Immunization Communication
Valeria Forero, Jada Chevalier, Zainib Mohammad, Salsabil Taleb, Sayed Hossan
Abstract
This paper explores vaccine communication and how health professionals can better communicate the benefits of vaccines to their patients in a way that does not elicit a negative reaction. Vaccinations have been a vital necessity used to fight major pathogens for a very long time. Recently there has been a controversy stating the use of vaccines can lead to health defects and many have opted out of them. Many claims have been made forbidding the use of vaccines due to certain people believing it may be related to autism, or many of them just forbid the use of it because of religious reasons. Our controversy research issue is to find a convincing and successful way to communicate with patients presenting the benefits of vaccines and persuading them to get immunized. In a study conducted by Graham N. Dixon, Making Vaccine Messaging Stick: Perceived Causal Instability as a Barrier to Effective Vaccine Messaging, it states that communication plays a major role in a patient’s choice to receive or not receive a vaccine. From there we used other research studies and articles to strengthen our argument towards the need and attitude for immunization. We develop our paper with every article we use and each of those academic articles have studies concerning the use of vaccines. Each side of the spectrum from anti-vaxxers all the way to doctors administering the drug is shown along with methods If we can find a method of communication between health physicians and patients that can showcase the health benefits of vaccines without receiving negative connotation, than the risk of major infections and diseases spreading will be limited.
Immunization Communication
Vaccines are made from small amounts of weak or dead germs that can cause diseases, such as viruses, bacteria, or toxins. Vaccines help keep the public healthy because they trick the immune system into making a “memory” of a specific pathogen without having to fight the actual germ. Later, when the immune system encounters the real pathogen, it will recall its prior interaction with it and be ready to attack. As a result, the vaccinated individual will not get sick. Health professionals often face challenges when trying to convince patients to get vaccinated due to unclear and ineffective ways they deliver information about vaccines. This study’s motivating research issue is to find a successful way to communicate with patients by showing the benefits of vaccines and convincing them to get immunized rather than provoke an opposite reaction. This study is worth conducting because thanks to vaccines, Americans do not have to worry about polio, measles, or tetanus among other deadly diseases. However, due to routine immunization, many Americans have forgotten about the severe consequences of a world without vaccines and have opted to not get them.
“Before the measles, vaccines were introduced in 1963. Nearly every child had gotten measles by the time they were 15; tens of thousands of patients ended up hospitalized and more than 400 deaths every year.” (UNIFEC, 2019). Diseases that were once eradicated are now resurfacing due to a mass refusal of vaccinations based on the belief that they lead to autism and other developmental disorders. The evidence pertaining to these accusations of vaccines have not been proven, yet the information has spread like wildfire. The spread of false information regarding vaccines has lead to an increased danger to the human body and people’s lives. Graham N. Dixon performed a study named Making Vaccine Messaging Stick: Perceived Causal Instability as a Barrier to Effective Vaccine Messaging, which serves to not only describe why people in the medical field have not been able to communicate the importance of immunization but to provide us with the best way to deliver the message to the general public for a higher success rate.
In effect of the overuse and misuse of antibiotics, we have evolved to become more resistant to them. “By the time a patient takes an antibiotic, the bacterial population is already large and varied enough that a resistant strain is likely to have arisen… The larger a microbial population is at the time of treatment, the more likely drug resistance is to evolve… vaccines are administered prior to infection. Their role is to prime the immune system to fight any future infections so that they can be brought under control before the bacteria has a chance to multiply.” (Loud, 2017). Due to the fact that humans have not developed any resistance to vaccines despite its constant use throughout the years, they prove to be a better option when combating diseases than antibiotics do. The purpose of the study is to find the right way to communicate to people the importance of getting vaccinated.
Gain-loss framing has played a key role in health communication research. Messages that can be framed by highlighting desirable consequences are known as gains, while those highlighted by undesirable consequences are known as losses. Although gain-loss framing has been utilized for decades, a meta-analysis of over a hundred studies has failed to show a significant advantage of either frame. This not only proves that gain-loss framing holds very little power in persuading individuals on health-related issues, but makes effective communication difficult as well (Dixon, 2017).
Regarding vaccinations, gain frame messaging that highlights the positive consequences of actions (disease prevention due to vaccination), rather than one that highlights the negative consequences of inaction (disease contraction by failing to vaccinate), fails to improve persuasive effects and disease prevention behaviors. Although loss frame messaging that highlights vaccine-preventable disease via inaction is believed to better prevention behaviors, it is affected by the omission bias. The omission bias, or the tendency to react more strongly towards harmful actions than to harmful inactions, therefore puts pro-vaccine messaging at a disadvantage. In a study conducted by Graham N. Dixon, loss frame messaging is utilized to ascertain the mechanisms behind failed persuasive attempts relative to vaccines and other health-related issues. An analysis of the differences between action: the consequences of receiving a flu vaccine, and inaction: the consequences of not receiving a flu vaccine, is introduced as well.
Dixon recruited a total of 163 participants from MTurk, a crowdsourcing website where businesses can hire remotely located “crowd workers” to perform on-demand tasks, to complete his online questionnaire in June 2016. A population of 48.5% male, 80.4% white, and the mean age of 34.9 served as the demographics for this study. These values were later deduced to 48.4% male, 80% white, and mean age of 35.01 when two participants failed to correctly answer attentiveness-based questions (Dixon, 2017). Upon consenting to the study, a randomization feature was utilized to randomly assign a passage to each participant. Each message was a paragraph long in length and depicted an actor whose illness derived from either receiving or not receiving a flu vaccine. Guillain-Barre Syndrome is known as an outcome of both action and inaction and served as an identical negative outcome. The message quality on the other hand, differed solely due to the manipulated risk frame. Once participants read a passage, they were then asked to answer a series of questions that gave insight into the paragraph’s emotional response and causal attributions. The participants were then given another message supplied with a set of identical questions. After successfully completing the questionnaire, participants were rewarded with a small payment.
In order to ensure both passages were identical in terms of quality, Dixon, within his questionnaire, asked participants whether they felt the messages were clear, informative, persuasive, and realistic. By utilizing Likert’s six-point scale, with one being strongly disagreed and six being strongly agreed, Dixon was able to prove the two passages were statistically different from one another by conducting a t-test. The t-critical, which was greater than the t-value, proves that one is not considered more realistic or persuasive than the other. In order to measure the emotional response elicited by each message, participants were asked to rate the level of intensity for a four-item negative affect scale. The four emotions, guilt, irritation, sadness, and worry, were specified with a number between one, not at all, to five, maximum intensity (Dixon, 2017).
According to Dixon, “negative discrete emotions represent the major forms of negative affect” (Dixon, 2017). A three-dimension scale, focusing on the locus of causality, causal stability, and personal control, was then used to measure causal attributions. Using Likert’s scale, the locus of causality used three items to measure the degree participants perceived the attributed cause as the cause of the illness due to receiving or not receiving the vaccine. Causal stability, on the other hand, used an eleven-point bipolar scale with three items. It measured to what extent participants perceived the act of receiving or not receiving the flu vaccine as temporary versus permanent, changeable versus unchangeable, and reversible versus irreversible. Lastly, personal control was also measured using an eleven-point, three-item scale. It measured to what extent participants perceived the actors receiving or not receiving the vaccine as something that cannot be managed versus managed, cannot be regulated versus regulated, and holds no power versus hold power. All three dimensions obtained Cronbach’s alpha values that validated their reliability and consistency.
In Dixon’s experiment, participants served as the independent variable, while their reactions to each passage served as the dependent variable. In order to accurately measure the dependent variable, the quality of the messages and questions asked served as scientific constants. Current research suggests that health messaging that highlights the consequences of not receiving a vaccine will likely elicit low levels of negative affect when compared to an identical message that highlights the cause of the outcome of receiving a vaccine. Therefore, the first hypothesis Dixon provides states that inaction-based loss framing will exhibit a significantly lower negative affect than action-based loss framing (Dixon, 2017).
The second hypothesis is theorized to counter the omission bias. Dixon provides three reasons for the existence of the omission bias. The first states that an action is considered a deviation from the norm, while inaction serves as a restorative alternative. Therefore, a negative outcome due to action is viewed with greater regret than an identical outcome due to inaction. Dixon’s second and third reasoning state that actions seem more important and noticeable than inactions, while asymmetrical reactions to identical action or inaction framed outcomes align with causal attribution. Causal attribution, or how people ascertain the cause of an outcome, can be analyzed as separate dimensions. The first dimension, the locus of causality, questions whether outcomes are thought to be caused by internal versus external factors. In this scenario, negative outcomes are thought to be caused by one’s decision to perform or not perform an action. However, external factors can also play a role in one’s decision-making process. As a result of this, evoking a desired response from health-related messaging is made clearer by analyzing the differences between imaginative or external outcomes, such as chance, and one’s behavioral action. Dixon thus hypothesizes that inaction-based loss framing will elicit fewer responses that correlate the cause of the outcome to the attributed cause than the action-based loss frame (Dixon, 2017).
The second dimension of causal attribution, stability, questions whether the cause of an outcome is viewed as permanent versus temporary. For example, once a vaccine is administered it cannot be revoked. The perceived stability for this case will most likely be high, while a decision to not vaccinate, which is seen as temporary or reversible, will not. The estimated permeability of a cause might play a role in how people react to an outcome. This is because it may be more likely to garner greater counterfactual mindsets and negative affect. The third hypothesis Dixon provides states that action-based loss framing will elicit more responses that correlate the cause of the outcome as permanent and irrevocable, in comparison to inaction-based loss frame messaging (Dixon, 2017).
The last dimension, personal control, questions whether the cause of an outcome is controllable or uncontrollable. For example, the action of receiving a vaccine can be seen as uncontrollable because the vaccine is administered by healthcare professionals. Inaction, on the other hand, can be viewed as controllable due to one’s decision being the only contributing factor. Hence, inaction-based loss framing is thought to garner a greater sense of control. The fourth hypothesis Dixon states that inaction-based loss framing will elicit a greater awareness that the attributed causes of the outcome is more controllable than action-based loss frame messaging (Dixon, 2017).
The three-dimension scale for causal attribution plays a key role in explaining that action and inaction-based frames generate varying levels of negative affect. The effect of an inaction-based loss frame on negative effect is conciliated by the three-dimensions: locus of causality, stability, and personal control. Thus, the fifth and final hypothesis introduced by Dixon states that the three-dimensions mediate the effect of inaction-based loss framing on effect (Dixon, 2017).
In Dixon’s study there were a total of five hypotheses. In Hypothesis 1, a sample t-test was conducted with conditions being the independent variable and the negative affect scores as the dependent variable which showed a significant difference. Particularly, the inaction-based loss frame induced significantly lower negative affect scores, (M being the mean and SD being the standard deviation) M = 2.63, SD = 1, than the action-based loss frame, M = 2.95 SD = 1, t(159) = −1.99, p = .048, 95% CI (confidence level) of mean difference, Cohen’s d (effect size) = .32 This result supports Hypothesis 1.
Hypothesis 2 through 4 were mainly tests that assessed if dissimilarity between the frame types occurred. Hypothesis 2 predicted that the message that prioritized on the outcome of non-vaccination will evoke a lower perception than the leading cause (which is to vaccinate or not to vaccinate) and that the attributed cause is the cause of result than the action-based loss frame. The differences in mean locus of causality scores between the two frame types supports “Hypothesis 2, t(159) = −4.55, p < .001, 95% CI of mean difference [–.96, –.38], Cohen’s d = .73.” In particular, those reading the inaction-based loss frame, M = 2.85, SD = .94, reported significantly lower locus of causality scores than those in the action-based loss-frame group, M = 3.53, SD = .93. Therefore, Hypothesis 2 achieved support. (Dixon, 2017)
Hypothesis 3 was the prediction that action-based loss frame will evoke a larger perception in which the attributed cause of the result is more indefinite and unchangeable than the inaction-based loss frame. There was a difference in the mean stability that provided support for “Hypothesis 3 which suggested that the action-based loss frame M = 6.52, SD = 2.1 creates a larger perception that the cause is permanent than the inaction-based loss frame (M = 6.52, SD = 3.3, t(127.55) = 5.1, p < .001, 95% CI of mean difference, Cohen’s d = .8” (Dixon, 2017).
Hypothesis 4 anticipated that the inaction-based loss frame will create a larger perception that the attributed cause can be directed by the actor. “While the inaction-based loss frame, (M = 8.43, SD = 2.5) did elicit higher mean control scores than the action-based loss frame, M = 7.65, SD = 2.88, the differences were not statistically significant, t(157.632) = 1.83, p = .07, 95% CI of mean difference: –.061, 1.61” (Dixon, 2017).
Hypothesis 5 went in-depth on whether the three causal attribution measurements are components of the inaction versus action impact on the negative effects. The analyses were conducted in the PROCESS macro, which proved to be a useful tool as it had many advantages on previous methods which can provide a rough calculation of an indirect effect. By using the program, two out of four dimensions (locus of causality, causal stability, personal control, message quality) had a significant direct effect and all together out of the four causal dimensions, only stability had the most significant indirect effect.
The significant remedies described in this paper are represented to effectively showcase how health professionals should communicate immunization to the public. Messages that state the negative outcomes of not receiving vaccinations generate lower affects to the public than outcomes that are from vaccinations. Effects in stability of action-based outcomes are not favored considering there is nothing that can be done to stop what is occurring, versus the stability for inaction-based outcomes that can be changed. People are more comfortable with handling things they can control. For example, Dixon states that “action-based loss frame could be applied to sunscreen… applying sunscreen might not be perceived as permanent given that it can be removed and requires continued use” (Dixon, 2017). There are different approaches depending on the health issue, however a balance in controllable needs will draw in a more appropriate reaction.
This study would be more credible if the specifications of the guidelines were made prior to the conduction of the experiment between adults and children. Dixon states more research is needed so that health professionals can find more persuasive ways of communicating information about vaccines. For example, in accordance to Fischhoff’s article The Sciences of Science Communication, scientists do not have the patience to communicate with the general population, who have not received education or prior knowledge of most scientific facts, and have no will to. “Effective science communications inform people about the benefits, risks, and other costs of their decisions, thereby allowing them to make sound choices” (Fischhoff, 2013). Scientists who act as if they do not care about losing laypeople’s faith (those without secure education) have greater chances of not receiving their loyalty. In order for people to understand what is going on, scientists and health professionals must first identify what the issue is that everyone is having difficulty understanding. Right now it is vaccines. Not everyone is going to grasp the depths of information that comes with dealing with vaccines. Distinguishing what is known and not known, however, makes it effective to what type of information and statistics is needed to be shared to get a positive reaction. If anything is hidden, the trust between the scientific world and people is thrown off. People want to hear and do what is beneficial to them and will be less likely to cause harm while understanding its long term use.
This study failed to conduct variables based off of individuals prior knowledge and beliefs towards vaccines. “For instance, the difference in negative affect scores between conditions might be more pronounced for those with unfavorable attitudes toward vaccines than those with favorable attitudes, further demonstrating the challenges to communicating vaccine inaction risk along with the mediation effects,” Dixion explains (Dixon, 2017). Thus indicating that future research needs to be conducted on these variables. The use of MTurk also brings questions upon validity and liability. If experiments involve a lot of intellectual work to arrive at an outcome, then those outcomes may show up inconsistent. MTurk is not appropriate since it generalizes more on simple designs, meaning there needs to be more research done for accuracy in results.
Anti-Vaxxers are people who are vaccine-hesitant. Vaccine hesitancy “describes anyone who is doubtful about vaccinations or who chooses to delay or refuse immunizations even when they are readily available” (Bohannon & Mckee, 2016). A variety of studies have been conducted examining the reasons behind parents’ hesitation, delay, or refusal to get vaccinated. Four far-reaching categories have been stated: “religious reasons, personal beliefs or philosophical reasons, safety concerns, and a desire for more information from healthcare providers,” (Bohannon & McKee, 2016). Health professionals need to understand all the reasons behind a parent’s decision against immunization so that they can deliver the awareness of results from non-vaccination and convince them into making a more responsible choice.
Religious reasons are hardest to persuade since parents are fixated on the idea that no vaccines are good. “The animal-derived gelatin used in producing some vaccines as well as the human fetus tissue used in the rubella component pose the largest concerns,” (Bohannon & McKee, 2016). Addressing and understanding these concerns for religious reasons can encourage more research that creates exceptional vaccines for them to agree taking. Personal/philosophical reasons have parents favoring natural immunization rather than vaccine immunization for preventing diseases. “Diseases that people get vaccinated for are very unlikely to occur in an outbreak thus making it a minimal risk of catching if they do not vaccinate” (Bohannon & McKee, 2016). Everything nowadays is treatable, so what is the need for vaccines? The safety concerns parents deal with are in regards to what they hear and read in the media or acquire from fellow associates. A lot of heat in the media about vaccines make it harder on indecisive parents to choose which option is best for themselves and family regarding short-term and long-term effects.
Lastly, this paper explores the need for more accessible and reliable information regarding the benefits and importance of vaccines for parents. The best way to get anti-vaxxers to want to vaccinate is to provide them with more research on the people who get vaccinated. Genetically there can be vaccines that can turn on a gene and cause a negative outbreak. Also the fact the immunizations are a yearly thing, health professionals expect to give the same vaccines to millions of people within a small time period, which can lead to someone getting sick due to what other people may be carrying. Parents are in more favor of having timely, spread out vaccinations rather than taking three vaccines in one visit. Physicians have a vital role in informing parents of the various resources they have for information that is more in depth about vaccines if they are uneasy about its effects (Bohannon & McKee, 2016). If parents outsource information that is misleading and not given directly from their providers, they are exposed making substandard decisions. Advising for vaccines should not feel as though parents are being targeted, but are being open to the option based on sufficient information and open conversations with their providers.
Antimicrobial resistance has caused the use of antibiotics to be ineffective and the best treatable solution is vaccines. Bacteria has started to arise due to the abundant prescribing and use of antibiotics. This has led to a growing bacterial resistance that can no longer be controlled by antibiotics. Vaccines are fast acting and are required before infections even occur. They strengthen the chance of not getting sick with antibodies ready to attack resistant bacteria at a faster rate than antibiotics would. “Vaccines aid in preventing the spread of resistant strains” (Loud, 2017). Vaccinations can be used to protect the public against antimicrobial strands that exist due to the abuse of antibiotics.
Furthermore, this paper explains the importance of effective and understanding communication messaging regarding vaccines between patients and doctors. Taking the time to understand, explain, and offer information about the welfare and value that comes with getting immunized to parents can help elicit positive reactions. Since there were small base variables missing in account of prior opinions towards vaccines, “future research is needed to calculate the gain/loss framings and omission bias of other health and risk issues,” (Dixon, 2017). Communication in a society is most successful when the people are getting what they want, yet in a way that can be to the providers benefit. Scientists need accurate information before sharing it with the world in order to avoid confusion and ensure everyone is on the same page.
References
Americans Who Never Forget: Life Without Vaccines. (2019, April 25). Retrieved from https://www.unicefusa.org/stories/americans-who-never-forget-life-without-vaccines/32150
Bohannon, Kristin and McKee, Chephra. 2016, March). Exploring the Reasons Behind Parental Refusal of Vaccines. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869767
Dixon, G. N. (2017, August). Making Vaccine Messaging Stick: Perceived Causal Instability as a Barrier to Effective Vaccine Messaging. Retrieved from https://web-a-ebscohost-com.ccny-proxy1.libr.ccny.cuny.edu/ehost/detail/detail?vid=4&sid=34d34e6f-6724-47e4-87ba-fc6e93d5e183%40sessionmgr4006&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#AN=124803842&db=a9h
Fischoff, Baruch (2013, August 20). The sciences of science communication. Retrieved from https://21003efall19.commons.gc.cuny.edu/files/2019/08/FISCHHOFF-The-Sciences-of-Science-Communication.pdf
Loud, E. (2017, November 30). Why do vaccines work against antibiotic resistance? Retrieved from https://www.vaccineswork.org/why-do-vaccines-work-against-antibiotic-resistance
Six common misconceptions about immunization. (2013, February 19). Retrieved from https://www.who.int/vaccine_safety/initiative/detection/immunization_misconceptions/en/index6.html.
