We believe that flu vaccination campaigners are basically right. We believe that their messaging is often hyped, especially on side-issues. And we believe (without much evidence) that the hype is a major factor in HCW resistance to vaccination.
You don’t have to be able to parse the hype to learn to mistrust the hype.
We understand that most people don’t comb through flu vaccination messaging the way we do, searching for half-truths and exaggerations. But they still smell a rat when messages are misleading.
Everyone has experienced this with regard to “the bad guys.” Without ever parsing their words, we have all learned to mistrust “greenwash” ads by corporate polluters and glowing prose from used car salesmen.
But “the good guys” – such as flu vaccination proponents – imagine that their hype doesn’t smell.
Hype undermines the messaging of good guys and bad guys alike. The results are much more serious when it’s the good guys doing the hyping, losing credibility, and therefore failing to convince their audience about life-saving precautions.
What is our prescription for reducing HCWs’ learned mistrust about flu vaccination? Flu prevention advice that is nuanced and two-sided, that respectfully acknowledges people’s reasons for not wanting to get vaccinated, and that doesn’t misrepresent the evidence.
Getting from here to there – from hype to respectful dialogue – is a long haul. Many HCWs are accustomed to one-sided, exaggerated messaging from their employers
. They expect it, and they discount it. They won’t necessarily stop discounting on the day their employers stop hyping. The transition will go faster if you can get yourself to acknowledge the change, and faster still if you can get yourself to say you’re sorry: “We have been overselling vaccination and other flu precautions in ways our employees have learned to mistrust. We apologize, and we’re determined to change.” (Yeah, okay, that’s not likely. We can dream.)
Then go ahead and share some of your own anguish about the tragedy of vaccine-preventable influenza deaths. Letting your humanity show is a risk communication strategy that surprises a lot of public health professionals, who tend to become hyper-professional in uncomfortable situations.
The typical flu prevention campaign tries to give the impression (without directly saying so) that vaccination virtually guarantees immunity, while cough etiquette and hand-washing are somewhat less effective but still extremely useful against the flu. By contrast, here’s what the evidence says:
In years when the vaccine and circulating viruses are well-matched, vaccination reduces the odds of getting the flu 70–90% in healthy adults under 65, and it reduces flu-related hospitalizations 30–70% in people over 65 who live at home. In years when the vaccine strains are not well-matched to the main circulating viruses, vaccination helps less, though it still helps. As for coughing into your sleeve instead of your hand and washing your hands as often as you can, they presumably help at least a little but there’s no proof – though they greatly reduce transmission of many other diseases.
What’s so hard about saying that?
Flu vaccination is somewhat less effective than we typically imply, while everything else is probably much less effective than we imply. Thus, a more candid communications effort wouldn’t just avoid triggering learned mistrust; it would also make vaccination look like what it is: not perfect, but far and away the most effective way to protect yourself and others from influenza.
You’re asking HCWs to get vaccinated mostly for the sake of the institution and its patients, and you should say so. In fact, we recommend empathizing explicitly with HCWs on this point: “Most people get to decide for themselves whether they want a flu shot or not, but our employees are urged to get one regardless of their personal preference, for the sake of patient safety and staff workload. That’s an imposition on you. It’s not fair.” There’s a seesaw at work here. The more you acknowledge that you’re intruding on HCWs’ autonomy, the easier it will be for them to notice that you have good reasons to do so.
Threatening to fire HCWs unless they get vaccinated does increase vaccination rates, but with very high collateral damage: litigation, union grievances, morale problems, overt and covert hostility, etc. Even worse is when the threats exempt the highest-ranking health care workers – doctors and top administrators.
Any flu vaccination program that puts more pressure (or more visible pressure) on orderlies and nurses than on doctors and administrators is probably doomed. By contrast, seeing the top guns get their shots helps convince HCWs that the program is serious, and it eliminates the sting of condescension. It’s okay for HCWs to learn that some of the doctors weren’t crazy about the pressure either, and even that some of them resisted getting the shot (or nasal spray). The credibility of starting with doctors doesn’t come from “The docs don’t mind, so why should you?” It comes from “We pushed them hard, and now we’re working our way around to you.”