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Changing the Frame on Vaccination PDF Print E-mail
Swift

In my talk at TAM 2011 Las Vegas, one thing I mentioned is that the anti-immunization movement has science advocates stuck in a bad frame. A frame is a particular way of looking at an issue based on how it fits into a pre-existing narrative. People use frames in order to quickly categorize a complex situation they don’t fully understand by fitting it into a simple story that is easy to understand.

For example, one way of framing the current debates over state budget cuts is that it’s about hardworking public servants who are standing up to protect our state from politicians who want to gut education and vital public services to please their corporate donors. Another way of framing it is to say that it’s about hardworking taxpayers standing up to powerful public sector unions who are holding the state hostage to protect their jobs and ‘Cadillac’ benefit plans. When the conflict is framed around public services, people tend to agree that public services are good and support funding public services. When the conflict is framed around taxes, people tend to agree that taxes are bad and support cuts. The same person may even support opposite sides of the same issue when it is presented to them using different frames. Frames are important.

The frame that anti-immunization movement presents to the public is one of scientists as bought-and-paid-for corporate denialists, and anti-immunization activists as a grassroots community of parents banding together to protect their kids. This is a great frame for their side of the issue, because business-sponsored “research” is thing that people know is real: For years, “scientists” supposedly told us there was no solid link between tobacco smoking and lung cancer or other health problems. There are scientists sponsored by oil companies who say there's no proof of global warming. This frame means that when pro-immunization advocates respond with the facts—that vaccines are much safer than children having no immunity—what many people hear is, "trust the scientists, they know better than you what's best for your children." As long as we are stuck in that frame with a particular audience, we can't win with them. We have to get out of that box by giving people a different way to understand the conflict.

Another strike against immunization: Parents’ huge responsibility for our children, and insecurity about ‘doing it right,’ make us especially loss averse. Even more powerful than the fear that something bad will happen to our child is the fear that something bad will happen to our child and it will be our fault. It stands to reason that when presented with a choice between action or inaction when both options are perceived as risky, we tend to favor inaction—the choice that allows us to avoid blame—even when action will likely lead to a better outcome. (See: Trolley problem) When parents aren’t absolutely certain that vaccines are safe, many may find the pre-existing risk of preventable illness more palatable than the thought of possibly causing a serious problem through intervention, however unlikely.

So, how can we overcome these challenges to win over parents to support childhood immunization? This is one of the most common questions people have asked me since I raised the issue in my TAM talk.

First, we need a frame that can compete with the anti-immunization activists’ frame of scientists as pawns of industry. An alternative frame must ‘fit’ the conflict in a way that offers our audience instant understanding of who’s on which side, and it should be a frame that is favorable to us and unfavorable to anti-immunization activists.

To win parent’s trust, I think we need to start by validating parents’ concerns rather than dismissing them. Parents also know that healthcare companies have the same bottom-line goal of any other company—to make a profit—and they don’t necessarily have our children’s best interests at heart. If we are seen as dismissive of (or worse, ridiculing) that concern, parents will not take us seriously as advocates for their children’s health.

Being solely responsible for the health and well-being of a helpless human being, knowing that everyone is watching and ready to blame you if anything goes wrong, is terrifying. Parents want to do what makes us feel more secure and less afraid. Piling on to that fear by telling parents how their kids could die of measles may just lead parents to tune us out with all the other fearmongering directed at them.

Parents know about people trying to scare us and tell us what to do. It starts even before we have a child. People whose knowledge comes from rumors and things they heard third-hand try to snatch the food off our plates and scold us that we’re not supposed to eat fish during pregnancy. A store clerk told my wife, at 40 weeks pregnant, that she shouldn’t raise her arms above her head or the umbilical cord would twist around the baby’s neck. People who say and do things like that to pregnant women and new parents are horrible and annoying. If we use fear to push immunization, we run the risk of joining that chorus. Instead, pro-immunization advocates should be the ones who tell parents they don’t have to be afraid, and let the anti-immunization fearmongers be the people who are uninformed and up in their personal business when it comes to parenting.

A strong pro-immunization message could help parents escape the fear, rather than piling on. We could validate that yes, being a parent is scary, but immunization shouldn’t be. When we have the facts, we can all make healthy decisions for our kids without fear, without being intimidated by uninformed people who want to scare us.

In order for this message to ring true, pro-immunization advocates who use this approach should stick to language about helping parents understand the facts, rather than judging the outcomes. It’s possible to get so caught up with the research and the numbers that one forgets that human choice has a place in medical decisions as well. For example, in a recent post on Skepchick about home birth, some commenters expressed judgment against women who choose to give birth at home, on the basis of a study showing that babies born at home to first-time mothers have a 0.9 percent risk of an adverse event during birth, compared with 0.3 percent for hospital births. Some said the increased risk was unacceptable and should outweigh women’s reasons for wanting to give birth at home. Yet, few people would judge parents who drive their children around in a car instead of using public transportation, or parents who have their babies in the United States instead of Sweden, where the infant mortality rate is roughly a third that of the U.S. In our public messages, even if not in our hearts, we need to accept the value of parents making their own decisions about medical matters for their children. Parents should understand that our goal is to give them the facts they need to make healthy decisions for their children, rather than thinking we’ll say whatever it takes to get a needle in their kid.

We should also insist on the words immunity and immunization as favored alternatives to vaccination. Vaccination conjures up images of strangers stabbing you with sharp things and injecting you with things you don’t understand. The root word refers to cowpox. It’s not a pretty word. Immunity and immunization remind the audience of the benefit rather than the painful process.

Finally, given parents’ understandable loss aversion, we should present scheduled immunization as the status quo, and non-immunization as the risky action. Instead of “get your children vaccinated,” we could say, “Don’t withdraw your children from important immunizations.”

These points outline a different direction for pro-immunization messages that avoid the traps the other side has set up for us. What do you think? Is there another way of framing the issue that gets science advocates out of the “big pharma” box? Leave your ideas in the comments.

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written by Davis, February 14, 2012
The same could be said for other subjects too. For example, the folks I know who are believers in homeopathy, chiropractors, etc., would say that doctors and scientists are bought-and-paid-for corporate denialists, and that there is this vast conspiracy to dupe the public, all for money. And it is difficult (if not impossible at times) to change their frame of reference.
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written by Morrigan, February 14, 2012
You spoke at 2012? OMG time traveler smilies/wink.gif
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written by garyg, February 15, 2012
It should also be pointed out, however, that doctors, nurses, and scientists VACCINATE THEIR OWN CHILDREN AND THEMSELVES.

It might also be useful to highlight just who the anti-vax leaders are (e.g. they oppose vaccination out of their naturopathic leanings) and their lack of medical background (some bill themselves as "independent researchers", when all that means is that they cherry-pick alt med websites).
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written by Willy K, February 15, 2012
Alas, as I read this article I saw lots of information that won't make a dent in the hard heads of most anti-vaccers.

Except to refer to vaccinations as immunizations.
Hmmmm... I'll try that. Hopefully it will provoke a positive response. smilies/kiss.gif
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written by Loxton, February 15, 2012
Well done! I completely agree with your identification of the choice parents face as a trolley problem. (I've often described it in those terms myself.)

I'd also add my voice in support of your recommendations, both because they are (in my experience) very effective, and because they are ethical. I always start any vaccine conversation by acknowledging the challenges and fears parents face when trying to make wise decisions to keep our children safe and healthy in the face of so much conflicting information—and by acknowledging the genuine risks of immunization. As a parent, I can tell you: parents deserve that respect, and we deserve accurate, complete information.

With that foundation of mutual trust, we can talk openly about the known side-effects and risks of immunization (thankfully very small) the safety benefits for our children and their loved ones (large) and the best news of all: the robust confirmation that some fears we've heard a lot about in the sensation-loving media turned out not to be necessary fears. Thank god, autism (for example) turns out not to be one of the risks of immunization—and yet, there's a tragedy in that news, too. After all, if there had turned out to be a connection between autism and vaccines, we would have been that much closer to understanding autism, and that much better able to help those families.
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some difference from the trolley problem
written by sibtrag, February 16, 2012
One feature of the immunization decision (and I like that reminder to use more positive words) is that a decision to not immunize can always be reversed, while a decision to immunize cannot be. This is a strong factor for children who are cared for at home (and are too young for pre-school) and thus have limited exposure. Also, some immunizations are against diseases unlikely to be encountered by young children (such as hepatitis or HPV) so that one can choose to delay...and continue to consider...rather than the time pressure and irreversibility implied in the Trolley scenarios.

[[ I personally faced these decisions back when the "evidence" for vaccination-autism and mercury-autism links was first published and before the links were dis-proven. Delay was an attractive option to consider, especially since autism seemed to have a narrow window of onset. ]]

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Say what?
written by Vipermag, February 23, 2012
I am a parent of three, and they are all vaccinated through our vaccination program.
My eldest is 15, and he has had them all. With one exception, we did NOT take the vaccine for Swine flue.
In my country, Norway, there are now 92 confirmed cases of children having contracted narcolepsy after being vaccinated with Pandemrix. (Remember we are a small country :-)
Which I read about, and found insufficiently tested, to agree to letting my children receive. There was a lot of controversy surrounding this drug, and I chose right not to be vaccinated. As it turns out, the vaccine was not necessary, and I am glad I didn't let my children get vaccinated. I would be devastated had one of my children, or all of them for that matter, contracted this horrible "disease". So when you state that you have to put us in another frame of mind when it comes to immunization, I actually become more confused. There is no question about the power and greed that the pharmaceutical industry have demonstrated again and again through their behavior in hundreds of cases during the last 100 years. They are run by greed, and not by their concern for humanity, and that alone makes me a skeptic, and makes me question almost everything they say and do.
And of all the things to be skeptic about, this is one of the more important ones. Because their actions directly affect our lives.
I look at this the same way as food. What I eat is affecting me the same way as what medicine I take.
What religion some nuts practice has no affect on me what so ever. Therefore I think not taking everything told us from the medical community as the whole truth is a healthy thing. If you are a skeptic, you have to be skeptic to everything that can be questioned, and not just what other people say you should be skeptic about.
For me, being a skeptic means I question everything until I get a satisfactory answer, that my brain tells me is logical and makes sense to me. I do not question gravity, because that makes sense to me. I question religion because it does not make sense to me, and until otherwise proven, I will always do.
Now, I agree, that a lot of people have trouble sorting through the magnitude of information that is presented to them, and that this prevents them from making the right decisions in many cases. And that this is a problem we must attack ferociously, but that is a problem that stems from bad education. As a result of people having to focus more on getting a job than to getting better informed, they are prone to misconception and misinformation. We can not all be philosophers, some of us has work for a living.
Several comics has addressed this in the past, but I think it's worth repeating, modern medicine has yet to cure anything. They make medicine that alleviate symptoms and discomfort, but the illness itself is still out there. Some of them are almost gone, but as you know even polio is back. I know that if we really wanted it gone for good, we could have, but something inside me tells me that is not the case. I don't know why, but it's a nagging feeling that somewhere there is a group of people that made sure it didn't go away completely.
I know it's a horrible thought, but I can't shake it of somehow. It's just there.
There is also the history of DDT. Which was banned just short of eradicating malaria. Why?
As I understand, the alleged carcinogens in DDT was not as dangerous as they thought. In retrospect, people exposed to DDT had a significant lower death rate than people who died from malaria. This is of course just based on statistics, but is none the less important, since it tells us what would have happened had we not stopped spraying with DDT. (This is off course based only on the information i have found on the subject)

I could go on, but I think for now I have said what I needed to say, and I hope you take your time reading this. Please excuse me if the English not correct, I am Norwegian, and it is difficult to think in one language, and express yourself in another.
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