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Simply correcting myths may be counterproductive- context is everything

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The spritely 80 year old man who sat in my consulting room was adamant.

No thanks doctor every time I get a flu jab I get the flu. So not this year. Thank you.

That was the third time that day that I had heard this argument against the flu vaccine. It troubled me. The individuals most likely to benefit were refusing vaccination and some of them say the same thing every year. And yet authoritative advice is that:

In randomized, blinded studies, where some people get inactivated flu shots and others get salt-water shots, the only differences in symptoms was increased soreness in the arm and redness at the injection site among people who got the flu shot. There were no differences in terms of body aches, fever, cough, runny nose or sore throat. CDC

Nonetheless 43% of the American public believes that flu vaccine can give you the flu. In the same study it was found that:

Corrective information adapted from the Centers for Disease Control and Prevention (CDC) website significantly reduced belief in the myth that the flu vaccine can give you the flu as well as concerns about its safety. However, the correction also significantly reduced intent to vaccinate among respondents with high levels of concern about vaccine side effects–a response that was not observed among those with low levels of concern. This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about vaccines may not be an effective approach to promoting immunization. Nyhan and Reifler

So it seems that providing information, no matter how authoritative,  is not enough to get people who are already opposed to being vaccinated to change their minds, in fact it may do the opposite! According to the theory of planned behaviour human actions are guided by three kinds of considerations:

  1. Behavioural beliefs ( beliefs about the likely consequences of their behaviour)
  2. Normative beliefs ( beliefs about the normative expectations of others)
  3. Control beliefs ( beliefs about the presence of factors that may facilitate or impede performance of the behaviour)

Therefore interventions that are aimed at providing information only do not work. We need to address attitudes, perceived norms and control if we are to see increased rates of immunisation. When this theory was applied to understanding how to improve flu vaccination rates it was concluded that:

Future studies could use social cognition models to identify predictors of actual vaccine uptake, and potentially compare these findings to predictors of people’s intentions to be vaccinated. Once identified, these factors could be used to craft targeted interventions aimed at increasing vaccine uptake. Myers and Goodwin

It seems that the intervention needs to be targeted and that there are several factors that identify people who intend to be immunised:

  • The employed,
  • Older people
  • Having a positive attitude to flu vaccination,
  • Scoring high on subjective norm, perceived control, and anticipated regret,
  • Intending to have a seasonal flu vaccination this year,
  • Scoring low on not being bothered to have a vaccination and
  • Believing that flu vaccination decreases the likelihood of getting flu or its complications and would result in a decrease in the frequency of consulting their doctor.

Those less keen on  vaccination may be from specific ethnic groups. The authors advise that

These racial disparities emphasise the need to involve stakeholders in the community and to reassure the community and address their concerns and resistance attitudes and beliefs.

Also people may also be more influenced by information obtained from peers and news media than information distributed by the government in print. Such “external” influences also need to be addressed in order to facilitate vaccination uptake. And so back to my patient, it seems that information alone would not change his mind- which was indeed my experience. In order change his mind we will need to target him in the context of his community, his family and his concerns. The battle for hearts and minds includes both hearts and minds. As always context is everything.

Picture by NHS Employers

Comments

  1. A drill-down on the Theory of Planned Behaviour is Petrie and Weinman’s Illness Perceptions model (http://cdp.sagepub.com/content/21/1/60.short). Their research has shown that change in health-related behaviours is best predicted by specific, measurable categories of beliefs and that targeting particular beliefs held by a particular patient at a particular time can effectively change patient behaviour. The particularity is important because there is considerable inter-individual variation in these beliefs across patients and time, even within defined disease and demographic groups. But particularity is where primary healthcare excels!

  2. Thank you Grant. You are right. From what we know, or at least what many of us experience, the same information has a different impact on the same patient at different times. Beliefs can be very difficult to shift- People chose what suits them to ‘believe’ at a particular time. The time to talk to many men about their lifestyle is when they hit 50, or when a woman gets pregnant or when a child is admitted to hospital etc. These teachable moments happen at different times in different people’s lives. The good GP, at least in those countries where that person has a longterm relationship with the patient is well placed to make the most of that window of opportunity.

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