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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