Challenging Dogma - Fall 2011

Monday, December 19, 2011

A Critique: A Look At Promoting Flu Vaccination Compliance By Correcting Current Problems – Sophia Thornton

Effective vaccines have been around for decades. These vaccines have been life saving and affording innumerable benefits. Just thirty years ago people were still dying of smallpox, which has since been eradicated (1). Smallpox was a highly contagious disease with a terrible prognosis for those who were infected. Smallpox could not be cured but vaccines could prevented the disease (2). An effective vaccination program spearheaded by the World Health Organization finally stomped out this disastrous disease that killed every fourth person who contracted it (3).
Early scientists discovered methods to activate the human immune system so as to prevent the real disease. The same basic principles are used to develop new vaccines. The vaccines that we get today keep us and those near us healthy because of herd immunity, or protection for the entire community by a critical mass of individuals being immune to a disease (4). Furthermore, because of vaccines, a focal point of the first epidemiological revolution, people alive in America today cannot recall the time when diseases like mumps, measles, and pertussis ran rampant. Also, we enjoy a lower mortality rate and a higher life expectancy (5) since these diseases were no longer a threat.
Because of the intrinsic and undeniable benefits of the flu vaccine, its relatively cheap costs, and high returns the public health approach to flu vaccines needs close examination and adjustments to increase compliancy rates.

Severity of the Flu
The success we have seen with the great reduction of preventable diseases isn’t guaranteed. As evidence from the past indicates, we as a population must remain vigilant in vaccination maintenance. Recent outbreaks of measles in 1989 and pertussis in 2010 killed many Americans (1). For this reason continued efforts are needed to ensure that children as well as adults get vaccinated and receive timely booster shots.
One example of a disease that can easily turn deadly without the proper preventive measures is influenza. While there have been rare pandemics like the 1918 pandemic that killed more Americans than fighting during World War I (6), the seasonal flu is a constant threat that can be avoided with a simple vaccination. Scientists from the Center for Disease Control and Prevention estimate that 36,000 people die each year due to flu related complications. These numbers vary based on the severity of the seasonal flu then circulating (7). Those that don’t die still run the risk of developing complications such as pneumonia, ear infections, sinus infections, or worsening of chronic ailments such as asthma or diabetes (8). These conditions can lead to hospitalization.
The nature and biology of influenza varies from smallpox. For this reason we will never be able to eradicate the disease from the planet (9). The best way to counter complications and deaths from flu is to avoid it all together by creating immunity through vaccination. With advances in science and the methods we use to track the strains of the virus, scientists are able to develop vaccines each year that are generally 70 to 90 percent effective in protecting against the flu.
The effectiveness increases when measuring reduction in flu related deaths (10). Still with all of the scientific facts to back up the effectiveness of flu vaccines the numbers of recipients could be much greater. In 2010 only 43 percent of Americans received their flu vaccination, which is up from the previous year (11), but that is still too low a percentage. Even more shocking among high-risk adults vaccination rates for flu were only 50 percent (12).
Generally, more than 10 billion dollars a year are attributed to the overall societal costs of vaccine preventable diseases (12), with flu related hospitalizations taking up a larger portion of these costs each year (13). Hospitalization and missed days from work or school because of flu symptoms have huge consequences for our economy. This coupled with the continued threat the virus poses for the future results in serious economic and public health implications. Successful administration of a cheap vaccine would be an ideal public health intervention - one that would not only save money in healthcare costs, reduce forfeited wages, and provide intangible benefits such as avoided pain and suffering. Little however has been done, successfully, to address the situation. The public health initiatives taken thus far have many pitfalls. The next section outlines some of the undeniable problems regarding public views on flu shots. Finally, I will propose solutions to the problems I have identified.

1. Both Sides: Optimistic and Pessimistic Bias
Optimistic and pessimistic biases are important aspects of regulating peoples’ behavior and decision-making. Simply stated optimistic bias means that people understand that bad things do indeed happen, but they grossly underestimate the likelihood that one of those bad things will happen to them (14). People with optimistic bias see themselves as better off than the average person of a population. On the flip side pessimistic bias states that people believe that they are more likely to experience negative life events, or they are more vulnerable (15). Both of these theories have been explained as a self-preservation method. Their duality plays an interesting role in explaining two versions of people’s unwillingness to receive the flu vaccine.
The optimistic bias is a very important problem that needs to be confronted in any vaccination program. In the case of flu vaccines it is very easy for people to convince themselves, “I don’t need a vaccines since I never get sick”, or “everyone else has gotten the vaccine, so I will be ok”. These rationales are seriously flawed. Gregory Poland summed up the optimistic bias as the ‘not me’ syndrome. He further elaborates by saying that if an individual has not recently experienced an event such as disease, lost work days, transmission of illness, or sickness then a call to action is not inherent and therefore will not result in action (12). This unrealistic perception resulting in the diminishing probability of negative life events can halt a person’s impetus to vaccinate.
The anti-vaccine movement has contorted optimistic bias theory to its benefit, namely provoking pessimistic bias. Poland explains this as the ‘yes me’ syndrome. According to him the ‘yes me’ syndrome explains a person’s overestimate of the potentially harmful side effects (12). By playing into peoples’ fears of contracting adverse side effects, the anti-vaccine movement propagandizes vaccines as dangerous. This together with peoples’ natural reluctance to get vaccinated has creating a strong opposition to flu shots.
Furthermore, celebrities champion anti-vaccine movements. They contend that vaccines cause autism, and could be linked to other serious illnesses. Statistics aren’t going to sway a parent, but images of Jenny McCarthy’s autistic child, and her insinuation that there is a direct link between her son’s disease and a vaccine (16) definitely could. In a Time magazine interview Ms. McCarthy blames the pharmaceutical companies for not producing safe vaccines saying, “it should not be polio versus autism” (13). With these unfounded claims she has the ability to terrify parents who are trying to protect their children.
Other influential figures have made socially irresponsible claims, like Michele Bachman contending the HPV vaccines can cause mental retardation (17), Bill Maher urging people to not get the N1H1 vaccine in 2009 (13), and the erroneous news report claiming a cheerleader developed dystonia after receiving a flu shot (18). These and other sensational news stories make headlines and are widely circulated through social media; the public health truths about vaccines are not. These dramatic claims only further peoples’ misconceptions that they will be spared from the flu, or don’t want to risk potentially devastating side effects and therefore shouldn’t get the vaccine.

2. Factoring in Psychological Reactance Theory
Psychological Reactance Theory is another tenant of behavior largely ignored by the flu vaccine promoters. The theory postulates that individuals greatly value freedom and the ability to make their own decisions. When this freedom is threatened the individual is likely to display reactance (19). Health is a very personal thing. When an individual’s freedom to make a decision regarding his or her own health is threated he or she is likely to experience reactance against a prescribed action.
While some vaccines are mandatory for school attendance, the flu vaccine is not. In Massachusetts there are six required vaccines (often with many doses or booster shots) that are prerequisites to school attendance (20). Given all of these required vaccines any additional shot that is ‘recommended,’ i.e. the flu shot, will be ignored. Reactance to the recommendation will be intensified if receiving a shot requires extra effort, for example an added trip to a doctor’s office. These constrictions to obtain the vaccine all threaten an individual’s freedom.
If an individual is able to relate to the messenger delivering a health message reactance can be mitigated (21). Flu campaigns do not take advantage of this. Doctor William Schaffner, the president of the National Foundation for Infectious Diseases, received his flu shot while on television. He encouraged all leaders in the community, from business professional to school principles to “lead by example” (11) and get the vaccination. On the surface this isn’t a bad idea but according to the psychological reactance theory his actions have the potential to provoke reactance among the public. The majority of people are not able to identity with a well-educated white male, instructing everyone to get vaccinated.
On top of perceived risks of receiving (flu) vaccines, just getting a vaccination is scary for most children, and many adults. Furthermore, people largely don’t understand the biology and mechanics of the immune system and creating immunity. This lack of obvious association between the benefits (i.e. not getting the flu) and the actual shot makes the campaign for flu vaccines a difficult sell. Given the opt out alternative and the likelihood of reactance the current flu vaccine campaigns do not appropriately motivate the population.

3. Reliance on the Health Belief Model
Many of current public health initiatives for vaccination (as well as other interventions) currently circulating unfortunately still depend on the Health Belief Model (HBM), which insinuates that an individual who is presented with the facts about a disease or a condition will rationally come to a conclusion based on the costs and benefits of the proposed intervention. It goes on to say that those who don’t react appropriately by either quitting a risky behavior or participating in healthy behaviors are fundamentally irrational (22). New light has been shed on this matter. We now understand that there are aspects of human behavior that are not rational, and that we follow patterns that need to be explored through a group level lens.
As it is now people are told that they should get a flu shot, and they are presented with statistical evidence as to why, but few actually do. The CDC’s page on the flu vaccines is covered with facts about the vaccine’s safety, the symptoms of the flu, possible side effects, and who is most susceptible (23). This is a losing tactic for those who are trying to encourage as many people as possible to get vaccinated, because as with all health interventions people aren’t likely to react rationally to the most rational evidence. Individuals need something more.
The “Face of Influenza” is an attempt to rectify the blandness of the traditional HBM. In this campaign the American Lung Association, tries to put a face to the disease. While the website (, which shares families flu stricken stories, is compelling, it falls short. On the interactive main page real people are interviewed about how the flu touch their lives. Other than the opening page, the campaign falls back into the reliance on HBM. Every other portion of the website offers facts and statistics.
Additionally, an untaken opportunity was in the ‘grassroots campaign’ portion of the website (24). Here the campaign missed the opportunity to reverse the HBM approach. The website provides ready to use materials for informational/awareness sessions in different communities. Inappropriately, the bulk of the well designed and visually appealing materials are all facts and figures. Relegated to a small corner on one of the handouts are the more compelling personal stories.
The missed opportunity could have been tapping into people’s emotions and appealing to their core values, in this case protecting their loved ones, a very persuasive way to motivate someone (25). While this is one example of how HBM is pervasive in immunization campaigns there are many others.

Fixing the Problems
In general flu vaccination programs assume that people will behave rationally. However, time and time again this has been disproven. The Faces of Influenza campaign has solid groundwork, but needs to be expanded to be effective. An appeal that tugs on a person’s heartstrings will be given more weight when deciding whether to be vaccinated or not. Furthermore, core values of love or caring for others must be appealed to (26). Marketing the flu vaccine as something you do because you care about others and want to do everything to protect loved ones is an excellent way to promote compliance. A new national campaign called “Because We Care” would build on the groundwork already in place and take flu compliance campaigning to the next level. “Because We Care” would be a multifaceted campaign mainly implementing marketing theory but drawing on other group level theories to stimulate it’s success.
Advertisements would be developed for schools, television, and billboards. Each advertisement would display two contrasting images to target two main emotions. The first set of images would show the devastating result of not getting a flu vaccine. For instance, it will show hospital bed with a patient hooked up to tubes and machine. Brief stories will accompany the images, for example “Beth, aged 6, died from flu related complications.” Keeping these statement as brief and to the point ensures that the message isn’t lost. To be most effective the advertisements will picture either elderly or young people. Juxtaposed to the images of pain and suffering would be images of people walking away with smiles after receiving a flu vaccines. Here the advertisement would display the message “Because We Care, We Chose to Get Vaccinated.” Using “we” in the accompanying messages fosters a sense of community, which in turns gets people to buy into the campaign. The first portion of the advertisement would arouse similar emotions to that of some of the “Truth” campaign advertisements, specifically the feeling that the suffering portrayed was avoidable. The second set of images would show ease of getting the vaccine.
No statistic would be on the advertisement, but there would be three bullets to address certain key reasons for the current non-compliance. First, since a significant portion of people don’t like getting shot because they are scared of needles the new intradermal shot and nasal spray would be highlighted in the campaign. Second, financial reasons often factor into decisions. To address this concern the word FREE would appear on the advertisement. To offer the vaccine as free will take coordination with the CDC and other health organizations, but considering the overall costs caused by hospitalizations something certainly could be worked out. Finally, a website will be listed where people can find more information like where to receive vaccines and a list of frequently asked questions. Following is a deeper discussion of “Because We Care” and how the intervention can correct the problems previously noted with the current approach in Public Health towards flu vaccination.

1. Fighting Fire with Fire
Marketing theory is an exceptional tool to use to promote flu vaccines. Without focusing on the gritty details that often bog people down marketing theory allows for a story to be told. Using real people and real stories in the advertisements encouraging action (26) because people can connect to those images and desire to be part of the same movement.
In order to combat the problems presented by optimistic bias or an individual’s belief that they won’t get sick, expansion of the Grassroots Campaign materials started in the Faces of Influenza are needed. The opportunity to share people’s stories in order to demonstrate the human suffering that the flu can cause shouldn’t be underestimated. Revamping these materials to include more biographical evidence, and fewer scientific based arguments, could shift flu shot prioritization. Currently the website for Faces of Influenza has stories published with wrenching quotes like, “One flu shot could have saved his life,” and “I wouldn’t want any mother to go through what I went through” (25). These stories have been left out of the materials made for distribution in doctor’s offices or in local pharmacies, losing their usefulness. The “Because We Care” campaign would reverse the ratio of personal stories and facts and making the stories much more prominent. Many concerns still linger and people’s distrust of the flu vaccine is prevalent. Because of this information regarding any questions about safety or efficacy would be easily accessible, but not the main feature of the website.
Looking at the pessimistic bias is equally as important. Making sure that the stories on the news and the valid risks associated with not getting a vaccination is a greater societal problem. Holding the new media community more accountable for the stories reported is an important step, and one that will require federal legislation while respecting First Amendment free speech. The “Because We Care” campaign would contest pessimistic bias by reversing the sensationalist urgings with continued awareness raising efforts focusing on the genuine risks of getting the flu, not the made up risk of being vaccinated.

2. Reducing Reactance

Some things have already been done to relieve potential causes of reactance for the flu shot. Namely vaccines are now conveniently available in many pharmacies and grocery stores. These accessible locations are helpful in lessening potential loss of freedom due to an additional visit to the doctor’s office. But much more can be done to further reduce psychological reactance.
As mentioned earlier, the Psychological Reactance Theory suggests that the reliance on doctors to spearhead programs encouraging flu vaccination may not be the most effective. Not being able to identify with the messenger results in reactance. On a deeper level, many of the messages are delivered by organizations like the CDC, WHO, or other health entities associated with government. This association only furthers reactance. “Because We Care” can successfully separate the message from these official messengers and use more identifiable persons to encourage compliance. The better option for a messenger is a mother, because mothers generally are responsible for the health of the family unit (27). Convincing mothers of the fundamental benefits of vaccinations opens pathways to the rest of the family unit. Children would be good messengers to demonstrate that vaccination is not painful thereby removing fear associated with the vaccination. Finally, getting key sports players associated with various large cities would also be excellent.
Avoiding Psychological Reactance can also be accomplished by avoiding messages that seem manipulative (21). In order to do this presentation of pertinent and clear information is essential, but this will only be useful after a person is emotionally involved in the prevention of spreading the flu. The images associated with the “Because We Care” campaign make it easy for people to see the potential devastation caused by the flu. The campaign links the outcomes to the causes without blatant conjecture. Furthermore, the website would a one stop hub of all the information people need. The website connected with “Because We Care” would differ from many .gov website. There would be more interactivity and facilitated learning. This simple change in the presentation would have positive effects. Making the information more interactive gives curious people a sense of self-efficacy, which is one aspect of traditional models, but more importantly it enhances the overall learning experience (28).

3. Reframing the Flu

The majority of people do not choose to receive the flu vaccine, clear evidence the traditional HBM approach is flawed. Those who already receive the flu vaccine see it as a necessary evil, in that the small amount of pain experienced while receiving the shot is worth it in the long run. The vaccine will protect them and prevent the virus from spreading. But this is a very rational argument, not likely to be followed, so it is without wide societal application.
Implementing another model instead of HBM is necessary. The HBM is an individual model that is ineffectual in public health and therefore needs to be replaced entirely. In its place “Because We Care” would implement the framing theory to promote the desirable actions of receiving flu shots. Ideally, the correct frame would change the perception that the vaccine is an option to a routine that everyone participates in each fall. With the advent of the nasal spray and the intradermal shot that is “completely ouchless,” (11) the threat of pain is removed from the equation. The remaining challenge is removing people’s mental objections. As explained earlier appealing to the core values of people and framing flu vaccination as essential to the health of grandma, grandpa, babies, and friends can change behavior.


Increasing flu vaccine compliance is a difficult task but one that is extremely important and possible. Many myths surround this vaccination and even people with the correct information are still unwilling to get the vaccine. But, there are too many heartbreaking stories about children dying because they were not vaccinated or an immune deficient person catching the virus from a healthy person and being unable to recover to let this problem remain on the backburner of public health initiatives. Since we aren’t getting rid of the annual and costly disease we need to get rid of the opposition to vaccines.
With Because We Care shifting our approach to the broad yet critical public health obstacle non-compliance for flu vaccination there is great potential for better results. Because We Care can go beyond programs like the CDC coordinated annual National Influenza Vaccination Week (29). Approaches like this just scratch the surface without motivating compliance to acceptable levels, but new approaches like the one outlined can do much more.


1. History of Vaccines. Timeline. The College of Physicians of Philadelphia.

2. Center for Disease Control and Prevention. Smallpox Disease Overview. Atlanta, GA: CDC, 2007

3. World Health Organization. Smallpox: historical significance. Geneva, Switzerland: WHO.

4. National Institute of Allergy and Infectious Disease. Community Immunity: Herd Immunity. US Department of Health and Human Services

5. Bodenheimer, T., K. Grumbach, Understanding Health Policy, A Clinical Approach. USA: Appleton & Lange, 2007.

6. Public Broadcasting Service. American Experience: Influenza 1918. Arlington, VA: PBS.

7. Thompson, W. et al. Mortality Associated with Influenza and Respiratory Syncytial Virus in the United States. Jama: the Journal of the American Medical Association 2003; 289(2): 179-186

8. Center for Disease Control and Prevention. Flu Symptoms and Severity. Atlanta, GA.: CDC, 2011.

9. LaMorte, W. Lecture: Human Immunology. Boston University, Boston, MA. 10/5/2011.

10. Center for Disease Control and Prevention. Vaccine Effectives – How well does the flu vaccine work?. Atlanta, GA.: CDC, 2011.

11. MSNBC. CDC urges all Americans to get flu vaccine. Health News, 09/21/11.

12. Poland, G. Current paradoxes and changing paradigms in vaccinology. Vaccines 1999; 17 13-14: 1605-1611.

13. Center for Disease Control and Prevention. Seasonal Influenza – Associated Hospitalization in the United States. Atlanta, GA.: CDC, 2011.

14. Siegel M. Lecture: Five New Models, Optimistic Bias. Boston University, Boston MA. 12/01/11.

15. Blanton H. et al. Pessimistic Bias in Comparative Evaluations: A Case of Perceived Vulnerability to the Effects of Negative Life Events. Personality and Social Psychology Bulletin 2001; 27 12: 1627-1636.

16. Time Health. The Dangers of the Antivaccine Movement. Time Magazine, 02/24/2011.

17. ABC News. Michele Bachmann’s HPV Vaccines Safety and “Retardation” Comment Misleading, Doctors Say. ABC News Medical Unit, 09/11/11.

18. ABC. Medical Mystery of Hoax: Did Cheerleader Fake a Muscle Disorder? New York, NY: 20/20, 07/23/10.

19. Brehm, J. Chapter 22: A Theory of Psychological Reactance (pp. 377-390). In: Burke, W. et al. Organizational Change: A Comprehensive Reader. San Francisco, CA: Jossey-Bass, 2009.

20. National Network of Immunization Information. Massachusetts. Boston, MA: The Massachusetts Department of Public Health, 03/02/04.

21. Siegel M. Lecture: Psychological Reactance Theory. Boston University, Boston MA. 11/17/11.

22. Siegel M. Lecture: Traditional Models. Boston University, Boston MA. 10/06/11.

23. Center for Disease Control and Prevention. Key Facts About Seasonal Flu Vaccine. Atlanta, GA.: CDC, 2011.

24. American Lung Association. Faces of Influenza: Grassroots Campaign Tool Kit. Washington DC, 2011.

25. Siegel M. Lecture: Group Level Models. Boston University, Boston MA. 11/03/11.

26. Siegel M. Lecture: Marketing Theory: an Alternative Approach. Boston University, Boston MA. 10/06/11.

27. Kaiser Family Foundation. Women, Work, and a Healthy Family: A Balancing Act. Menlo Park, CA: KFF, Issue Brief: An Update on Women’s Health Policy, 2003.

28. Stout, P. et al. Enhancing learning through use of interactive tolls on health-related websites. Health Education Research Theory and Practice, 2001. 16 16; 721-733.

29. Center for Disease Control and Prevention. National Influenza Vaccination Week. Atlanta, GA.: CDC, 2011.

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