Editor’s Note: This is part 1 in a three-part series focused on considerations when working with families regarding vaccines.
How do you feel about these statements related to vaccines?
- Vaccines are a great public health accomplishment.
- Vaccines are well tested.
- COVID-19 vaccines were made on the shortest timeline ever.
Chances are if you agreed with #1 and #2, you would be impressed, or excited, about #3. However, if you disagreed with either #1 or #2, you would likely view #3 as problematic.
This short exercise demonstrates the importance of a person’s feelings or attitudes about a subject when they hear related information. For many who work in medicine and public health, the short timeline by which COVID-19 vaccines became available was a great scientific accomplishment — indeed, Drs. Drew Weissman and Katalin Karikó received the 2023 Nobel Prize in Medicine for their work on mRNA vaccines. However, for others, the short timeline was a reason to doubt the safety of COVID-19 vaccines. To some of them, statement #3 likely offered “evidence” that #2 is not true.
When we talk with families about the science of vaccines, we realize that facts alone will not determine how someone receives a message. As such, we have to understand something about a person’s existing attitudes. Social Judgement Theory, developed in the early 1960s, posits that people have pre-existing attitude structures about topics and how they receive a message about one of those topics depends on how the idea they are hearing fits into that attitude structure. The theory has a few components:
- Anchor: A person’s most salient idea about the topic
- Latitudes: Ideas can be described in one of three categories: acceptance, rejection and noncommitment. The latter are ideas that don’t affect the person one way or the other.
- Ego involvement: The degree to which a person is invested impacts how malleable their attitudes are related to the topic.
The authors of this theory made the point that when someone hears a message, they will evaluate it based on this attitude structure. If it is within their latitude of acceptance, they will “make room for it,” but if it is in their latitude of rejection, they will be unaccepting and may even push back on the idea. In psychology, we sometimes hear this described as the “boomerang effect.” So, the authors of the theory, Sherif and Hovland, suggested that if you want to create change, you must deliver messages that are within, but toward the outer edges of, a person’s latitude of acceptance. The result will be a series of small attitude changes rather than a single “eureka” moment.
This is not to say that those “eureka” moments can’t happen, but they are more likely from some external and dynamic change of situation personal to the individual rather than as the result of a health message or conversation. Most often, these more dramatic attitude changes occur because a person’s sense of risk changed. When it comes to vaccines, we have seen that large outbreaks or knowing someone negatively impacted by a vaccine-preventable disease may cause a dramatic shift, but most often, change occurs more gradually — maybe one conversation or one vaccination at a time.
So, what does this mean clinically?
From a clinical perspective, understanding this helps us in a few ways. First, it manages our own expectations of ourselves and our team. A single health message or conversation is unlikely to dramatically change a person’s attitudes. Second, when we talk with patients or even friends, family or other parents, our conversations can help us to understand a person’s attitude structure about a topic. This understanding can help us better relate to the other person, be in a position to help them get the kinds of information they need, and foster an ongoing and more meaningful working relationship. Third, when we evaluate whether the person is open to what they are hearing — that is whether their attitudes are changing or if they are open to change — we are less likely to overlook small changes simply because we are focused on bigger, faster changes.
In busy clinical practices with long lists of information to cover, this may seem like more than is possible, especially given today’s short appointment times. However, it is critical work in this moment, and there are ways to work together:
- First, people’s attitudes are shaped by what happens not only at the point of care but every time they encounter a message relevant to the subject. As such, healthcare providers are only one part of the equation. That said, healthcare providers should work together like a relay team — whether on social media, in a clinical setting, or when providing outreach at a public event or on a website — to continue delivering messages that not only address a person’s needs but also push toward the edges of that latitude of acceptance. Pre-bunking is also an effective strategy, as it can establish a person’s anchor on a topic that they have not yet considered.
- Second, at the practice or institutional level, evaluate whether opportunities exist to expand conversations around hot topics, like vaccines, to ensure that there is time to both address a person’s concerns and better understand their attitudes. Where are they coming from with their questions? To accomplish this, your team may consider questions like: Is there someone who can field questions or hold “topic-specific office hours”? Are there sources of information that you can provide through waiting room televisions, posters, handouts or electronic communication systems that you have in place? Are some of the concerns around barriers that can readily be addressed through practice changes, like number of available vaccine appointments (especially in the fall), appointment times, and costs?
- Third, some companies and researchers are evaluating tools to help clinicians develop a sense of patient’s attitudes about specific topics. In these cases, patients (or their parents) may be asked to complete a few questions prior to the visit, so providers have information before entering the exam room or even while sitting with the patient. Some examples are Rehavior and Chadis. See more about each of these in the “Resources” section of this article.
- Fourth, research agendas that bring together experts in communications, behavioral psychology, public health and vaccinology are uniquely suited to provide insights into the most effective ways to communicate around topics that have become highly emotional or political in nature as opposed to research done in the silo of one field. Best practices from research then need to be disseminated and implemented in real-world settings. We can all benefit from being attuned to this work and open to trying new approaches in the clinical setting.
Resources
Chadis offers “patient engagement and online screening tools and assessments with clinical process support.” Started by two pediatricians, this group offers a variety of resources, including questionnaires, data collection tools, and decision support.
Rehavior focuses on the importance of targeted communication in healthcare to move away from a one-size-fits-all approach. By evaluating common concerns and questions around a healthcare topic, they are able to develop a tool that integrates into electronic health records systems to aid providers in understanding the motivating ideas for different patients.
Contributed by: Lori Handy, MD, MSCE , Charlotte A. Moser, MS
Editor’s Note: This is part 1 in a three-part series focused on considerations when working with families regarding vaccines.
How do you feel about these statements related to vaccines?
- Vaccines are a great public health accomplishment.
- Vaccines are well tested.
- COVID-19 vaccines were made on the shortest timeline ever.
Chances are if you agreed with #1 and #2, you would be impressed, or excited, about #3. However, if you disagreed with either #1 or #2, you would likely view #3 as problematic.
This short exercise demonstrates the importance of a person’s feelings or attitudes about a subject when they hear related information. For many who work in medicine and public health, the short timeline by which COVID-19 vaccines became available was a great scientific accomplishment — indeed, Drs. Drew Weissman and Katalin Karikó received the 2023 Nobel Prize in Medicine for their work on mRNA vaccines. However, for others, the short timeline was a reason to doubt the safety of COVID-19 vaccines. To some of them, statement #3 likely offered “evidence” that #2 is not true.
When we talk with families about the science of vaccines, we realize that facts alone will not determine how someone receives a message. As such, we have to understand something about a person’s existing attitudes. Social Judgement Theory, developed in the early 1960s, posits that people have pre-existing attitude structures about topics and how they receive a message about one of those topics depends on how the idea they are hearing fits into that attitude structure. The theory has a few components:
- Anchor: A person’s most salient idea about the topic
- Latitudes: Ideas can be described in one of three categories: acceptance, rejection and noncommitment. The latter are ideas that don’t affect the person one way or the other.
- Ego involvement: The degree to which a person is invested impacts how malleable their attitudes are related to the topic.
The authors of this theory made the point that when someone hears a message, they will evaluate it based on this attitude structure. If it is within their latitude of acceptance, they will “make room for it,” but if it is in their latitude of rejection, they will be unaccepting and may even push back on the idea. In psychology, we sometimes hear this described as the “boomerang effect.” So, the authors of the theory, Sherif and Hovland, suggested that if you want to create change, you must deliver messages that are within, but toward the outer edges of, a person’s latitude of acceptance. The result will be a series of small attitude changes rather than a single “eureka” moment.
This is not to say that those “eureka” moments can’t happen, but they are more likely from some external and dynamic change of situation personal to the individual rather than as the result of a health message or conversation. Most often, these more dramatic attitude changes occur because a person’s sense of risk changed. When it comes to vaccines, we have seen that large outbreaks or knowing someone negatively impacted by a vaccine-preventable disease may cause a dramatic shift, but most often, change occurs more gradually — maybe one conversation or one vaccination at a time.
So, what does this mean clinically?
From a clinical perspective, understanding this helps us in a few ways. First, it manages our own expectations of ourselves and our team. A single health message or conversation is unlikely to dramatically change a person’s attitudes. Second, when we talk with patients or even friends, family or other parents, our conversations can help us to understand a person’s attitude structure about a topic. This understanding can help us better relate to the other person, be in a position to help them get the kinds of information they need, and foster an ongoing and more meaningful working relationship. Third, when we evaluate whether the person is open to what they are hearing — that is whether their attitudes are changing or if they are open to change — we are less likely to overlook small changes simply because we are focused on bigger, faster changes.
In busy clinical practices with long lists of information to cover, this may seem like more than is possible, especially given today’s short appointment times. However, it is critical work in this moment, and there are ways to work together:
- First, people’s attitudes are shaped by what happens not only at the point of care but every time they encounter a message relevant to the subject. As such, healthcare providers are only one part of the equation. That said, healthcare providers should work together like a relay team — whether on social media, in a clinical setting, or when providing outreach at a public event or on a website — to continue delivering messages that not only address a person’s needs but also push toward the edges of that latitude of acceptance. Pre-bunking is also an effective strategy, as it can establish a person’s anchor on a topic that they have not yet considered.
- Second, at the practice or institutional level, evaluate whether opportunities exist to expand conversations around hot topics, like vaccines, to ensure that there is time to both address a person’s concerns and better understand their attitudes. Where are they coming from with their questions? To accomplish this, your team may consider questions like: Is there someone who can field questions or hold “topic-specific office hours”? Are there sources of information that you can provide through waiting room televisions, posters, handouts or electronic communication systems that you have in place? Are some of the concerns around barriers that can readily be addressed through practice changes, like number of available vaccine appointments (especially in the fall), appointment times, and costs?
- Third, some companies and researchers are evaluating tools to help clinicians develop a sense of patient’s attitudes about specific topics. In these cases, patients (or their parents) may be asked to complete a few questions prior to the visit, so providers have information before entering the exam room or even while sitting with the patient. Some examples are Rehavior and Chadis. See more about each of these in the “Resources” section of this article.
- Fourth, research agendas that bring together experts in communications, behavioral psychology, public health and vaccinology are uniquely suited to provide insights into the most effective ways to communicate around topics that have become highly emotional or political in nature as opposed to research done in the silo of one field. Best practices from research then need to be disseminated and implemented in real-world settings. We can all benefit from being attuned to this work and open to trying new approaches in the clinical setting.
Resources
Chadis offers “patient engagement and online screening tools and assessments with clinical process support.” Started by two pediatricians, this group offers a variety of resources, including questionnaires, data collection tools, and decision support.
Rehavior focuses on the importance of targeted communication in healthcare to move away from a one-size-fits-all approach. By evaluating common concerns and questions around a healthcare topic, they are able to develop a tool that integrates into electronic health records systems to aid providers in understanding the motivating ideas for different patients.
Contributed by: Lori Handy, MD, MSCE , Charlotte A. Moser, MS