Posted: January 10, 2009
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Article SummaryConvincing health care workers to get a flu shot might normally be seen as a straightforward problem in precaution advocacy, but this column focuses on an aspect of the problem that’s grounded in outrage management: flu protection hype. By means of three case studies, Jody Lanard and I document that hype – misleading, one-sided messaging on behalf of vaccination and other flu precautions – does in fact characterize much of what’s produced by flu prevention campaigners. We also argue, with much less evidence, that the hype leads health care workers to mistrust what the campaigners are telling them, and that the mistrust probably reduces their willingness to get vaccinated. The column ends with a list of less tendentious recommendations for convincing health care workers to get a flu shot.

Convincing Health Care Workers to
Get a Flu Shot … Without the Hype

Susan Keady, an infection control practitioner in Alaska, recently sent the following comment to this website’s Guestbook:

My hospital is struggling, as we do every year, trying to get hospital employees to accept influenza immunization. There seem to be two issues here.

First, people say “I don’t need a vaccine because the flu is no big deal” or “because I never get the flu.” It’s a high-hazard, low-outrage risk. Of course, most of the hazard is to our patients.

Second, employees tell us that the flu vaccine is dangerous, has serious side effects, and may have unrecognized adverse effects on health. Vaccination is low-hazard, high-outrage.

Any suggestions on preparing messages to deal with both these issues? We are not finding that education or evidence work!

Keady framed the problem perfectly. For all too many health care workers (HCWs), influenza is high-hazard and low-outrage, whereas vaccination to protect against it is low-hazard and high-outrage. Since outrage influences people’s responses to risk more than hazard does, it’s not shocking that only about 40% of U.S. health care workers actually get the shot, not much higher than the percentage of the general population.

An important new reason why some HCWs are outraged about flu vaccination is the increasing pressure they’re under to get vaccinated. Outside the health care field, vaccination outrage attaches mainly to childhood vaccines that are required or near-required, especially the MMR. Flu vaccination is usually a low-outrage issue; people simply decide yea or nay as they prefer. But that may be changing. If flu vaccination pressure on the general public mounts, and especially if more states and school districts add influenza to the mandatory vaccination list, we should expect increases in community outrage, parallel to the increases we’re already seeing among HCWs.

So how should a hospital, nursing home, or doctor’s office persuade its people to roll up their sleeves (or inhale the nasal spray)?

Whenever vaccination is high-outrage, you have to do precaution advocacy about the disease and outrage management about the vaccine at the same time. People will resist learning that the disease is serious unless their reservations about the vaccine are being sensitively addressed. And since the two issues are so closely connected, you have to do outrage management even about the seriousness of the disease – by not overselling your case, for example.

Most flu vaccination education programs work hard on the precaution advocacy task: instructing HCWs that influenza is serious and the flu vaccine is safe and effective. But they neglect the outrage management task. Surveys show that many HCWs aren’t getting the message. We believe the neglect of outrage management is one key reason why. So we are going to focus on flu vaccination outrage management.

Much of what follows may seem counterintuitive and even uncomplimentary (and thus hard to hear). And our recommendations are far from a silver bullet; there is no perfect way to convince HCWs to get vaccinated, just as there’s no perfect protection against the flu. This is the best that we have been able to come up with.

We will start with an aspect of the HCW flu vaccination problem that is usually ignored: learned mistrust resulting from flu prevention hype. As a strategy of precaution advocacy for high-hazard, low-outrage risks, exaggeration isn’t rare. And it can be effective, at least in the short term. But not when the key recommended precaution is high-outrage! When flu prevention in general and flu vaccination in particular are hyped to an audience that is feeling some outrage already, learned mistrust and increased outrage are likely outcomes.

After discussing learned mistrust and analyzing three examples of flu prevention hype, we will offer some other, less tendentious recommendations on convincing HCWs to get vaccinated.

Learned Mistrust

When HCWs explain why they didn’t get a flu shot, they often cite the same misinformation and false beliefs mentioned by non-medical people:

  • They don’t think influenza is a serious problem.
  • They don’t think they’re likely to get the flu, and they invent reasons why they’re less susceptible than other people. (“I’m constantly bombarded [with germs] so I have a natural increased immunity to the flu,” one nurse told an Anchorage Daily News reporter.)
  • They doubt the vaccine works all that well.
  • They believe the vaccine can give people the flu, or frequently cause other health problems they consider worse than the flu.

Even many doctors have these unfounded beliefs – a fact that strongly suggests the core problem isn’t insufficient health education. We think part of the problem is exaggerated, hyped health education.

Understandably, we get a lot of pushback when we accuse dedicated public health experts of flu prevention hype. Usually they deny it, but sometimes they defend it.

In September 2008, for example, the New York Times asked epidemiologist Kristin Nichol, a highly respected flu vaccine proponent, about a recent Lancet study showing reduced flu vaccine efficacy in old people. Her response (log-in required):

I really feel, and I feel very strongly about this, that the public health message should be that vaccines are effective…. I don’t think that science is necessarily best hashed out in the media.

In the next section of this column, we will present three extended examples of flu prevention hype – misleading exaggeration that may trigger learned mistrust in HCWs. Before we start, though, we need to acknowledge two defects in our argument.

First, we don’t have direct evidence that hyped messaging contributes significantly to HCW resistance to flu vaccination. We have strong evidence that vaccine messaging is often hyped, and strong evidence (from many fields) that hype often leads to mistrust – but the impact of vaccination hype specifically on vaccination compliance hasn’t been studied. So when we accuse flu vaccination proponents of making statements that go beyond their evidence, we are vulnerable to the charge that we are doing that too. We therefore want to be scrupulous – more scrupulous than flu vaccination campaigners usually are – in conceding here, at the outset, that we have virtually no evidence for a key assertion in this column.

We are speculating when we claim that hype undermines the effectiveness of flu prevention campaigns. In a very different context, we have written that “responsible speculation” should acknowledge uncertainty, and should err in an alarming rather than a reassuring direction. We believe the speculation in this column meets these two criteria. A lot of flu vaccination messages, by contrast, constitute irresponsible speculation, because they are overconfident and over-reassuring.

A second defect in our argument is that the three examples of flu prevention hype we will document all concern side-issues in the effort to convince HCWs to get vaccinated. Keady rightly summarizes the two core issues: HCWs underestimate the hazard of influenza, and they overestimate the hazard of vaccination. There is some hyping with regard to these core issues too – for example, the (small) number of serious side effects from flu vaccination gets less attention than it should, while the (huge) number of deaths from influenza isn’t as firm a figure as is usually implied. But the worst of the hype is with regard to issues less central to HCW resistance, like our three examples: the need for a new shot every year, the effectiveness of cough etiquette and hand-washing, and the closeness of the match between each year’s vaccine and circulating flu viruses.

This is a common pattern in the dynamics of risk communication. When people are excessively worried about a small risk (in this case, the very small risk of the flu vaccine), one major cause of their misjudgment is outrage. One major source of the outrage is mistrust, arising from people’s sense that they are being fed half-truths and exaggerations. And quite often the hype is about side-issues. The messengers are basically right but can’t resist gilding the lily – and that undermines their messaging. (We have sometimes called this “misleading toward the truth.”)

We believe that flu vaccination campaigners are basically right. We believe that their messaging is often hyped, especially on side-issues. And we believe (without much evidence) that the hype is a major factor in HCW resistance to vaccination.

You don’t have to be able to parse the hype to learn to mistrust the hype.

We understand that most people don’t comb through flu vaccination messaging the way we do, searching for half-truths and exaggerations. But they still smell a rat when messages are misleading.

Everyone has experienced this with regard to “the bad guys.” Without ever parsing their words, we have all learned to mistrust “greenwash” ads by corporate polluters and glowing prose from used car salesmen.

But “the good guys” – such as flu vaccination proponents – imagine that their hype doesn’t smell.

Hype undermines the messaging of good guys and bad guys alike. The results are much more serious when it’s the good guys doing the hyping, losing credibility, and therefore failing to convince their audience about life-saving precautions.

Flu Prevention Hype: Three Examples

Now consider our three examples.

Example One: The need to get a flu shot every year.

Many doctors tell their patients (and their employees) that a new flu shot is needed every year because the vaccine changes every year to match the flu strains currently in circulation. Well, guess what: In the 30 years since the seasonal vaccine was first formulated to contain three flu strains, there have been six years in which the Northern Hemisphere flu vaccine was exactly the same as the previous year’s vaccine. In eleven years only one of the three strains was changed. Only once – the 2008-2009 season – were all three strains changed.

Now, suppose you’re a health care worker who has been told, again and again, that it’s a new vaccine every year. Then you learn you were misinformed. Suppose you notice that the docs in your office keep repeating the same misleading, oversimplified message – perhaps even after you’ve pointed out that it’s not so. Suppose you’re instructed to keep repeating that message yourself when you talk to patients. Would that contribute to learned mistrust? We think so.

This example is very personal for one of us. Lanard learned in medical school that you need a new flu shot every year because the vaccine changes every year, period. When we started working on bird flu risk communication, she was taken aback to discover that her professors had misleadingly oversimplified the facts – that you may need a new shot every year, but not “because the vaccine changes every year.”

This misleading message is still extremely common. Here it is on a National Institutes of Health website page:

Why Do You Need A Flu Shot Every Year?

Flu viruses change often. Each year’s virus is just a little different than the year before. So every year the vaccine in the flu shot is changed. That’s one reason why you need a flu shot every fall.

No other reason is mentioned. The one reason given is false.

And here is the current (2008) official word from the Vaccine Education Center connected with Lanard’s medical school:

The influenza vaccine is unusual in that each year a different vaccine is made. Because strains of influenza virus that circulate in the community can differ from one season to the next, the vaccine must change to best protect against those different strains. Every year in the United States, the Centers for Disease Control and Prevention (CDC) determines what strains of influenza are circulating, and makes sure that all the influenza vaccines that are made that season contain viruses that would protect against the circulating strains.

The first two sentences are misleading, except for the words “can differ,” which at least hint that the strains don’t always differ. The final sentence adds the overoptimistic misimpression that vaccine decisions made in early spring will be “sure” to match the flu viruses that end up circulating the following winter. In fact, they end up matching fairly well … most of the time.

In April 2008, Professor Steven L. Salzberg of the Center for Bioinformatics & Computational Biology at the University of Maryland wrote a commentary for Google News. The commentary (which is no longer online) contained this sentence:

Let me explain: each year the flu mutates quite a bit from previous years, which necessitates a new vaccine (a new flu shot) every year.

We wrote to Dr. Salzberg, pointing out that “the idea that a new vaccine is necessary every year because of mutation is a common belief, but it is not actually true.” Dr. Salzberg wrote back promptly. Here’s what he said:

I know that the vaccine doesn’t change every year. But I was writing for a general audience, and I want to encourage people to get an annual flu shot. I don’t want people to start thinking they only need the shot every few years, or only when the vaccine strains change, as that might have harmful public health effects.

This is an unusually candid confession of an extremely common misbehavior. Dr. Salzberg intentionally published a falsehood in Google News in order to encourage the public to get a flu shot every year.

We think this kind of well-intentioned “misleading toward the truth” (the truth in this case: it is indeed wise to get a flu shot every year) helps perpetuate learned mistrust of flu prevention campaigns – and of public health experts and officials more generally.

When they’re not claiming that the vaccine changes every year, flu vaccination advocates often lean on a different argument: that flu antibodies start to wane after a few months.

It turns out there hasn’t been much research on how long flu vaccine antibodies remain protective, beyond the first six to eight months. A few peer-reviewed studies show persistence at levels considered protective twelve months after vaccination. We didn’t find any studies that looked at a longer timeline to see if the vaccine was still protective for a second season. We didn’t find any studies that examined the incidence and severity of influenza in unvaccinated people who had been vaccinated the year before in the six seasons when there was no change in the vaccine. And we didn’t find any studies that assessed the potency of leftover vaccine from the previous season; officials always just bemoaned the fact that unused vaccine had to be thrown away, without trying to find out whether it was still usable.

So flu vaccination proponents can’t justify claims that last year’s vaccine isn’t still protective against this year’s circulating virus of the same strain. Instead, they claim that it “may” not be protective. That’s a true statement, technically. But it is misleadingly one-sided, neglecting to mention the existence of studies showing protectiveness at twelve months and the absence of studies extending beyond twelve months.

Thus the CDC has a seasonal flu vaccine Q&A that states:

Another reason to get flu vaccine every year is that after you get vaccinated your immunity declines over time and may be too low to provide protection after a year.

A pharmaceutical company, in the product report for its flu vaccine , says the same thing with a more technical tone:

It is postulated that immunity after administration of the inactivated vaccine lasts < 1 year.

It makes commercial sense for a pharma company to “postulate” that the vaccine is no good for a second year. But why wouldn’t the CDC seek evidence?

Medical organizations also advise that last year’s vaccine (or illness) “may” not help, as in this excerpt from an American Academy of Pediatrics “Immunization Initiatives Newsletter”:

Further, immunity to the disease declines over time and may be too low to provide protection after one year.

The bottom line on whether you need a new flu shot every year because the vaccine changes every year:  It is still being taught, but it isn’t so.

The bottom line on whether you need a new flu shot every year because protective immunity may not last longer than one season:  Immunity may be that short-lived, but we can’t find any studies that say so.

The lesson for health care workers: “My hospital/nursing home/medical practice/health department hypes flu shots.” Is it really so surprising that HCWs don’t always take the hype to heart?

Just in case it sounds like we are skeptical about the value of flu vaccination: We’re not. Vaccination is far and away the best tool available to reduce the enormous annual mortality and morbidity from influenza, and it does so with extremely low levels of serious side effects. The science behind that statement is very strong.

We’re comfortable with a modified version of the usual recommendation: Most people (and most HCWs) should get a flu shot every year, at least until research shows whether or not protective immunity lasts long enough to cover a second season in those years when the vaccine components do not change.

There are also a behavioral reason and a public health reason for getting a flu shot every year:

  • Habitual behaviors are easier to maintain than judgment calls. That’s why wise drivers always lock their car doors, rather than deciding each time they park. Lock your door. Get a flu shot. No need to think about it every time.
  • Next year’s vaccine supply depends on how many doses are used up this year. Every additional vaccinated person helps build demand for increased vaccine production capacity, which will be a matter of life and death in the next influenza pandemic.

Because they’re not actually about why “you need” a flu shot every year, these two reasons are rarely on the list of talking points aimed at patients or HCWs.

The Vaccine Education Center website is appropriately emphatic when it states that “influenza hospitalizes and kills more people in this country than any other vaccine-preventable disease….” Flu vaccination proponents should continue to emphasize that fact. They can do so without claiming that the vaccine changes every year, and without overstating what is known about the persistence of immunity.

And without hyping any other aspects of influenza. The excellent statement we just quoted from the Vaccine Education Center ends with the claim that “40,000 deaths [from flu] occur every year” – a number this short page cites three times in 14 paragraphs. The number in standard use, 36,000 flu deaths per year in the U.S., is itself a soft number. Most deaths from “flu-like illnesses” occur in the elderly, and are complicated by pneumonia and other illnesses; flu tests are not always performed. While experts are certain that influenza kills far more Americans than other vaccine-preventable diseases, they are only guesstimating that the average number is 36,000. That number should be used with understated tentativeness … and shouldn’t be arbitrarily rounded up to 40,000.

Not hyping the facts doesn’t mean not dramatizing the issue. Here’s sample language that is emphatic but not hyped:

We think around 36,000 people die of flu in the U.S. every year, but it’s hard to know for sure. What do we know for sure? Flu kills far more people in this country than any other vaccine-preventable disease, and that is an outrage and a tragedy!

Many readers of this column may think we’re nitpicking. Is there really all that much difference between the vaccine changing every year and some parts of the vaccine changing most years; between knowing that immunity has waned after a year and worrying that it might have waned; between 40,000 annual flu deaths and 36,000? Maybe not when outrage is low. But HCWs who are already feeling some outrage about flu vaccination are likely to smell out exaggerations and oversimplifications like these. And the result – and here is where we’re speculating, going beyond the evidence – may be increased mistrust, increased outrage, and increased resistance to vaccination.

Example Two: The value of cough etiquette and hand-washing.

Flu shots get top billing in the trio of major influenza precautions. The other two highly recommended precautions are cough etiquette – coughing into your sleeve or a tissue, not into your hand – and hand-washing. (A fourth precaution, staying home when you’re sick, is also officially recommended, though HCWs often get the opposite signal from their bosses and coworkers.)

But wait a minute. The experts are pretty sure that influenza is transmitted mostly face-to-face by droplets. Covering your mouth with anything – hand, sleeve, tissue, or facemask – should help prevent that, with a mask obviously providing better coverage than the other three. Preferring a sleeve or a tissue to a hand makes sense to the extent that we’re worried about hand-to-hand transmission, or hand-to-fomite-to-hand transmission (such as via doorknobs or telephones). But the distinction seems pretty irrelevant to the main flu transmission pathway. And so is hand-washing.

Presumably some flu transmission does happen by hand. Presumably using your sleeve and washing your hands will help at least a little, and for sure they can’t hurt.

Still, compare the propaganda with the research. The gap is the hype.

The “Cover Your Cough” page on the CDC’s seasonal flu website begins this way:

Serious respiratory illnesses like influenza, respiratory syncytial virus (RSV), whooping cough, and severe acute respiratory syndrome (SARS) are spread by:

  • Coughing or sneezing
  • Unclean hands….

If you don’t have a tissue, cough or sneeze into your upper sleeve, not your hands.

We have been unable to find a single study that supports this recommendation with regard to influenza. The World Health Organization Writing Group report on “Nonpharmaceutical Interventions for Pandemic Influenza” makes the same recommendation for flu specifically, but concedes that it has been made “more on the basis of plausible effectiveness than controlled studies.”

As for hand-washing, a Mayo Clinic publication on hand-washing includes flu on a list of infectious diseases “that are commonly spread through hand-to-hand contact.” The Government of Alberta’s “Influenza Self-Care” publication advises: “Wash Your Hands to Prevent Influenza…. Next to immunization, the single most important way to prevent influenza is to wash your hands often.”

But here’s what the World Health Organization Writing Group report says: “Most, but not all, controlled studies show a protective effect of handwashing in reducing upper respiratory infections.… Most of the infections studied were likely viral, but only a small percentage were due to influenza.… No studies appear to address influenza specifically.”

In 2007, the CDC summarized the situation this way:

Nonpharmacologic interventions (e.g., advising frequent handwashing and improved respiratory hygiene) are reasonable and inexpensive; these strategies have been demonstrated to reduce respiratory diseases … but have not been studied adequately to determine if they reduce transmission of influenza virus.

And from a 2007 article in Eurosurveillance:

There are studies showing that influenza viruses can survive for hours or days on non-porous surfaces. However, a careful systematic review found that human-to-human transmission through this route had not been well studied and hardly ever documented. Similarly while there have been trials showing that hand-washing reduces respiratory infections in general, there has never been a trial regarding its effect on influenza transmission.

If you’re a health care worker who knows that there’s virtually no evidence supporting sleeves and hand-washing as precautions against the flu, mightn’t that make you wonder if they’re hyping the vaccine evidence too?

Added: May 22, 2009

Evidence for Hand-Washing
Is Better Than We Thought

A 2007 Cochrane review of “Interventions to interrupt or reduce the spread of respiratory viruses(link is to a PDF file)  concluded: “Implementing barriers to transmission, isolation, and hygienic measures may be effective at containing respiratory virus epidemics” – especially around young children. Hand-washing is explicitly mentioned in the Cochrane summary as an intervention that turned out potentially useful. Masks are also mentioned (with “limited evidence” that N-95 masks might work better than surgical masks). Cough etiquette – e.g. covering your cough with your sleeve – didn’t make the summary; only a few of the individual studies in the review included it as one of the interventions they examined.

Cochrane reviews are widely considered the gold standard for assessing the state of evidence in health care. They gather all the published empirical studies, assess the quality of their methodologies, focus on the best ones, and figure out what conclusions are justified. They are extremely conservative, insisting on a high level of proof in several well-designed studies before accepting any conclusion.

Based on this Cochrane review, the evidence that hand-washing helps is far from conclusive as regards adult transmission of flu specifically … but it’s not as weak as our column suggests.

Or suppose you’re a health care worker who doesn’t know that there’s virtually no evidence supporting sleeves and hand-washing as precautions against the flu. Then mightn’t you decide that sleeves and hand-washing are enough?

Occasionally, flu prevention hype can lead to an excessive sense of security about non-pharmaceutical precautions. The same nurse who told the Anchorage Daily News she had a natural immunity to the flu also said she objected to pressure to get vaccinated “when regular hand washing and the wearing of face masks can prevent the spread of germs.” Similarly, a California nurse told ABC News she was less likely to catch the flu than the general public because “nurses wear gloves and wash their hands constantly.”

But these are not the reasons that keep showing up on surveys of why HCWs don’t get the flu vaccine. We doubt that many HCWs really buy the hype about cough etiquette and hand-washing. Like the hype about vaccination, we think it registers as grounds for mistrust.

Added: October 28, 2010

Survey Shows Hand-Washing
Can Deter Flu Vaccination

In October 2010, the National Foundation for Infectious Diseases published the results of a flu vaccination public opinion is to a PDF file Among the findings: “More than one-third (34 percent) of all Americans erroneously believe that hand washing works just as well – or better – than vaccination to prevent flu.”

So it seems likely that hand-washing hype deters flu vaccination in two ways – probably among health care workers just like everyone else. If the audience buys the hype, getting vaccinated seems less necessary. And if the audience doesn’t buy the hype, influenza public health campaigns seem less credible.

Example Three: “It’s a good match” – prematurely overselling vaccination benefits.

First, a counter-example. By November 2007, the CDC was candidly reporting its concern that one of the three strains in that season’s vaccine, H3N2, might not be a good match for the strains of H3N2 starting to circulate. In a CDC telebriefing on November 9, Dr. Joe Bresee told reporters:

It’s a little too early to tell whether this year’s vaccine will match this year’s strains…. The strain that we are most concerned about is the H3N2, mainly because the strains of those types that are circulating in Latin America over our summertime seem to be slightly different than the vaccine strain. And so it may set up for a mismatch.

Dr. Bresee went on to stress that vaccination is valuable even if one of the three vaccine strains might be mismatched, and that even a mismatched strain would probably provide some protection. But he made no effort to minimize the early data suggesting a possible H3N2 mismatch.

Fast-forward a year. On December 31, 2008, MSNBC reported that “This year’s vaccine appears to be a better match than last year’s to the strains of flu circulating around the country,” citing infectious disease expert and University of Pennsylvania Professor Neil Fishman.

Other prematurely optimistic “good match” statements:

The vaccine appears to be a good match to the strains of flu circulating this flu season.

—Dr. Karen Landers, a state health officer in Alabama, January 3, 2009

The vaccination this year is a good match for what is circulating.

—Barb Buhler, South Dakota Department of Health, January 4, 2009

[T]he flu vaccines administered this season were a good match to the three strains of flu that are in circulation, meaning those who got their shots are unlikely to get the influenza virus.

—Reporter’s paraphrase of a statement by Dr. Barbara Adams,
a Texas health department epidemiologist, January 4, 2009

(The last clause in this sentence – that those who are vaccinated are “unlikely” to get the flu – is another variety of flu vaccination hype. They are certainly far less likely to get the flu than unvaccinated people. But vaccination is 70–90% effective in healthy adults, leaving 10–30% of healthy adult vaccinees unprotected; that’s not what most people mean by “unlikely.”)

When Dr. Fishman told MSNBC that this year’s vaccine looked like a better match than last year’s, the CDC’s most recent weekly influenza report was for the week ending December 20. By that date, the CDC had completed antigenic analyses of 85 flu viruses to see what antigenic types were circulating at this early point in the season, and how those viruses matched up against the inactivated vaccine strains. Here is what they had found with regard to influenza B:

  • Of the 85 viruses fully tested so far, 29 were influenza B (one of the three strains of killed influenza virus in each year’s vaccine).
  • Of the 29 B viruses tested, 20 – 69% – turned out to be a mismatch. The weekly report said they “belong to the B/Victoria lineage and are not related to the vaccine strain” of influenza B.
  • The report was explicit that “limited to no protection may be expected when the vaccine and circulating virus strains are so different as to be from different lineages, as is seen with the two lineages of influenza B viruses.”

In other words, based on very early data, which may change rapidly as the season progresses, there is one clear yellow flag about this year’s vaccine match.

Good risk communication principles suggest acknowledging this yellow flag matter-of-factly and explaining its implications candidly, just as the CDC did with regard to the possible H3N2 mismatch a year earlier. Like last year’s CDC telebriefing, this year’s CDC weekly report is admirably straight. But far too many public health officials and other experts are failing to acknowledge the yellow flag; instead, they are prematurely and overconfidently claiming a good match.

Flu Protection Hype and HCW Mistrust

Obviously, health care workers’ mistrust of flu protection messaging isn’t all a result of too much hype in the messages. There are other factors at work.

For one thing, workplace mistrust of management rhetoric is the norm. It isn’t confined to health care settings – and in health care settings it isn’t confined to messaging about influenza. A lot may depend on how HCWs feel about the reliability of other kinds of information they get from their employers. If they have learned to mistrust what you say about flextime and parking spaces, it will be harder for them to trust what you say about flu protection.

Moreover, mistrust, discomfort, and even some fear seem to be hard-wired responses to vaccination, whether the messaging is hyped or not. This goes well beyond anxiety about injections (though many HCWs do mention their dislike of shots as a reason for not getting vaccinated). It goes well beyond the controversies that have beset some other vaccines (though it’s certainly possible that controversy over one vaccine engenders anxiety about another). All over the world, and throughout history, people have had a sense of awe and wonder – and fear and mistrust – about vaccines. Arthur Allen, author of the book Vaccine, put it this way in an online discussion of his book:

There’s something about vaccines that creeps people out – always has been, since Cotton Mather’s time (he brought the first form of smallpox vaccination to the Colonies, in 1721). Like Mather’s “Wonders of the Invisible World” they can achieve great things, yet are often accused of subterranean mischief in the human body.

We doubt many HCWs are comfortable admitting this, even to themselves. They are supposed to believe in vaccines! And they do, intellectually – but that doesn’t prevent many HCWs from experiencing the fear and mistrust. Occasionally they tell us so (with some embarrassment) during coffee breaks in consultations and seminars about vaccine risk communication.

Addressing this hard-wired communication challenge calls for more than just avoiding flu vaccination hype. It calls for acknowledging empathically that vaccine fear and mistrust are both prevalent and understandable – not accusing anybody of feeling that way, but getting the feelings into the room. (See Sandman’s column on “Empathy in Risk Communication” for some strategies for addressing feelings and beliefs that people aren’t ready to own.)

Meanwhile, avoiding flu vaccination hype would be a good start.

What is our prescription for reducing HCWs’ learned mistrust about flu vaccination? Flu prevention advice that is nuanced and two-sided, that respectfully acknowledges people’s reasons for not wanting to get vaccinated, and that doesn’t misrepresent the evidence.

Getting from here to there – from hype to respectful dialogue – is a long haul. Many HCWs are accustomed to one-sided, exaggerated messaging from their employers. They expect it, and they discount it. They won’t necessarily stop discounting on the day their employers stop hyping. The transition will go faster if you can get yourself to acknowledge the change, and faster still if you can get yourself to say you’re sorry: “We have been overselling vaccination and other flu precautions in ways our employees have learned to mistrust. We apologize, and we’re determined to change.” (Yeah, okay, that’s not likely. We can dream.)

Then go ahead and share some of your own anguish about the tragedy of vaccine-preventable influenza deaths. Letting your humanity show is a risk communication strategy that surprises a lot of public health professionals, who tend to become hyper-professional in uncomfortable situations.

The typical flu prevention campaign tries to give the impression (without directly saying so) that vaccination virtually guarantees immunity, while cough etiquette and hand-washing are somewhat less effective but still extremely useful against the flu. By contrast, here’s what the evidence says:

In years when the vaccine and circulating viruses are well-matched, vaccination reduces the odds of getting the flu 70–90% in healthy adults under 65, and it reduces flu-related hospitalizations 30–70% in people over 65 who live at home. In years when the vaccine strains are not well-matched to the main circulating viruses, vaccination helps less, though it still helps. As for coughing into your sleeve instead of your hand and washing your hands as often as you can, they presumably help at least a little but there’s no proof – though they greatly reduce transmission of many other diseases.

What’s so hard about saying that?

Flu vaccination is somewhat less effective than we typically imply, while everything else is probably much less effective than we imply. Thus, a more candid communications effort wouldn’t just avoid triggering learned mistrust; it would also make vaccination look like what it is: not perfect, but far and away the most effective way to protect yourself and others from influenza.

Other Observations and Suggestions

While we consider learned mistrust a significant barrier to getting HCWs vaccinated, we don’t want to leave the impression that we think that’s the whole problem. Moreover, correcting the hype and earning trust from HCWs are long-term tasks. What can you do in the meantime?

1. Work to increase HCWs’ awareness and factual knowledge.

We wanted to make our case for dealing with learned mistrust before we endorsed this standard building block of HCW flu vaccination communications.

As we said at the outset, convincing HCWs to get vaccinated requires both precaution advocacy and outrage management. We believe your good precaution advocacy efforts will “take” better if you “prime” your HCW audience with good outrage management as well. That means factoring in HCWs’ learned mistrust when you tell them the facts. It means, for example: acknowledging their skepticism; acknowledging their valid reservations; acknowledging that their misimpressions are widespread and understandable; and whatever else you can harvest from this column and our other writing on outrage management.

But you can’t forget the precaution advocacy! No one questions that education about influenza and the influenza vaccine is a linchpin of any serious effort to convince HCWs to get vaccinated. They need to know that the flu is more dangerous than they may suppose, that the vaccine is less dangerous than they may imagine, etc.

Start with a few comprehensive and authoritative sources like “Influenza Vaccination of Health-Care Personnel,” published by the U.S. Centers for Disease Control and Prevention. It has a wealth of information, with headings like “Efficacy and Effectiveness of Influenza Vaccines Among Adults,” “Transmission of Influenza in Health-Care Settings,” and “Strategies for Improving HCP [Health Care Personnel] Vaccination Rates.”

Whatever information sources you use, be on the lookout for hype – and tone it down (if you find any) before you package the information into your educational program. Try to integrate your efforts to combat learned mistrust with your efforts to convey the factual information about flu vaccination that you want your HCWs to learn and accept.

2. Make vaccination cheaper and easier.

Two of the main reasons HCWs give for not getting their flu shots are that it’s expensive and it’s inconvenient. The most successful HCW vaccination programs make the process cheap (or free) and as convenient as possible.

A 2007 article in the American Journal of Infection Control, for example, has a title that asks: “Will carrots or sticks raise influenza immunization rates of health care personnel?” The article concludes that the most successful strategies are “robust interactive education, and onsite, easily accessible vaccination at no cost to employees.” Similarly, the report we just mentioned on “Influenza Vaccination of Health-Care Personnel” notes:

In a 3-year prospective study in a 630-bed acute care hospital, a sustained four- to fivefold increase in vaccination rates was associated with using mobile carts to deliver vaccine to staff rather than requiring [health care personnel] to visit an employee health center to receive vaccine.

Making vaccination cheaper and easier helps for at least three reasons:

  • It makes vaccination cheaper and easier.
  • It fuels group pressure to comply. “Today’s the day. Let’s all go downstairs for our shots now.”
  • It communicates that management is serious. “You’re paying for it? You’re sending the mobile vaccination cart around door-to-door? I guess you really mean it!”

3. Don’t rely too much on coercion and punishment.

Threatening to fire HCWs unless they get vaccinated does increase vaccination rates, but with very high collateral damage: litigation, union grievances, morale problems, overt and covert hostility, etc. Even worse is when the threats exempt the highest-ranking health care workers – doctors and top administrators.

In December 2008, for example, the Anchorage Daily News reported that all employees at Providence Alaska Medical Center would face dismissal unless they got flu vaccinations by year’s end. According to the story, the hospital’s infectious disease specialist said that “Doctors on the hospital’s infection control committee unanimously supported the requirement.” The kicker: Most of the hospital’s doctors aren’t covered by the requirement; technically, they are not hospital employees. Such a policy is and feels disrespectful to non-physician employees, and is bound to increase their outrage. The story prompted one commentator to post the following editorial cartoon:

old newspaper photo of a firing squad
“We told you to get vaccinated.”

4. Make more use of incentives and rewards.

In other areas of employee health and safety, the evidence is strong that incentives and rewards work better than punishments – and that positive and negative reinforcement in combination work better than either alone. Incentivizing HCWs by making vaccination free and convenient reliably raises compliance rates. But there isn’t strong evidence yet regarding other incentive, reward, and punishment combinations in HCW flu vaccination campaigns.

Hospitals and doctors’ offices may resist rewarding HCWs for getting vaccinated – either on the grounds that it’s good for them (so we shouldn’t need to reward them) or on the grounds that it’s part of their job (so we shouldn’t need to reward them). But the problem is largely that many HCWs don’t believe a flu vaccination is good for them and they don’t consider it part of their job. So why not reward them?

5. Go easy on the “it’s good for you” rationale.

Of course you should tell HCWs that they’re better off getting a flu shot than not getting a flu shot. And you should try hard to correct the misimpressions that make them think otherwise: that the flu isn’t serious for healthy people, that the vaccine can give you the flu, etc. Surveys show that for HCWs who do get vaccinated, self-protection and protection of loved ones are usually their top reasons; patient protection is further down on the list.

But the irrefutable answer to “It’s good for you” is: “That’s none of your business.” So while self-protection is many HCWs’ main reason for getting vaccinated, it shouldn’t be your main argument to those who are resisting.

You’re asking HCWs to get vaccinated mostly for the sake of the institution and its patients, and you should say so. In fact, we recommend empathizing explicitly with HCWs on this point: “Most people get to decide for themselves whether they want a flu shot or not, but our employees are urged to get one regardless of their personal preference, for the sake of patient safety and staff workload. That’s an imposition on you. It’s not fair.” There’s a seesaw at work here. The more you acknowledge that you’re intruding on HCWs’ autonomy, the easier it will be for them to notice that you have good reasons to do so.

6. Stress patient welfare – but acknowledge the holes in your case.

Almost all HCWs care about patients. They do a lot of things for the sake of patients (including washing their hands repeatedly) that they wouldn’t otherwise choose to do. But when vaccinated HCWs explain why they got a flu shot, patient welfare isn’t usually first on the list. This suggests that they may not realize that HCW vaccination probably protects patient health. “Do it for your patients” is thus an important message – especially since it is a paramount institutional rationale for pushing HCW vaccination in the first place.

But don’t hype that message either. Like so much of what we think we know about flu prevention, it hasn’t been proven. Most studies of the impact of HCW flu vaccination on patients were conducted in long-term care facilities, and several have found a benefit. But a statistical analysis of the best studies concluded: “There is no high quality evidence that vaccinating healthcare workers reduces the incidence of influenza or its complications in the elderly in institutions.”

And there are grounds for accusations of inconsistency. We don’t usually require coughing patients in doctors’ waiting rooms to wear masks. We don’t ask all hospital visitors during flu season to wear masks, take their temperature, or prove they’ve been vaccinated before we let them in. So why do we pick on HCWs?

Acknowledging these inconsistencies and the (apparently) low quality of the “benefit to patients” evidence will ultimately increase your credibility as a flu vaccination proponent. It may even lead to HCW pressure for better mask and temperature-screening policies during flu season – and then research to see if that helps!

7. Stress absenteeism and “presenteeism.”

The strongest evidence-based institutional argument for asking HCWs to get vaccinated is that sick HCWs can’t do their jobs as well. The evidence that flu vaccination reduces staff absenteeism is solid. (At last: something we actually know.)

It’s also worth pointing out a well-documented parallel problem: “presenteeism.” HCWs often come to work with flu-like illnesses, potentially putting patients and other HCWs at risk. Both employees and employers are ambivalent about presenteeism. Many HCWs want to work, even though they know they should stay home when they’re sick; many of their employers want them to work, even though they know they should send them home when they’re sick. The more HCWs are vaccinated, the less often this dilemma arises.

8. Acknowledge, acknowledge, acknowledge.

Acknowledgment is to risk communication as location is to real estate. Among the many things you need to acknowledge to HCWs about flu vaccination, three stand out:

  • Our remedies aren’t perfect. Even vaccination, by far our best remedy, has many drawbacks: It doesn’t always take, it can have side effects, sometimes we wind up with the wrong strains in the vaccine, etc. (Acknowledging people’s valid reservations about getting vaccinated is every bit as important as rebutting their mistaken reservations. The more aggressively you do the first, the more they’ll listen when you do the second.)
  • There’s so much we don’t know. We suspect hand-washing and good respiratory etiquette reduce the flu transmission rate at least a little (and perhaps a lot), but the evidence is scanty. We suspect patients get the flu less when health care workers are vaccinated, but the evidence is scanty there too.
  • We haven’t always been completely upfront about the imperfections in our remedies and the gaps in our knowledge.

Why would you want to make that difficult final admission, along with the acknowledgments and empathic statements that precede it? Remember: One of your main vaccination communication goals is to reduce learned mistrust and the resulting outrage. Acknowledging prior misbehavior – well-intentioned though it is, flu vaccination hype is misbehavior – is one of the best ways we know to reduce outrage.

9. Start with doctors.

Any flu vaccination program that puts more pressure (or more visible pressure) on orderlies and nurses than on doctors and administrators is probably doomed. By contrast, seeing the top guns get their shots helps convince HCWs that the program is serious, and it eliminates the sting of condescension. It’s okay for HCWs to learn that some of the doctors weren’t crazy about the pressure either, and even that some of them resisted getting the shot (or nasal spray). The credibility of starting with doctors doesn’t come from “The docs don’t mind, so why should you?” It comes from “We pushed them hard, and now we’re working our way around to you.”

10. Do your HCW campaign as early in the season as possible.

Earlier flu vaccination is always better, since you never know when the season will start. But we have a special reason for recommending that you try to vaccinate HCWs before flu is circulating in your area. It’s a way of addressing the persistent myth that flu shots can give people the flu. By contrast, people who are vaccinated later in the season may already be incubating the flu when they get their shot – a coincidence that looks like confirmation of the myth.

Actively follow up all HCW vaccinees to see if they think they have the flu (or any other side effects). If they report flu-like symptoms, push them to come in – wearing a surgical mask, of course – for a free influenza test. When they feel better, invite them into the lab to see how the rapid flu tests are done. Post the aggregate, anonymous results. Help debunk “the flu shot gave me the flu” by showing, not just by telling.

11. Pay attention to your own feelings.

Vaccination messaging for HCWs is inevitably influenced by the feelings of the messengers – especially their feelings about their continuing failure to convince HCWs to get vaccinated. There are at least three emotional traps in which some flu vaccine campaigners are stuck:

  • Inadequacy. Some vaccination proponents are truly suffering because of the enormous cost, pain, and mortality they could prevent if only they figured out how to convince HCWs (and the general public) to get flu shots. They feel inadequate, guilty, frustrated, sad.
  • Anger. Some vaccination proponents externalize their feelings of failure in the form of anger and contempt. They may even feel secretly vindicated when an unvaccinated health care worker gets a bad case of flu. Failed communication is always the communicator’s fault, by definition. But we are very familiar with the temptation to blame the audience.
  • Resignation. Some vaccination proponents avoid feelings of inadequacy/frustration and anger/contempt by settling into a kind of chipper, doomed diligence. They are resigned to forever running health education campaigns that don’t accomplish much, and they’re okay about it. It’s not fair to say they’re just going through the motions. They’re trying. But there’s not a lot of heart in it anymore; it’s just part of the annual work cycle.

None of these three states-of-mind is optimal for thinking strategically – harvesting the available research and theory; listening hard to your audience; taking your best shot; and then evaluating, revising, and trying again.

A great deal is known about good ways to convince health care workers to get a flu shot. Except for our diatribe on learned mistrust, we have only skimmed the surface. The most successful HCW vaccination programs are much more successful than the average ones. Too often, the average programs don’t seem to be learning much from the most successful ones. Feelings of inadequacy, anger, and resignation may be part of the reason why.

So give each other emotional support, and challenge each other to see what’s new and what’s working elsewhere in the HCW influenza vaccination campaign universe.

Yes, we know, it’s easier said than done.

Postscript: We both get a flu shot every year. Because of her work travel schedule, Jody Lanard sometimes gets the Southern Hemisphere flu shot as well. One of our children organizes free on-site flu vaccine clinics at his (non-medical) workplace.

Copyright © 2009 by Peter M. Sandman and Jody Lanard

For more on precaution advocacy:    link to Precaution Advocacy index
For more on outrage management:    link to Outrage Management index
For more on infectious diseases risk communication:    link to Pandemic and Other Infectious Diseases index
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