A range of immeasurable and variable effects makes it a hard sell.

by Leah Shaffer 

Say you manufacture a product, but some years that product works better than others. Your customers either actively mistrust this product or, at best, grudgingly tolerate it. Oh, and when this product works, its effectiveness can be difficult to demonstrate, in part because it varies along a spectrum of very effective to sort of effective but still helpful. How do you sell that?

In this case, the “product” is the flu shot. And the goal of selling the public on the benefits of this vaccine is an ever-shifting public health challenge, possibly the most challenging among all of the vaccines available.

Vaccines contain a killed or weakened virus that allow the immune system to master a threat before it engages the active virus. We use vaccines to develop immunity to a variety of deadly diseases. For some diseases, such as measles, it takes only two doses to develop life-long immunity. However, because influenza viruses constantly change form, scientists need to develop new vaccines every flu season. It’s a mad chase every year to keep up with the flu, which doesn’t make for a very easy public health message.

In spite of this, taking a look at influenza vaccination rates over the past decade reveals a few bright spots. For most age groups, vaccination rates have been gradually ticking up over the past two decades, or at least holding steady. According to the National Health Interview Survey from the year 2000, approximately 17% of adults age 18–49 received a flu shot. That value had increased to 29% for the 2011–2012 season.

Although this isn’t exactly a stellar improvement, a more promising picture emerges when looking specifically at certain subgroups that are at high risk for life-threatening flu complications, including pregnant women. In 2000, only 10% of pregnant women received a flu shot. Contrast that with a 47% vaccination rate in this same group for the 2011–2012 season. So what’s at play here? What factors came together to lead to such an increase? The short answer: A crisis and a culminated effort.

H1N1

In 2004, the American College of Obstetricians and Gynecologists issued its recommendation that all pregnant women receive a flu vaccine, but prior to the infamous 2009 H1N1 pandemic, the vaccination rate was between 15 and 25%. Pregnant women are more at risk for life-threatening flu complications, including dehydration or pneumonia. The flu vaccine is especially important for this group because it can also protect a newborn until the child is old enough to be vaccinated at age 6 months.

But when H1N1, known colloquially if not quite accurately as the “swine flu,” emerged in the spring of 2009, the risk had changed. Pregnant women with the flu were ending up in intensive care units. When they caught the flu, it was much more severe than was typical for previous years, says Linda Eckert, an associate professor of obstetrics and gynecology at the University of Washington. Eckert, who had been on sabbatical at the World Health Organization, returned in time to help coordinate the H1N1 response at her home institution, Women’s Clinic at Harborview in Seattle.

Because of the media coverage of the H1N1 outbreak, “there was enhanced patient awareness,” says Eckert, noting that patients were actually asking for the vaccine. Adding to that heightened sensibility, clinics like Eckert’s were mobilizing like never before, with a multicultural approach to getting information out.

Harborview Medical Center serves a large number of people whose first language isn’t English. For this reason, the clinic staff put together training for its cultural caseworkers, who handle translation work and ended up providing information about the flu in nine languages.

Cultural adaptation wasn’t the only step the medical center took to influence vaccine decisions. Harborview’s work in educating its staff was a key step in its information campaign. It seems counterintuitive, but ensuring that all staff — not only doctors — are consistent with their flu vaccine message is a challenge for hospitals because a sizable portion of healthcare staff share the general public’s skepticism about the flu shot. Before the 2009 H1N1 season, healthcare personnel vaccine coverage was at 49%, although it has climbed now to 67%. Eckert cites surveys showing only 35–65% of office medical office staff believe the flu vaccine is safe during pregnancy

In addition to putting out a consistent message, the clinic developed a database to offer real-time tracking of vaccinations, says Eckert. All patients were called and reminded to get a flu vaccine when it became available. The end result at Eckert’s clinic was a 76% vaccination rate.

The strides made in 2009–2010 were good, but Eckert is not stopping there. “It was extremely successful,” she acknowledges, but “the question is, How reproducible is it?”

And still, during the past few flu seasons, the national vaccination rate for pregnant women has remained steady at 45–50%.

“We were hoping that it would continue to go up,” Eckert says.

Finding the message

Does it take a crisis and full-blown media frenzy to really improve vaccination rates, or are other forces at play?

“There’s never that silver bullet message or piece of information that will work for everybody, and that’s one of the challenging things with promoting influenza vaccination,” says Kristine Sheedy, associate director of communication science at the Centers for Disease Control and Prevention (CDC). “We’re having to talk to the entire population every season and get everybody back.”

Sheedy has worked in vaccine communication at the CDC since 2000. Her office handles a variety of communications activities including media interviews, web presence, social marketing campaigns, and audience research and message testing. Just as there is ongoing research on how to improve the flu vaccine, there’s a whole science behind how to communicate with the public about the flu vaccine.

As covered by DXS Health Editor Tara Haelle last week, recent studies have found that social networks factor significantly into vaccination decisions. One study that looked at Twitter messages about the H1N1 vaccine found that negative vaccine views spread much more quickly than positive views. The same study found that both negative and positive tweets encouraged more negative tweets.

“It is a struggle to know how best to use social media channels,” says Sheedy. “We are trying to be very strategic in how we use social media.”

The CDC has been taking an increasingly tailored approach to using these sites. They target their message to leaders in specific groups.

In one recent pilot project, the CDC partnered with leaders of different Meetup groups that include people who are at high risk for flu complications, such as pregnant-women. They’ve also hosted webinars to provide flu vaccine information for influential mommy bloggers, says Sheedy.

“It’s really about educating the influencers and the opinion leaders and making sure that they have the tools and information they need to share with their consituents and the people they network with,” says Sheedy.

A key component to increasing vaccination rates is for doctors themselves to make recommendations to their patients to get a flu shot. In a 2011 CDC survey of pregnant women, 75% ended up getting vaccinated when the doctor both recommended it and offered to give them the shot. Only 10% sought a vaccination when they had not received a recommendation from the doctor.

It seems obvious, but in the increasingly time-starved medical profession, taking time for preventative care is not a given. And yet, really addressing the common concerns about a flu shot goes beyond a simple statement to a patient. It takes a conversation.

And it’s a complicated conversation because of the numerous concerns about vaccines. The misconception that autism is connected to vaccines has gotten a lot of media attention the past decade and a half, but that’s just one issue. Another common fear is that the vaccine somehow causes the flu (it can’t). It takes two weeks for a flu shot to be effective. In that period of time, a person can still get the flu, which may be a reason for the occasional stories about people who come down with the flu shortly after being vaccinated. Communicating the basics of how the flu shot works is one of the messaging challenges in the efforts to improve vaccination rates, but the science doesn’t fit into a sound bite.

For starters, flu seasons are unpredictable — annual influenza deaths have ranged from as few as 3,000 to as many as 49,000 people over the last 30 years. Sometimes the flu vaccine is highly effective, and other times it is less so. Sheedy and her colleagues at the CDC must also get across the complex message that even if an immunized person does get the flu, the vaccine will often mitigate the severity of the illness.

Sheedy says her time at the CDC has reinforced the importance of taking a “risk communication” approach to her job, meaning that communicators have to be forthright in sharing what they do or don’t know about risk. Getting any vaccination is not without a risk for complications, yet those complications are rare. Clinicians must empathically acknowledge patient concerns while still making a persuasive case for the vaccine, says Sheedy.

Beyond the fear that the flu shot gives the flu or that it doesn’t work, one of the main arguments against getting the flu shot is that people feel they don’t need it. In focus groups, however, when public health staff have explained the danger of passing the flu to vulnerable populations, Sheedy has seen even those who are staunchly against vaccination can start to change their minds.

“Once you get people thinking along those lines, it does make a difference,” says Sheedy.

Sheedy is already gearing up for the next flu season. One of her main challenges coming off the previous season is countering the perception that the flu shot doesn’t work.

That perception arose because a number of news stories reported that the vaccine was only 9% effective in adults age 65 or older.

Sheedy pointed out that the 9% value doesn’t take in account the vaccine’s effect on reducing hospitalizations.

In the focus groups this year, Sheedy heard much discussion about the issue of vaccine effectiveness. She recalls that one older participant pointed out that he never got the flu vaccine, saying, “now I hear it hardly even works.”

Sheedy says he had more to say. “You folks back there need to get your act together,” he told them.

Some seasons have really disappointing vaccine effectiveness, she acknowledges, but then there are others that are much better. It’s a complicated message, and Sheedy says, “We’ve got our work cut out for us.”

Resources

• Data on vaccination trends are from the Centers for Disease Control and Prevention. Vaccination trends from 1989 to 2008
• Health Care Personnel flu vaccination survey from the 2012-13 season
• Pregnant women flu shot survey and data from previous seasons
• Recent vaccination trends for the general population and for 2011-2012
• Linda Eckert’s “OB/GYN as Vaccinators” presentation for the 2011 National Influenza Vaccine Summit

 

[Leah Shaffer is a freelance writer based in St. Louis. As a community reporter in Eden Prairie, Minnesota, she covered topics ranging from struggles of the Somali immigrant community to STEM education initiatives. Her most recent work has appeared in Scholastic Instructor magazine. You can follow her on Twitter as @LeahabShaffer.]

[Homepage and thumbnail image credit, US Government public domain image via Wikimedia Commons.]