Tag Archives: vaccines

Does fear-based messaging help public health campaigns?

This post was originally published here.

A recent, well-publicized paper in Pediatrics cast considerable doubt on a tool public health practitioners value highly: informational messaging campaigns. The paper, based on a randomized-controlled trial, showed that neither information on the safety of vaccines nor details about the diseases being prevented by vaccination increased parental intent to vaccinate their children. In a surprising twist, graphic images of children suffering from vaccine-preventable childhood diseases, such as measles and pertussis, actually increased parental belief in an association between vaccines and autism and dramatic narratives about unvaccinated children who became ill increased parental belief in serious vaccine side effects.

The results of this study are decidedly disappointing to public health practitioners who strongly champion the utility of informational campaigns in producing better health outcomes and increasing rates of preventive behaviors. The study makes clear that much more research is needed on the particular effects of pro-vaccine messaging and that many public health campaign messages should be tested before being rolled out, not only to measure effectiveness but also to protect against any unforeseen negative effects. Testing for unintended consequences of health messaging is something that is often ignored in public health informational campaigns but may be just as important as testing for efficacy. Yet this study evokes an even wider question about public health campaign strategy: does fear-based messaging help or harm the cause? Does scaring people result in better health outcomes and increased uptake of preventive medical care or is it possible that this kind of messaging is actually associated with increased denial, psychological reactance, and increased distrust of the health and medical establishments?

Fear messaging in public health as well as in other related fields has a long history. In the past, public health authorities have tended to believe that fear messaging has the capacity to backfire. Yet recently, some health authorities such as the New York City Department of Health have begun to rely more heavily on fear appeals. For example, the city has launched a series of subway ads as well as television commercials featuring the terrifying consequences of lifetime smoking and graphic photos on the subway of amputated limbs due to diabetes from consuming too many sugary drinks. Widespread fear about an increasing tendency for parents to refrain from vaccinating their children and reports of several troubling measles and pertussis outbreaks in pockets of the country with low vaccination rates have led public health authorities to consider extending the fear appeal method to convince parents of the absolute necessity of vaccination. But is this the best way forward? If the method has a high likelihood of backfiring, as the evidence from the Pediatrics study seems to indicate, great care must be taken to vet and test all messages before they are disseminated to the public.

Several guidelines about constructing useful fear appeals do exist. In order to increase effectiveness, fear appeals must emphasize the severity of the threat as well as the intended population’s susceptibility. Without these factors, any fear-based campaign will inevitably be disregarded and fail. But these prerogatives do not justify simply flooding the public with gruesome images and messages about their inevitable susceptibility to the threat. Perhaps most importantly, fear-based messages should always be accompanied by strong efficacy messages. That is, the barriers that the intended population may face in preventing the dreaded health outcome must be carefully weighed and comprehensively addressed in any fear-based messaging campaign. Without reassuring people about their ability to prevent the feared outcome, strong fear appeals have a very high likelihood of backfiring. Public health practitioners must therefore walk the line between creating strong, efficacious messages about real, severe health threats and reassuring intended audiences that they do have the means and resources to prevent these threats. In addition, common counterproductive psychological responses, including denial and reactance, must always be taken into account when designing these types of messaging campaigns. The delicate balance between inventing efficacious fear-based messages and providing the public with hope for escaping these threatening outcomes is a large part of the reason why it is so important to test any fear-based messaging campaign before it is launched. Most importantly, if people are made aware of threatening health effects for which no practical solution seems accessible, fear-based messaging may result in precisely the reverse of the intended effect, including increased risk-taking behavior, denial, and hopelessness. It is the prerogative of public health officials to insure that messaging campaigns are not only effective but also, and perhaps even more importantly, not harmful.

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What do we really know about social resistance to vaccines?

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Last year, polio eradication efforts were severely compromised by a rash of killings by militants in Pakistan and Nigeria. Between December 2012 and January 2013, at least 16 polio workers were killed in Pakistan. In early February, more bad news arrived: 9 health workers were murdered in northern Nigeria while working on the polio eradication campaign.

Potential explanations and suggestions for future action poured out following the attacks. Some people thought the CIA’s actions years earlier in the Bin Laden assassination laid the groundwork for Pakistani suspicion of Western vaccination campaigns. By employing a Pakistani doctor to gain entry into what was thought to be the Bin Laden compound by feigning a vaccination program, the agency perhaps stirred local suspicion of the real motives behind Western-based vaccination campaigns. Of course, the resistance to polio vaccination is also largely political, especially in countries like Pakistan, where polio workers have been seen as “soft targets” for anti-Western terrorism. Some people believe that the murders are connected to beliefs that the vaccination campaign is really an effort to sterilize Muslim children. In response to these allegations, some are suggesting better education, outreach, and communications about the devastating effects of polio and the real benefits and risks involved in vaccination.

These killings should be stimulating an essential set of questions about our knowledge of vaccine resistance: what do we really know about social resistance to vaccines? How much do we know about the demographics of vaccine resistance, and how well do we truly understand fear of vaccines, a fear so overpowering that it has motivated murder? How much does social resistance to vaccination vary across cultures? In other words, are Muslim fears that foreign vaccination programs are designed to sterilize Muslim children that different from U.S. parents’ conviction that the government has been poisoning children with vaccines for decades and is intentionally covering it up?

A few, but not many, studies have been done to begin to understand the demographics, spread, and circumstances behind various anti-vaccination movements or instances of vaccine non-compliance. One study published inPLOS One in September 2012 examined fear and resistance to the polio eradication program in Aligarh, India in 2009. The study found that vaccine fear and resistance were borne from a kind of fatigue and suspicion that stemmed from confusion about changing vaccination strategies. When the polio eradication program shifted from a strategy of vaccinating a few times per year to a strategy of a more aggressive short-term vaccination campaign involving shots once per month, families were left confused and suspicious about the efficacy of the vaccine in the absence of explanation by officials. The result was what the authors call “vaccine fatigue,” suggesting that lack of proper explanation of all the details in a vaccine program, including the frequency of administration of shots, may contribute to suspicion and fear of vaccines. A 2007 study published inPLOS Medicine investigated the polio vaccine boycott situation in Nigeria. The author of this article insists that social resistance to vaccines be placed in the wider political and social context of health services in northern Nigeria. Controls on population growth in the region since the 1980s led to suspicion of vaccine programs in particular, which were believed to be a method of checking on the number of children in each family. Similarly, aggressive vaccination campaigns are particularly eyebrow-raising in a region where healthcare is generally difficult to attain. As the author notes, free door-to-door healthcare in northern Nigeria is as bizarre as a stranger going door to door handing out $100 bills in America. In the end, the study urges widespread public awareness campaigns about the benefits of vaccination and sensitivity to local politics to help avoid future boycotts.

A few similar studies following disease outbreaks in the absence of vaccination in pockets of the U.S. have revealed the general demographic of the anti-vaccine movement: middle-to-high-income whites who favor natural, organic foods and remedies. A few other studies have taken a close look at anti-vaccination websites to try and gain a better understanding of how anti-vaccination materials are formulated and how they spread.

The truth is, we have relatively little data about the demographics and nature of anti-vaccination thought and the mechanisms of its spread. But we do know that anti-vaccination sentiments have a very long history, at least in developed nations such as the U.S. and England. A common belief is that smallpox elimination in the U.S. represents a case of unique cooperation between a terrified public and an even-handed, responsible public administration. But resistance to smallpox vaccination was potent, probably much stronger than today’s American anti-vaccination movement. In fact, vaccination against smallpox in those days was often a risky business, with little government control over quality and safety. Compulsory vaccination was seen as potentially dangerous and certainly a threat to civil liberties. Antivaccination leagues in 1900performed very similar actions to antivaccination activists in 2013: they challenged compulsory vaccination laws and staged boycotts. They even rioted and hid sick children from vaccination authorities.

What can we learn from this long history of antivaccination sentiments and what do we still need to discover about today’s antivaccination movements, active all over the world? We can probably learn something from certain “golden ages” in vaccine history. When were people particularly cooperative, and what circumstances helped to produce this acceptance? Perhaps looking back to the types of messages and outreach that public health officials provided in times of low vaccine resistance might give us some ideas about how to offer a more effective PR message about vaccines today. Perhaps most importantly, we need to know more about how vaccine resistance movements operate. What exactly are the demographics behind these movements? What methods do they use to spread information? Are anti-vaccine believers clustered in certain geographical areas or social networks? How can we best distribute pro-vaccine messages to target the right people? These are all essential questions if we are to successfully encourage widespread uptake of this crucial public health tool. At present, the medical and public health communities often resort to pedantic educational campaigns and exhortation in the face of vaccine skepticism. But berating anti-vaccine adherents has not proven useful. Rather, we need to understand the roots and motivations of misguided health-related ideas in order to design effective counter efforts.

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