In
reaction to the persisting decrease of vaccination rates in developed
countries, public authorities, the media and non-profits counteract with information
campaigns. In my opinion, this approach is self-defeating because it ignores
the phenomenon’s behavioral realities.
1. Raising awareness is typical for information campaigns.
Articles
with headlines such as Wealthy L.A.
Schools' Vaccination Rates Are as Low as South Sudan's are well intended,
but ignore the effect of social proof.
When unsure what to do, people use others’ behaviors as cues for their own
behavior. When faced with information on the increasing number of parents who refuse
vaccination, others might interpret the message as: it’s OK not to vaccinate your children since others are doing this.
In
many developed countries the overall situation is not as dramatic as some
headlines indicate. The ideal vaccination rate is 95%+ which ensures herd immunity. The actual vaccination
rates are somewhere in the 80-90% range. Healthcare professionals are worried mainly
because of the trend and because of the real danger of losing the herd immunity. As I understand the societal benefits of
vaccination are not linear. Simply put, the societal benefit of improving
vaccination rates from 80% to 85% is smaller than getting it from 90% to 95%
(where heard immunity is achieved).
While
from an epidemiological point of view a vaccination rate of 80% is worrisome
news, from a behavioral science perspective things aren’t as dramatic. While
most news focus on the increasing number of children who are not vaccinated,
the upside is that the very large majority of children (in the USA) are
vaccinated.
Saying
that 20% of children are not vaccinated can be reframed as 80% are getting
vaccines!
In other
similar situations, this type of simple reframing proved extremely effective in
achieving behavioral change. Just as an example, many people have no problem
buying a ham that is 97% fat free, but they would be very reluctant to purchase
ham that is 3% pure fat.
Couple
this reframing with social proof and you have a nice tool for reaching the goal
of increasing vaccination rates.
Whereas
headlines need to be dramatic in order to get clicks (or sell newspapers),
public information campaigns need to be effective in achieving behavioral
change – in this case get more children vaccinated.
Instead
of relying on alarmist messages, why not simply say that the great majority (80%)
of parents (in USA) do vaccinate their children.
Social
proof and reframing of information can be used in even less favorable
circumstances. A few months ago, I heard on the radio a commercial aimed at
increasing the flu-vaccination rate. Unfortunately, the commercial said
something like: “If you are one of the 65% of Americans who don’t get the shot,
you can get the flu”.
Beyond
the obvious errors in communication (from a behavioral science perspective),
the reality of the numbers seems discouraging. When only (approx.) 35% of
people get a vaccine, it is hard to leverage social proof – the great majority
of people is not doing what is desired.
There
is, however, a silver lining: 35% of the US population (311 million) is roughly
100 million people. Very likely, saying that over 100 million people (fellow
Americans) get the flu shot is more convincing than 65% of Americans don’t get
the flu shot.
2. Doctors are spokespeople in pro-vaccination
campaigns.
The
use of medical doctors as authority figures (recommenders) in communication has
a long history. Doctors (or actors dressed as doctors) have recommended
anything from detergent to cigarettes and from pharmaceutic drugs to diets.
While
in many commercials using medical doctors as recommenders proved to increase
the communication’s effectiveness, in the case of pro-vaccination (or anti
anti-vaccination) campaigns is not exactly appropriate.
Doctors’
presence and messages are reassuring for people who favor vaccination. However,
those who are reluctant to vaccination don’t perceive doctors as authority figures, thus the message’s impact
is severely diminished.
Simply
put, in the eyes of (some) people who refuse vaccination, regular medicine is
not trustworthy and so are medical doctors. Maybe herbalists, alternative
healers etc. would be more credible.
3. The rational message favoring vaccination is
inadequate for tackling highly-emotional (false) concerns.
Strongly
related to using medical doctors as advocates for vaccination is the messaging
of pro-vaccination endeavors. Doctors dressed in their uniforms speak about the
scientifically proven benefits of vaccination and talk about the serious
dangers of not using this simple and effective prevention tool.
Although
correct, this rational message is highly ineffective for those who oppose
vaccination. Many anti-vaccination arguments have a high emotional load. Nobody
(falsely) claims vaccines to cause kidney-failure – a serious condition with a
low emotional load / fear-factor.
Yet, all anti-vaccination advocates mention that vaccines can cause autism – a condition
that has a high emotional component or fear-factor.
By the way, vaccines don’t cause autism, but at one point someone made a false
claim they did and the research has been proven to rely on faked data and the
paper was later retracted. Yet, the legacy of fear left by that paper stands.
4. Vaccination’s benefits are Non-Events & the
Availability Heuristic
The
benefit of vaccination is very difficult to observe because it is a non-event –
something that doesn’t happen. We humans are terrible at understanding
non-events and in the case of vaccination things are even worse than in other situations.
Taking
a step side-ways, I think we can all agree that a fire-fighter who goes into a
burning building and saves a person (or cute puppy) is a hero worthy of public praise.
At
the same time, the huge majority ignores other people who (indirectly) save
many more lives from fires – the fire-safety inspectors: The bureaucrats who
come with checklists and regulations, who generally are grumpy and somehow
annoying because they keep insisting on even small features of compliance to fire-safety
regulations.
These
people save lives not by entering burning buildings, but by ensuring the
conditions to prevent fires altogether and / or decrease the damage caused by
fires.
The vaccination
situation is somehow similar.
Preventing a disease is not the same with curing one. A doctor who cured a
patient with smallpox will receive many thankyou notes and will be held in high
regard, but the nurse who gave thousands of anti-smallpox vaccines, thus
preventing the disease, is still anonymous.
Earlier
I mentioned that the situation is somehow
similar. The high effectiveness of mass vaccination in preventing diseases, in
fact, makes it more difficult to see the benefits of vaccination.
Let’s
go back to the firefighter – fire-safety inspector illustration. The (paradoxical)
reason for complying with fire-safety regulation is that there are enough (?!) fires to make the danger
salient in our minds. Either in real life or in movies, fires are frequent
enough to remind us that preventive action is needed.
In
the case of vaccination things are a bit different. In developed countries recent
cases of smallpox, poliomyelitis etc. are extremely rare. Mass vaccination led
to having two-three generations free of such diseases and their devastating
consequences. While during our (great-) grandparents’ childhood it was common
for families to lose one or more children to diseases such as poliomyelitis,
nowadays such instances are (almost) inexistent.
This
is when the availability heuristic comes into play and distorts decision making
on accepting vaccination.
The
availability heuristic means that we judge the probability of an event based on
the salience and frequency of memories of that event. We know of a lot of
killings by firearms and very few suicides by guns, thus we perceive that there
are more killings than suicides by firearms. The reality, however, is
different: there are more suicides than killings by guns (at least in the US).
Because
instances of terrible diseases that are prevented by vaccines are extremely
rare and inconspicuous, we erroneously perceive the risk of not vaccinating a
lot smaller than it actually is.
Here’s
where movie makers can lend a hand. Instead (alongside) of scaring people with
terrorist plots, doomsday scenarios etc. they could include more instances of
people suffering and dying from poliomyelitis, smallpox etc.
5. Costs are in the present and benefits are in the
future
Most
people prefer 100$ now over 110$ in one year from now. This is an illustration
of a psychological phenomenon called discounting
future outcomes.
Vaccinations’
(non-event) benefits occur in the future (1-20 years) and, subsequently, are
discounted in the present. The discomforts of vaccination– parents have to take
their child to the clinic to get the shot, normal minor side-effects (fever, local
swelling etc.) – are in the present.
The
false dangers of vaccination allegedly occur very soon after getting the shot
(in the present, not in the distant future).
While
it is impossible to change the nature of non-events and to eliminate the
discounting of future outcomes, there are several things that can be done.
First,
to tackle time discounting we can bring the benefits in the present. Naturally,
vaccination’s benefits cannot be brought in the present (more so since they are
non-events), but decreasing costs (hassle) in the present could be a great
approach. In addition, although it might seem unethical, we could offer
incentives in the present for getting vaccinated.
Second,
to tackle the issue of non-events, we could try to make the immediate benefit
more concrete by offering tangible rewards. As mentioned earlier, we could
increase the frequency and salience of the dangers of non-vaccination and
movies are the best way (at least in my view).
