Education versus anti-vaxxers: evidence from Europe

Vaccine skepticism and hesitancy – the distrust and skepticism that some members of the public feel for vaccines, as well as for institutions that deliver and encourage vaccination – has emerged as a major threat to world health. Vaccine skepticism is not limited to any particular place; it has been observed across a range of countries, cultures, and levels of prosperity. Vaccine skeptics have made themselves known in Hollywood, led protests in Washington D.C., and lashed out violently against vaccination in Pakistan and Northern Nigeria. Vaccine skepticism has truly gone global.

Vaccine skepticism comes at odds with the proven benefits that vaccines have brought to humanity. The widespread adoption and use of vaccines and antibiotics led to sharp declines in the incidence of, and mortality caused by, infectious diseases. Except for the 1918 global flu epidemic, infectious disease mortality in the United States fell linearly before plateauing in the 1950s, at under one-tenth of the rate seen in 1900.

Vacine hesitancy threatens to reverse years of progress towards reducing measles deaths and ultimately eliminating measles as a threat, as immunization levels in many communities are at or below the 95% level required for herd immunity. In fact, the World Health Organization has seen more cases reported in the first half of 2019 than in any year since 2006. It is clearly time to reappraise vaccine policies and programs.

The role of education

Many people may find it difficult to understand and assess risks and benefits of vaccination, especially in the presence of Wakefield’s fraudulent argument that the MMR vaccine causes autism, while vaccines have been so successful that more people have seen autism than the diseases targeted by the vaccines.

Since one might hope that education can provide both the facts needed to make intelligent decisions about vaccination and the ability to reason, we ask here what is the relation between education and vaccine skepticism.

We use 2017 education data from the United Nations Development Program Human Development Reports, and data on vaccination attitudes from the Vaccine Confidence Project, published in 2016. These data include 28 European countries, with wide ranges in the prevalence of vaccine skepticism (13.5% in the median country did not agree that vaccines were safe, with a range from 4.2% in Portugal, to 51% in France) and years of education (16.4 in the median country, with a range from 12.7 in Azerbaijan to 19.8 in Belgium).

We found a weak (R2 = 0.1847) but statistically significant (p = 0.022) inverse relationship between education level and vaccine skepticism: by country vaccine skepticism decreased by about 2% for each additional year of education.

The relationship between years of schooling and vaccine skepticism, by country.

However, there are significant outliers, consistent with the low coefficient of correlation. For example, among the least educated countries, vaccine skepticism in Bosnia and Herzegovina is 36%, compared with 13% in the less educated Azerbaijan. Vaccine skepticism is 51% in France but 4.2% in Portugal, again despite similar educational levels (16.3 years in Portugal, 16.4 in France). Among the most educated countries, vaccine skepticism was 5.5% in Israel but 14% in the more educated Belgium.

Questions for research

It is clearly important to understand the cultural and other reasons behind the outliers in these data, in order to address the health challenge of vaccine skepticism. Here we offer some speculations and questions for further study.

The European countries with the best systems of education are generally those that were the first to industrialize, reach developed status, and adopt nationwide vaccination programs. As such, their present populations may be very historically removed from the infectious diseases that once plagued the European continent. As such, people in these countries may be less appreciative of the difference that vaccines have made, and more likely to be influenced by anti-vaccine messages.

Another factor to consider may be the politicization of anti-vaccine attitudes. It is possible that vaccine skepticism has become more prevalent simply because more people subscribe to political ideologies that are distrustful of the medical establishment and, more generally, institutions typically associated with their governments. France is again one such country where people are increasingly doubtful of their political institutions and are therefore wary of completely trusting ideas promoted by their government. This is more apparent than ever with the recent yellow vest protests seen across the country.

Distrust is often rooted in real instances of the abuse of public trust by, as well as the failure of, institutions, such as the Tuskegee syphilis trials, the Thalidomide birth defect crisis of the 50s and 60s, as well as unethical pharmaceutical trials that modern drug companies have carried out in developing countries, such the meningitis antibiotic trials that Pfizer carried out in Northern Nigeria during the mid 1990s. Vaccine skeptics have also lobbied for religious exemptions to be upheld in places that were considering their removal due to the resurgence of certain diseases like measles.

A study conducted in Romania concluded that unfavorable information spread by the media regarding vaccines was the lead cause in increasing vaccine skepticism in the country. With one third of the population being skeptical about vaccines, politicians and the reputation of the pharmaceutical industry were also named as reasons people feared vaccines.

In some countries, such as Greece and Romania, medical professionals have often been found to be skeptical of vaccines themselves. These health care workers have expressed concerns regarding the guilt they would feel if patients were to experience negative side effects after receiving vaccines, claiming that certain hepatitis and HPV vaccines have been banned in other countries due to fears of patients developing tumors and autism. These claims are reminiscent of Wakefield’s false and damaging claims that the MMR vaccine caused autism.

Residents of former Yugoslav countries, such as Bosnia and Herzegovina, have attributed lack of vaccine confidence to a discomfort with the relationship between physicians and patients. By evoking the times when the practice of immunization went unquestioned, physicians appear to be advocating the reestablishment of the authoritative power relationship between physicians and patients under socialism.

Given the well-documented strong evidence of the benefits of vaccines, we are left with a communication challenge – how to communicate key scientific facts needed for intelligent decision-making in a respectful, non-threating, non-condescending way.

Credit

Agent relationships and information asymmetries in public health

The agent relationship and information asymmetry are two features of healthcare economics – but how do they apply to public health policy around processed foods?

Why is health different to other goods?

Arrow’s 1963 seminal paper helped lay the foundations for health economics as a discipline. The Nobel-winning economist talks about what makes healthcare different to other types of market goods. Two of the principal things are agent relationship – that a clinician often makes choices on behalf of a patient (Arrow calls them a “controlling agent”); and information asymmetry – that a clinician knows more than the patient (“informational inequality”). Whereas if someone is buying a new car, they make their own choices, and they might read up on the extensive information available so that they are reasonably knowledgeable about what to buy. These two factors have evolved and possibly diminished over time, especially among highly educated people in developed countries; people often have more choice over their treatment options, and some people have become ‘expert patients‘. Patients may no longer believe that the Götter in Weiß (Gods dressed in white) always know best.

Agent relationship and information asymmetry are features of healthcare economics but they also apply to public health economics. But where people accept clinicians as having more knowledge or acting as their agent, people don’t always accept advice on food from public health policy makers in the same way. People may think, “well I know how to buy a bottle of beer, or a can of coke, or a pizza”, and may not see any potential information asymmetry. Some of it might be ‘akrasia’ – they know that food is unhealthy, but they eat it anyway because it is delicious! However, few people may be aware that poor diet and obesity are the biggest risk factors for ill health and mortality in England.

People might ask “why should a nanny state agent make my food or drink decisions for me?” Of course, this is ignoring the fact that processed food companies might be making those decisions, and reinforcing them using huge marketing budgets. Consumers see government influences but they don’t always see the other information asymmetry and agent relationship; the latent power structures that drive their behaviours – from the food, drinks, alcohol industry, etc. Unsustainable food systems that promote obesity and poor health might be an example of market failure or a tragedy of the commons. The English food system has not moved on enough from post-world war 2 rationing, where food security was the major concern; it still has an objective to maximise calorie supply across the population, rather than maximise population health.

Some of the big UK misselling scandals like mortgage PPI are asymmetries. You could argue that processed foods (junk food high in salt, sugar and saturated fats) might be missold because producers try to misrepresent the true mix of ingredients – for example, many advertisements for processed foods try to misrepresent their products by showing lots of fresh fruit and vegetables. Even though processed foods might have ingredients listed, people have an information asymmetry (or at least, a deficit around information processing) around truly understanding the amount of hidden salt and sugars, because they may assume that the preparation process is similar to a familiar home cooked method. In the US there have been several lawsuits from consumers alleging that companies have misled them by promoting products as being wholesome and natural when they are in fact loaded with added sugars.

The agent relationship and information asymmetry as applied to food policy and health.

How acceptable are public health policies?

A 2012 UK poll carried out by YouGov, funded by the Adam Smith Institute (a right wing free market think tank), found that 22% of people in England thought that the government should tell people what to eat and drink, and 44% thought the government should not. Does this indicate a lack of respect for public health as a specialism? But telling people what to eat and drink is not the same as enacting structural policies to improve foods. Research has shown that interventions like reducing salt in processed foods in the UK or added sugar labelling in the US could be very cost effective. There has been some progress with US and UK programmes like the sugary drinks industry levy, which now has a good level of public support. But voluntary initiatives like the UK sugar reduction programme have been less effective, which may be because they are weakly enforced, and not ambitious enough.

A recent UK study used another YouGov survey to assess the public acceptability of behavioural ‘nudge’ interventions around tobacco, alcohol, and high-calorie snack foods. It compared four types of nudges: labelling (adding graphic warning labels to products); size (reducing pack size of snacks, serving size for alcohol, and number of cigarettes in packets for tobacco); tax (increasing the price to consumers); and availability (banning sales from corner shops). This study found that labelling was the most acceptable policy, then size, tax, and availability. It found that targeting tobacco use was more acceptable than targeting alcohol or food. Acceptability was lower in people who participated in the relevant behaviour regularly, i.e. smokers, heavy drinkers, frequent snackers.

What should public health experts do?

Perhaps public health experts need to do more to enhance their reputation with the public. But when they are competing with a partnership between right wing think tanks, the media and politicians, all funded by big food, tobacco and alcohol, it is difficult for public health experts to get their message out. Perhaps it falls to celebrities and TV chefs like Jamie Oliver and Hugh Fearnley-Whittingstall to push for healthy (and often more sustainable) food policy, or fiscal measures to internalise the externalities around unhealthy foods. The food industry falls back on saying that obesity is complex, exercise is important as well as diet, and more research is needed. They are right that obesity is complex, but there is enough evidence to act. There is good evidence for an ‘equity effectiveness hierarchy‘ where policy-level interventions are more effective at a population level, and more likely to reduce inequalities between rich and poor, than individual, agentic interventions. This means that individual education and promoting exercise may not be as effective as national policy interventions around food.

The answer to these issues may be in doing more to reduce information asymmetries by educating the public about what is in processed food, starting with schools. At the same time understanding that industries are not benevolent; they have an agent relationship in deciding what is in the foods that arrive at our tables, and the main objectives for their shareholders are that food is cheap, palatable, and with a long shelf life. Healthy comes lower on the list of priorities. Government action is needed to set standards for foods or make unhealthy foods more expensive and harder to buy on impulse, and restrict marketing, as previously done with other harmful commodities such as tobacco.

In conclusion, there are hidden agent relationships and information asymmetries around public health policies, for instance around healthy food and drinks. Public health can potentially learn from economic instruments that have been used in other industries to mitigate information asymmetries and agent relationships. If Government and the food industry had shared incentives to create a healthier population then good things might happen. I would be curious to know what others think about this!

Health economics and behaviour change: a workshop

Authors of a paper entitled What can health psychologists learn from health economics: from monetary incentives to policy programmes note that they

…believe that health psychologists would benefit from greater familiarisation with the methodologies, theories, and tools of economics”.

I wonder what discourse a research paper examining what health economists could learn from health psychologists or health behaviour change would take; particularly in the area of intervention design and evaluation. Intervention design and evaluation is an area in which multidisciplinary research has become the name of the game! Over the last decade, the intersection of economics and psychology has become even more apparent. The announcement of the 2017 Nobel Memorial Prize for economics, to Richard Thaler, for his groundbreaking work incorporating psychology into economic theory, was a victory not only for the Professor but also for behaviourally-informed policy worldwide.

A workshop

As the Intensive Follow-Up Workshop on Designing Effective Interventions for Health Behaviour Change approaches, I reflect back on the introductory workshop that I attended at the Health Behaviour Change Research Group (HBCRG), NUI Galway. The aim of that workshop was for participants to learn about, and practice using, emerging methods for designing and evaluating behavioural interventions. It was delivered by Dr Molly Byrne, Dr Jenny McSharry and Milou Fredrix.

My background is in health economics. I currently work in a large multidisciplinary team (we call ourselves the CHErIsH team!); a melting pot of health behaviour change, health psychology, public health, health economics and general practice. The different elements of our disciplines are “melting together” into a harmonious common goal of developing an intervention for childhood obesity prevention. I am extremely fortunate to have learnt a lot working with this team. I have been exposed to different methodologies, theories and frameworks in behaviour change and health psychology which has greatly enriched my health economics research thinking. Prior to becoming part of the CHErIsH team, I had little to no experience of working in behaviour change or health psychology. Admittedly throughout my PhD, my thoughts on health behaviour change and psychology models and frameworks wandered from imagining them to be very complex with almost an overload of frameworks and theories – to the other extreme of thinking this area to be a fairly unassuming area of research and that behaviour change could be easily evaluated.

It is safe to say that I left the introductory workshop with the confirmation that behaviour change is a complex area, but that this complexity is OK! The workshop fuelled me with a wealth of knowledge, reassurance and confidence regarding how I might apply behaviour change theoretical models to inform my health economics research. I also left the workshop with a greater understanding of the emerging methods for evaluating behaviour change interventions (which coincidentally I will be doing very shortly).

Whilst this blog post does not cover all of the material outlined in the workshop, below are some nuggets of information that I took home with me.

The big picture

What we do in our behaviours are hugely predictive of morbidity and mortality. Justify the importance of health behaviour in the particular setting that you are researching. This is important in health economic evaluations when we think of health outcomes and how behaviour might impact on these. Or indeed within the less traditional methodologies in health economics such as discrete choice experiments examining individual preferences and behaviour.

When designing a behavioural intervention…

  1. Identify and define the specific behaviour that you are trying to change, this is as good as having a good research question or a good systematic review question. Be aware of the spillover effects that the intervention might have, along with thinking how this intervention might be measured. The more precisely you specify the behaviour, the better!
  2. Understand the psychological theory – why a particular person or group is behaving a certain way in a particular setting. Understand how you can change it.
  3. Specify clearly what the intervention is in your research paper, describe it – clearly. There is a greater need for specificity. There is loose terminology in behaviour change, which often has more complex interventions than biomedical subjects. There is a real need for common language, but try to be clear when describing your intervention. Don’t make it hard on those trying to evaluate it later.

Take home messages

Behaviour change is complex. But, complexity is not a problem once we are aware and acknowledge the complexity that exists.

I previously mentioned that I left the workshop reassured. I was reassured to be reminded by the experts that it is OK not to know exactly what your intervention is going to be or going to look like from the onset.

Last, but by no means least, this workshop provided me with access to the psychological and health behaviour change frameworks. There are in fact 83 theories! Molly and Jenny spoke about “on the ground reality”. So whilst theoretically there are all of these theories, pragmatically the intervention needs to be designed and tested. So a pilot should be about optimising the components of the intervention and testing which components are more feasible.