking out a treatment and not an understanding (24,25).
The ways in which the medical community is attempting to police itself and face the antimicrobial resistance issue most closely fit with social learning (social cognitive) theory (26). The Get Smart campaign promotes intra-professional action with resources for stewardship initiation and promotes hand-washing policies that fall under the control of hospital or system Infectious Diseases leadership. Social learning theory takes into account learning behavior and modeling one’s self after others, and also can include the effects of self-efficacy on outcomes. This model unfortunately still allows for irrational decisions and does not remove the individual as the main controller of outcomes (27,28). Reasoned and planned action does not preclude an outcome from being irrational and inconsistent when the individual is left in control.

The Second Flaw in Current Initiatives
A comparison of a transtheoretical model (explained in steps a-e below) to the medical community’s stewardship approach, as well as other initiatives, is readily visible and should not be ignored.  A part of the transtheoritical model is the assessment of physician’s readiness to accept change.  Transtheoretical modeling relies on individual patient facing physicians to follow rationally planned behaviors.  
Core elements of the CDC’s listed stewardship example are Tracking and Monitoring, with measures that relate to cost and level of antibiotic use to show how well targets are met and what might need to be changed to meet them (29). The medical community and governing agencies follow transtheoretical modeling: with their pre-contemplation phase of (a) thinking about initiating action to change growing antibiotic resistance; contemplation phase of (b) meeting to discuss the issue and possible actions; preparation phase of (c) planning out possible actions, and making preparations to carry-out selected actions; action phases of (d) implementing policy and programs; and checking the maintenance needed with (e) efficiency and results of implemented actions (30). This cycle repeats often and has slowed forward movement with discrete steps. This model also provides some comfort to the medical community because of its likeness to the scientific method. There are stages of planning, measuring and experimentation to prove a hypothesis, with results adding to the knowledge base and allowing for a change in hypothesis and retesting(31). This comfort is unfounded though, because the scientific method does not need to account for human behavior and emotion like the transtheoretical model. Patient treating physicians may be unwilling to adhere to new prescription protocols due to emotional attachments and limited views on positive evaluations, or limitations of a policy that the transtheoretical model underestimates.
A Third Flaw with Current Initiatives
Planned behavior modeling in public education campaigns rely on people acting rationally, such as anti-smoking ads and healthy diet information campaigns (32–34). While it is helpful to think that providing relevant information to the public and explanations of the information is sufficient, individuals irrational behavior is not accounted for, which can  lead to lower than theoretical efficiency.  Planned behavior cannot account for how individuals act in “hot” mental states (35). A “cold” mental state would be the rational, planning state of mind individuals are in, but when they are “hot,” on the spot or agitated, plans are not followed. The rational situations patients encounter are ones where they learn information about viruses and illnesses in a receptive mindset. However, when a patient enters a hot state they cannot predict or always understand their behavior. Failure to implement or follow a planned cold state action is imminent; like ignoring explained information on drug effectiveness, time for action, or duration of treatment when a patient falls ill and suddenly starts demanding drugs and treatments. Mental perception and self-efficacy changes again when patients start to feel better and they stop taking medications they once agreed they needed to finish completely to recover fully.  Stopping a course of antimicrobials before the treatment plan is finished leads to antimicrobial resistance by not allowing the body to clear the infectious agents completely, creating a reservoir of resistant, infectious microorganisms.  Therefore, planned behavior model dispensing of information, with individual level targets, and without properly accounting for other individual factors and social influences, will not work to alter the future of antimicrobial resistance.

Proposed Changes to Make Effective Interventions
Overall, individual modeling and inadequate social approaches have been employed in an attempt to alter the course of a national and global problem. Correction of flaws discussed above can be achieved with different theories that apply to large-scale groups, like social networking theories, and alternative individual modeling, like labeling theories, that account for irrationality and end user variability. Proper attention and effective outcomes can be gained without losing the health information at the basis of the message by changing the modeling and campaign approaches.

Intervention Change of Flaw 1
By applying a social network approach to responsible use and dispensing of antimicrobial drugs, stewardship can become self-promoting and spread in the medical community.  Granovetter (35) demonstrated that there are different tie strengths within a social network (strong, weak or absent).  Strong ties consist of close friends or family members.  However, weak-ties have the ability to spread information over a large social network (36). Targeting a few small networks can spread information faster and more easily than targeting important individuals with strong-ties. Since this interaction is also through peers, psychological reactance is minimized (37). Routine interactions by medical staff can reinforce new common policy and reasoning behind it once adoption begins and evolves.
A program based on social networking can employ branding and labeling strategies to gain more traction within the medical community. Creating a brand of antimicrobial responsibility allows individuals and networks alike to label themselves as something new and different (38). By labeling themselves and their networks, medical staff have a greater likelihood of living up to those labels and achieving cognizant, responsible used of antimicrobial drugs (39–41). Something as simple as gold pins and stickers in the shape of pills for self-labeling and a mantra like “I am a responsible physician, so I utilize precious antimicrobials responsibly,” for network labels would work.

Intervention Change of Flaw 2
By placing emphasis on the patient-physician interaction, initiatives with responsible use of antimicrobials will have better success by removing the physician as the sole, rationally dependent participant affecting the outcome. Advertising theories lend themselves well in this situation, and ownership possibilities provide opportunity for emotional and personal investment in care planning. Short hospital and network based advertisements can be created to emphasize cooperation of care and health management. Building of trust with patients can be shown by physician-patient interactions with rewarding exchanges of more than just medicine as a routine business. The more participation in their care plan design, the more ownership patients have of it. This translates to increased follow-through with care plans that may have been disliked because stronger, attached feelings created in cooperative development carried ownership of the individual care plan (35,42–46). Further, this allows for the opportunity of medically guided, responsible care when using antibiotics, while simultaneously preventing the use of antibiotics when it is medically contraindicated.  

Intervention Change of Flaw 3
Public education campaigns need a greater focus from initiatives, like Get Smart. The end user of all antibiotics is the healthcare consumer. A lot of this consumption happens outside of the hospital setting, especially outside the United States. By increasing understanding with consumers and promoting correct treatment, general awareness can be raised about proper and improper activity around antimicrobial drugs. Whether it is sharing medications, incomplete medication consumption, improper environmental disposal, or irrational requests, consumers are beyond the medical community once they leave the physician office. Advertising theory is applicable again, but combined with personalized messages, elimination of unrealistic perception of life events is achieved and message integration reached. Individuals have an unrealistic perception of their inherent chances of negative and positive life events (35,44,47,48). Consumers will not chose to believe that they are susceptible to dangerous strains of infectious agents they may have encountered before, or know others who had infections caused by before, that were easily treated and cured. Individuals may admit the existence of such highly dangerous infectious agents as Methicillin Resistant Staph. Aureus (MRSA), but they are relying too much on personal beliefs that they have been OK up to now and “that kind of thing happens to other people.” Ignoring that others have the same chances for infection as they do, with the same helpful deterrents or susceptibility risks, general consumers use unrealistic optimism when faced with events they do not like. Personalized messages, like one from a mother with a son who had community acquired MRSA and fell significantly ill, or the neighbor who got sick with campylobacter food poisoning, will penetrate the unrealistic view consumers hold. Aristotle’s concepts of persuasion still hold true, by applying to one side of an individual, here emotional, you can gain attention and be received (49). This approach is similar to the anti-smoking ads once used depicting a father who explains how smoking caused his wife to live only half a life. The ads do not explicitly say smoking is bad for your health, but they demonstrate outcomes. Similarly, a neighbor with food poisoning can explain why they were sicker longer than expected and how they were not sure if they would get better, and how their family suffered as well. It is important to invoke emotion in this approach, but not fear. Safety is important to hold as a feature in a positive manner.

With the impending crisis of antimicrobial resistance, it is now more important than ever to start facing the issue and implement effective public health campaigns to stall the spread of deadly infectious diseases. Individual based modeling is no longer sufficient for dispensing health information on this topic with the hope that it will spur some level of activity. The medical community as a whole needs to make large-scale adjustments and initiatives that encompass public education and medical system flaws that led to slow adoption of what policies and information does exist. The change to alternative modeling and social networking theory from dated, traditional ideals like the transtheoretical model and health belief modeling can achieve the required level of attention and accomplishment for significant progress in reduction of antimicrobial progression. Without new approaches to this looming hardship, we may not retain our current ability to treat curable illnesses.


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