I Immunise: An evaluation of a values-based campaign to change attitudes and beliefs

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ContentslistsavailableatScienceDirect

Vaccine

jo u rn al h om ep a g e :w w w . e l s e v i e r . c o m / l o c a t e / v a c c i n e

I

Immunise:

An

evaluation

of

a

values-based

campaign

to

change

attitudes

and

beliefs

Katie

Attwell

a,b,∗

,

Melanie

Freeman

a,b

aImmunisationAllianceofWesternAustralia,CockburnGPSuperClinic,Success,WesternAustralia6164,Australia

bMurdochUniversity,SouthStreet,Murdoch,WesternAustralia6150,Australia

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received1May2015 Receivedinrevisedform 21September2015 Accepted23September2015 Availableonline11October2015

Keywords:

Immunisation Vaccination Vaccinehesitancy Behaviourchange Community Campaign

a

b

s

t

r

a

c

t

Thispaperpresentsresultsofastudydeterminingtheefficacyofavaluesbasedapproachtochanging vaccinationattitudes.Itreportsanevaluationsurveyofthe“IImmunise”campaign,conductedin Fre-mantle,WesternAustralia,in2014.“IImmunise”explicitlyengagedwithvaluesandidentity;formulated bylocalsinacommunityknownforitsalternativelifestylesandlower-than-nationalvaccinecoverage rates.Datawascollectedfrom304onlinerespondents.Thecampaignpolarisedattitudestowards vac-cinationandledsometofeelmorenegatively.However,ithadanoverallpositiveresponsewith77%of participants.Despitethecampaignonlyresonatingpositivelywithathirdofparentswhohadrefusedor doubtedvaccines,itdemonstratesanimportantin-roadintothishard-to-reachgroup.

©2015TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBYlicense (http://creativecommons.org/licenses/by/4.0/).

1. Introduction

Vaccine hesitancy in the developed world is a concern for governments, healthpractitioners, academicsand communities. Whilstagrowingliteratureinformstheeffortsofpolicy-makersand healthprofessionals[1–6],community,socialidentityandlifestyle remainunderutilisedsitestoenactsocialchangeinvaccine atti-tudes.

Particularcommunities have more reasonthan others tobe concernedaboutvaccinehesitancy,becausewhenrefuserscluster, localvaccinationrateswillbelowerthannationalaverages, threat-eningherdimmunity[7].Thishasinspiredsometoformaction groupstopromotevaccinationatlocal,nationalandinternational levels[8].InAustralia,theStoptheAustralian(Anti)Vaccination NetworkFacebook groupcountersthenation’smostprominent anti-vaccinationorganisation[9],whileNorthernRivers Vaccina-tionSupportersprovidessupportandinformationforparentsina geographicalregionwithsomeofthelowestvaccinationcoverage ratesinthecountry[10–12].

Vaccineinterventionsderivingfromcommunitiesutiliselocal advocates,a modelwellutilisedbyNorthernRiversVaccination

∗Correspondingauthorat:MurdochUniversity,SouthStreet,Murdoch,Western Australia6150,Australia.Tel.:+61893606781.

E-mailaddress:k.attwell@murdoch.edu.au(K.Attwell).

Supporters.Information,includingthereportingandtranslationof scientificdata,isimportant,butcommunity-basedinterventions can employmechanisms buildingupon social norming, values-framingandstory-telling.Evidencesuggeststhat‘letting people knowwhatotherpeopledoisoneofthemosteffectivewaysof increasingthatbehaviour’[13].Studiesofothercontestedissues suggestthatleadingwithvaluesinsteadoffactscanbean effec-tivewayofchallengingideologicallyloadedbeliefs[14].Moreover, emphasising sharedvalues, identity and lifestyleof local advo-cates is important, because behaviour change literature shows thattrustedandlike-mindedsourcesaremorelikelytoinfluence peers[15].Sharingmessagesthroughstoriesisastrategyvaccine advocateshaveemployed,explicitlyborrowingsuccessfultactics fromtheopposition [8].Thisrelationshipbetweeninformation, values,identity,lifestyleandstory-tellingcanbeconceptualised asasocial-identitytheorybasedapproachto(lasting)attitudinal change,advancedasbestpracticebyleading policyresearchers [15]. Such an approach takes seriouslythe social relationships betweenhumans,thewaysinwhichidentitiesareformedwithin and through theserelationships, and theconstruction of social normsthatencourageustoactinwaysthataffirmthem[16].

Thisarticleevaluates a researchprojectconducted arounda communityinterventioninFremantle,WesternAustralia,runby theImmunisationAllianceofWA,thenation’sfirstnot-for-profit pro-vaccination advocacy organisation [17]. Fremantle reports amongstthelowestvaccinationcoverageratesinAustralia,with

http://dx.doi.org/10.1016/j.vaccine.2015.09.092

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85.6%ofoneandfive-yearoldsfullyimmunised,and86.6%oftwo yearolds[12].The“IImmunise”campaignusedcommunity advo-catesand explicitly appealedto(because itderived from) local valuesaroundsocialjustice,parentingandalternativelifestyles.

“I Immunise” builtfrom a set of observations linked tothe broaderevidencerelatingtobehaviourchange(above),and vac-cination behaviours (examined below). We hypothesised that Fremantle’slowvaccinationratesderivedatleastinpartfromits prominentalternativelifestylecommunity.Alternativelifestyles, inparticularattitudestowardshealthandmedicine,canimpacton howparentsthinkandactwithregardtovaccines[2,18,19],ascan thegeographicalclusteringoflike-mindedfamilies[3,7,10,19,20]. Thecampaigndesigner’sexperienceswithintheFremantle alter-nativecommunityviahome-birthing,breastfeeding,baby-wearing andcloth-nappyingforums,indicatedthatvax-hesitantviewswere hegemonicinthesesettings.Highlyeducatedparentshavemuch higherlevelsofconcernaboutvaccinesafetythanthosewithless education[3];researchershavenotedthatmiddleclassmothersare morelikelytoquestionvaccination,and‘canhavea disproportion-ateinfluenceonothersinopinionformation’[21].InFremantle’s birthingandinfantscene, educated,middle-classparentslearnt fromeachothertoprioritiseparticularparentingpracticesinstead ofvaccinationtoprotect children;a tendencymirroredin sim-ilardemographicselsewhere[22,23].Self-styledexpertsonone aspectofparenting,suchasbreastfeedingornaturalbirth,could claimauthorityonvaccinesandinfluencediscourseinpeer-groups, demonstratingthephenomenonof‘bandwagoning,’withparents informedbythedecisionsofthosearoundthem[24,25].Wesought tocommunicatethat‘othersinthecommunityhavemadegood choicesonthebasisofaccurateinformation’[25](p.185). How-ever,whatwereallyemphasisedwasthevaluesandlifestyleof campaignparticipants.Byappealingtosharedidentification,we soughttopersuadepeopletovaccinateforreasonsthatwouldbe salienttothem[3,13].

Thereweretwodistinctaudiencesforthe“IImmunise” cam-paign.Leasketal.,intheirfive-foldtypologyofparentalattitudes andbehaviours,identify‘hesitant’parentsasthosewhovaccinate butwithsignificantconcerns,and‘lateorselectivevaccinators’who cherry-pickordelayvaccines[1]–together,thesewereour ‘fence-sitters’.OurotheraudiencewasmadeupofwhatLeasketal.call ‘unquestioningacceptors’and‘cautiousacceptors’[1].However, wefocusedonparents’outwardstancetowardsvaccinationrather thantheirinwardfeelings,conceptualising‘inthecloset’and‘out andproud’vaccinators.Thelaterfeaturedinthecampaign,whereas theformerwereitssecondtargetaudience.Giventhehegemony ofvax-hesitantviewsinthealternativecommunity,weexpected manyparentswhofullyvaccinatedkeptthisquiettoavoidconflict withpeers.Byencouragingtheseindividualstomoveoutofthe closetandclaimlegitimacyas‘alternative’parents,thecampaign soughttoaltercommunitydiscourse;astrategyadvocatedin gen-eraltermsbyBrunson,whofoundthatthevaccinationattitudes prevalentinaparent’snetworkareastrongerpredictorofvaccine acceptancethantheparents’ownperceptions[26].

Theaimofthisstudywastodetermineifsuchavalues-based approachisaneffectivetoolforchangingattitudesandbehaviour regardingvaccination.

2. Materialsandmethods

The“IImmunise”campaignfeaturedsixFremantleresidents whoidentifiedaslivinganalternativelifestyle.Campaign devel-opmentinvolvedcollaboratingwitheachspokespersontodevelop a300-wordtestimonialoutliningwhyvaccinationwaspartofhis orheralternativelifestyle.Thesetestimonialsfeaturedona web-sitealongwithprofessionalphotographsofthespokespeoplein

Fig.1. “IImmunise”poster.

iconicFremantlelocations.Eachspokesperson’stestimonialwas distilledintoaposter,listingfirstname,age,numberofchildren andtwocorelifestyleattributes,followedwiththewords,“I Immu-nise.”Lifestyleattributesincludedhome-birthing,breastfeeding, baby-wearingandeatingwholefoods.Onemotherbreastfedinher photograph;a fatherwore hisbabyson ina wrapmadebyhis artisanwife(seeFig.1below)[27].

Twopostersbecame billboards, erectedfor a month;others becamelargesignsdisplayedonpublicbuildings.Fourfeatured asweeklyadvertisementsintheindependentnewspaper,The Fre-mantle Herald. Eachposter became ameme ontheIImmunise Facebookpage,includingonewhich‘wentviral’with12,086views asofAugust2014[28].Theseriesofsixpostersweredistributedto doctors’surgeries,childhealthclinics,maternityservices,childcare centres,playgroupsandprivatebusinesses inFremantle, where manyofthemremainondisplay.Thecampaignattractedlocalstate andnationalmediaattention,particularlyafterthebillboardswere vandalised bysupportersoftheAustralianVaccination Skeptics Network[29].

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thoughtsandfeelingscouldbeeitherpositiveornegativeandasa result,fivedependentvariableswerecollectedcapturingthe posi-tiveornegativeimpactonthoughtsandfeelingsandanychanges inbehaviour.Alargevolumeofdatawascollectedandjustthe resultsdescribingtheevaluationofthecampaign(Part3ofthe sur-vey),arepresentedhere,includingresponsestosomeopen-ended questions.

Recruitment of participantswas via snowball sampling and directcampaigncontact.Thecampaignmaterialsreferencedthe“I Immunise”website,whichdirectedparticipantstotheonline sur-vey.Someparticipantsnotedintheirwrittencommentstheyhad passedthewebsiteandsurveyontotheirfriendsandfamily,and interestedpartiesofthecampaignemailedthesurveylinktotheir networks.Samplepostersandtestimonialswerepresentedinthe surveytoensurerespondentshadseenthecampaign.

Limiteddemographicinformationwascollectedfrom partici-pantsfor comparisonpurposes. Participants wereaskedif they self-identifiedas“someonewholivesanalternativelifestyle”or not.Thosethatdidnotself-identifyaslivinganalternativelifestyle wereusedasacomparisongroup.

Statisticalanalysiswasprimarilydescriptive(frequencies)or non-parametric(chi-squared).Participantswereidentifiedas vac-cinehesitantafterrecodingthreevariables.Threequestionsasked participantsiftheyhadeverrefusedavaccinationfortheirchild, haddoubtsaboutavaccinationorhadhadanyworriesabout vac-cination.A‘yes’toanyofthesequestionsplacedaparticipantin thevaccinehesitantgroup,enablinganalysisoftheeffectsofthe campaignonthisspecificgroup.

TheonlinequestionnairehadethicsapprovalunderUniversity of WesternAustralia permitnumber RA/4/1/5890, andsubjects wereinformedwhydatawasbeingcollectedand howitwould becollatedandused.

3. Results

Atotalof304respondentsevaluatedthecampaign.Thebasic demographic information of the respondents is presented in Table1.Therespondentswereprimarilyfemale(90.3%)inboththe alternativelifestylegroupandthenon-alternativelifestylers,and theytendedtohavesimilarnumbersofchildrenandlevelsof edu-cation.Thereweresignificantdifferencesbetweenthetwogroups whencomparingagesandoccupationalclassifications.More alter-native lifestyle respondents reported being 25–44yrs (86.0%) comparedtothenon-alternativelifestylers(73.6%),indicatingthey wereproportionallyolder (2 (3,n=302)=8.26; p<0.05). More

alternative lifestyle respondents reported being self-employed and stay-at-home parents (57.0%) compared to non-alternative lifestylers (32.1%), and a higher proportion of non-alternative lifestylers reported theyworked in supervisory or professional roles(49.0%comparedto30.2%)(2(5,n=270)=18.64;p<0.01).

Just over half of the participants reported they had either refused,doubtedorworriedaboutvaccinationsfortheirchildren (56.5%).Asexpected,thereweresignificantlymorevaccine hesi-tantparticipantsinthealternativelifestylegroup(72.0%)thanin thenon-alternativelifestylegroup(56.5%)(2(1,n=302)=6.59,

p<0.05).

Fig.2outlines whichelementsofthecampaignrespondents reportedseeing.Themostvisiblecampaigncomponentwasthe “IImmunise”website,whichwasseenbyoverathirdofall respon-dents.Forthealternativelifestylegroup,themostvisibleelements werethe campaign website(36.6%), the billboards (24.7%) and storiesinthelocalpaper(20.4%).Forthenon-alternativelifestylers, themostvisibleelementwasthecampaignwebsite(over41%)with allotherelements(exceptastallatalocalFarmersMarket)being seenbyasimilarnumberofrespondents.

Whenlookingatdifferencesbetweenthealternativelifestylers and non-alternativelifestylers(Table2), therewasa significant differenceinonlyone dependentvariable– feelingmore nega-tiveaboutvaccinationpostthecampaign(2 (1,n=304)=4.36,

p<0.05).

Afterrecodingthedataabove,therewere180(59.2%) respon-dentsindicatingapositiveimpactofthecampaign(eitherfeeling orthoughts),51(16.8%)indicatinganegativeimpact(either feel-ingsorthoughts),and73(24.0%)indicatingnoimpactonfeelings orthoughts.Therewasnosignificantdifferencebetweenthe alter-nativelifestylerespondents’positive,negativeornilimpactand non-alternativelifestylers’positive,negativeornilimpact.Leaving outthenilimpact,ofthe67alternativelifestyleparticipants indi-catinganimpactfromthecampaign,48or71.6%ofthemreporteda positiveimpact.Ofthe156non-alternativelifestylers,125or80.1% reportedapositiveimpact.

Asecondary aimofthecurrentstudywastoinvestigatethe perceptionsofvaccinehesitateparticipants.Analysingjustthose respondentswhoreportedanimpactfromthecampaign, signif-icantdifferenceswerefoundbetweenhesitantandnon-hesitant, indicatingthatnegativethoughts(2(1,n=158)=29.98;p<0.001)

andfeelings(2(1,n=169)=31.87;p<0.001)weremorelikelyto

begeneratedbythiscampaignforvaccinehesitantparticipants(see Table3).

4. Discussion

Themostimportanteffectofthecampaignwesoughtto mea-surewaswhetherithadmadealternativelifestyleparentsthink andfeelmorepositivelyaboutvaccination.Respondentsfromboth thealternativelifestylegroupandthenon-alternativelifestylers reportedmorepositivethoughtsorfeelingsthannegativethoughts orfeelingsafterseeingthecampaign.Thecampaignhadan over-allpositiveeffectforatleast77%;71%ofthealternativelifestyle groupand80.1%ofthenon-alternativelifestylers.Thefactthatthe campaigndidimpactpositivelyatleastthreequartersofthetarget groupsuggeststhatithasvalueasonetypeofinfluencingtool.

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Table1

Demographiccharacteristicsofsurveyrespondents.

Totalgroupn(%) Alternativelifestylen(%) Non-alternativelifestylen(%) Groupcomparisons

Numberofrespondents 304 93(30.6) 211(69.4)

Vaccinehesitant 2(1,n=302)=6.59,p<0.05

Yes 185(61.3) 67(72.0) 118(56.5)

No 117(38.7) 26(28.0) 91(43.5)

Gender n.s.

Males 29(9.7) 6(6.6) 23(11.1)

Females 269(90.3) 85(93.4) 184(88.9)

Agegroup(years) 2(3,n=302)=8.26;p<0.05

15–24yr 10(3.3) 4(4.3) 6(2.9)

25–34yr 106(35.1) 38(40.9) 68(32.5)

35–44yr 128(42.4) 42(45.2) 86(41.1)

45yr+ 58(19.2) 9(9.7) 49(23.4)

Numberofchildreninfamily n.s.

1 89(30.6) 27(31.0) 62(30.4)

2 128(44.0) 42(48.3) 86(42.2)

3+ 74(25.4) 18(20.7) 56(27.5)

Highesteducationalqualification n.s.

Year10or11 11(3.6) 2(2.2) 9(4.3)

Year12 19(6.3) 8(8.6) 11(5.2)

TAFEortrade 47(15.5) 14(15.1) 33(15.7)

Universitydegree 119(39.3) 40(43.0) 79(37.6)

Post-graduatequalification 107(35.3) 29(31.2) 78(37.1)

Occupationalclassification 2(5,n=270)=18.64;p<0.01

Management 29(10.74.4) 7(8.1) 22(11.9)

SupervisoryorProfessional 116(43.0) 26(30.2) 90(49.0)

Technicaloccupations 15(5.6) 3(3.5) 12(6.5)

Self-employedorsmallbusinessowner 40(14.8) 22(25.6) 18(9.8)

Homedutiesorstayathomeparent 68(25.2) 27(31.4) 41(22.3)

Unemployed 2(0.7) 1(1.2) 1(0.5)

Fig.2.Campaignactivitiesrecalledbyrespondents.

Table2

Impactofthecampaignonthoughts,feelingsandbehaviourregardingvaccination.

Alternativelifestylen(%) Non-alternativelifestylersn(%) Chisquareresults

Thinkmorepositivelyaboutit

Yes 32(25.8) 92(74.2) n.s.

No 61(33.9) 119(66.1)

Thinkmorenegativelyaboutit

Yes 14(37.8) 23(62.2) n.s.

No 79(29.6) 188(70.4)

Feelmorepositivelyaboutit

Yes 39(29.8) 92(70.2) n.s.

No 54(31.2) 119(68.8)

Feelmorenegativelyaboutit

Yes 19(44.2) 24(55.8) 2(1,n=304)=4.36,p<0.05

No 74(28.4) 187(71.6)

Dosomething–behavedifferently

Yes 19(34.6) 36(65.4) n.s.

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Table3

Impactofthecampaignacrossvaccinehesitantandnon-vaccinehesitantparticipants.

Vaccinehesitantn(%) Notvaccinehesitantn(%) Chisquareresults

Impactonthoughts

Positiveimpact 56(45.9) 66(54.1) 2(1,n=158)=29.98;p<0.001

Negativeimpact 35(97.2) 1(2.8)

Impactonfeelings

Positiveimpact 61(47.3) 68(52.7) 2(1,n=169)=31.87;p<0.001

Negativeimpact 39(97.5) 1(2.5)

By contrast, those who lived an alternative lifestyle and respondedpositivelytothecampaignreportedthattheywould takeactionssuchasgettingtheirownvaccinationsupdated, shar-ingthecampaignontheirFacebook“eventhoughIknewsomeof myfriendswouldstronglydisagree”,keeptheirchildrenawayfrom thosewhowerenotimmunised.Oneparentwrote,“Decidedonce andforalltoimmunisemybaby.”Parentsreportedfeelingmore comfortablewiththeirdecisionstoimmunisetheirchildrenand onespecifiedthat“itmademerealisethatvaccinationiscompatible withethicalparenting.”

The “I Immunise” campaign was novel in that it expressly engagedwithvalues,ideologyand identity.Morethanone tes-timonial of the ‘out and proud’ vaccinators emphasised social responsibility,seeingthisasakeypartoftheircommunity’s val-ues[27].However,sinceresearchdemonstratesthatparentsmake vaccinationdecisionsprimarilyabouttheirownchildren rather thanthebenefittoothers[22,39],moreresearchisrequiredinto how,andwhether,socialresponsibilitycanbeenhancedthrough pro-socialnormswithinspecificcommunities,andwhether cam-paignssuchas“IImmunise”couldbetransferabletoothersimilar communities.

Althoughthecampaignwasconductedwithreferencetothe geographicalcommunityofFremantleandthebroaderlifestylethat thisFremantleidentityconnotes,ourfindingsarepotentially appli-cabletoothersimilarcommunities,particularlybecausewedid notlimitsurveyresponsestoFremantleresidentsonly.Thereare isolated“Fremantle-type”individualsthroughoutbroader popula-tions,connectedbyonlineandsocialmedia,andthereareother communitieswithapparentsimilaritiestoFremantleintermsof lifestyle and values, with Portland in the USA[41,42] a popu-larlyreferencedexample.Whilesimilaritiesbetweennationaland international‘hesitantcommunities’needtobemappedand cross-nationalvirtual‘hesitantcommunities’alsorequireinvestigation, wehopeourstrategyandlimitedfindingswillhelpresearchersin thosesettingsdevelopandtestnewideas.However,allcampaigns shouldbeconceived,developed,testedandexecutedby commit-tedmembersoflocalcommunities,tofittheauthenticityneedsof theiraudiences.

Thereweresomereallimitationstothisstudy,manyofwhich derivefromthefact thatit wasactionresearchconnected toa grass-rootscommunity-ledcampaign[43].Thepresentationofthe campaigntoageographicalandwideronlinecommunityprecluded anexperimentaldesign.Datawasgatheredopportunisticallyand viasnowballsamplingrather thanviadoubleblindrandomised controlledtrials.Theresponseratewaslowgiventhattherewere nolimitsplacedonwhocouldrespond,andthisimpactedonour abilitytodrilldowntotheeven smallercohortofvaccine hes-itantorrefusingrespondents.ALikertscalewould havehelped ustomeasurestrengthofreach,ratherthanasimpleyes/no.We didnotcollectdataonresidencewithin,nearoroutside Freman-tle,whichwasasignificantweakness.Becauseofsocialmedia,we couldnotadequatelycontrolwhosawthecampaignandwishedto respond.However,althoughthecampaignwasgeographically sit-uatedwithinFremantle,weknowitwasviewedandsharedwidely withinAustraliaandbeyond.Onthisbasis,webelievethat mea-suringpeople’sresponsestoitviatheirself-ascribedsocialidentity

caninformusaboutvaccinationasasocialpractice,andasasite forsocialinterventions.

Weseeourprojectcontributingtodevelopingevidence-based strategies for dealing with vaccine hesitancy and refusal. Such strategieswillbeessentialforincreasingvaccinationratesin com-munitiesatriskofoutbreaksofvaccinepreventablediseases[5,6]. Wereiteratethatevenifthecampaignpolarisedsomeinthe com-munity,aswesurmise,whenitcametoparentswhohaddoubted, worriedaboutthesafetyorevenrefusedvaccines,areasonable pro-portionthoughtandfeltmorepositivelyaboutimmunisationafter seeingthecampaign.Tobeabletoalterpositivelythemindsets ofoveronethirdofvaccinehesitantrespondents–whichwould includecommittedanti-vaccinatorsaswellasfence-sitters–is,we argue,asuccess.Differentstrategiesareclearlyrequiredforthose whomwewerenotabletopersuade.

Acknowledgementsanddisclosures

ThisresearchwasfundedbytheImmunisationAllianceof West-ernAustraliausinganunrestrictedVaxigrantfromSanofiPasteur. The “I Immunise” campaign was funded by the Immunisation AllianceofWAwithagrantfromtheCommunicableDisease Con-trolDirectorateof theHealth DepartmentofWesternAustralia. KatieAttwellreceivedfundingfromtheImmunisationAllianceof WAtodesign,deliverandresearchtheIImmunisecampaign,in whichshewasalsoaparticipant.MelanieFreemanisthe Secre-taryoftheImmunisationAllianceofWA.Inadditiontotheauthors, MichaelWiseandJaneJonescontributedtotheprojectandresearch design, SarahLeeParker participatedin thedatacollectionand LeoniMoleassistedwiththequalitativedataanalysis.

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