Wednesday, December 15, 2010

Failure to Increase Knowledge and Address Important Barriers to Flu Vaccination: Why the Current Public Health Campaign to Increase Flu Vaccination Fa

Flu vaccination is the single most effective measure to decrease rates of, and deaths from, seasonal influenza (1). While it is known that influenza is the eighth largest killer in America (2), rates of flu vaccinations are startlingly low. The national goal of 90% of the population receiving flu vaccines (3) is far from the actual rate of 35% (4). Ineffective utilization of the Health Belief Model accounts for this large gap. Specifically, the discrepancy is due to futile campaigns that fail to address three main factors, each connected with the core principles of the Health Belief Model. The first is a lack of ethnic specific education concerning flu vaccines. There are huge misconceptions about flu vaccines that are significantly higher in ethnic minority populations. The second factor is that campaigns unsuccessfully address general barriers to receiving a flu vaccine. These include concerns about effectiveness and severity of side effects. Finally, campaigns do not take into account accessibility of flu vaccines, both the physical location of clinics and the cost of vaccines. All of these factors have implications in the perceived severity, susceptibility, benefits of vaccination, and barriers to vaccination. These are the main aspects in the Health Belief Model and it is essential to create an intervention that increases the perceived severity, susceptibility, and benefits, while decreasing barriers so that vaccination rates will increase. By designing and implementing an intervention that addresses the three main factors currently hindering the principles of the Health Belief Model, rates of immunizations will increase.

The Health Belief Model is a commonly used model in public health interventions (5). The model suggests health behaviors are motivated by four factors. These factors include perceived susceptibility to disease, perceived severity if one should contract disease, perceived benefits of action, and perceived barriers to taking action to change behaviors (5). Current flu vaccination campaigns rely on the Health Belief Model, yet fail to address the low public knowledge, which accounts for low perceived benefits of flu vaccination and low perceived susceptibility to influenza. Additionally, national campaigns fail to make flu vaccinations fully accessible, which results in high barriers to action. The assumption that everyone cares about the flu, understands the flu, and has access to vaccines, is simply untrue. It is not a problem that vaccination campaigns utilize the Health Belief Model. The problem lies in the fact that national campaigns fail to adequately address the four factors outlined in the model, and most importantly, how the population fits into the four factors regarding flu vaccination.

Low Ethnic Specific Interventions Decreases Perceived Severity and Susceptibility to Influenza

Vaccine campaigns do not consider differences in perception and understanding between ethnicities. When information is limited, the perceived threat of getting the flu decreases (5), as does vaccination rates. The effect of low information in regards to vaccination is clearly seen by comparing ethnic vaccination trends. When compared to Caucasians, research shows considerable differences in perceptions of flu vaccines and influenza among African Americans and Hispanics. A 2002 National Health Interview Survey shows that 70% of whites received the flu vaccine, compared with 51% of African Americans and 55% of Latinos (6). This large gap is attributed to many factors affecting ethnic minorities. Education, income, low health concern, and health insurance all affect rates of vaccination (6). The effect of these factors is readily apparent when comparing Latinos to white Americans. Hispanic Americans have significantly lower levels of education and annual income than the white population (6). Additionally, Latinos have the highest uninsured rate of any ethnic group in America (6). These environmental factors affecting Latinos make it difficult to understand the need for and actually receive a flu vaccine. In low-income families, any money coming in goes to aspects of basic living-food, shelter, and clothing. Preventing the flu is not high on the list of priorities when other basic needs are not being met. A flu vaccine, in fact, becomes a luxury rather than a necessity (7). No health insurance, a common problem in Latino communities, makes it even less likely that Latinos will receive flu vaccines. In this population, availability and cost are limiting factors, which are magnified with low income, low education, and lack of insurance.

General beliefs regarding influenza and the flu vaccine strongly contribute to the large gap between ethnic groups. 96% of white Americans express concern with contracting the flu virus, while only 45% of Black and Latino Americans express concern (6). This “laissez-faire” attitude puts the whole population at risk, as it decreases the perceived susceptibility and severity of the flu, and thus the likelihood of vaccination. As current minorities are expected to make up 50% of the American population by 2050 (8), this discrepancy will affect the health of the country even more. Poor education appears to be the primary reason for the different beliefs among ethnic groups. For example, 32% of African Americans belief the flu vaccine actually gives an individual the flu (6). African Americans, who understand the premise of a flu vaccine, simply feel they are not at risk or they do now want a vaccine (6). Culturally, minorities in America, specifically black Americans tend to dislike Western medical practices and for many, the flu vaccine represents a “Western” practice. This stems from the unethical Tuskegee study, which infected black men with syphilis (9). Additionally, there is a belief that culturally supported, that if immediate family has fared well without the vaccine, then “why do I need the vaccine?”

Unfortunately, these beliefs and ethnic disparities are affecting the whole population. As fear of a major flu pandemic rise, unvaccinated individuals are a risk for propagating the disease further. In addition, it is unacceptable the influenza is the eighth largest killer in America (2), as the majority of deaths are completely preventable with a vaccine. Flu vaccination campaigns are missing a vital population. By failing to educate adequately minorities about the flu and vaccines, the population experiences a lower perceived threat to influenza. This decreases the likelihood that minorities will be immunized, as seen in the Health Belief Model (5). Current campaigns fall short without specific ethnic education, as education greatly affects the probability of vaccination.

Inadequate Education Hinders Levels of Perceived Severity, Susceptibility, and Benefits to Action

Flu vaccination campaigns rely on the public to have a strong perceived susceptibility to the flu and perceived severity if they should get the flu. In theory, individuals are more likely to be vaccinated if they feel not being vaccinated will strongly affect their lives (5). Unfortunately, both of these factors rely on adequate knowledge of influenza and vaccinations. There is strong evidence that suggest many Americans have strong fears and doubts regarding the flu vaccine (10) and lack knowledge of the flu and vaccination. These factors severely hinder perceived severity and susceptibility, a major component to taking action (5). Lack of general knowledge concerning vaccines and the flu, accounts for 35% of Americans refusing vaccines every year (11). For instance, the majority of Americans think that less than 1000 people die per year from influenza (1). In reality, more than 40,000 people die each year from influenza and hundreds of thousands are hospitalized (1,2,12). Additionally, only 44% of Americans believe the flu vaccine is the most effective way to avoid the flu and only 30% belief the vaccine is effective (1). Fears are attributed to low understanding of the flu, the vaccine, and the effects on life. These statistics are troubling and indicate the astoundingly low knowledge of most Americans concerning the flu vaccine. If people do not understand the severity of influenza, and how the flu vaccine can truly prevent the disease, vaccinations rates will be, and are, dismal. Having a needle stuck into one’s arm, when they believe it is not necessary, is not desirable. For many individuals, the low, effective information available results in low perceived benefits of being vaccinated.

Current vaccination campaigns do not adequately address the fears of many Americans, or explain the severity of the flu and the helpfulness of vaccines. This is not to say current campaigns do not educate the public at all, just that it is not done in an effective manner as seen by statistics. These flaws act as strong barriers to vaccination and result in a low perceived severity for much of the public. Many Americans worry about the safety of the vaccines or believe they are low-risk for the disease (1). For instance, more than 35% of Americans believe vaccines are risky (13, 14). Side effects are a huge concern of the American public as well. These range from simple concern over pain of vaccine to potential diseases resulting from the vaccine. Developing a potential disease most likely stems from research that indicated vaccines could cause autoimmune diseases and autism, studies that have since been repealed. However, research shows that Americans still far overestimate the occurrence and severity of any side effect that may occur (14). An example of this phenomenon is Americans’ fear of Guillain-Barre syndrome, which is believed by the public to be related to flu vaccines. Occurrence of Guillain-Barre is 1/100,000 vaccinations, and it is not even known if the occurrence is related to the vaccine (14). Guillain-Barre causes severe muscle weakness and is incurable, so fear of vaccines for this reason is common (15). Experience with previous vaccines also influences future vaccination behavior. Experiencing negative side effect once, significantly decreases likelihood that an individual with receive the flu vaccine (16). This results in more than 50% of Americans never intending to receive a flu vaccine (12). Even more concerning is that half of the population is not concerned with preventable diseases, especially the flu (13). These statistics clearly indicate how vital education of the public is to increasing flu vaccination rates. Campaigns need to highlight the positives of receiving flu shots and educate the public so that vaccination rates can rise due to increased perceived susceptibility and severity.

Limited Accessibility to Flu Vaccinates Significantly Increases Barriers to Action

Perceived barriers to taking action are a major factor in determining health behavior according the Health Belief Model (5). National flu vaccination campaigns that utilize this model need to recognize that not every citizen has easy access to vaccines and that this crucial barricade must be eliminated if vaccination rates are to increase. Currently, barriers to vaccination affect many citizens. It is important to note that where an individual lives in a strong predictor of vaccination rates. Vaccination rates are particularly low in rural areas and low-income urban areas (17, 18). Low vaccination rates in urban areas poses significant risks to the public. This is because individuals often live very close together in public housing, take public transportation, and have low access to healthcare (17). Therefore, these individuals are likely to get more seriously ill and spread influenza very easily. In rural areas, vaccination rates are low due low quantities of vaccination centers (16). When an individual has to plan trips specifically to get a flu vaccine, it becomes an inconvenience, thus decreasing vaccination rates. Studies have shown that convenient location is a considerable indicator of positive vaccination rates (14). A study in Israel found that influenza vaccination rates are significantly higher among the general population when vaccines are offered in the workplace (19). In this case, a flu vaccine can be part of a normal day and poses no nuisance to the individual. For similar reasons, 75% of elders receiving home care are vaccinated (11), which is significantly higher than the American average of 35% (4). This is directly related to the ease, that the person never even has to leave their home. This convenient vaccination is particularly important in an elderly population, as they are at increased risk for influenza. By not addressing the issue of location and convenience to the public, national campaigns are missing an opportunity to reduce barriers to action and vaccinate an immense number of people.

An additional obstacle to access in flu vaccinations is the cost of a vaccine. A study found that a momentous determinant of flu vaccination in the elderly population was whether Medicare will cover the cost (20). This barrier is not only true in the geriatric population though, as 22% of Americans indicated in a national health survey that they would not be vaccinated if they had to pay (13). These figures are very telling. For many Americans, their health is not worth the money it would cost for vaccination. Current campaigns do not adequately inform the public of the potential cost of vaccinations or programs that can help offset the cost-at least not in a way that is evident to a large portion of the public. National flu campaigns must speak to this issue, as cost is seen to be a strong barrier to people being vaccinated.


Current national campaigns to promote flu vaccinations are falling short, putting the public at risk for a potentially fatal disease. Campaigns today employ the Health Belief Model, which utilizes four key factors to account for health behavior changes. These factors include perceived susceptibility to the disease, perceived severity if one contracts the disease, perceived benefits of taking action, and perceived barriers to taking action (5). The belief that all individuals experience the same, high level of perceived susceptibility to the flu or have no barriers to action is naive. The problem does not lie in the actual utilization of this model, but rather that campaigns do not address problems that affect the four factors outlined. This oversight decreases the vaccination rate significantly. There are three specific flaws in current campaigns that need to be dealt with in order to increase perceived susceptibility and severity of the flu; and to decrease barriers. These include the wide knowledge gaps of ethnic minorities, low general public education on influenza, and failure to tackle location and cost barriers. These issues result in the public misunderstanding influenza, vaccines, and experiencing strong barriers to vaccination. Failure to concentrate on these aspects results in ineffective utilization of the Health Belief Model, hindering efforts to boost flu vaccination rates.

Creating a More Effective Vaccination Campaign by Addressing Current Barriers and Low Understanding of Influenza

For an effective flu vaccination campaign, three main factors must be addressed to increase vaccination rates. The first is the ethnic divide between minorities and Caucasians in America. Using the theory of psychological reactance ensures that minorities do not automatically oppose health information from the government. This theory allows for minority specific interventions that will increase knowledge and acceptance of flu vaccination in the culture. Secondly, an improvement in the public’s knowledge of influenza and vaccines is necessary. Utilizing advertising theory allows interventions to appeal to core values that will augment knowledge in a large population. Finally, increases in vaccination rates will occur if the poor accessibility of vaccines is addressed. This change is vital and involves the use of “branding” as well as changes in government policy that make clinics more widespread. All factors involve actually changing specific behavior and perceptions of the public, in addition to changes in the structure of vaccination, as seen in the third factor. Resolving these problems enables individuals to understand the issue, increase perceived susceptibility and severity, decreases barriers, and is willing to receive the flu vaccine.

Using Psychological Reactance Theory to Decrease Ethnic Disparities of Vaccination in America

Psychological reactance theory is a method to change behavior based on the premise that individuals are threaten by their freedom being taken away (21). It is possible to achieve behavior change simply by telling the public to do a “bad” health behavior, which will seem “controlling”. In theory, they will do the opposite, implementing a desirable health behavior. Additionally, the theory can be used to decrease reactance of the public, which is how the theory can be applied to this invention. Decreasing reactance is particularly key in minorities (21). Minorities, specifically African Americans, tend to be distrusting of the US healthcare system from unethical experiments such as Tuskegee (9). For this reason, decreasing reactance is this particular population is vital if vaccination behaviors are to change. By decreasing the dominance of the message and increasing reason, black American’s reactance towards vaccination campaigns will decrease as knowledge increases.

One of the best ways to decrease reactance of a public health message is to decrease the perceived authoritativeness of the message (21). Utilizing African Americans in a media campaign is more relatable to the population at hand. Because of this, the media will ignite less reactance than, say, a white doctor. In such media campaigns, African Americans can tell personal stories of how the flu has affected them, which will support and increase the reason associated with the intervention (21). For example, a story that explains how a family member died of the flu, even though it could have been easily prevented with a vaccine. This type of story targets emotional factors and raises awareness that vaccination prevents influenza. Additionally, using a slogan with the campaign that suggest not being vaccinated takes away the freedom to choose one’s fate, will strongly encourage reactance-in a good way. A potential slogan could be “Do not let the flu control YOUR life!” The only way for individuals to resolve this threat to freedom would be to get a flu vaccine. This type of media campaign will be most effective, of course, if ads are run in areas that are high in ethnic minorities. When this message reaches the ethnic populations targeted, the distrust with United States’ medicine will decrease, as the knowledge concerning the importance of vaccination will increase.

Implementing Advertising Theory to Increase General Public Knowledge of Influenza and Vaccination

Creating a more in-depth knowledge of influenza and vaccinations is vital to strengthen vaccination rates in the public. Using advertising theory allows information to reach a large population, in a well-received manor. Advertising theory relies on a large “promise”, and the support to back up that promise (22). The “promise” of the campaign targets core values of the public, which increases people’s attentiveness to the message (22). Support that backs up this “promise” is more than just statistics, which often fall short of convincing the public of anything (22). Support that emphasizes emotional connections, especially to the targeted core value, intensifies the significance of the promise (22). Building an effective intervention based on advertising theory will work to encourage knowledge of influenza and vaccines, and ultimately increase vaccination rates due to increases in perceived susceptibility.

Developing an intervention based on advertising theory will allow important information to reach more people. For the particular case of vaccinations, the core value to target is the importance of family. The population best suited to appreciate this value is middle-aged parents, those with young children and with older parents. This population is particularly sensitive to the importance of family and will be eager to protect their vulnerable children and aging parents. A media campaign that promises that “flu vaccination protects your family” registers with the deep core value of protecting ones family. To support this promise, while providing more information regarding the flu and vaccination, commercials can show average parents sharing personal stories. For example, one woman could share that “my mother became one of the 40,000 people who die every year from the flu.” This statement will make others think of their own mothers and protecting them, and of the surprisingly large number of people who die every year from influenza. Another story could say, “My doctor recommended that me, and my children, get vaccinated because it is the most effective way to keep my children healthy.” Parents will do anything to keep their children healthy and will react to this message. Their children will be vaccinated, as well as themselves as a measure to protect their children. Additionally, the public will learn that flu vaccination is, in fact, the most effective way to avoid the flu. An added bonus of this story is that people are significantly more likely to be vaccinated if a physician recommends it (3, 10). Once knowledge is enhanced, the perceived susceptibility and severity of the flu will also build. These increases will actual amplify the number of individuals seeking out flu vaccinations (5). The main principles of advertising theory, used in this intervention, amplify the knowledge of influenza and vaccination. This intervention provides important facts but also elicits behavior change. By targeting the core value of protecting one’s family, vaccination rates of children, middle-aged, and elderly will increase.

Increasing Accessibility of Flu Vaccines to Improve Ease and Rates of Vaccination

Improving the accessibility of flu vaccines can be done in two ways. Firstly, Marketing Theory, and specifically the use of "branding", provides a means to
create a new image surrounding flu vaccination (23). Branding creates a set of associations linked to the name, mark, or symbol associated with the service (24). This is crucial because it allows positive associates to form within social and individual settings (23). By creating a positive brand image and message for flu vaccination, people will find ways to be vaccinated to be associated with the positive brand image, and thus increase the public's perception of them (24). Understanding the importance of branding is vital to make flu vaccination seem like a viable, desirable course of action. Once this idea is established in a wide community, people will go out of their way to be vaccinated (24). It is a tall order, but if a positive brand is created around flu vaccinations, issues of accessibility will become much less of a problem. Cost and location of flu vaccines could diminish as issues, with proper branding. Branding that makes vaccines look too “cool” to miss, regardless of the trouble of getting one, will increase vaccinations. To establish a brand, marketing officials must develop a mascot of sorts to represent the flu vaccination campaign. Through careful media and advertising, this mascot will come to represent control over one's life, longevity, coolness, and ease.

While branding will make vaccination "cool" and promote vaccination, improving the actual accessibility of vaccination is still desirable. Because convenience is such an
important factor to individuals (14), increases locations and easing cost of vaccination
is essential. For example, in urban housing where vaccination rates are low, door-to-door vaccines could be provided (17). Because of the close proximity of the houses, many people could be vaccinated in little time. Additionally, because elderly struggle with
getting to a doctor’s office to be vaccinated (16), a "vaccines on wheels" program could
be adopted. Similar to "meals on wheels", which delivers hot meals to immobile elderly,
delivering vaccines provides a necessity in a convenient way. Furthermore, mandating
vaccination on-site for office buildings with more than 20 employees will increase
vaccination rates. Studies show that 13% of people are just "too busy" to be vaccinated
(13). By providing vaccination at a location where individuals are 40 hours a week, that
problem is eliminated.

In terms of the problem of cost, new healthcare reform will likely eliminate this issue. The new government legislation mandates that every American have health insurance (25). This bill extends coverage to over 32 million Americans (25). For low-income individuals who cannot receive insurance through work, subsidies will be provided to allow for purchase of healthcare plans. Most large health insurance companies fully cover flu vaccination (26). This is because they realize that the vaccine is far cheaper than flu treatment or any complications that may arise. Additionally, flu campaigns must include information regarding healthcare and coverage of flu vaccines. This will inform the public of ways to offset the cost of vaccines, through informative commercials, pamphlets, and physicians-a particular effective outlet (3, 10). While this healthcare solution will not be fully in place until 2012 (25), it provides a viable solution to the cost preventing flu vaccination. “Branding” of vaccines will help eliminate cost as a barrier, but proper information of vaccine coverage will even further decrease the issue of cost.


Influenza is a major public health problem, killing thousands of people
every year (2). The disease is completely preventable through seasonable vaccinations (2). Because of this information, increasing the low rates of flu vaccination is crucial to
abating this public health problem. By implementing social science theories, three main
problems hindering flu vaccination, can be addressed. The first problem, the large ethnic divide in vaccination, can be addressed through psychological reactance theory. This theory allows campaigns to reduce the natural reactance towards government health suggestions in ethnic communities, while increasing knowledge. By decreasing such aversion to vaccination, and providing information through reliable sources, ethnic
disparities in vaccination rates will decrease. The second issue in the current
campaign, is that is does not effectively inform the public. This aspect can be altered
by using advertizing theory. An intervention that implements this theory will be able to
appeal to core values that motivate behavior change, while sneaking in important
information. Finally, accessibility of vaccines is a significant barrier to vaccination.
This factor can be changed by creating a "brand" for vaccination through marketing theory, as well as strategic policy changes. Branding vaccinations makes them "cool" and promotes vaccination as a desirable action-so that inconvenience is ignored. However, increasing actual accessibly will also help this issue. Providing more locations for vaccination and by insurance coverage of vaccination, receiving a flu vaccine becomes easier. The combination of these theories fixes three main problems currently associated with flu campaigns. By increasing vaccination rates in this manor, the health of the public can greatly improve.


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