Poison Or Prevention? Understanding the Linkages Between Vaccine

HEALTH COMMUNICATION https://doi.org/10.1080/10410236.2017.1331307

Poison or Prevention? Understanding the Linkages between Vaccine-Negative Individuals’ Knowledge Deficiency, Motivations, and Active Communication Behaviors Arunima Krishna Department of Mass Communication, Advertising, and Public Relations, College of Communication, Boston University

ABSTRACT The last few decades have seen growing concerns among parents regarding the safety of childhood vaccines, arguably leading to the rise of the anti-vaccine movement. This study is an effort to understand situational and cross-situational factors that influence individuals’ negative attitudes toward vaccines, referred to as vaccine negativity. In doing so, this study elucidated how situational and cross-situational factors influence vaccine negativity. Specifically, this study tested how knowledge deficiency, or acceptance of scientifically inaccurate data about vaccines, and institutional trust influenced negative attitudes toward vaccines. Using the situational theory of problem solving as the theoretical framework, this study also identified and tested a knowledge–attitude–motivation–behavior framework of vaccine negative individuals’ cognitions and behaviors about the issue.

The last few decades have seen growing concerns among reportedly facing a measles and a whooping cough epidemic parents regarding the safety of childhood vaccines, leading (Hiltzik, 2014), both diseases for which vaccines are routinely to the rise of the anti-vaccine movement, an issue that has administered during infancy, this issue of rich, educated received extensive scholarly attention (e.g., Kata, 2012). parents choosing not to vaccinate their children deserves Although arguments against vaccines have been advanced attention. Such negative attitudes toward vaccines are referred since the early eighteenth century (Warraich, 2009), mod- to as vaccine negativity in this study. ern-day opposition to vaccinating children and the resultant With the rampant spread of inaccurate messages about anti-vaccination movements arguably started when British vaccines, the impact of such messages on negative attitudes surgeon Andrew Wakefield published a now-discredited about vaccines as a health issue deserves scholarly attention. research paper, claiming a link between the Measles/ The evaluation and acceptance of (scientifically inaccurate, Mumps/Rubella (MMR) vaccine and autism (Ross, 2011). invalidated) non-factual data about an issue are referred to Wakefield’s controversial work gained so much notoriety in as knowledge deficiency in this study and will be discussed in the scientific community that Time magazine included his detail later. This study is an attempt to bring knowledge name in the list of Great Science Frauds (Park, 2012), receiv- deficiency in conversation with attitudes, as the impact of ing extensive media coverage (Holton, Weberling, Clarke, and knowledge deficiency on the attitudes, motivations and active Smith (2012). Besides the alleged link to autism, anti-vaccine communication behaviors of individuals is explored. Using activists also cite fear of safety, links to intestinal problems, the situational theory of problem solving (STOPS; Kim &

Downloaded by [Universita Cattolica del Sacro Cuore] at 04:20 18 September 2017 and infringement of personal liberty to be their reasons for Grunig, 2011; Kim & Krishna, 2014) as the theoretical frame- opposing vaccinations for their children (Heyworth, 2014). work, this study seeks to explicate the relationships between An interesting aspect of this movement is that there are issue-specific knowledge deficiency, attitudes, motivation, and indicators of parents who do not vaccinate their children behaviors about vaccines to forward our discipline’s under- being educated high-income. Kim, Frimpong, Rivers, and standing of anti-vaccine attitudes, and take a step toward Kronenfeld (2007) found that low maternal education and addressing the problem. The next section is organized as low income were positively associated with complete immu- follows. First, the theoretical framework used in this study, nizations. A 2014 report revealed that the vaccination rates in the STOPS, is discussed. Then, knowledge deficiency and some of Los Angeles’ wealthiest school districts were as low as negative attitudes as they are conceptualized in this study those in Chad and South Sudan, with 60–70% parents filing are explained, particularly as they relate to the theoretical personal belief exemptions which allow their children to framework, after which issue-specific situational antecedents attend school without being vaccinated (Ghazan, 2014). and outcomes of vaccine negativity and the attendant research When put into context with the fact that California is questions and hypotheses are proposed.

Literature Review Similar to the STP, the STOPS conceptualizes individuals’ communication behaviors to be predicted by their problem Situational Theory of Problem Solving perceptions. According to the situational theories, an indivi- The situational theory of problem solving (Kim & Grunig, dual who recognizes a discrepancy between expected and 2011) is a theory of communication that explains why indivi- experienced state (problem recognition), recognizes his/her duals communicate about a specific problem or issue. Like its involvement in the problem (involvement recognition in the parent theory, the situational theory of publics (STP; Grunig, STOPS, level of involvement in the STP), and perceives few 1997), STOPS theorizes that individuals’ perceptions about an barriers in his/her path of addressing the problem (constraint issue will predict their communication behaviors about it. recognition) is theorized to engage in a variety of commu- However, unlike the STP, which assumed individuals to be nication behaviors about the issue (i.e., CAPS). However, economic decision makers, the STOPS views individuals as unlike the STP, the STOPS does not conceptualize problem problem solvers, social actors trying to “solve a problem perceptions to directly impact communication behaviors. and cope with problematic consequences” (Kim & Krishna, Instead, the relationship between issue-specific perceptions 2014, p. 76). and communication behaviors, as per the STOPS framework, Not only does the STOPS posit that an individual’s percep- is mediated by situational motivation in problem solving tions of a problem explain his/her communicative behaviors (Kim & Grunig, 2011). Situational motivation in problem about the problem, it also elucidates how individuals commu- solving is defined as the “a state of situation-specific cognitive nicate when they perceive a problem, by expanding the and epistemic readiness to make problem-solving efforts— kinds of communication behaviors individuals engage in. that is, to decrease the perceived discrepancy between the Specifically, while the focus of most information behavior- expected and experiential states” (Kim & Grunig, 2011, related studies is on information seeking or acquisition (Ni & p. 132). Kim, 2009), the STOPS captures three categories of commu- Operationally, situational motivation in problem solving is nication behaviors individuals may display when faced with a measured by “the extent to which a person stops to think problem—information acquisition, information selection, and about, is curious about, or wants more understanding of a information transmission (communicative actions in problem problem” (Kim & Grunig, 2011, p. 132). The “stop to think solving, CAPS; Kim, Grunig, & Ni, 2010). This broader con- about” aspect of the definition is a remnant of Grunig’s(1997) ceptualization of communication behaviors represents original conceptualization of problem recognition, which was another shift in the STOPS from the STP, which envisaged defined in the STP as a state in which “people detect that information behaviors to be limited to information acquisi- something should be done about a situation and stop to think tion. Each of the three categories of communication behaviors about it” (Grunig, 1997, p. 10). However, Kim and Grunig has active and passive dimensions, such that CAPS consists of (2011) argued that recognizing a problem “increases one’s six communication behaviors. Such a dichotomization is probability of ‘‘stopping to think about what to do,’’ but the reflective of Lippmann’s(1925) proposition that a public discrepancy alone cannot determine the extent of subsequent sphere consists of (active) actors about a problem, and thinking” (Kim & Grunig, 2011, p. 128). Other situational (passive) spectators. perceptions, that is, perceived proximity to the problem and The STOPS conceptualizes the six communication beha- perceived constraints in solving the problem also affect viors as follows. Information acquisition consists of informa- whether or not and to what extent individuals think about a tion seeking (active search for issue-related information) and problem (Kim & Krishna, 2014). In other words, the STOPS information attending (passive attention to information when captures the “stop to think about” aspect of the STP not as one comes across it without meaning to). Information selection part of problem recognition, but as an effect of problem refers to the degree to which an individual shows selectivity in recognition, constraint recognition, and involvement recogni- his/her appetite for issue-specific information. The active tion. Situational motivation in problem solving, then, sums up

Downloaded by [Universita Cattolica del Sacro Cuore] at 04:20 18 September 2017 dimension, information forefending, happens when an indivi- the effect of and mediates the relationship between individual actively rejects certain types or sources of information, duals’ perceptions and their communication behaviors (Kim while the passive dimension, information permitting, refers to & Grunig, 2011). the acceptance of any information deemed related to the issue In other words, perceptions about a problem may not at hand. Information transmission involves active information necessarily predict communication behaviors directly; when forwarding, or the volunteering of information without being individuals perceive a problem and their involvement in it, prompted, and information sharing, when an individual pro- and don’t feel constrained, they are motivated to do some- vides information to others when asked. Important to note here thing about it, and go on to communicate about the problem. is that the active and passive dimensions are not mutually Conceptually, the presence of motivation assumes problem exclusive; indeed, an individual engaging in the active beha- perceptions (Kim & Grunig, 2011). Operationally, then, situa- viors also engages in the passive behaviors, but not vice-versa tional motivation in problem solving may act as a proxy for (Kim & Krishna, 2014). Therefore, in this study, the three active problem perceptions (e.g., Kim, Shen, & Morgan, 2011), as it dimensions of the communicative actions in problem solving, sums and mediates the effect of perceptions (i.e., problem, that is, information seeking, information forwarding, and constraint, and involvement recognition) on (active commu- information forefending, were investigated to articulate a nication) behaviors. Situational motivation in problem solving model of individuals’ active communication behaviors. is the final piece of the issue-specific perceptions–motivation– HEALTH COMMUNICATION 3

behaviors framework of the STOPS. This study is an attempt toward the object than a positive pre-disposition is related to to bring two more cognitive pieces in conversation with the a positive attitude (Bizer & Petty, 2005), providing further existing framework of the STOPS, knowledge, and attitudes, argument for explication of a link between knowledge and to make sense of why individuals refuse to vaccinate their attitude. This study builds on studies that focus on general children and engage in negative communication behaviors cognitive and behavioral factors that influence certain atti- about vaccines. tudes, and examines issue-specific, context driven factors and how they are related to negative attitudes held toward a key health issue. In doing so, this study builds on the strong Knowledge Deficiency foundation of the theoretical knowledge we have on attitudes Before defining knowledge deficiency, it is important to note by bringing negative attitudes in conversation with knowledge the conceptual differences between data, information, and deficiency, and examining how negative attitudes are related knowledge as used in this study. This study follows to issue-specific motivations and active communication McDonough’s(1963) definition of information as having behaviors. To investigate the relationship between attitudes, three components: data, or unevaluated messages one comes motivations and active communication behaviors about vac- across, information, data evaluated and judged to be relevant cines, the following research questions are posited in this study: to a given problem situation, and knowledge, data evaluated but not judged relevant to the current situation, and (cogni- RQ1: How is vaccine negativity related to situational motiva- tively) filed away for future use in case a relevant problem tion about vaccines? arises. To illustrate, an individual may come across Andrew Wakefield’s now discredited study on the link between the RQ2: How is vaccine negativity related to active communi- MMR vaccine and autism. This message, as is, constitutes cative behaviors about vaccines? data. If the individual evaluating these data is facing a choice of whether or not to vaccine his/her child, he/she may judge these data to be relevant to that decision, and these evaluated Vaccine Negativity: Safety and Liberty-Based Objections data become information. Note that, evaluation and establish- ing relevance of data do not necessarily mean acceptance of The importance of vaccines in controlling the spread of and, the data. On the other hand, if this individual is trying to in some cases, even eliminating potentially-fatal infections make a vaccination-related decision, he/she may still evaluate and diseases has been recognized by governments and medi- the data to be irrelevant now, but perhaps applicable later, and cal researchers for years (Fine, 1993; Garnett, 2005) leading to store it mentally as knowledge. If that individual is later faced concentrated efforts from governments around the world to with a vaccination-decision, he/she will then be able to provide their populations with access to vaccines at a very retrieve this knowledge and re-evaluate its usefulness to the early age. Indeed, organizations such as the World Bank have decision. Such knowledge may then provide a frame for acknowledged vaccines to be key to achieving the Millennium information seeking behavior related to the problem situation Development Goals (MDG) set by world leaders in 2000, and (e.g., Google search for “MMR vaccine autism” for more great strides have been made in improving immunization information about the previously-learnt piece of knowledge). rates and vaccine delivery in much of the developing world Knowledge deficiency, then, refers to the positive evalua- (World Health Organization, United Nations International tion and acceptance of inaccurate data that has been stored Children’s Emergency Fund, & World Bank, 2009), not only for future use. For the purpose of this study, “accurate data” protecting vaccinated individuals from diseases, but also pro- or “fact” refers to scientifically accepted and validated data of viding herd immunity for those who cannot be vaccinated. the day. In the context of vaccines, the link between the MMR Unfortunately, while the developing world is seeing an vaccine and autism is an example of inaccurate data, and improvement in immunization rates, developed countries,

Downloaded by [Universita Cattolica del Sacro Cuore] at 04:20 18 September 2017 acceptance of such data as knowledge would constitute particularly in North America, are showing a decline in child- knowledge deficiency. hood immunizations. In 2013, a total of 113 nations in the world had higher immunization rates against measles (for infants under 1 year) than the US, including China, Saudi Attitudes Arabia, and Zimbabwe (Noack, 2015). In the US, the current The relationship between knowledge and attitude has been immunization rate against measles is at 91%, while in Canada studied by social scientists in a variety of ways, including it is 84%, both well below the 95% immunization rate required attitude development through exposure to stimuli (Eagly & for herd immunity (Akumu, 2015). It is unsurprising, then, Chaiken, 1993), additional data about the attitude object that both the US and Canada have suffered from multiple (Wood, Rhodes, & Biek, 1995), and repeated expression measles outbreaks in the last five years (Akumu, 2015; (Powell & Fazio, 1984). Attitudes refer to object-evaluation Measles cases and outbreaks, n.d.). In 2015 alone, there were associations in an individual’s memory (Fazio, 1989) and a 189 reported cases of measles spanning 24 states and “disposition to respond positively or negatively toward a parti- the District of Columbia (Centers for Disease Control cular object, for example, a person, issue, or organization” [CDC], n.d.). Since 2010, a total of 1,381 cases of measles (Binder, Dalrymple, Brossard, & Scheufele, 2009, p. 316). have been reported, a startling number given that, in 2000, Additionally, a negative pre-disposition to an object is asso- measles was documented to have been eliminated from the US ciated with the development of a stronger negative attitude (CDC, n.d.). 4 A. KRISHNA

The drop in vaccination rates has been widely attributed to linkages between the types of vaccine negativity, the following a wide range of fears related to vaccines and their safety research question is posited: (Benin, Wisler-Scher, Colson, Shapiro, & Holmboe, 2006), including a widely discredited study that linked the MMR RQ3: How are general, safety-related, and liberty-related (measles, mumps, rubella) vaccine to autism (White, 2002). vaccine associated with each other? Andrew Wakefield’s (now retracted) 1998 study, which linked autism to the MMR vaccine, arguably led to a direct decline in immunization rates in the UK (White, 2002) and the US Antecedents of Vaccine Negativity (Smith, Ellenberg, Bell, & Rubin, 2008). Despite longitudinal, Vaccine negative attitudes, particularly those related to their rigorous medical studies to the contrary (e.g., Farrington, safety, are rooted in unscientific, widely discredited pieces of Miller, & Taylor, 2001) the fear of autism from the MMR data, such as vaccines contain too much mercury, they cause vaccine continues to prevent parents from vaccinating their autism, and so on. It would follow, then, that individuals who children, driving down immunization rates and endangering lack factual knowledge about vaccines and continue to believe herd immunity (Haberman, 2015). the non-factual data are likely to hold negative attitudes However, the fear of autism from the MMR vaccine is just against them. Knowledge deficiency, the lack of scientifically one of the reasons that parents are opting out of vaccinating accurate information as conceptualized in this study, would their children in the U.S. (Benin et al., 2006). Fear that vaccines likely influence individuals’ attitudes against vaccines. are unnatural and harmful (Salmon et al., 2005), and that they Accordingly, the following hypothesis is posited: might overload the system, in addition to fears about autism have been found to influence parents’ decisions not to vacci- Hypothesis 1: Individuals’ issue-specific knowledge deficiency is nate their children. Such attitudes toward vaccines, stemming positively associated with vaccine negativity (H1) from media representations of scientific research (Smith et al., 2008), as well as over-reliance on alternative medicine such as Despite overwhelming medical evidence about the benefits naturopathy (Benin et al., 2006) are referred to as safety-related and safety of vaccines, negative attitudes toward vaccines in the vaccine negativity in this study. US continue to thrive and are evidenced by the dropping Interestingly, vaccine safety is not the only category of vaccination rates. A factor that has been investigated by scho- negative attitudes toward vaccines evident in immunization lars as an influencer in the vaccine decision-making process is debates. Central to debates on mandatory vaccination require- that of trust. Trust in various stakeholders, including healthcare ments is the question of diminished authority of parents to providers and the government, has been routinely discussed in make medical decisions for their children (Salmon et al., conjunction with vaccine hesitation and vaccine rejection. 2006). Much of this backlash against mandatory vaccines Benin et al. (2006) undertook a qualitative investigation of stems from the fact that most states in the US require children new mothers’ vaccine beliefs, attitude, and knowledge, and to be vaccinated to be admitted into K-12 state or private found that trust in healthcare professionals and distrust in the schools. The institution of “personal belief” exemptions in doctors’ and the pharmaceutical industry’s motives in pushing some states such as Colorado and California allows parents more and more vaccines was a recurring theme, particularly to opt of vaccinating their children if it interferes with their among non-vaccinators. Jolley and Douglas (2014) too found religious or personal beliefs, allowing those with vaccine safety that mistrust in authorities mediated the relationship between concerns to not immunize their children. A recent poll from vaccine conspiracy beliefs and vaccine intentions among the Pew Research Center revealed that millennials, individuals British parents. Furthermore, research on vaccine acceptance between the ages of 18 and 29, believe that the choice to or rejection, particularly behavioral research published in med- vaccinate should rest with the parents, and not be mandated ical journals, routinely accounts for trust in authorities when by the government (Sifferlin, 2015). Since the recent out- modeling vaccine intentions (e.g., Brownlie & Howson, 2006).

Downloaded by [Universita Cattolica del Sacro Cuore] at 04:20 18 September 2017 breaks of measles, however, states are reconsidering their However, much of the empirical research, particularly about vaccination policies. In particular, California, which saw the parental rejection of childhood vaccines tends to be based in bulk of the measles cases in 2014 and 2015, has introduced the UK (e.g., Jolley & Douglas, 2014), and few have attempted strict new laws that do away with the controversial personal to understand the relationships among trust in various institu- belief objections (Firgir, 2015), meaning that in absence of tions, vaccine negative attitudes, and behavioral intentions. The medical reasons to do so, the only way for parents to refuse present study moves this research forward by attempting to vaccines for their children is for them to homeschool them. understand the relationships between trust and behavioral The long and heated debate about parents’ right to choose intentions using two types of vaccine negativity. Accordingly, immunizations for their children (Medina, 2015) underscores the following hypotheses are posited: a different kind of negative attitude toward vaccines—vaccine negativity with regard to liberty. However, whether the types Hypothesis 2: Individuals’ trust in government is negatively of vaccine negativity are related or are mutually exclusive is associated with vaccine negativity (H2). not yet clear. Indeed, news reports of parental choice activists indicate that their attitudes toward vaccines include both Hypothesis 3: Individuals’ trust in healthcare professionals safety- and liberty-related objections, and general professions is negatively associated with vaccine negativ- of anti-vaccine attitudes. To empirically understand the ity (H3). HEALTH COMMUNICATION 5

Hypothesis 4: Individuals’ trust in the pharmaceutical industry measure of vaccine knowledge was, “Scientists have shown is negatively associated with vaccine negativ- that the measles, mumps and rubella (MMR) vaccine has been ity (H4). shown to cause a special type of autism in children.” All other items used in this survey other than demographic questions Hypothesis 5: Individuals’ trust in the CDC is negatively were measured on a 1 to 5 strongly disagree to strongly agree associated with vaccine negativity (H5). Likert-type scale, unless specifically stated otherwise. Vaccine negativity was measured by seven items, which yielded Cronbach’s alpha of .921. Items included two general Outcomes of Vaccine Negativity measures of attitude toward childhood vaccines (i.e., I am The most commonly discussed behavioral outcome of knowl- opposed to vaccinations for children; I believe that vaccina- edge deficiency and vaccine hesitancy is vaccination intention. tions can protect me and my (future) children from any Considering that most research on vaccine acceptance or chance of contracting those diseases [reversed]; α = .768), rejection has been conducted by medical practitioners for three measures that spoke to vaccines’ safety (i.e., I believe whom intentions to vaccinate or not are the most important, that the MMR vaccine causes autism; I believe that vaccina- it is unsurprising that vaccination intention forms the out- tions lower our immune systems; I believe vaccines to be come for most such research (e.g., Jolley & Douglas, 2014). unnatural; α = .880), and two related to parents’ choice (I The following hypothesis is posited to explicate the attitude- believe mandatory vaccines to be an infringement on my behavior link: rights; Parents should have the right to choose whether or not to vaccinate their children; α = .861). A single item, which Hypothesis 6: Vaccine negativity (H6) is associated with read “I do not intend to vaccinate my (future) children” intentions not to vaccinate. measured behavioral intention. Items from Huang’s(2001) Organization-Public Relationship Assessment Scale (OPRA) were used to evaluate trust in various institutions and included four items. These measures yielded Method Cronbach’s alphas of .883 (federal government), .888 (CDC), In order to answer the research questions and test the hypoth- .878 (pharmaceutical industry), and .785 (healthcare profes- eses, a Qualtrics survey was conducted among US partici- sionals) for each of the four institutions. The measures for pants. The survey1 was conducted between August and situational motivation in problem solving active communication December, 2015 and was open to participants in the US via behaviors were adapted from Kim and Grunig (2011). MTurk, and participants were paid between $.75 and $1.5 for Situational motivation was measured by three items with responding to the survey. Studies have shown that the popu- Cronbach’s alpha being .724. The four items for information lation of MTurk users closely mirrors the demographic dis- seeking yielded a Cronbach’s alpha of .859. Three items mea- tribution of the United States (Casler, Bickel, & Hackett, sured information forwarding, yielding a Cronbach’s alpha value 2013), and using such samples for social scientific research of .754. eliminates the concerns of using student samples, particularly Information forefending was measured by 4 items, the those related to diversity (e.g., Henrich, Heine, & Norenzayan, Cronbach’s alpha for which was .623. Given that the reliability 2010). For these reasons, MTurk was deemed an appropriate estimate for this variable was below the conventional .7 cut- participant recruitment pool. A total of 163 males and 272 off point, further analyses were conducted. Confirmatory females responded to the survey, while 13 did not respond to factor analysis of information forefending yielded good fit, the gender question (N = 448). The youngest participant in with χ2 (2) = 4.02, p = .134; CFI = .990, RMSEA = .048, the study was 18 years old, while the oldest participant was 71 SRMR = .022. Based on this additional analysis, the four items (M = 33.05, SD = 10.36). Of the 434 who responded to the measuring information forefending were retained.

Downloaded by [Universita Cattolica del Sacro Cuore] at 04:20 18 September 2017 question on education, 210 (48%) had at least completed college, 147 (34%) had attended some college, 25 (6%) had Data Analysis had vocational training, 51 (12%) had completed high school, and 1 had completed grammar school. Although the percen- The hypotheses posited and research questions asked with tage of college graduates in the sample was higher than the regard to antecedents and outcomes of and vaccine negativity 33% national average (Ryan & Bauman, 2015), given that were tested using structural equation modeling. To assess data education is negatively associated with complete immuniza- fit, Hu and Bentler’s(1999) joint-criteria were used. Hu and tion (Kim, Frimpong, Rivers, & Kronenfeld, 2007), the sample Bentler (1999) joint-criteria are the one of the most conserva- used in this study was deemed appropriate. tive evaluation criteria under which conventionally a model of CFI ≥ .95 is considered a good model. According to the joint- criteria, a good structural testing model approaches to CFI ≥ Measures .95 and SRMR ≤ .8, or RMSEA ≤ .06 and SRMR ≤ .8. In this In order to test the hypotheses and address the research study, the results were interpreted only when the overall questions, a survey was constructed using existing scales for model met the joint-criteria. All data analyses were conducted all variables, all except for knowledge. Vaccine-related knowl- using Stata IC 13. The SEM analyses were conducted using edge was measured by nine true/false statements derived from maximum likelihood measures; standardized coefficients are common misconceptions about vaccines. For example, one reported. 6 A. KRISHNA

Results (10) = 18.19, p = .0519; CFI = .996, RMSEA = .043, SRMR = .017), indicating a high degree of commonality between general, safety- First, RQs 1 and 2 were examined. These research questions related, and liberty-related concerns. pertained to the associations between negative attitudes, situa- Following these analyses, the hypotheses (H1 through H6) tional motivation, and communication behaviors. To start with, were tested. First, the measurement model was tested and the measurement model2 containing the three latent variables found to have good fit based on the Hu and Bentler (1999) along with their respective measures was evaluated and was criteria (χ2(21) = 33.67, p = .039; CFI = .979, RMSEA = .042, foundtohaveacceptablefit(χ2 (183) = 595.59, p < .001; SRMR = .046). Then, the structural model (Figure 2) with all CFI = .914, RMSEA = 0.073, SRMR = .060). A model which the hypotheses related to vaccine negativity was tested. The included paths between vaccine negativity and situational motiva- model was found to have good fit (χ2(34) = 54.37, p = .014; tion, vaccine negativity and communicative actions, and situa- CFI = .985, RMSEA = .042, SRMR = .035). Hypotheses 1 to 6 tional motivation and communicative actions was tested were then examined. Knowledge deficiency about vaccines (Figure 1). Attitude (vaccine negativity) was found to predict was found to predict vaccine negativity (H1; β = .511, situational motivation (β = .294, p < .001). An indirect relationship p < .001). H2 predicted a negative relationship between trust was also found between vaccine negativity and communicative in the government and vaccine negativity and was not sup- actions through situational motivation. However, no significant ported (β = −.06, n.s.). The relationship between trust in direct relationship was found between attitudes and behaviors healthcare professionals and vaccine negativity (H3), although (β = .038, n.s.). The model was therefore respecified without the not significant at p < .05 levels, trended toward significance non-significant path, and the resulting model was found to have (H4; β = −.082, p = .054). H4, which examined the relation- good model fit (χ2 (174) = 295.97, p < .001; CFI = .973, ship between trust in the pharmaceutical industry and vaccine RMSEA = .041, SRMR = .048). In the resulting model, vaccine negativity was not supported (H4; β = −.077, n.s.). In H5, a negativity was found to positively predict situational motivation negative relationship between CDC trust and vaccine negativ- (β = .294, p < .001), which in turn predicted individuals’ active ity was expected and was supported (β = −.237, p < .001). H6 communication behaviors (β = .846, p < .001). Therefore, it was predicted that vaccine negativity would be associated with found that although there was no direct relationship between intentions not to vaccinate, and a strong relationship was attitudes and active communication behaviors, the two are linked found (β = .847, p < .001). indirectly by situational motivation. So, an indirect effect of motivation was found between attitudes and active communication behaviors. Discussion Then, the answer to RQ3 was examined, which sought to The purpose of this study was to contribute to the conceptual understand the relationship between general vaccine negativity, and theoretical understanding of vaccine negativity by exam- and safety-related and liberty-related vaccine negativity. To do so, ining knowledge (deficiency), attitudes, motivations and com- a principal components analysis of the seven items for vaccine munication behaviors about vaccines. In addition to these negativity was first conducted to identify the underlying latent issue-specific, situational variables, this study also sought to structure of the data. The PCA of the seven measures of vaccine understand the impact of institutional trust (government, negativity yielded one component only with an eigenvalue of CDC, the pharmaceutical industry, and healthcare profes- 4.773, explaining 68% of the variance in the data. Factor loadings sionals). Results revealed negative attitudes about vaccines ranged from .31 to .41. These findings were supported with a influenced individuals’ active communication behaviors, but confirmatory factor analysis, which was found to have good fit (χ2 that this effect was mediated by situational motivation in problem solving. Furthermore, knowledge deficiency about vaccines contributed to vaccine negativity, which in turn impacted active communication behaviors (through motiva-

Downloaded by [Universita Cattolica del Sacro Cuore] at 04:20 18 September 2017 tion) and (vaccination) behavioral intention. The theoretical and practical implications of this research are explored next.

Advancing a Knowledge-Attitude-Motivation-Behavior Framework From a theoretical standpoint, this study contributes by bringing issue-specific knowledge deficiency and negative attitudes in conversation with motivation and communication behaviors about vaccines. In doing so, this study extends scholarship on attitudes beyond being in relation to general individual characteristics to issue-specific cognitive characteristics such as knowledge deficiency and situational motivation. These findings serve to com- plement current health communication scholarship on individuals’ vaccine intentions (e.g., Nan, 2012;Yang,2015), as well as health-related information behaviors (e.g., Shim, Kelly, & Figure 1. Results for RQ1 and RQ2. Hornik, 2006) to identify individual factors that influence HEALTH COMMUNICATION 7

Figure 2. Resultant Model to test H1 through H6.

communication and behavioral intentions. Furthermore, by CDC did significantly (negatively) predict vaccine attitudes. showing the strong positive relationships between knowledge These results indicate the possible effectiveness of government- deficiency, attitudes, and intentions not to vaccinate, and com- initiated efforts to reduce vaccine negativity about safety, munication behaviors, the results of this study also help situate and campaign strategies to address this issue may be a worthy vaccine negativity as a communication issue. Theoretically, stra- direction of research, particularly for engaged scholars. tegies aimed at reducing individuals’ knowledge deficiency Furthermore, the results of this study revealed that lack of (increasing acceptance of factual, scientifically validated data) trust in the CDC and (and marginally, healthcare profes- may help reduce vaccine negativity and increase the likelihood sionals) was associated with vaccine negativity, and through of vaccination intentions. Overall, the knowledge–attitude–moti- these attitudes, in vaccine rejection. In doing so, the results of vation–behavior framework advanced in this study builds on this study further underscore the importance of trust relations current research to understand the impact of health knowledge in healthcare (Calnan & Rowe, 2006) as well as the societal on communication (e.g., Shim et al., 2006) and behavioral inten- implications of the failure of institutions’ communication tions (e.g., Pinkleton, Austin, Cohen, Chen, & Fitzgerald, 2008) policies, and make the argument for institutions such as the andextendstheSTOPStoincludemorecognitive,situation- CDC to enhance their efforts to engage with these individuals. specific explanations for The results indicate that to engage with these individuals individuals’ motivations. Future research may validate these find- these institutions must first (re)build trust with them, and ings across other contexts and cultures. how they might do so may be a fruitful area of research for communication scholars.

An Integrated Model of Situational and Cross-Situational Downloaded by [Universita Cattolica del Sacro Cuore] at 04:20 18 September 2017 Variables Two Types of Vaccine Negative Attitudes Besides examining situational variables to understand Furthermore, this research helps provide more nuance to communication behaviors, this study also provided an inte- discussions about vaccine-related attitudes by articulating a grated model of situational and cross-situational factors, scale that captures different categories of vaccine negativity— and how they relate to motivation and behaviors. The cross- safety-related and liberty-related. In doing so, the results of situational factors tested for vaccine negativity provide clues this study help parse out the differences and commonalities in about how knowledge deficiency, and by extension, vaccine cognitions held by individuals holding these different reasons negativity, may be reduced. Building on prior research on the for negative attitudes toward vaccines. The results, therefore, linkages between trust in information sources and behavioral help deepen our theoretical understanding of vaccine negativ- responses (e.g., Meredith, Eisenman, Rhodes, Ryan, & Long, ity, and help provide alternate explanations for why indivi- 2007), this study examined trust in health-related institutions, duals may choose not to vaccinate their children other than that is, the CDC, the pharmaceutical industry, the federal safety-related concerns. From a practical standpoint, results of government, and healthcare professionals, as an antecedent to this study point to the need for health communicators seeking vaccine-negative attitudes. Results showed that although trust in to improve vaccination rates to pay attention not only to the pharmaceutical industry, the government and healthcare issues of vaccine safety, but also to parents’ concerns of losing professionals were unrelated to vaccine attitudes, trust in the autonomy over making decisions about their children’s health 8 A. KRISHNA

(Charo, 2007). Results indicate that communication efforts across different cultural contexts, particularly in identifying what that fail to address vaccine-negative individuals’ liberty- counts as knowledge deficiency across contexts. related concerns may not succeed. Notes Social Amplification Potential 1. The complete survey is available from the author upon request. This study also found that individuals who held knowledge 2. All co-variance matrices are available from the author upon deficiency about an issue also held negative attitudes about request. the issue and were motivated to do something about it. For instance, belief in Wakefield’s study was associated with negative attitudes about the safety of vaccines, intention not to Funding vaccinate (future) children, and communicative actions to This project was supported in part through funds from the Regenstrief others about vaccines as a social and health issue. These Center for Healthcare Engineering, Purdue University. findings point to the importance of health communication scholarship and practice coming together to devise strategies to address the spread of these negative attitudes and misin- References formed beliefs, and engage with the publics holding such Akumu, P. (2015, February 7). Measles vaccination rates in parts of erroneous beliefs. Future research may use this study as a Africa surpass those in North America. The Guardian. Retrieved starting point to identify what needs to be addressed (i.e., from http://www.theguardian.com/society/2015/feb/07/measles-vacci knowledge, differentiated attitudes, institutional trust) before nation-rates-africa-surpass-north-america theorizing about how to address them (i.e., message content, Benin, A. L., Wisler-Scher, D. J., Colson, E., Shapiro, E. D., & Holmboe, E. S. (2006). Qualitative analysis of mothers’ decision-making about form, etc.). vaccines for infants: The importance of trust. Pediatrics, 117, 1532– The information diffusion and social amplification potential 1541. doi:10.1542/peds.2005-1728 of individuals holding negative attitudes about vaccines too are Binder, A. R., Dalrymple, K. E., Brossard, D., & Scheufele, D. A. (2009). brought out by this study. The digitalized environment we find The soul of a polarized democracy: Testing theoretical linkages ourselves in makes it easy for individuals to spread their (inac- between talk and attitude extremity during the 2004 presidential election. Communication Research, 36, 315–340. doi:10.1177/ curate) information, motivations and attitudes to others in 0093650209333023 their social networks, particularly through the Internet. Bizer, G. Y., & Petty, R. E. (2005). How we conceptualize our attitudes Findings show that vaccine negativity, through motivation, is matters: The effects of valence framing on the resistance of political associated with communication behaviors, including informa- attitudes. Political Psychology, 26, 553–568. doi:10.1111/j.1467- tion transmission. This means that vaccine negative individuals 9221.2005.00431.x Brownlie, J., & Howson, A. (2006). “Between the demands of truth and have the potential and motivation to disseminate their knowl- government”: Health practitioners, trust and immunisation work. edge deficiency to others. This finding may also begin to Social Science & Medicine, 62, 433–443. doi:10.1016/j. explain the rejection of vaccines in pockets around the US, socscimed.2005.05.033 particularly in California. Future research should undertake Calnan, M., & Rowe, R. (2006). Researching trust relations in health care: social network analyses to identify patterns of information Conceptual and methodological challenges-an introduction. Journal of Health Organization and Management, 20, 349–358. doi:10.1108/ and behavior spread, identify key influencers and opinion 14777260610701759 leaders, as well as weak ties in these pockets of social networks Casler, K., Bickel, L., & Hackett, E. (2013). Separate but equal? A for more tailored strategies to address this issue. comparison of participants and data gathered via Amazon’s MTurk, social media, and face-to-face behavioral testing. Computers in Human Behavior, 29, 2156–2160. doi:10.1016/j.chb.2013.05.009 Limitations Charo, R. A. (2007). Politics, parents, and prophylaxis: Mandating HPV vaccination in the United States. New England Journal of Medicine,

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