Abstinence-Only vs. Comprehensive Sexual Education Efficacy in Reducing Teenage Pregnancy Rates in the United States—Lauren Dustin

Teenage Pregnancy Rates in the U.S.

Teenage pregnancy is a public health issue that affects every individual in a community. In 2006, 750,000 teenage girls, aged 15-19, became pregnant. Having a child during teenage years carries many emotional, physical, and financial costs to the parents and community. Teen childbearing costs $9 billion to taxpayers annually, and teen birth rates in the U.S. are up to 9 times higher than most other developed countries. (1) Teens get most information about sex and pregnancy prevention from their school curriculum. About 70% of school districts teach comprehensive sex education that includes information on the risks of sexually transmitted diseases, unintended pregnancies, contraception methods, and abstinence, while other schools teach abstinence-only curriculums. Between the years of 2006-2008, most teens had received information about most of these topics; however, about one-third of teens had not received any formal instruction about contraceptive methods and use. (2) In 2009, there were 39.1 births per 1,000 women aged 15-19, marking an historic low with a decline of 37% from the peak rate of 61.8 in 1991. (3) Although the rate of teenage pregnancy has been steadily declining, there is still a lot more work to be done in finding the most effective educational program.

How Teen Pregnancy is Currently Addressed

Sexual health education is handled in varying ways throughout our nation’s schools. About 35% of school districts in the U.S. believe in abstinence-only education that does not provide any additional information on other methods of prevention from STDs and pregnancy. Discussion of contraception is either prohibited completely, or only permitted in order to emphasize its ineffectiveness. The remaining school districts use comprehensive sex education programs sometimes referred to as abstinence-plus programs. These programs teach abstinence as the most effective method, but also include information and resources on other effective measures of prevention. There have been some shifts in which programs schools prefer, and the biggest change in sex education policies has been toward more schools using abstinence-plus policies. (4)
Abstinence-only education is based on the belief that young men and women are unable to develop committed, loving relationships, and that this leads to childbearing out-of-wedlock. These programs focus on how to develop loving and enduring relationships first before sexual activity. Supporters of abstinence-only programs argue that teaching teenagers about contraception implicitly encourages sexual activity. (5) So instead, abstinence-only education teaches that abstinence is the only way to avoid STDs and pregnancy, and every other method is ineffective. Most programs focus on instilling moral or religious values rather than providing accurate health information. Evaluation of abstinence-only programs found no delay in first sex and analysis of federally funded programs were even found to contain false, misleading, or inaccurate information about reproductive health. (6)

Supporters of comprehensive sex education or abstinence-plus programs say that it may not be reducing sexual activity in teens, but it is teaching them how to do it safely in order to prevent negative outcomes. About half of all teens ages 15-19 are sexually active, and a sexually active teen that does not use contraception has a 90% chance of becoming pregnant within one year. (2) This type of program recognizes the inevitability that most teens are going to be sexually active at some point during their adolescence, and their aim is to prepare them to make healthy and informed choices about contraception. A national survey revealed that 78% of parents of teenagers agree and believe that their children should learn about birth control and safer sex in school. Many medical organizations such as the Institute of Medicine, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics also support the inclusion of contraceptive information with abstinence education to prevent teen pregnancy and STDs. (7)

There is no evidence to date that abstinence-only education delays teen sexual activity. However, research shows that abstinence-only strategies may deter contraceptive use and increase a teen’s risk of unintended pregnancies and STDs. (2) A study that compared abstinence-only and abstinence-plus education found that programs offering contraceptive education significantly influenced students’ knowledge and use of contraception methods. The study also found that abstinence-plus education led to increased contraception use by teens at follow-up compared to abstinence-only education. In addition, the use of abstinence-plus programs did not lead to an increase in sexual activity by teens, as mistakenly believed. (7) Evaluations of comprehensive sex education show that they do not increase rates of sexual initiation, they do not lower the age of first sex, and they do not increase the frequency of sexual activity or number of partners. In fact, teens who receive comprehensive sex education have a lower risk of pregnancy than those who receive abstinence-only or no sex education. (8)

New studies have shown that an increase in contraception use, not abstinence, is responsible for the decline in teenage pregnancy rates. According to the Guttmacher Institute, “86% of the decline can be attributed to the use of contraception, while only 14% can be attributed to abstinence.” (9) To reduce rates of teenage pregnancy, programs need to either improve contraceptive behaviors, reduce teen sexual activity, or both. Prohibiting contraceptive education in school-based programs keeps the very information that may have the greatest potential to decrease pregnancy rates from the people who need it the most. However, community attitudes towards teenage sexuality, rather than evidence-based interventions, greatly impact the acceptance of publicly funded school-based sex education programs. (7)

Government funding and policy-making by Congress, and individual state governments provide the basis for which type of education is used in certain school districts. In December 2009, Congress replaced the rigid Community-Based Abstinence Education Program with a new $114.5 million teen pregnancy prevention program to support evidence-based interventions and created the five-year Personal Responsibility Education Program (PREP). Its purpose is to educate adolescents on both abstinence and contraception, and to prepare them for adulthood by teaching subjects such as healthy relationships, financial literacy, and decision-making. Congress also renewed the Title V abstinence-only programs for another five years to provide funding to schools that choose to promote abstinence. (3)

Critique of Abstinence-Only Sexual Education Programs

Although abstinence-only education has not been proven to be effective or ineffective in preventing teen pregnancy in the United States, we can see how these programs have failed to apply social science theories correctly and are flawed in three fundamental ways.

The first major flaw in abstinence-only education programs is that it takes freedom and control away from teenagers when it comes to making decisions about sexual activity. Abstinence is stressed as the only effective method to prevent STDs and pregnancy, and teens are simply told to abstain. There is no information given about other methods of contraception so teens are not even given a choice to make, it is made for them. This type of program fails to consider the Theory of Psychological Reactance and how people react to their freedom being threatened or taken away. The theory says that when a person feels their freedom is being threatened, they experience reactance, a motivational state aimed at restoring the threatened freedom. (10, 11) In other words, they react by doing the negative behavior they are told not to do. When a teen is not given the freedom to make their own choices about sexual activity and contraception and they are simply told not to have sex, they will act out by doing the opposite of what they are told. Since abstinence-only programs do not provide information about contraception, these teens are at a greater risk for STDs and pregnancy because they are less likely to use any form of contraception when they do engage in sexual activity. (7)

Another flaw in abstinence-only education is the use of an improper communicator. These programs use adults, specifically teachers, to convey the message of abstinence as the only option. Teachers are the dominant player in the student-teacher relationship and their dominant and explicit messages can evoke increased psychological reactance. (11) Abstinence-only programs do not take into account the importance of similarity that is stressed in the Communication Theory, and that is also used as a way to reduce reactance and increase compliance. Teenagers who find it hard to relate to adults teaching them about abstinence will resist the very message. One of the most important aspects of the Communication Theory is the use of a messenger that is as similar as possible to the target audience. (12) The use of similarity has been found to reduce reactance and increase compliance. In a study done by Silvia, results showed that similarity increases liking and positive forces towards compliance while reducing negative forces toward resistance. Similarity also increases the communicator’s credibility and reduces the perceived threat to freedom. (10) Teachers and other adults may be the most practical communicator for school-based education, but in reality they are the least similar to the target audience and most likely to evoke reactance.

The last flaw of abstinence-only sex education is that providing inaccurate information or withholding information about contraception is morally and ethically wrong and unsafe. Abstinence is often presented as the moral choice for adolescents contemplating sexual activity. However, the current federal approach to supporting more funding for abstinence-only education raises serious human rights concerns. Access to complete and accurate sexual health information has been recognized as a basic human right and essential to make critical health decisions regarding sexual activity and the prevention of STDs and pregnancy. Abstinence-only programs are problematic because they withhold information and promote sometimes questionable and inaccurate opinions rather than facts. This threatens the fundamental human rights to health, information, and life. (13)

This flaw is a result of the incorrect usage of the Consumer Information Processing Model. This model explains that information is a necessary tool in health education; however, it is not sufficient for knowledge in general. Consumers, or students in this case, tend not to engage in extended searches for information. Therefore, if information about safe sex practices is not given to them in a structured way, they will most likely not seek it out themselves and this puts them in danger of contracting an STD or becoming pregnant if they do not know how to protect themselves. The Consumer Information Processing Model also states that before people will use health information it must be: available, seen as useful and new, and presented in a friendly format. This is where abstinence-only programs are flawed. They do not provide the new, useful, and necessary information in the first place, and the information they do provide, sometimes inaccurate, is not presented in a friendly way. (14)
Without complete and accurate information about sexual health and contraception, teens are unable to make a fully informed decision regarding sexual activity and STD and pregnancy prevention. In fact, teens who only receive abstinence messages face a greater risk of contracting an STD or becoming pregnant because they do not possess the necessary resources on other methods of contraception. (7)

Assessment

The actual causes of teenage pregnancy are not fully understood, but public health professionals would likely argue that a lack of information is a main reason. Teens that are not getting information about contraception and other prevention resources are at an increased risk for negative consequences because they are not informed or prepared to make these important decisions in a safe way. As discussed, abstinence-only sex education programs may be the least effective way to reduce teenage pregnancy rates because they are severely flawed. The explicit, forceful, and dominant messages portrayed by abstinence-only educators are the definition of what evokes psychological reactance in teens. When teenagers are told simply not to do something, they perceive their freedom to be threatened and they react to gain back that freedom by doing that behavior. This is the opposite of what abstinence-only programs want. Additionally, the use of a dissimilar communicator only heightens reactance and resistance to the abstinence-messages. People respond well and tend to comply with the beliefs and messages of a person who is most similar to them, often regardless of how threatening the message is. Lastly, the use of abstinence-only sex education in schools is morally and ethically wrong because they withhold crucial information that can be considered a basic human right in the context of making sexual health decisions. Teens need to be given the information that is new and useful to them because they are likely not going to seek out the information themselves. All of these flaws create inefficiencies that can severely hinder any possible progress made towards lowering the rate of teenage pregnancy.

New Theories

Using the social and behavioral theories previously discussed in the correct way along with several new theories will help to create a new and more effective sexual education intervention. These theories keep the target audience in mind and they recognize the need to reduce reactance in order to be successful. The new intervention will be comprehensive to include information not only about abstinence as the most effective method of STD and pregnancy prevention, but also additional information on other methods of contraception and how to use them.

Limiting Psychological Reactance & the Illusion of Control

Instead of using forceful abstinence-only messages, sex education programs should give the freedom of choice. Don’t tell teens what to do (abstain from sex), tell them what they can do instead (use protection if they become sexually active). Psychological Reactance can be a risk factor for initiation of the negative health behavior so it is important to limit reactance in order for an intervention to be successful in achieving its goal. One way to limit reactance to an intervention is to measure it before starting by finding out if the campaign would elicit reactance in the target audience. Public health professionals can do this through pilot studies or through questionnaires given to teens to assess their attitudes towards abstinence-only versus comprehensive abstinence-plus programs. To avoid reactance we need to know what elements can lead to it. Explicitness, dominance, and reason are three items that can influence reactance. The more explicit or forceful a message is, the more it evokes psychological reactance. When a communicator is perceived to have dominance over the message recipient, this increases reactance as well. However, when reason or support is given for the claim, this is likely to reduce perceived threats and reduce reactance. (11)

The Illusion of Control Theory explains that people value control over their lives or events that happen to them most when they have ownership over that behavior. If public health professionals were to use an intervention that sells control rather than takes it away, this would be accepted much more readily by our target audience. To give teen’s ownership over their sexual health decisions they will value their sexual health and choices they make much more, and this will lead to more informed choices about sex and contraception. The Illusion of Control Theory can also be used to decide when to intervene on a behavior. Intervening during the hot state (when someone is thinking about sexual activity or is already sexually active) will have the greatest effect on helping teens develop realistic plans for sexual activity and the use of contraception. (15)

Communication Theory & the Use of Similarity

The school setting is the most common place where teens learn about sex, both from their teachers and their peers. It is a logical strategy that the adults or teachers of the school system are the ones who educate teens about sex, but perhaps using a more similar messenger would have an additional impact on lowering the teen pregnancy rates. In addition to adults teaching sex education in the classroom, peers can be used to convey messages and information to other teens about contraception and pregnancy prevention in other settings through various forms of media. Interventions can use peers from the same school who are around the same age or even a celebrity who is of similar age.

The Communication Theory and study done by Silvia explains that the most important part of effective communication is to use a messenger that is similar, well-liked, and attractive to the target audience in order to increase compliance and reduce psychological reactance. The messenger should also deliver non-threatening information, unlike the messages in abstinence-only programs. (10, 12) Teens should be given the freedom of choice and control over their sexual health. Using similarity will help to balance positive and negative forces of compliance and reactance and give teens the confidence and freedom to make their own decisions about their sexual health. Providing the resources will enable them to make safer choices and help to decrease the teen pregnancy rate.

Bringing About Change with the Agenda Setting Theory

To learn from the flaws of abstinence-only programs and to eventually eliminate these programs all together I would propose using the Agenda Setting Theory. This theory is based on the idea that there is a public agenda, and it consists of what people are talking about and what people are interested in at that specific moment in history. If you can get people to think and talk about your issue, it will be a part of the public agenda and it will be much easier to have an impact on the public health issue. Public health professionals can use this theory to get people to realize the flaws with abstinence-only programs and why comprehensive programs can be more effective and safer for teens. This would tie in very well with the use of a media campaign targeting teens because often times the media dictates the public agenda. (12)

New Intervention

The first strategy towards creating a more effective sexual education intervention program that reduces the rate of teenage pregnancy in the U.S. would be to make all education programs comprehensive. I believe having comprehensive sex education as the primary form would be the most effective in increasing contraception use, and reducing STDs and pregnancy rates in teens age 15-19 as previously supported. (7) Information about safe sex and contraception is critical to teenagers who are faced with decisions about sexual activity. To withhold this information puts them at greater risk for negative consequences. The new intervention will offer control and freedom to the teenagers so as to not threaten them and evoke psychological reactance. Instead of explicitly stating that abstinence is the only way to go, the new intervention will feature other choices for contraception and prevention, in addition to abstinence. This has shown to be more effective in increasing the use of contraception, which in turn leads to a decrease in pregnancy rates. (9) The most effective curriculum-based programs have focused on a specific behavior, such as using contraception, and provide the basic information, not too much detail . They are age appropriate and based on theoretical approaches; they address peer pressure, and teach skills in problem-solving and decision-making to prepare students for difficult life choices they will encounter. Teaching basic life skills along with sex education has shown to be effective in increasing knowledge and changing attitudes and behavior towards contraception. (16, 17)

To give teens the freedom to choose how they handle their sexual health may not be enough to achieve the overall goal of reducing teen pregnancy. For this reason, the new intervention will also add another communicator to the program who is more similar to the target audience to deliver messages to teens. On top of the comprehensive school curriculum, the program will feature media ad campaigns emphasizing safe sex and “the choice is yours” type statements. The campaign will be marketed like a mass movement, urging teens to join the “Safe Sex” movement by choosing to abstain or use contraception, and realizing they have the freedom to choose and they have control over their sexual health decisions and the consequences of those decisions. By joining a movement, this will make the teens feel like they truly are in control and they will not feel threatened to obey abstinence-only messages. These messages will be delivered by someone who is familiar and similar to the target audience. Studies by Silvia show that similarity increases compliance and decreases resistance. This will have the greatest effect on getting teens to use contraception in order to reduce the teen pregnancy rates. (10, 12) Teens can relate to someone who is most similar to themselves, and this is not going to be the teachers or adults in a school. A peer-to-peer media campaigns will be a more effective element to the comprehensive sex education already in place.

The intervention will feature positive and freedom enforcing messages on posters throughout the schools, on computers, on school news broadcasts, on local television, and social networking websites. The campaign will say things like “Safe sex is sexy”, “The choice is yours, own it” and other positive, non-dominant messages. Teens say that they would prefer to get information about sex from their parents, but more than half of them report getting information about sex, birth control, and pregnancy from television shows, movies, and magazines. (18) Because teens most often learn about sex through these channels of communication, using magazines and local television would successfully reach the target audience. The messages will be created and delivered by peers and persons who are the most similar to the target audience such as students from the same school. The combination of control and the use of a similar communicator will greatly reduce reactance and increase compliance. (10)

Summary

Although many school-based and community interventions have been used to try to reduce the rate of teenage pregnancy in the U.S., most have been ineffective. The designs of abstinence-only programs are especially flawed because they evoke psychological reactance from the dominant and forceful messages they portray. They fail to provide the necessary information about contraception that teens need in order to make safe decisions about their sexual activity. Teens that do not receive information about contraception are at an increased risk for getting and STD or becoming pregnant. Educational programs that are comprehensive in nature and include information on both abstinence and other methods of prevention, as well as teach important life skills, are the most successful at increasing knowledge and changing attitudes and behavior. Teens respond best and tend to comply more with messages that use a communicator that is most similar to them. Interventions that take advantage of similarity effectively limit reactance while increasing compliance. This will have a positive effect on reducing the teen pregnancy rate in the U.S. The first step in creating a more effective sexual education program for all school districts to use is to get this issue on the public agenda through the use of the media. This intervention will depend on public support and community acceptance in order to be successful, and this will be the most difficult element to achieve.

References
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Milwaukee Campaign Against Sleeping with Baby – Natasha Neal

Infant Mortality in Milwaukee, Wisconsin
Milwaukee, Wisconsin has higher rates of infant mortality in comparison to other areas of the United States and other parts of the world. Infant mortality is the number of infants that die during their first year of life (1). Milwaukee’s African-American infant mortality rate is ranked higher than at least 35 other countries, including some developing countries (2). The top four reasons for infant death in Milwaukee are complications of prematurity; congenital abnormalities and related complications; sudden infant death syndrome (SIDS), overlay, and accidental suffocation; and infections (2). In particular, Wisconsin is a state with one of the largest differences in infant mortality based on race. The gap between non-Hispanic white infants and African-American infants is quite large: for every five white infants that die prematurely, 14 African-American babies die (1). Based on the list of most common deaths in infants, the only cause that is preventable after birth is SIDS, overlay, and accidental suffocation.

In order to address the dismal situation, the City of Milwaukee’s Health Department created a Safe Sleep Awareness Campaign, in which they discourage the practice of co-sleeping, and more specifically, babies and adults sharing the same bed (3). They have used posters, as well as radio and television advertisements to get their point across to the public. To view the public health campaign advertisements, visit http://city.milwaukee.gov/SafeSleep (3). The public has perceived these advertisements with mixed views as they depict a small baby sleeping in a bed next to a large knife. The poster states: “Your baby sleeping with you can be just as dangerous.” Some responses have been supportive towards catching parents’ attention on an important matter; however, others feel that the City of Milwaukee is demonizing parents. These posters were created with the intention of grabbing the attention of parents that may bed-share. It is very unlikely that parents that co-sleep are consciously putting their babies in harm’s way, explaining the negative reactions of some parents.

Problems with Milwaukee’s Campaign Against Co-Sleeping

Despite correctly identifying the large racial disparity in infant mortality, Milwaukee’s campaign is unlikely to be successful in closing this gap. The Health Department has chosen to focus on a much narrower health behavior in the hopes that it will significantly reduce the rates of infant mortality. The advertisements used in the campaign overlook four important social behavioral models: Labeling Theory, Optimism Bias, the Law of Small Numbers, and Psychological Reactance. Furthermore, The City of Milwaukee’s Health Department has done a poor job of approaching such a controversial, and poorly understood health behavior.

The Health Department has been quick to pinpoint bed-sharing as the form of unsafe sleeping practice that results in sudden infant death syndrome (SIDS) or sudden unexpected death in infancy (SUDI). However, based on a study released in 2011, the major risk factors for SIDS also include inadequate prenatal care, low birth weight, premature birth, short interval between births, and maternal substance abuse (4). It becomes clear that many of these factors are uncontrollable, and are often completely independent from whether an infant sleeps in the same bed as an adult or not, except for maternal substance abuse. Therefore, even infants that sleep in their own bassinet or crib are at risk of SIDS. In some unfortunate cases, despite parents following the safest child-rearing practices, an infant will still experience SIDS. In combination with the disparity in infant mortality between races, it encourages one to question whether an ethnic community in particular is engaging or has a history of increased risk factors, in addition to bed-sharing. It is important to examine the situation in relation to different races as one of the goals is to narrow the gap between infant mortality rates in Milwaukee.

Data included in the City of Milwaukee’s Fetal Infant Mortality Review (FIMR) also does not concretely support their view on targeting co-sleeping. The FIMR stated that Singapore had the lowest infant mortality rates, despite approximately 70% of the population engaging in bed-sharing, showing that bed-sharing can be practiced safely (5). Armed with this knowledge, one must ask what specifically, during bed-sharing, is the cause for increased infant mortality in the United States versus Singapore. Research has been conducted on this point, and it has been found that there are often other factors playing a role. For instance, the risk of infant death during bed-sharing often occurs if a parent also engages in smoking or alcohol abuse (6). In addition to this, in other countries where bed-sharing is the predominant form of sleep practice, it is important to be aware that in these countries, families often sleep on firm mats instead of softer mattresses (7). Therefore, it is a combination of the risks mentioned previously, including premature birth and maternal substance use, combined with bed-sharing, that can increase the risk of infant death.

Another critical consideration of this intervention is the message that public health officials want to send. Research has shown that the risk of SIDS increases when babies sleep in a different room from parents (8). Despite this known fact, the advertisements do not include information indicating that although bed-sharing should not occur, room-sharing is important to the health of infants. The advertisements, while depicting the dangers of bed-sharing, contain little information on how to mitigate the risks. This information only appears on the website, and yet there is no guarantee that parents will spend the time going to the website. All information must easily reach parents in order for individuals to make educated decisions. The City of Milwaukee also ignores the positives that have been identified in literature regarding bed-sharing. These positive elements include making breastfeeding easier, allowing babies and parents to get more sleep, ensuring mothers are more responsive to the needs of the infant, and the practice encourages bonding and security between parent and infant (7). By purposely omitting this information, the public may feel as though the City of Milwaukee’s Health Department is trying to deceive or manipulate their behavior. This may be especially likely to occur in parents that are well-versed in the sleeping practices of other non-Western cultures.

Due to the vast majority and somewhat contradictory information available in regards to bed-sharing and co-sleeping, it becomes apparent that education must be the first step to behavior change. Parents are unaware of the pros and cons of different sleep practices. As well, many parents are misinformed about the definition of co-sleeping; some believe that co-sleeping is defined specifically as the practice of sharing the same bed with a baby; however, this is not true (3). Having a baby sleep in a bassinet or crib next to the parents’ bed is also a form of co-sleeping. Some experts have begun referring to room-sharing versus bed-sharing in order to clarify the difference in the two practices (3). One problem with the campaign is that the ads do not clarify this distinction. Therefore, the overall impression parents may be getting is that their babies need to sleep in a completely different room.

Labeling Theory and Racism's Effect on Health Disparities

Milwaukee’s Health Department has been quick to identify the difference in infant mortality rates between African Americans and non-Hispanic whites (2). However, one major flaw in their intervention was the obvious avoidance of addressing these differences in their campaign, other than including two versions of their ads, one featuring a white infant and the other featuring an African-American infant (3). It is important to consider the reasons behind why the rates of infant mortality differ so drastically between the two races, even when all other factors are similar. It has been reported that an African-American woman with a college degree has poorer infant mortality rates compared to a white woman with only a high school education (1). One contributing factor to this phenomenon may be due to labeling theory, and its relation to race. Institutionalized racism may play a huge role in the differences in infant morality rates between white and African-American infants. Differences in race are especially important as the City of Milwaukee is dramatically racially segregated (9).

One study has looked at biological differences between people of different races in order to determine reasons for such dramatic differences in health disparities in different populations of people. One study was conducted in order to identify why blood pressure can differ so drastically between black and white individuals (10). Researchers Krieger and Sydney concluded that when examining blood pressure, it was important to take into account how discrimination may affect health (10). Similarly, it is important to take into account the biological differences of African-American women in comparison to white women. African-American women typically have babies with lower birth weights and are more often born prematurely (9). Institutional racism, a form of racism that is not necessarily obvious, can result in African-American women having increased stress levels, perhaps due to the expectation that discrimination will occur in everyday life events (11). Increased stress levels may then lead to increased risk of premature births and low birth weight. It is important to help these women that must live with institutional racism overcome the hardships they may face, especially during pregnancy.

One other study looked at the differences in infant mortality between African-Americans and white mothers in relation to sleeping position. The study identified that the sleeping positions varied distinctly between the two races. African-American infants were more likely to sleep in the prone position, or on their stomachs, rather than the nonprone position (on the back or side) (12). The prone position is more highly associated with SIDS. This could be one reason why the disparity in infant mortality exists between the two races. The study also went on to find that African-American mothers more often recalled or were incorrectly told by health professionals that the prone position should be used (12). Here we see a form of institutionalized racism that impacts the mothers of different races, as it is unlikely physicians were purposely suggesting unsafe sleeping practices.

A separate study found that interpersonal racial discrimination experienced by African-American women a year prior to birth as well as over a lifetime was a risk factor for premature birth (13). Nancy Krieger defines interpersonal racism as “directly perceived discriminatory interactions” (14). The City of Milwaukee should consider examining whether members of the African-American community experience higher levels of interpersonal racism, in order to prevent this from occurring. In the study conducted by Rankin, David, and Collins, they found that using active coping behaviors to deal with interpersonal racism could weaken the association between the risk factor and premature birth (13).

Understanding the differences between African-American women and white women is one way to focus Milwaukee’s intervention and an important factor in determining how to reduce the infant mortality rate. Milwaukee’s campaign does not inform women that babies born prematurely or with low birth weights are at higher risks for SIDS, and the necessity to take more precautions. The racial segregation in Milwaukee can further impact the situation as areas with high populations of African-Americans may have fewer resources for pregnant and new mothers, such as clinics, primary care offices, and prenatal classes.

Optimistic Bias and the Law of Small Numbers

The Health Department has overlooked the roles that the theory of optimistic bias in combination with the law of small numbers may play in this campaign. The Law of Small Numbers is the theory that people will often associate their risk with one positive case despite substantial information contradicting this (15). For example, a smoker will doubt that smoking increases the risk of cancer despite the vast evidence supporting this simply because they have a family member who smoked their entire life and never developed cancer. Optimism bias refers to the fact that an individual will know the risks of a particular behavior, but will underestimate their own risk (16). The campaign against bed-sharing emphasizes the dangers through the use of the knife and tombstones in the ads (3). While this may communicate the risk of bed-sharing with the public, individuals may believe that they will be the exception to the statistics. In the television ad depicting a mother that tosses and turns while sleeping, the overall impression is that bed-sharing may lead to a parent or adult suffocating their child. However, based on optimistic bias, people viewing the ad may think that while suffocation of a child may happen to others, it will not happen to them – they will be the exception to the rule (16). This becomes especially important for parents who already have had a child, and who practiced bed-sharing without any incidence of SIDS or SUDI. Based on their previous experience, they are likely to experience the law of small numbers, and be confident they can bed-share with smaller risks than the general public, although this may not necessarily true (17). Another factor to consider is the social networks of people, and the different sleeping practices friends and families engage in. One study found that at 2 weeks of age, 42% of parents shared a bed, at 3 months 34% shared a bed, and 28% at a year of age (18). These statistics show that bed-sharing is not rare and many people likely know of other parents that sleep in the same bed as their infants. The knowledge of others that have bed-shared successfully can lead people to believe in the Law of Small Numbers - that those people that have successfully practiced bed-sharing are in fact the norm. These individuals will question the veracity of the ads in conjunction with having an increased risk of infant death, especially if these parents believe that bed-sharing is a better parenting technique. Combined with optimistic bias, knowing others that successfully bed-share make it unlikely that these ads will be effective in changing the behavior of parents that co-sleep in the same bed, especially those that have never known someone whose child suffered from SIDS or SUDI.

Psychological Reactance and Pushback Against the Ads

It is very important to gauge how the public perceives the advertisements. Psychological reactance occurs when people feel their control is being taken away (19). It becomes particularly important in the issue of co-sleeping because parents have differing opinions on the pros and cons of bed-sharing based on the literature available and the cultural norms of different populations. Therefore, when advertisements tell people that their method of child-rearing is incorrect or unsafe and should not be practiced anymore, it is in effect taking away the freedom for people to decide how they want to raise their children, and what they believe is best for their child’s development. In a study conducted, investigators found that countercultural parents in the US were more likely to also be “pronatural.” This group of parents was interested in following “natural parenting” and often follows practices more common in non-Western countries, such as breast-feeding rather than formula use, bed-sharing, and using only organic foods (20). However, they may be unaware that in non-Western countries, firmer mats instead of softer mattresses are used. These parents believe that they are practicing the best form of parenting, and will therefore not heed the warning, and they will perceive a loss of control over their style of parenting. When people experience psychological reactance, they will often engage in the prohibited behavior much more strongly (19).

Solutions for Co-Sleeping and High Infant Mortality Rates

It is important to consider the root causes of high infant mortality. Despite perhaps not being the largest cause of SIDS and SUDI, proper co-sleeping may lower the rates of infant mortality in Milwaukee. However, identifying the differences in racial groups will also be impactful if addressed in the intervention. A new intervention is being proposed that will effectively remove the barriers in the already existing intervention.

The new intervention will consist of various different platforms: it will use television advertisements as well as offering educational programs in the community. This new intervention is based largely on three models useful for changing behavior: the Theory of Planned Behavior, Social Expectations Theory, and Advertising Theory. In combination, these will overcome the problems seen in Milwaukee’s current campaign, and will hopefully reduce the number of deaths that can be attributable to unsafe sleeping practice, as well as reducing the number of SIDS and SIDU deaths in general in Milwaukee.

New television advertisements will be created for the intervention. The advertisements will depict images of the important milestones in a child’s life: first birthday, first steps, first day of school, graduation, marriage, and then the birth of a grandchild. Following the images, a parent who experienced the death of an infant due to SIDS or SIDU will speak out. More specifically, the parent will emphasize the point that they were unaware of the importance of safe-sleep practices, that they missed out on so many of the milestones they expected to experience, and they will encourage parents to seek out new information regarding safe sleep practices. They will also suggest ensuring children sleep in an environment without blankets or pillows, to avoid the risk of suffocation, and that parents always place their babies on their back or supine position to sleep (8). If parents are concerned about moving in their sleep, the ad will go on to explain that the safest place for a child is in a crib or bassinet. However, it will emphasize the importance of infants sleeping in the same room as a parent.

In addition, the new intervention will have nurses available at churches, clinics, or community centers for expecting and new mothers. These nurses will be concentrated in African-Americans communities, where clinics and services may be harder to come by and where infant mortality rates are much higher – in particular, the zip codes of 53206, 53210, and 53233, which have the highest rates of infant mortality in Milwaukee (2). The nurses will act as educators, talking about the increased risk of SIDS for premature or low birth weight babies. They will ensure that African-Americans have strategies in place to deal with any type of discrimination they may face. They will describe common safe sleep practices outlined in the report by the American Academy of Pediatrics, such as always placing an infant in a supine position, using a firm mattress, avoiding pillows and blankets near the infant, encouraging breast-feeding, encouraging room-sharing over bed-sharing, and encouraging the avoidance of exposure to tobacco smoke, alcohol, and illegal drugs (8).

Finally, the City of Milwaukee should start a program where parents can donate cribs or bassinets once they are no longer needed. These will be provided to parents of newborns that are interested in room-sharing rather than bed-sharing, but that may not have the means to purchase these items.

Social Expectations Theory for Community-Based Interventions

The Social Expectations Theory suggests the importance of examining individuals based on the community they live in and the values they hold (21). As Milwaukee is racially segregated, this theory would be very helpful in addressing the differences in community norms and values. This theory, and its examination based on a community level, will help overcome weaknesses due to the Labeling Theory and racism. Do mothers in the African-American communities place more importance on bed-sharing or sleeping in the prone position? Does this belief stem from the norms and values of their culture? Is there a way to educate these mothers on safer methods of co-sleeping that may reduce risk of smothering and suffocation?

It is also important to focus on the issue of infant mortality among African-Americans in general, as this population has the highest rates of infant mortality in the city. The first step would be to identify the resources available to new and expecting mothers. Placing more resources in these lacking communities may have a profound effect on infant mortality. Finally, it will be important to examine the communities, and in particular, the African-American communities, for indicators of excess stress levels mothers may encounter due to discrimination and racism. If these two issues can be combatted, perhaps the number of premature or low birth weight cases will decrease. Following this identification, if the City of Milwaukee can take a more active role in the resources available to pregnant women combatting discrimination, perhaps Labeling Theory and racism can be overcome, in turn decreasing the number of cases of premature and low birth weight babies, and in turn decreasing the number of cases of SIDS or SIDU.

The Theory of Planned Behavior

The first step to effecting behavior change, especially in regards to a topic that individuals may not be familiar with, is education. Using the Theory of Planned Behavior, one can begin to develop a new intervention that may be more effective in reaching people that currently do not practice safe sleep techniques. The Theory of Planned Behavior is based on the fact that individuals weigh their attitudes and social norms against expected outcomes when engaging in a particular action (22). An important factor is their perceived behavioral control, also known as self-efficacy, in carrying out a particular behavior (22). This theory, with a focus on education, can be used to overcome optimism bias and the law of small numbers. In order for this to occur, it is imperative that individuals are educated on the safest sleeping practices for children from birth to the age of one.

If prenatal classes are available in the community and are well attended, the City of Milwaukee should ensure that expectant mothers are educated about safe sleeping practices during these classes. This allows mothers to be exposed to the information, and they can include it during their decision process. If prenatal classes are not offered, programs will be created in churches, community centers, and clinics in the community, which will be free of charge. By basing these educational events in a group setting, new social norms are being created around safe sleeping practices. These safe-sleeping practices can be geared towards room-sharing over bed-sharing.

The information presented in the sessions will include information about the pros of co-sleeping, the definitions of co-sleeping, room-sharing, and bed-sharing and the pros and cons of each. Classes will encourage parents to use bassinets or cribs that can be close to the bed, which are completely empty except for the mattress. For parents that are determined to bed-share, it is important to portray a safe way to do so – by placing blankets and pillows away from infants, by placing infants on their backs to sleep, and by ensuring that the parents are not restless sleepers that tend to move in their sleep. It is important, on the part of the educators, not to give the impression that parents are being told how to raise their children. By using education rather than commanding or ordering parents to engage in a particular behavior, we are allowing parents to make their own decisions on child-rearing practices. This will help mitigate psychological reactance because we are not taking away individuals’ sense of control (19). Instead, we are giving control to parents – they are now in control of making safe and smart decisions when choosing a particular sleep practice based on all of the information available.

One important addition to the Theory of Planned Behavior is the component of self-efficacy (22). Parents must be made to feel as though they can actually change their behavior and be successful. One barrier to self-efficacy in the context of room-sharing may be that the parent does not have access to a bassinet or a crib, due to financial circumstances. Therefore, this needs to be addressed in the intervention. It is unreasonable to institute a campaign encouraging mothers to practice safe-sleeping techniques if they are unable to afford the necessary requirements. The program involving crib and bassinet donations from the public will allow parents to obtain these needed items when financial limitations exist. By using donations, Milwaukee’s Health Department will not need to worry about financial constraints.

Advertising Theory and Connecting to the Community

Advertising theory should be considered when reaching out to the target population. Advertising theory is composed of three main components: the promise, core values, and support. These work together to reach the public on an emotional level (23). Therefore, advertisements need to be created which touch individuals on all three components. The promise the new set of advertisements will offer to viewers is the possibility of being a part of all important milestones in a child’s lifetime: first steps, first birthday, graduation, wedding, and the birth of their first child. These are all experiences that parents will treasure over the course of their child’s life, and will reach a wider target. These images will support the promise of experiencing life’s many milestones, and will play on the values of love, family, and aspirations. In order to overcome the law of small numbers, following the images, a parent will speak about how they missed out on all of these important life events because they were unaware of safe sleep practices, and therefore, they suffered the death of a child. They will show a picture of their baby that passed away due to SIDS. This overcomes the law of small numbers because people can now relate to someone who has experienced SIDS rather than knowing someone that has successfully bed-shared. Advertising Theory has proven successful in an intervention known as the Truth Campaign in Florida (24). This campaign was able to build a brand based on values, and resulted in decreased rates of high school and middle school students smoking (24). Similarly to this campaign, Milwaukee’s safe-sleeping campaign will place most attention on life’s important milestones for a parent, and the values of love and family, in order to connect with parents and change behavior.

Conclusion

Milwaukee is a city that is unique in its mortality rate differences based on ethnicity. It is critical to narrow the gap, and decrease the infant mortality rate. Milwaukee has correctly identified one potential area that may reduce the rates of infant mortality – the incidence of bed-sharing, but by basing their intervention on fear alone, they are unable to make an emotional connection with viewers that will encourage parents to change their behavior. Using the Social Expectations Theory, The Theory of Planned Behavior, and Advertising Theory for the basis of a new intervention, Milwaukee will be more successful in reaching their target population, and lowering the rates of infant mortality due to SIDS and SIDU.

References:
1. City of Milwaukee. Infant Mortality. Available at: http://city.milwaukee.gov/InfantMortality.htm. Accessed December 12, 2011.
2. City of Milwaukee Health Department. 2010 City of Milwaukee Fetal Infant Mortality Review (FIMR) Report: Understanding and Preventing Infant Death and Stillbirth in Milwaukee. Milwaukee, Wisconsin: City of Milwaukee Health Department; 2008.
3. City of Milwaukee Health Department. Safe Sleep for Your Baby. City of Milwaukee. Available at: http://city.milwaukee.gov/SafeSleep. Accessed December 14, 2011.
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An Analysis of the United States Vaccination Policy and Corresponding Campaigns – Deborah McSparren

Introduction

Vaccines are one of the greatest medical achievements of the 20^th century. The success of vaccine use, especially in children, has eliminated two diseases in the United States, polio and smallpox, plus reduced the incidence of several other diseases by at least 95%. By the end of the 20^th century, immunization rates in children under two reached a record high of 90%. There is a relatively successful movement that discourages parents from vaccinating their children. This population experiences increased hospitalizations and deaths due to these vaccine-preventable diseases (1). Additionally, there is a societal burden associated with the anti-vaccination movement which can be significant; this includes missed school days, missed work days and secondary illness in family members (2).

The Centers for Disease Control and Prevention (CDC) is the main advocate for vaccines within the United States and recommends vaccine scheduling guidelines. However, federal law allows each individual state to establish its own requirements. Historically, people have always challenged these laws and requirements. In 1809, Massachusetts was the first state to require the smallpox vaccine. This law’s constitutionality was challenged because a resident was concerned about an adverse reaction to the vaccine. The Supreme Court in 1905 affirmed the rights of the state to require vaccination because “the protection of the health of the public supersedes certain individual interests, within reasonable boundaries” (3). By 1963, 20 states required immunization of children before entering school. The effects of not requiring immunizations were obvious during the 1970s when occasional outbreaks of the measles occurred most commonly in states without immunization requirements. This prompted activists to push for compulsory laws and measles eradication. By 1980, all 50 states passed laws requiring vaccinations before school entrance. There are exceptions to the requirements; all states allow medical exemptions with a doctor’s permission and 48 states allow religious and/or philosophical exemptions (3).

The high vaccination rates and declining disease incidence creates an environment that evokes public debate about the safety of vaccines. The anti-vaccination movement appeals to people’s anxieties by alluding to a number of unsubstantiated claims such as: safety issues, cover-ups by medical professionals, bureaucrats regulating parenting and greedy pharmaceutical companies (4).

The current anti-vaccination campaign is successful at accessing larger populations because of the reach of internet and social networks. At the forefront of the anti-vaccine campaign is the supposed link between thiomersal in the measles, mumps, rubella (MMR) vaccine to autism in children. This belief was perpetuated by the Wakefield paper from 1998 that linked the MMR vaccine to autism. The Wakefield paper was later retracted after subsequent studies failed to reproduce his results but the public mistrust remained (5). After investigating this claim, the Institute of Medicine (IOM) and the Immunization Safety Review Committee (ISRC) concluded there was no scientific basis to establish a causal relationship between the MMR vaccine and autism (1). Despite these reassurances, rates of the MMR vaccine have declined in some areas. An effective aspect of this anti-vaccination campaign is the ability to exaggerate isolated, coincidental incidents and promote them as fact. These claims are accepted without scientific evidence of causality and exacerbate parental fears about their child’s health (6).

Health practitioners fear that once immunization rates fall below 90%, herd immunity will be lost. Herd immunity refers to high immunization rates among the population that protect the few who are not immunized from disease. This drop in vaccination rates may result in vaccine-preventable diseases circulating more freely with an increased incidence of disease (6). This phenomenon has already occurred with various outbreaks of measles, pertussis and whooping cough in the United States. One study found that un-immunized children aged 6 to 10 years were 15 to 59 times more likely to acquire pertussis and measles than immunized children (1). This resurgence of vaccine-preventable disease shows that vaccination campaigns need to become more effective to counteract the anti-vaccination movement.

Critique #1: Vaccination Requirements Invoke Psychological Reactance

All states require that children be vaccinated before attending school (1). These requirements, although meant to protect the population, cause some parents to react negatively toward the idea of vaccinating their children. This is an example of Psychological Reactance Theory. It describes a motivational state when someone perceives their freedom is being threatened, reduced or eliminated (7,8). Reactance occurs when rules, regulations and policies limit behavioral freedoms and people are forced to accept a particular view. People try to restore their freedom by embracing a contrary stance; thus these parents opt out of vaccinating their children. Psychological reactance is an emotional response that is not based on rational decision making, which helps explain the appeal of the anti-vaccination movement. This phenomenon parallels Brehm’s observations, people respond negatively to an influence even when the influence is in their own best interest (7).

Psychological reactance to vaccination requirements can be found throughout history. People and groups have been challenging requirements since the 1800s on the basis that the government is intruding on personal autonomy. However, governments and courts in the United States have always upheld vaccine mandates because of their success in virtually eliminating disease (3). Some parents object to vaccine requirements because they believe it affects their right to make decisions about their child’s health (1). In regards to vaccinations being required versus voluntary, governments have always had to weigh individual freedoms against the benefits of the society as a whole (3). Anti-vaccination movements have always been able to build support based on people’s reactance to the perceived threat on their freedom and irrational behavior. Even though overwhelming evidence points to the effectiveness of vaccines, some people still choose to embrace the autism link to support their anti-vaccination stance, despite the lack of scientific evidence supporting these conclusions.

Parental attitudes toward vaccinations have also been examined and the outcomes have confirmed Psychological Reactance Theory. Even though vaccines are required for school entry, they are voluntary in theory because of the “opt out” options for parents. One study found that health professionals are resistant to the idea of parents making their own informed choices. By not presenting parents with vaccination options, parents view health professionals as obstacles to information. The same is true with the immunization literature. Parents felt that the information in pamphlets was not designed to inform but to generate conformity. This tactic causes parents, especially educated ones, to be resentful and perceive the plan as a deterrent to making an informed decision. Further analysis finds a contradiction between health care’s emphasis on patient’s rights to informed consent and the actual practices around immunization (6). Parents may construe these practices as a perceived threat to their freedom and thus react against vaccinations. This choice endangers their children because without the immunization they are vulnerable to vaccine-preventable diseases.

Critique #2: Vaccination Campaigns Use of the Health Belief Model

Government sponsored campaigns promoting vaccines traditionally employ the Health Belief Model (HBM) to encourage parents to get their child vaccinated. The Health Belief Model is based on four main constructs: perceived seriousness of a disease, perceived susceptibility of acquiring the disease, perceived benefit of the behavior and perceived obstacles to adopting the behavior (2). Theoretically, this model relies upon people making informed, rational decisions and modifying their behavior based on this information (9). But, campaigns that inform the public about vaccines and the consequences of vaccine-preventable illnesses do not take into account parental attitudes and the emotions the anti-vaccination invoked. The anti-vaccination movement was able to establish vaccines as a perceived barrier to a child’s health by suggesting vaccines could cause autism. Studies have found that parents are already aware of these diseases and the threat to their children but this knowledge does not necessarily convince them to immunize their children (10). While educating parents through the HBM remains necessary, campaigns need to be adapted and modified to address the root causes of anti-vaccination behavior.

Most public health campaigns still only rely upon the HBM to increase vaccination rates. This one dimensional approach severely limits the effectiveness of the campaign’s message. The CDC’s website lists the goals and objectives for their vaccination campaigns. For example, the objectives for their preteen and teen campaign rely heavily on the HBM. The current six objectives on the CDC website are focused on raising awareness, educating stakeholders and promoting open lines of communication. One example of the HBM in action is a CDC brochure that pictures a father playing basketball with his son. The caption reads “Thinks meningitis is a band from the 80s” (11). This is purely the Health Belief Model in action because the objective of the campaign is limited to informing the public about the existence of the disease and no other pertinent information is provided. Most people are exposed to reports in the news media reporting outbreaks of bacterial and viral meningitis; it would be difficult to have never heard of this disease. The CDC appears to be wasting time and money focusing on informing the public about diseases instead of finding the actual reasons for not vaccinating children and teens.

The CDC’s use of the HBM to promote vaccinations in the meningitis campaign mentioned above assumes rational behavior, whereas the success of the anti-vaccination movement has taken advantage of people’s emotions causing irrational decision making. Anti-vaccination messages have dramatized single cases of autism lacking a causal link to the MMR vaccine while ignoring the prevention of disease in millions of people. Public health authorities are perplexed at the popularity of the anti-vaccination campaign since their main themes are based on irrationality and misunderstandings (6). Their confusion stems from believing that people act rationally and educating the population will result in higher vaccination rates. Public health organizations must take into account the emotional, sociocultural and psychological factors that affect vaccination rates.

Critique #3: Law of Small Numbers Applied to Perceived Disease Risk

The Law of Small Numbers is used to explain that even though people realize they are susceptible to vaccine-preventable diseases, this belief does not always translate into actually being vaccinated. The theory states that people have erroneous assumptions about the laws of chance, more specifically their individual chances of acquiring a disease. They tend to believe that small samples taken from the population are representative of the population as a whole (12). In other words, if a person has never known anyone that has contracted a vaccine-preventable disease, then they will believe that they cannot get the diseases themselves. This causes people to be overly optimistic and they expect other people to acquire a disease, not them (13). Studies have found that people underestimate the likelihood of a negative event and overestimate the likelihood of a positive event. So being overly optimistic coupled with a person’s direct experience of a vaccine-preventable illness results in a reduction in vaccination rates.

Vaccines have become a victim of their own success. They are so effective that people have paid more attention to potential side effects of vaccines rather than the diseases themselves that are much less prevalent (5). The public’s loss of confidence in immunizations will result in declining rates of vaccine use, whereas disease outbreaks can occur again and have already taken place in some areas. An effective intervention needs to convince the public that everyone is susceptible to vaccine-preventable disease.

Proposed Interventions

There are two factors that point to the necessity for policies and campaigns focused on public health interventions to be reexamined and likely modified. The factors are the anti-vaccination movement and declining rates of vaccinations. The issue with current practice is the expectation that people will act rationally by protecting themselves from vaccine-preventable diseases. However, the anti-vaccination movement is popular because it appeals to emotions while not having solid scientific evidence to support their claim. New interventions should look to present less factual statistics and education since it does not necessarily translate into modified behavior. I propose less traditional theories to increase vaccination rates: Framing Theory, Advertising Theory and Protection Motivation Theory.

Intervention #1: Use of Framing Theory to Modify Immunization Views

Framing Theory is a form to communicate meant to change the perception of a public health problem or intervention. Framing studies conclude that the way in which information is presented impacts health behaviors. People routinely respond to positive framing as opposed to negative framing (14). This first critique discusses psychological reactance as a result of the state requirements of vaccines. I also discuss how vaccines are voluntary in theory because of “opt out” options in all US states. I believe that the requirement aspect of vaccinations must be reframed for it to increase vaccination coverage.

A pro-vaccination campaign to reframe vaccinations as a choice and further expand parental options to include a flexible vaccination schedule would be optimal. Even though this campaign seems counterintuitive, but removing psychological reactance to vaccines may actually increase coverage. Many experts would disagree to this claim. Health practitioners are fearful of vaccination rates dropping below herd immunity and feel that voluntary vaccinations would facilitate lower rates (15). I believe that this aggressive change in framing vaccines will combat anti-vaccination proponents. Dr. Lawrence Rosen, who is a Vice Chair at the American Academy of Pediatrics, argues that a flexible schedule responds to the public’s mistrust of government agencies, such as the CDC which sets the vaccination schedule. He states that a flexible schedule would encourage parents who otherwise would not vaccinate their children to adopt a vaccination schedule of their choosing. The flexible schedule responds to parents who worry about autism to be able to vaccinate their children at an older age when emergence of autism is less likely. This option could also appeal to parents who have been ridiculed by health practitioners about their vaccination views (16).

This issue is considered reframing because vaccinations have always been a choice for parents and scheduling has always offered some flexibility. However, parents are constantly encountering, between doctors office visits, school districts and governments, vaccines as a “requirement” and schedules as rigid and uncompromising. Vaccines are understandably termed “required” because of concern about the health of children and society as a whole. Unfortunately, this method of presenting vaccines may be doing more harm as parents attempt to oppose authoritative messages. A revised, more focused campaign would frame vaccinations as a choice and offer flexible schedule options provides a positive environment for parents to increase vaccination coverage of their children.

Intervention #2: Use Advertising Theory to Appeal to Emotions

The decision to vaccinate is a complex social act. In order to make the decision to vaccinate, an individual may examine the issue on a number of levels. First, on the individual level a person is concerned about their own health in the possibility of contracting the disease; secondly an individual parent may be concerned about the safety of their children, and lastly an individual may be concerned with the probability of the disease spreading throughout the community. Trust in government and trust in health practitioners add to the complexity of the decision the individual must make (5). The traditional Health Belief Model is very one-dimensional and includes presenting facts and statistics to change behavior without accounting for the complexity of the problem. Because of this complexity, health practitioners find it difficult to create an effective campaign that addresses all individual and social behaviors. Advertising Theory is actually a very basic method to change health behaviors simply by making a promise to remain consistent within the core values of the target audience (17). The Advertising Theory uses branding to create associations that supersede other types of advertising mainly by invoking emotions. A public health brand can link a health behavior to an enviable lifestyle and therefore; change the health decisions of a person by ultimately adding value to the decision or lifestyle. A public health brand can also promote a beneficial exchange; most effectively by delivering a positive message (18). To paraphrase from Dr. Siegel’s class lecture, the most effective way to convey this promise is through stories, music and visual images (17).

I would design a campaign focused on appealing to the overwhelming public sentiment which at its core is an individual’s desire to exercise his or her right to freedom of choice. By presenting to the public a campaign that connects with the values of the individual decision-maker, Advertising Theory will be used effectively; I propose appealing to a person’s sense of freedom. I feel that most people, especially Americans, highly value their freedom and a positive campaign promoting freedom as a result of getting vaccinated may change beliefs and practices. The campaign would depict an American family on a road trip throughout the United States, showing famous landmarks in the background with a song playing in the background. I would show the same family traveling the world, again with European, Asian and other identifiable world landmarks in the picture frame. At the end of the clips I would ask “Do you want to freely travel around your town, state or country (or world)?” I would continue with “Do you want to travel without fear of illness?” I would conclude with “Then make sure that you and your children are vaccinated against preventable diseases.”

A successful pro-vaccination campaign would apply the guidelines of Advertising Theory. The ads will appeal to emotions and the core value of freedom by promising people the right to travel. Typically, people do not want their freedom taken away. Mandatory vaccinations cause the negative reaction leading to the choice not to vaccinate. A beneficial exchange is also offered in a positive manner; a person is offered freedom, more specifically freedom of travel, which they obtain by getting vaccinated. This approach is an improvement over HBM because instead of trying to change behaviors by informing and educating mainly by listing statistics; a marketing campaign will promise core values as a result of a health decision or behavior.

Intervention #3: Use of Protection Motivation Theory to Counteract the Anti-Vaccination Movement’s Use of Fear

The Protection Motivation Theory (PMT) was originally proposed by Rogers in 1975 to impart clarity in understanding fear and its influence on behavior. The theory states that behavior is based on the perceived severity of the threat, perceived vulnerability of occurrence, efficacy of the recommended behavior and perceived self-efficacy. This starts out exactly like the Health Belief Model; except the theory takes it one step further, it says that once a person evaluates the perceived risks and vulnerabilities, then that person processes a threat appraisal and later a coping appraisal based on the amount of fear the person experiences. The coping appraisal translates to decisions made about health behavior to reduce the threat (19,20). I think that the anti-vaccination movement employs this theory by producing fear in parents about giving their child autism after the MMR vaccination. Since the anti-vaccine campaign is successful with this tactic, I propose using the Protection Motivation Theory to instead promote vaccine use.

A campaign that uses PMT will increase a parent’s fears about vaccine-preventable diseases. As stated in the earlier critique, people usually do not have any memory of disease outbreaks and have never known anyone with any vaccine-preventable diseases; therefore, they concentrate their concerns on their fear of vaccine related autism. The campaign would show that the reality is that children still contract measles and other vaccine-preventable diseases; outbreaks are still possible. I would include some elements of Advertising Theory to invoke emotions by adding music and focus on the expressions of individual children. The catch-phrase of the advertisement would include the statistics related to children that have died as a result of these diseases. The overarching message would be, “These diseases can be prevented by vaccinating your child.”

This campaign is designed to appeal to the emotions of parents and show them that there remains concern about these diseases and that their children are vulnerable; thus creating a threat appraisal leading to a coping appraisal, which should result in parents having their children vaccinated. I think this campaign would be effective in promoting vaccines; especially when evaluating a parent’s reasoning when deciding for or against vaccines. Using focus groups, one study found that parents who were most likely to vaccinate their children did so because they found “vaccine preventable diseases as threatening and frightening” (4). The parents also added that they would feel tremendous guilt if their child contracted a vaccine-preventable disease (4). This evidence further supports my claim that the fear parents feel about the MMR vaccine and its link to autism can be combated by matching that emotion with a parent’s fear for their own children’s vulnerability to contract one of these diseases.

Conclusion

The advent of immunizations has been an extremely important health achievement by virtually eliminating multiple diseases in many countries. However, this practice has been threatened by anti-vaccination movements making sensational claims about the safety of vaccines. The strict requirements of vaccination policies coupled with the very basic educational campaigns and the public’s lack of exposure to vaccine-preventable diseases results in lower vaccination rates. Instead, governments should make vaccinations a choice for parents while creating campaigns that appeal to core values and emotions. This altering of perception will increase parent’s acceptance of vaccines and increase overall rates.

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