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.

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