“We Are The Herd”: How Social Science Can Help Improve Vaccination Rates in the United States. – Matthew Banos

Vaccinations against serious disease are undoubtedly one of the greatest advances in human health in mankind’s history. Yet it is often stated that vaccines have become a victim of their own success in recent years (5), as most people haven’t seen the potentially devastating effects of vaccine-preventable diseases in their lifetimes. So while immunization rates in the United States are high – as of 2007, 77.4% of toddlers had completed a full immunization series – threats still exist, and outbreaks of diseases such as the measles do continue to occur (14). It is important to continue to increase immunization rates to not only protect vaccinated individuals from disease, but to maintain “herd immunity” whereby everyone, especially the vulnerable who can’t be vaccinated, can be safe. However, there has been a growing anti-vaccination movement in the United States over the past decade. Parents have expressed growing fears over the safety of vaccinations, the number of vaccinations given, and their concurrence. Purported linkages of vaccines to diseases such as autism, not based in any scientific fact but fueled by the media and the internet, have added to this sentiment and could ultimately threaten rates of immunization in this country (15).
The significant methods currently in use in the United States for increasing immunization rates can be categorized in two ways: policies that make vaccinations mandatory and interventions targeted at providing risk and benefit information to individuals. Vaccinations have been made mandatory by law in all fifty states, but almost all states allow exemptions on religious, medical or personal grounds (5). Other policies aimed at increasing vaccination rates include the requirement of vaccinations by most public schools and colleges as a condition of enrollment. The primary intervention strategies used by organizations such as the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are focused at the individual level in a health-care setting. These generally entail educating parents about vaccinations and benefits they provide, as well as about the true risks of disease, through the mechanism of a health-care provider.

A review of prevailing policies and interventions in light of the social sciences reveals three major flaws in the current approaches to increasing immunization rates. First, prevailing interventions rely too heavily on the Health Belief Model. Interventions are focused on persuading the individual parent by educating them about their child’s susceptibility to disease, the severity of disease, the benefits of immunization and the risks of being vaccinated. While these are important factors, this intervention strategy ignores a host of factors which play a part in a parent’s decision. Second, many current vaccination policies engender psychological reactance, a response to the feeling that an individual’s freedom is being taken away. Mandatory immunization laws, requirements for children to be immunized in order to attend school, and even the refusal of some doctors to see patients who oppose vaccination all create threats to perceived freedom. Finally, interventions to increase childhood vaccination rates lack a cohesive marketing strategy grounded in advertising and marketing theory, particularly when contrasted with some anti-vaccination campaigns.

There’s more than just an “I” in behavior.

The Health Belief Model is one of the most widely-used behavioral explanation models throughout public health. It posits that health behaviors are determined by a rational decision process in which the individual weighs the perceived benefits of taking a health action against the barriers or perceived costs of taking that action. The benefits of the health action are influenced by the individual’s perceived susceptibility to a condition or problem, a disease in this case, and how serious they perceive that condition or problem to be (20). The Health Belief Model was developed largely out of research in the 1950s which attempted to show the reasons why some parents were failing vaccinate their children against polio (23), and still today it underlies the prevalent intervention strategies of organizations like the CDC and AAP for increasing childhood immunizations.

Studies have shown that the factors considered in the Health Belief Model are important in improving vaccination rates. For example, parents who refuse vaccines are less likely to believe that their child’s susceptibility to a vaccine-preventable disease is high and more likely to have concerns about the safety of vaccines (23). Provider-based interventions recommended by the CDC, AAP and other bodies (6) focus on these same factors. For example, an information sheet for health care professionals produced by the CDC discusses that parents “may believe that the risks of vaccinating infants outweigh the benefits of protecting them from infection with vaccine-preventable diseases”. The recommended responses to these concerns are making fact sheets available about the risks of disease and the safety of vaccines, “specifically reinforce[ing] the seriousness of the diseases prevented by vaccines” and asserting belief “that the risk of disease is greater than any risks posed by vaccines.” (7) Other documents and marketing materials provided by the CDC focus on similar messages.

While addressing concerns about risks and safety around immunization and vaccine-preventable disease are certainly important, the heavy reliance on the Health Belief Model has several limitations. First, the model assumes that the decision to vaccinate a child is purely a function of weighing the benefits against the costs. If this were the case, it would be difficult to imagine anyone deciding against vaccination, as analysis shows choosing vaccination and any risk associated with it is about one thousand times safer than remaining unvaccinated and risking acquisition of disease (5). In truth, there are numerous other factors involved in the decision to vaccinate a child. For example, historical or environmental factors can play a role in this decision. Minority groups, particularly people of color, have a tendency to mistrust the government and the medical system, and so may be reluctant to vaccinate a child based on this historical influence (5). Second, the Health Belief Model assumes that people make rational decisions about health behaviors. While vaccinating their child may be a routine, rational decision for some, it may not be for others. Even in the face of significant scientific evidence showing that the benefits far outweigh the risks, one emotional story on the evening news about a child who started showing signs of autism shortly after being vaccinated may be enough for someone to ignore science and choose not to vaccinate their child (19). Third, the model has an underlying assumption that health behaviors are influenced by decision-making at the individual level only. Vaccination decisions are certainly influenced by factors beyond the individual. The Social Ecological Model, for one, posits that people are influenced by four different spheres of influence, the broadest of which are macro-systems which include factors like culture (4). Hispanic parents were shown in one study to be more likely to be concerned about adverse affects of vaccines than other groups, so considering only the factors in the Health Belief Model they should be less likely to vaccinate. However, these parents were more likely than other racial groups to follow doctor’s recommendations about vaccinations (12). This is in part due to cultural influence, in that Latino cultures tend to trust health care providers more that some other cultures, and that Latino cultures are more collectivist than American culture and consider the impact of their decisions to the community more than Americans might (9).

I “have” to do it? Oh, no I don’t!

By the late 1970s, all fifty states had enacted laws to require certain compulsory immunizations, and to require certain immunizations as an entry requirement for children going to school (5). These policies were very effective and have contributed to the generally high rates of immunization in the United States. All but two states, however, allow exemptions to these policies for religious grounds, and a large number allow exemptions for undefined personal reasons. The number of parents claiming these exemptions has risen over the past decade (5,18). One response to the rising number of parents refusing vaccinations for their children is for pediatricians to dismiss, or no longer treat, families from their care. One study showed that more than one-third of pediatricians would no longer treat a family that refused all vaccinations, and more than a quarter would no longer treat a family for refusing just some vaccinations (11).

Government policies that make vaccines for children mandatory and physicians’ refusal to treat families who choose not to vaccinate naturally engender an emotional response called psychological reactance. Psychological reactance is “the motivational state that is hypothesized to occur when a freedom is eliminated or threatened with elimination” (3). The Theory of Psychological Reactance contends that when an individual is faced with a perceived threat to his or her freedom, he or she will be more likely to take actions to restore that freedom (8). As factors such as the purported link of vaccinations to health issues like autism cause more people question whether or not they should vaccinate their children, parents are met with two sets of policies that challenge their freedom to make choices for their children and make them more likely to choose not to vaccinate.

While having laws in place to require vaccination of children is certainly justifiable from a public health and safety standpoint, relying on laws that force compliance as a primary means to improve vaccination rates is a flawed approach. The ideas of “individualism, civil liberties and freedom from government intrusion” are highly valued in the United States, and distrust of the government is not insignificant (5). Relying on laws to compel vaccinations stirs these emotions and creates reactance. The response to this to “restore freedom” is to not vaccinate, an action which is seen by some as a sign of rebellion against an oppressive government and standing up for individual freedoms (5). This reactance response moves to reduce the immunization rate rather than improve it.

The decision of a significant number of pediatricians to not treat families who refuse vaccination creates a similar reactionary response. While the rationale for this decision tends to be lack of trust or even fear of litigation (11), there is a strong risk of such an action to be perceived by a parent as “do what I say or go somewhere else.” Being presented with such an ultimatum could certainly be interpreted as a threat to freedom, and could make a parent more likely to choose not to vaccinate. This is particularly concerning in the case of the parent who does not patently refuse vaccination, but seeks an alternative vaccination schedule out of concern for the safety of their child. Evoking a reactionary response like this could move the parent to not vaccinate at all as a method to restore freedom, as one response to such a threat is to do the very thing being forbidden (8). Pediatricians and health care professionals are shown to be a strong influence on the decision to vaccinate (15,24), but there is a fine line between asserting positive influence as a trusted professional and evoking psychological reactance as authoritarian, parental figure.

They’ve got Jenny McCarthy. We’ve got…statistics?

Like selling cars or athletic shoes or insurance, a cohesive marketing strategy is a key component to effectively promoting the goals of a public health intervention and persuading people to modify the behavior or take the action desired. Social marketing is the use of commercial marketing techniques to develop strategies to influence the voluntary behavior of some group of people to improve their personal and society’s well-being (1). It leverages concepts like branding, the “marketing mix” and target audience segmentation to create effective messaging and achieve the desired behavior change (17). While some anti-vaccination organizations have leveraged many social marketing techniques to promote their positions, interventions to increase immunization rates led by organizations like the CDC have failed to significantly take advantage of social marketing.

The current prevailing approaches to increasing vaccination rates fail to take advantage of social marketing strategies in a number of areas. First, programs and guidance from organizations such as the CDC (7) and AAP use health as a core value when promoting vaccination behavior. Health, particularly in terms of protection against a disease a parent has never encountered, is not a strong core value for persuading behavior change. In contrast, groups opposed to vaccination tend to use core values such as protecting your child from harm, love, and freedom in their messaging, all much stronger core values. Second, interventions to increase vaccination rates tend to rely on statistics to promote behavior change rather than personal stories. Sharing information on the risks of disease from not vaccinating and the true risk of an adverse reaction to a vaccine is important from a factual standpoint, but is not a compelling way to change behavior. Groups that continue to promote a linkage between vaccines and disorders like autism are able to convince people of their position, despite having no scientific evidence to back it up, by using emotionally-appealing, personal stories. Individual stories about adverse reactions to vaccines, though rare, are far more compelling than statistics about how many people are protected or how low rates of vaccine-preventable disease have become. Due to an effect known as the “false consensus bias”, people have a tendency to trust their personal experience rather than scientific evidence (5). Jenny McCarthy, an actress and outspoken advocate for the linkage between autism and vaccination, when confronted with scientific evidence refuting that linkage responded that “her science was her son” (16). Current vaccination promotion strategies fail to take advantage of the strong impact of personal stories.

A third area where current vaccination promotion strategies fail to take advantage of social marketing is in the effective use of the media. Public health officials promoting immunization are at a natural disadvantage when it comes to media coverage. The media gives coverage to the risks posed by vaccines, to purported links between immunizations and autism, and to rare vaccine-related injuries because these stories can “shock parents and catch viewers’ attention” (5). Preventing disease through vaccination does not lend itself so naturally to attracting media attention. In light of this disadvantage, public health officials should take active steps to use the media more effectively to support promotion of vaccination. Current intervention strategies do not utilize the media effectively. Finally, social marketing uses the ideas of branding and strong messenger to promote the desired behavior change (19). Interventions promoted by the CDC and AAP lack an overarching brand which defines the campaign and its values, and rely generally on individual health care providers to be the messenger. In contrast, Generation Rescue, a support organization for children with autism founded by actress Jenny McCarthy which has publicly questioned the safety and current use of vaccinations, has an identifiable logo, a slogan – Hope for Recovery – and a celebrity spokesperson as the face of the campaign with whom parents can connect (13). Interventions to promote vaccinations lack these traits of a good social marketing campaign.

A proposal: “I am The Herd.”

I propose an intervention to promote childhood vaccinations centered on the brand “The Herd”. The brand is a reference to the concept of herd immunity and alludes to some of the core themes of the campaign: that we protect ourselves from disease not as individuals but as a community, and that by vaccinating we protect not just our families but our communities as well. This intervention would be comprised of two core components: a media campaign to promote childhood immunization and a community-led effort to create opportunities beyond the pediatrician’s office to “be a part of The Herd” and vaccinate children.

The goal of the media campaign would be to use positive messaging to create a movement around childhood vaccination of which people want to be a part. This campaign would supplement the informational-based interventions currently in use by organizations like the CDC, not replace them. One example of messaging for the campaign would be a billboard or a poster showing a woman who looks like – or better yet, is – someone from the community in which the billboard or poster is located. She wears a t-shirt with “The Herd” logo, and the caption reads: “Parents of more than 3 out of every 4 children choose to fully vaccinate their child. Parents like [name of person]. She is The Herd.” Another example shows a recognizable celebrity with a younger sibling with the same shirts and imagery and a caption reading: “I chose vaccination for my family to protect my brother [name]. We are The Herd.” Additional messaging would state that some people can’t be vaccinated, so our community protects them by keeping immunization rates high. A final example would show a group of people, adults and children, representative of the community all wearing the branded shirts with captions near each of them reading: “I am The Herd”.

“The Herd” media campaign takes advantage of a number of principles of social science to persuade parents to vaccinate their children. One principle leveraged by this campaign is the concept of framing. Framing is the process of actively setting the way information on an issue is presented to someone in order to shape their opinion on that issue (22). The campaign would use this technique to present childhood immunization in a number of ways designed to make parents more likely choose vaccination. Other social science principles utilized are discussed below.

The second component of the intervention would create a coalition of community-level organizations to both promote childhood vaccination and provide broader opportunities to access vaccines. The goal of this component is to build the foundation for the community-owned movement portrayed in the media campaign and create community-level influences to persuade parents to vaccinate their children and be part of “The Herd”. The coalition would include community groups, churches, existing social services organizations active in the community, schools and childcare providers, and would work in partnership with organizations like the CDC and the local medical community. “Champions” within each of these organizations would provide peer-to-peer education and influence, and opportunities would be created to vaccinate children in venues such as schools, churches, or other places that may be more practical and convenient to parents.

The many influences on the “simple” decision to immunize.

“The Herd” intervention looks beyond the assumptions of the Health Belief Model and addresses other factors that influence the decision to vaccinate children. First, the campaign considers factors that influence behavior beyond cost and benefit. It reflects the idea that people takes cues from the behavior of others around them, and that they are influenced by practical factors like the convenience of taking a child to a health care facility regularly for vaccines. It also considers the influence of social norms. One key focus of the media campaign would be to frame vaccination as something that we as a community do as part of our community norms. The message that “Parents of more than 3 out of every 4 children choose to fully vaccinate their child” takes advantage of Social Expectations Theory to impact both the descriptive norm about vaccination behavior – the perception of how many people really do vaccinate their children – and the affective norm – helping to create the idea that vaccinating our children is something we as a community do (2). Second, this approach recognizes that people sometimes make irrational decisions based on factors other than fact. The campaign would take advantage of this principle by using techniques such as framing, and by using images and stories of individuals to create emotional appeal instead of relying on statistics. Finally, “The Herd” reflects the reality that vaccination behavior is influenced by more than just individual-level factors. Influence is exerted at all of the levels suggested in the Social Ecological Model, from peers at the interpersonal level to the community level, to even the cultural level through promotion of the communal benefits of immunization (4). Studies have shown some successes of vaccination campaigns that create influence at a number of levels (9-10).

The freedom to vaccinate.

The proposed intervention takes care not to elicit psychological reactance on an issue, due to the compulsory nature of immunization, prone to doing so. First, the campaign is a proactive approach to encouraging parents to voluntarily vaccinate their children. One core element of the media campaign would be the framing of vaccination as a voluntary behavior. Despite the fact that childhood vaccination is mandatory in the United States, “The Herd” campaign would accentuate the idea that it is a choice that parents make for their children. In the sample messaging proposed, parents “choose” to fully vaccinate their child. Proactively allowing a parent to “choose” vaccination before faced with the requirement of immunization for school entry should reduce threats to freedom and thereby the potential for reactance (8). The intervention also provides the freedom to choose locations outside of the pediatrician’s office to get vaccinations, putting more control in the hands of the parent. Second, this intervention seeks to minimize psychological reactance in three key areas where people perceive influence (8). The campaign reduces the explicitness of the messaging by not telling parents directly that they should vaccinate their children, but instead showing them that most people in their community do choose to immunize. It reduces dominance by using peers and members of their community to deliver the message instead of physicians who can be perceived as authoritarian and more threatening to their freedom. Finally, the campaign provides reasons why they should choose to vaccinate, such as to help their whole community be safe and to protect people who can’t protect themselves.

Be a part of “The Herd”. You know you want to.

“The Herd” campaign uses some of the principles of social marketing that many anti-vaccination movements utilize but interventions to increase immunization seem to lack. First, the core idea of “The Herd” is to create a community-based movement that people want to join. In the same way some people opposed to immunization feel part of a group rebelling against the government, this campaign aims to create something which fights together against a common enemy: disease. Second, the messaging of this campaign will feature core values that are stronger and more compelling than simply “health”. Instead, the messaging will feature core values such as love – love for your children, family and community – and freedom – the freedom to choose vaccination for your family. Third, “The Herd” campaign will make far greater use of personal stories than existing interventions. The use of stories is “one of the most effective strategies for arousing an audience emotionally” (19), and a tactic used successfully by anti-vaccination movements. The campaign will feature images of named individuals, people from the community, talking about why they choose to vaccinate. It will also utilize stories of vulnerable people who can’t be vaccinated, and the people who love them who vaccinate their children to protect them. Finally, the campaign takes advantage of some of the core features of traditional marketing theory, namely a strong brand and likeable messengers to deliver the message. The campaign would aim to create “The Herd” brand as something synonymous with strength, safety and success – success in defeating the enemy that is disease. “The Herd” logo would be a prominent part of all facets of the intervention, as would some form of the “I am The Herd” slogan. The campaign would also enlist a likeable celebrity to be one of the faces of the campaign, potentially someone with a sick child or relative such that parents could relate to the idea of doing something to protect a loved-one. Members of the community, as peers of the target audience, should be effective messengers for promoting vaccination as people tend to respond more positively to messages from people similar to them (19).

Conclusion

Despite generally high vaccination rates in the United States, disparities exist in some populations (21) and the overall goal of at least 80% coverage for a full set of vaccines laid out in Healthy People 2010 has not been met (14). Perhaps just as importantly, there is significant potential for high-profile adverse events or further questionable “research” to suddenly drive immunization rates lower. Finally, interventions driven solely by health care providers may not be effective at influencing some groups of parents. In light of these factors, it is important to develop a policy and intervention strategy for childhood vaccinations that will enable coverage rates to continue to rise over the coming years. I believe “The Herd” movement will do just that.
REFERENCES
1. Andreason, A. Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment. San Francisco, CA: Jossey-Bass, 1995.
2. Borsari B & Carey, KB. Descriptive and Injunctive Norms in College Drinking: A Meta-analytic Integration. Journal of Studies on Alcohol 2003; 64:331-341.
3. Brehm, S.S. and Brehm, J.W. Psychological reactance: A theory of freedom and control. New York: Academic Press, 1981.
4. Bronfenbrenner, U. The ecology of human development. Cambridge, MA: Harvard University Press, 1979.
5. Calandrillo SP. Vanishing vaccinations: why are so many Americans opting out of vaccinating their children? University of Michigan Journal of Law Reform 2004 Winter; 37(2):353-440.
6. Centers for Disease Control and Prevention. National Infant Immunization Week Media Tools. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/events/niiw/media-tools.html
7. Centers for Disease Control and Prevention. Provider resources for vaccine conversations with parents. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/spec-grps/hcp/conversations.htm.
8. Dillard, J. P., and Shen, L. On the nature of reactance and its role in persuasive health communication. Communication Monographs 2005; 72: 144–168.
9. Findley SE, Irigoyen M, Sanchez M, et al. Community-based strategies to reduce childhood immunization disparities. Health Promotion Practice 2006; 7 (3):191S–200S.
10. Findley SE, Irigoyen M, Sanchez M, et al. Effectiveness of a community coalition for improving child vaccination rates in New York City. American Journal of Public Health 2008; 98(11):1959-62.
11. Flanagan-Klygis EA, Sharp L, Frader JE. Dismissing the family who refuses vaccines: a study of pediatrician attitudes. Archives of Pediatrics and Adolescent Medicine 2005; 159:929-934.
12. Freed, GL. Clark SJ, Butchart AT, Singer DC, Davis MM. Parental Vaccine Safety Concerns in 2009. Pediatrics 2010; 125:654-659.
13. Generation Rescue. Background. Sherman Oaks, CA: Generation Rescue. http://www.generationrescue.org/
14. Hammer L, Curry E, Harlor A, et al. Increasing immunization coverage. Pediatrics 2010; 125:1295-1304.
15. Kennedy A, Basket M, Sheedy K. Vaccine attitudes, concerns and information sources reported by parents of young children: results from 2009 HealthStyles Survey. Pediatrics 2011; 127 (1);S92-S99.
16. Kennedy LH, Pruitt R, Smith K, Garrell RF. Closing the immunization gap. The Nurse Practitioner 2011: 36(3):39-45.
17. Kotler P, Lee NR. Social Marketing: Influencing Behaviors for Good, 4th ed. Thousand Oaks, CA: Sage, 2011.
18. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. New England Journal of Medicine 2009;360(19):1981–1988.
19. Opel DJ, Diekema DS, Lee NR, Marcuse EK. Social marketing as a strategy to increase immunization rates. Archives of Pediatrics and Adolescent Medicine 2009; 163:432–7.
20. Rosenstock, I.M. Why People Use Health Services. Milbank Memorial Fund Quarterly 1966; 44(3, Part 2): 94–124.
21. Rosenthal J, Rodewald L, McCauley M, et al. Immunization coverage levels among 19- to 35-month-old children in 4 diverse, medically underserved areas of the United States. Pediatrics 2004 ;113(4):e296–e302.
22. Scheufele, D. Framing as a theory of media effects. Journal of Communication 1999; 49: 103–122.
23. Smith PJ, Humiston SG, Marcuse EK, et al. Parental delay or 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.
24. Smith PJ, Kennedy AM, Wooten K, Gust DA, Pickering LK. Association between health care providers' influence on parents who have concerns about vaccine safety and vaccination coverage. Pediatrics 2006; 118:e1287-e1292.