A Breakdown in Public Health Communication

The Flu Message Is Not Getting Through

Back in December 2020 we posted a commentary about seasonal influenza, explaining how the flu vaccine works and why everyone should get it. That’s the same advice public health experts, like those at the U.S. Centers for Disease Control and Prevention (CDC), give us every year. We wondered what people really think about the flu and the flu vaccine and undertook a study to find out. The results of our inquiry, which we’ll describe below, are perhaps not surprising but they are certainly disheartening: people in our sample largely think the flu is a minor illness and that the flu shot either doesn’t work or actually gives people the flu. Almost no one seemed inclined to get the flu shot this year or any year.

Influenza— “the flu”—is a serious infectious disease that sends hundreds of thousands of people to the hospital in most years, especially young children and the elderly (image: Shutterstock).

What Critica Did

         Funded by a grant from the Robert Wood Johnson Foundation, Critica commissioned a firm called Fluent to conduct focus groups about attitudes toward flu and COVID-19 vaccines in three geographic areas, Newark NJ, Chicago Il, and central Texas. The pandemic prevented holding in person focus groups, so Fluent advised shifting to an online method called bulletin boards. As Fluent describes them, bulletin boards are asynchronous discussions involving greater numbers of individuals than typical focus groups, and over an extended period of time. Participants log into a password-protected site to answer questions that are posted and monitored by a moderator, who can also follow-up on responses for clarifications or elaboration. We conducted our bulletin board discussions about attitudes to vaccines between January 12 and January 28, 2021.

         A total of 94 people participated in this research, nearly evenly divided among the three regions. Fifty-four of the 94 participants were women. Forty-three identified themselves as white, 23 as African American/Black, 12 as Hispanic/Latinx, and 10 as Asian American/Pacific Islander. The participants had a range of education and household income levels. These volunteer participants were not selected to be a representative sample of the U.S. population, but they do represent a reasonable mix of sex, age, race, and socioeconomic status. This makes their near unanimity of opinion about the flu and the flu vaccine arresting.

What People Told Us About the Flu

         In general, respondents to our bulletin boards seemed unconcerned about the flu. They expressed the opinion that the flu is generally a mild illness, easy to get over with perhaps the assistance of readily obtainable over-the-counter medications. While public health officials stress that the flu kills thousands of Americans every year, including young children, the consensus of people we spoke with seemed to be that the flu is no big deal. That in turn meant that few people felt any great motivation to get the flu vaccine.

         Although many of our participants are aware that their own doctors, whom they generally trust, recommend an annual flu shot, they breezily reject their doctors’ advice, often in favor of “natural” or “holistic” treatments. People believe they can boost their immune systems and prevent getting the flu by taking a variety of supplements, eating a healthy diet, and getting exercise. Vaccines, like the flu shot, were seen as “unnatural” and akin to injecting “foreign substances” into their bodies.

         There was also an often-expressed belief that the flu shot either doesn’t work or can in fact cause the flu. A typical sentiment is reflected by one participant from Texas who said “I stopped taking any flu vaccine in the 1990s after one administered made me become very ill. It actually game me the full-blown flu.” We and many others explain repeatedly that it is impossible to get the flu from the flu shot. The vaccine does not contain live virus and cannot make anyone sick. Rather, it is possible to get the flu in spite of the flu vaccine because the influenza virus mutates rapidly and comes in multiple strains. Each season’s vaccine inevitably fails to cover all versions of the virus and therefore seasonal flu vaccines vary in effectiveness.

         That of course doesn’t mean they are ineffective but rather they are not 100% effective. Getting vaccinated lowers any individual’s chances of getting the flu and, if infected, usually decreases illness severity. That message does not seem to be getting through, however, as witnessed by comments like these from one of our study participants: “I don’t believe that the science behind the flu vaccines is as expert as the field makes it out to be since they are typically developing vaccines for the strain of flu the ‘think’ will be here in a given year.”

Influenza vaccination—“the flu shot”—significantly lowers the chance of getting the flu and, if infected, usually reduces illness severity (image: Shutterstock).

         Over and over again, participants related stories about people they know who got sick after receiving the flu shot. These stories clearly have more salience than anything people hear from experts. “I have heard,” one respondent told us, “that vaccines protect you from getting sick and keep you healthy. I heard this from my doctor or the news. I don’t believe it is true and I am not persuaded by the arguments…My mom got the flu vaccine and still got the flu.” Overall, 50 of the 94 people in our sample felt flu vaccine may be unsafe or believe it causes the flu.

Public Health Messaging Has Failed

         As we pointed out in December, according to the CDC, in most years millions of people contract the flu in the U.S., hundreds of thousands of them require hospitalization, and tens of thousands die. So there is obviously a huge gap between what public health authorities like the CDC tell us about the flu and what people believe. Moreover, it seems the CDC has been reassuring people for decades that the flu shot doesn’t cause the flu, but our observations indicate that the message is going unheard. People who trust their personal physicians and even value the information provided by federal health institutions like the CDC are nevertheless more often persuaded by their own personal experiences and by stories they have heard about the flu.

         To us, this suggests a nearly complete failure of public health messaging. It is not just that the flu is a serious illness and that its incidence can be substantially decreased by vaccination. It is that CDC, health departments, and doctors persistently tell us those things, but somehow no one believes them. The immediacy bias seems to reign here—if I never had a bad case of the flu, then it must mean that the flu isn’t serious; if I know someone who got a viral illness after getting the flu shot, then it is clear to me that the flu shot caused them to actually get the flu.

         The flu will be back next season, when it is likely that fewer people will be wearing facemasks or practicing social distancing. That makes the potential for more widespread flu outbreaks next year than last year a season a definite possibility. Next season’s flu might be milder than in past years because with fewer cases the virus itself has had less time to mutate to more serious strains. On the other hand, it could be more severe; people usually develop some at least partial immunity to the flu every season, but that will not happen this year because of the flu’s low prevalence rates. It will also be more difficult for scientists to decide which strains of the flu next year’s vaccine should target, something they do in part by observing the strains that are prevalent the previous year and on the Southern Hemisphere’s flu variants the preceding July and August. For 2021-22 there will be little to go on in order to make that determination.

         We need a new national strategy to educate people about the flu’s seriousness and motivate the public to get vaccinated. Since it appears, at least from our small sample, that personal experience and stories mean the most to people, perhaps that strategy needs to include advertising the stories of individuals who have developed serious cases of the flu and even telling stories about people who have died. This of course must be done only after research indicates it will be effective; telling the stories of children who die from the flu could backfire and make people even less likely to accept vaccination.

         Clearly, however, CDC and other public health experts need to dramatically rethink how they convey the flu story to the public. No matter how many advances molecular biologists and virologists make in developing more effective flu vaccinations, they are useless if people don’t believe in them.

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