ABSTRACT
Physician communication surrounding vaccination is important in driving patient compliance with schedules and recommendations, but patient psychological factors suggest that communication strategies may have differential effects on patients. This paper investigates how psychological reactance, defined as an individuals’ propensity to restore their autonomy when they perceive that others are trying to impose their will on them, impacts perceptions about physician communication and perceptions and prioritizations of vaccination. We propose and describe the results of a study that was conducted to assess the relationship between individual differences in reactance, perceived quality of pediatrician communication, perceptions of vaccination safety, and vaccination prioritization using a sample of parents. We recruited 300 parent participants via the online platform Prolific Academic in which they completed a computer-mediated survey. Results show that compared to those who are low in psychological reactance, those high in psychological reactance place less of a priority on vaccination, and that this relationship is driven by evaluations of physician communication quality and perceived vaccine safety. Our findings suggest that physicians should not adopt a one-size-fits-all approach when interacting with patients and should tailor messaging to patients based on psychological factors including reactance.
Introduction
Vaccines represent a key strategy for preventing the spread of many communicable diseases among children.1 The medical community supports childhood vaccinations and consequently has undertaken efforts to promote acceptance and compliance with recommended vaccination schedules via mass media and patient-provider communication. These efforts have been relatively successful as approximately 90% of parents have favorable attitudes toward vaccinating their children, while parents with strong anti-vaccination views are relatively rare.Citation2 Yet many parents who have generally positive attitudes toward vaccines and are inclined to vaccinate their children express some hesitancy, which can lead parents to postpone provider-recommended vaccinations or stop vaccinations altogether.Citation3 This sentiment seems to be growing; in fact, 87% of pediatricians reported that at least some parents refused vaccinating their children in 2013, up from 74.5% in 2006.Citation4 Concerns over vaccine safety, side effects, and efficacy do not simply reflect misinformation that can be remedied by educating parents about vaccine safety, because some hesitancy originates in persistent psychological traits that may operate at a nonconscious level.Citation5
In 2016, the American Academy of Pediatrics (AAP) released a policy statement that notified pediatricians that the organization sanctioned patient dismissal as a last resort for parents who refuse to comply with recommended vaccination schedules.Citation6 The statement, like most communication from the medical community, was intended to improve compliance. However, communication attempts that are perceived to be tools of persuasion (vs. information sharing), may result in a boomerang effect for some individuals. In this research, we examine the role of trait reactance, which is a characteristic where individuals have a general tendency to be resistant and, in some cases, react in opposition to messages perceived as threatening one’s freedom.Citation7–Citation9 High trait reactance individuals often counter-argue against persuasive attempts and may even discount the credibility of the person delivering a message perceived to be persuasive.Citation10–Citation12 Thus, beliefs that are contrary to the policy may be heightened for those high in reactance.
We sought to examine the role of the impact of psychological reactance on vaccine priority in a cross-sectional, online survey of patients from the United States. Based on this, we predict that individuals higher (vs. lower) in trait reactance will rate pediatrician communication quality more negatively because they perceive physician communication as an attempt to decrease choice and autonomy, rather than an attempt to initiate a participatory conversation. In turn, for high-reactance individuals, this experience is likely to drive beliefs that run counter to typical provider-patient communication, such as perceptions that vaccines are not safe, and result in decreases in vaccination priority. Furthermore, we investigate the relationship between trait reactance and vaccine priority as measured by satisfaction with physician communication quality and perceived vaccine safety. Specifically, we predict that those who are high in trait psychological reactance will evaluate pediatrician communication quality less favorably, will subsequently perceive vaccines as less safe, and reduce the priority placed on vaccinating their children.
Methods and materials
Participants completed the study for monetary compensation via the online survey recruitment platform Prolific Academic. This platform provides flexible pre-screening procedures that allowed us to recruit our targeted participant population of parents. Prolific requires that researchers pay participants a fair wage for their work ($10–15/hour in the U.S.), thus we compensated people $2.50 for the study, which lasted about 10 min. Because of this fair wage policy, recent research suggests that Prolific participants tend to answer survey questions more honestly than participants from other platforms such as Amazon Mechanical Turk, thus yielding higher data quality.Citation13 Parents in the sample had an average of 2.45 (SD = 1.03) children currently living at home. Further, because norms for physician-patient vaccine communication style and content are likely to differ across cultures, we limited our sample to parents who reported being of U.S. nationality and currently living in the United States.
We notified parents that we were interested not in what they think they should be doing, but rather in their actual behaviors and attitudes toward vaccinating their children. We measured perceived vaccine safety by asking participants to indicate their agreement with the statement (1 = strongly disagree, 2 = disagree moderately, 3 = disagree a little, 4 = neither agree nor disagree, 5 = agree a little, 6 = moderately agree, 7 = strongly agree), “I have some doubts about the safety of vaccines.” We then measured our key outcome variable, the priority placed on vaccinating, using the statement (1 = strongly disagree, 7 = strongly agree), “It is a priority for me to vaccinate my child(ren) on the schedule recommended by my pediatrician.” Notably, our research team generated these questions, but our measures of vaccine safety and priority are similar to other scales such as the Parent Attitudes about Childhood Vaccines (PACV) scale developed by Opel and colleagues.Citation14
We next measured participants’ ratings for the perceived quality of their pediatrician’s vaccine-related communication by soliciting their agreement with eight items adapted from the previously validated General Practice Assessment Survey (GPAS) measures related to communication and interpersonal careCitation15 on a 7-point Likert Scale (1 = strongly disagree, 2 = disagree moderately, 3 = disagree a little, 4 = neither agree nor disagree, 5 = agree a little, 6 = moderately agree, 7 = strongly agree). We chose these measures as we were interested in assessing parents perceived communication quality with their pediatrician and these measures most closely tapped into this construct. While the original GPAS contained only seven items measuring this construct, we included an eighth item to include the full range of possible experiences parents might have. For instance, while the original GPAS did not contain items indicating the physician asks for approval before offering immunizations, we included an item with this language to reflect that some pediatricians explicitly ask for approval before administering a vaccine whereas others do not. These items can be found in .
Table 1. Pediatrician’s Vaccine-related Communication adapted from the General Practice Assessment Survey (GPAS). Text in parenthesis indicates which domain of the GPAS the item was adapted from, though notably there is overlap between constructs related to communication (thoroughness answering questions and providing an explanation) and inter-personal care (how much time is spent with the patient and how much care, concern, and patience is shown)
Next, we measured psychological reactance, using a previously validated measure.Citation9 To illustrate, participants indicated their agreement (1 = strongly disagree, 2 = disagree moderately, 3 = disagree a little, 4 = neither agree nor disagree, 5 = agree a little, 6 = moderately agree, 7 = strongly agree) with items such as “I become angry when my freedom of choice is restricted,” “When someone forces me to do something, I feel like doing the opposite,” “I consider advice from others to be an intrusion,” and “regulations trigger a sense of resistance in me.” Higher scores on this measure indicate a higher predisposition toward reacting against authority, including persuasive appeals or other non-participatory conversations related to what one “should” do. This measure was included at the end of the survey so as to not create demand effects wherein participants who see themselves initially as high (or low) in reactance might respond in a particular fashion to our questions of vaccination priority, safety, and the communication quality of their pediatrician.
Finally, we measured demographic variables including age, sex, ethnicity, employment status, income, education level, and a number of children.
Results
Participants and demographics
Three hundred parents from the United States (173 women; Mage = 39.36 years, range = 20–71 years) completed the study for monetary compensation via the online survey recruitment platform Prolific Academic.
contains demographic information for all participants, including information about our measures of interest. We note that our sample was fairly educated (50% college graduates, with 76% of college graduates having a graduate-level degree), middle class, and predominantly white, as is consistent with current United States demographics (though other groups such as Native Americans were represented at higher rates than the United States demographic data would indicate).Citation16 The average income of participants was lower than that of the average American with 63% of participants making below the national average of $72,000.Citation16
Table 2. Demographic information and information about measures of interest. (NOTE: not all figures add up to 100% due to rounding)
Reliability of GPAS measures
The items from the GPAS were highly related (α = .80), thus we collapsed them into an index measure of communication quality by calculating the average across all of the individual items. Higher scores on this measure indicate more inclusive and participatory styles of vaccine-related decision-making (the pediatrician consults with the family, offers information, and is clear and easy to follow); that is, a higher score is associated with higher perceived vaccine-related communication quality. Lower scores indicate that the physician uses a more presumptive and heavy-handed approach by assuming their views on vaccination should be taken without much question or consultation.
Reliability of reactance measures
The items for trait reactance were highly related (α = .83), thus we used an average of all 10 items to compute a composite index measuring trait reactance that we used in our analyses.
Sequential mediation
We tested our main hypotheses with a sequential mediation model in SPSS Version 24 (using bias-corrected bootstrapped confidence intervals with 10,000 samples; see );Citation17 bootstrapping is commonly employed in mediation models as it is the best way to test for statistical significance of an indirect effect.Citation18 This model, depicted in , follows Model 6 in Hayes’ discussion of mediation models.Citation19 We develop this model as it allows us to test a potential path for our proposed sequence of effects. Specifically, we test the: (1) relationship between reactance (our independent variable) subsequent perceived vaccine-related communication quality (our proposed first mediator), (2) subsequent relationship between vaccine-related communication quality and perceived vaccination safety (our proposed second mediator), and vaccination priority (our dependent variable). We first present the direct effects of reactance on vaccination priority, perceived vaccine-related communication quality, and perceived vaccination safety.
Figure 1. A series mediation model between psychological reactance and vaccine priority, mediated by the perceived quality of the physician communication and the perceived safety of vaccines
The estimation output reveals a statistically significant effect of reactance on vaccination priority (β = −.223, SE = .103, t = −2.173, p < .03), indicating that those parents who possess stronger trait reactance reported lower vaccination priority. Second, reactance predicted perceived communication quality (β = −.164, SE = .06, t = −2.72, p < .01), indicating that those who score higher on our reactance measure (and thus prefer to maintain autonomy and rebel against presumptive authority figures) report lower feelings of perceived quality of vaccine-related pediatrician communication. There was no significant indirect effect from reactance to vaccination priority via vaccine safety concern alone (β = .001, SE = .055, 95% CI: [−.112, .107]).
We next examine the relationship between our proposed mediators and our variable of interest, vaccination priority. Our findings indicate that lower quality of pediatrician communication was itself associated with greater concerns about vaccine safety (β = −.968, SE = .104, t= −9.32, p < .001), which in turn was associated with lower vaccination priority (β = −.485, SE = .043, t= −11.40, p < .001).
Finally, we test our whole model whereby reactance predicts the perceived quality of pediatrician communication, which impacts perceived vaccination safety and, subsequently, vaccination priority. This indirect effect (whereby reactance impacts vaccination priority through both perceived quality of physician communication and perceived vaccine safety; see ) was statistically significant as the confidence interval does not include zero (β = −.0767, SE = .0338, 95% CI [−.154, −.018]).Footnotea
It is important to note that once we account for our proposed mediators, the direct effect from reactance to vaccination priority (i.e., the relationship between reactance and vaccination priority, excluding the impact of quality of pediatrician communication and vaccination safety) was no longer statistically significant (β = −.114, SE = .08, t= −1.42, p = .16, 95% CI: [−.271, .044]), demonstrating that the observed relationship between reactance and vaccination priority is completely dependent on the sequential mediation we hypothesized and tested.
Importantly, education level might play a role in communication and vaccine acceptance. When we include education level as a covariate in our sequential mediation model, reactance still predicts perceived communication quality and, in turn, perceived vaccine safety and vaccination priority (indirect effect: β = −.0759, SE = .03, 95% CI [−.15, −.01]).
Discussion
Health-care decisions are complex, and vaccination decisions are no exception. Although vaccine hesitancy is often positioned in the popular press as resulting from misinformation regarding the safety risks of vaccines, our findings highlight that psychological traits – like reactance – can also play a role. In this case, psychological reactance impacts perceived the quality of physician communication and subsequent perceptions of vaccination safety and priority.
Furthermore, our findings suggest that reactance impacts vaccination safety concerns and ultimately vaccination priority only to the extent that patients who are high in trait reactance perceive an authority figure (their pediatrician) is attempting to persuade them or restrict their freedom to make their own choice. Put another way, people who are high in trait reactance may prefer pediatricians use a more participatory approach, wherein doctors provide data on why vaccines are important, allows parents to voice their concerns, provide data to help alleviate those specific concerns, and finally seek approval before giving vaccinations. This type of approach allows for highly reactant parents to maintain feelings of autonomy and might alleviate concerns over being forcefully persuaded to adopt a plan for preventative care with which they are uncomfortable, or hesitant. For parents high in reactance, using a more presumptive approach may be unappealing and likely off-putting, and may, in turn, lead to decreased perceived vaccine safety and vaccination priority. Our findings also provide evidence that reactance impacts perceived communication quality, perceived vaccine safety, and vaccination priority above and beyond education, which is often related to health literacy. Similarly, physicians managing their own practices and organizations like the AAP are challenged with creating position statements that uniformly addresses vaccine policies. As an example, current guidance for a strong vaccine recommendation includes using a presumptive approach. Presumptive messages have been associated with a lower likelihood of vaccine safety concerns and increased likelihood of vaccination.Citation20,Citation21 Available evidence suggests that tailored communication strategies as a part of a strong recommendation can more successfully address vaccine hesitancy. Thus, more presumptive approaches or related techniques for highly reactant or hesitant parents might address the needs of the AAP, physicians, and policy-makers to take a strong stance on vaccination, while allowing for tailored communication with parents who need it most due to the potential for vaccine hesitancy or avoidance.
Our research suggests that vaccination-related policy statements might impact individuals differently depending on psychological reactance. Explicitly, those high in reactance may be most resistant to persuasive messages – even when they are largely in agreement with these messages (e.g., pro-vaccine parents) – if they view these messages as a threat to their autonomy. For this reason, it would be beneficial for physicians to attempt to identify highly reactant parents so that the physician can alter his/her communication style. However, this approach likely requires training physicians on how to identify reactant parents – perhaps via data such as tracking vaccination delays or through observation of interactions for other conditions that require compliance with a physician recommendation – and to develop effective communication strategies and interventions for those who delay or refuse vaccination based on reactance.Citation22–Citation25
Refusal of preventative treatments may be a way to identify highly reactant parents. For example, parents may refuse erythromycin eye ointment (for possible gonorrhea or chlamydia) or Vitamin K injections with Hepatitis B vaccines that are recommended for an infant after birth because they perceive the hospital medical staff as positioning the treatment as compulsory. However, refusal, in this case, could also be the result of the parent’s perceived impossibility of the diagnosis and therefore deeming the recommended treatment irrelevant or excessive (for example, a pro-vaccine monogamous couple may refuse erythromycin for their child because they know they do not have gonorrhea/chlamydia). Similarly, a parent may refuse vaccinations for their child due to their religion (for example, faith healing denominationsCitation26) and thus may be perceived as highly-reactant when the real reason underlying the resistance is because their religious beliefs conflict with medical advice.
With these examples in mind, one of the simplest strategies to identify this trait would be for physicians to survey parents when they join the practice on a variety of issues including measures to gauge reactance. A short, adapted reactance scaleCitation9 could be incorporated into a general questionnaire about how the parent(s) prefers to receive medical information, get results, or other outcomes related to care seeking and compliance. Patient files could them be flagged as high trait reactance, and communications could be altered in response to this flag. That being said, it could prove difficult in practice to obtain this information from parents, as they might not see this particular questionnaire as relevant to their children’s health.
Limitations
While the results of this research are important, several limitations exist. First, this is a single study utilizing an online population of parents who, by virtue of completing an anonymous study online, might exhibit patterns of behavior that are different than those physicians might observe in-office. Second, we measure (vs. observe) our variables of interest – including perceived pediatrician communication quality, perceived vaccination safety, and vaccination priority. While intentions and behaviors do tend to overlap, actual vaccination behaviors might differ in-office. Third, due to the age range of the respondents surveyed our results could be impacted by the fact that some participants may have children that are grown, and those responses may be different than respondents that currently have children at home and are currently dealing with vaccination-related decisions. As we note in our footnote, our pattern of effects still holds when we perform analyses isolating younger participants, who are more likely to have younger children, in our sample. Including all participants, even those whose children are grown and for whom situations that evoke reactance might be attenuated, provides a more conservative test of our theory as those whose children are fully grown and thus are not receiving childhood immunizations likely will not experience high levels of reactance as vaccination messaging and policy does not impact them. Finally, in this research, we do not empirically test which communication practices would work best for parents that are highly reactive and note this as an important direction for future work. While the limitations of this work do not diminish the importance of the findings, they are important to recognize.
Disclosure of potential conflicts of interest
None of the authors had a financial interest or benefit from the present work.
Ethical considerations
The present research was approved by the first author’s university IRB and the research is in accordance with the Helsinki Declaration.
Additional information
Funding
Notes
1. Note here that our sample includes people aged 20–71. Thus, it is possible that some of our older respondents do not currently experience concerns over childhood immunizations that might provoke reactance. To alleviate this concern, we conducted a second test, restricting our analysis to a younger subset of parents (age range: 20–50) for whom these concerns are likely to be more salient. Our pattern of results still holds in this analysis as the sequential mediation model wherein reactance predicts perceived quality of physician communication, which, in turn, impacts perceived vaccination and priority (indirect effect: β = −.082, SE = .04, 95% CI: [−.169, −0.004]).
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