A Behavior-Analytic Approach to Antivaccination Practices

"In recent years, there has been an increase in outbreaks of diseases that are preventable by vaccination. As vaccination involves behavior, behavior analysts are uniquely positioned to contribute solutions to this socially significant problem."

This article offers a behaviour-analytic approach to understanding the behaviour of people who do or do not have their children vaccinated and provides potential strategies to increase vaccination uptake that are modeled on empirically validated interventions.

It begins with a brief history of vaccines and antivaccination ideology. The modern "antivaxx" movement began with Andrew Wakefield's 1998 Lancet article fabricating a link between vaccines and autism. It was subsequently retracted - but not before it garnered international media attention.

Following a medical regime, such as receiving scheduled vaccinations, is described here as the behavioural process of "adherence". Actively choosing not to vaccinate despite the ability to do so is an example of "intentional nonadherence" to the medical regime, whereas "unintentional nonadherence" could involve forgetfulness or a lack of access to care. Numerous motivating operations, setting events, and contextual factors influence variability in vaccination practices. For this reason, antivaccination, vaccine hesitancy, and vaccine refusal cannot be explained based on a single antecedent or motivating operation.

The article explores why typical avoidance research is inadequate for understanding vaccinating behaviour among parents. Contingency-shaped avoidance behaviour is also usually not applicable, because the vaccination behaviour of most parents is not a result of direct experience with infectious disease; instead, it tends to be driven by other factors. Thus, it makes more sense, in the researchers' estimation, to conceptualise most parents' vaccinating behaviour as "rule governed".

For many people, religious practice and belief may be a source of rules. In general, religion capitalises on motivating operations to maintain adherence to its rules. If followers of a religion are commanded not to vaccinate, or they experience social pressure from other community members to not vaccinate, they may feel that the potential consequences for vaccinating (e.g., shame) are too severe to risk experiencing. Despite religions controlling the behaviour of some members, claiming religious exemption from vaccination is still an example of intentional nonadherence to a medical regime.

Rules such as "If you vaccinate your child, they will develop autism" describe enough of a contingency between behaviour and consequence that some parents choose not to vaccinate. When antivaccination behaviours are rule governed, parents have no reason to change their behaviour unless they have come into contact with a stronger competing contingency. Strategies to evoke vaccination behaviour that include rules might be less effective if motivating operations from social communities (e.g., religious, online) are strong.

In addition to use of rule governance as a method to understand antivaccination behaviour, relational frame theory could be applied. In short, parents may be exposed to events indicating that vaccines are undesirable for various reasons (e.g., because vaccines limit personal freedom), and these disparate events are presented via television, radio, the internet, and interactions with commentators, newscasters, celebrities, friends, and family. These disparate events participate in a common relational frame that decreases the probability of a parent vaccinating their child, even if he or she has never experienced a limit to personal freedom.

Within certain cultural contexts, personal liberties may be more highly valued than the needs of the larger group. Thus, complying with out-group rules associated with vaccination (as delivered by a doctor or community official) may be aversive for members of the antivaccination community. The antivaccination movement is an example of countercontrol (i.e., consisting of efforts to escape or avoid aversive control by individuals under aversive control). Members of this movement resist the authority of individuals who insist on vaccination.

Active antivaxxer demonstrations also create social influence over vaccination decisions, especially through peers and media. Such protests typically incorporate political and personal belief systems, which may function as motivating operations that influence vaccination decisions. When someone chooses not to vaccinate, they often receive strong praise from fellow antivaccination peers online, which serves as a valuable reinforcement.

"From the perspective of the broader culture, engaging in practices that reintroduce preventable disease, particularly in children or individuals who are immunocompromised, is undesirable. Thus, behavior analysts should approach this problem with a combination of compassion and evidence-based interventions." Potential interventions discussed here include:

• Modifying motivating operations - e.g., by asking more leaders within religions to release documents such as those explains the importance of vaccines and clarify that vaccination is permissible within Islam.
• Programming social reinforcement or punishment - e.g., by using rule governance to promote cultural change. ("[B]road campaigns to increase critical evaluation of false claims, coupled with the delivery of good information about the current understanding of medical science, may help to combat antivaccination behavior.")
• Using prompts - e.g., in the form of postcards, signed letters, and text messages containing information about susceptibility to a disease, severity of the disease, and risks and benefits of vaccination.
• Modeling - e.g., conveying the outcomes of the diseases via popular media.
• Reinforcing desired behaviours (contingency management) - e.g., giving people who vaccinate a sticker that says "I vaccinated", which may attract positive social attention (e.g., on social media) and may act as a visual prompt for other parents.
• Building relationships of trust between the families who are not vaccinating and the medical professionals who serve them - e.g., by focusing on modifications to the environment and by building additional opportunities for learning.

In conclusion: "The refusal to follow vaccination programs is a behavioral problem that is subject to a variety of motivating operations and social reinforcement processes. Modifying this behavior will require change on governmental, social, and provider levels."