PARENTS’ RESPONSE TO
CELEBRITY VS MEDICAL
EXPERT HEALTH MESSAGES IN
PROMOTING MMR
VACCINATION
An Experimental Study to Find the Effect of The Type of Spokesperson and
Message Framing on Parents’ Attitudes and Intention
Name : Fathya A. Utami
Student Number : 12471585
Word count : 6953
Master’s Thesis
Graduate School of Communication
Master’s Program of Communication Science
Supervisor : Birthe A. Lehmann
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Abstract
Measles remains one of the leading causes of preventable death globally among children.
However, the uptake of the Measles-Mumps-Rubella (MMR) vaccine is still not meeting Health authorities’ (i.e., WHO) expectations, especially in developing countries. Little is known about which messages are effective in overcoming parental reluctance to vaccinate
their child. This study examined the effects of the type of spokesperson (celebrity vs. medical
expert) and the message framing (loss- vs. gain-framed) on parents’ attitudes and intentions to obtain the measles, mumps, and rubella (MMR) vaccine for one’s child in Indonesia. An online experiment involving 310 parents revealed a significant effect of a celebrity as a spokesperson on parents’ attitudes compared to medical experts. Moreover, loss-framed messages also showed a stronger effect on parents’ attitude and intention compared to gain-framed messages. However, this study did not find an interaction effect of type of
spokesperson and the type of message framing. In addition to these results, the study found a mediation effect of source credibility on the relationship of type of spokesperson and parents’ attitude. Theoretical and practical implications are discussed.
Keywords: Measles; MMR Vaccination; Vaccine Hesitancy; Childhood Vaccination; Message Framing; Celebrity; Medical Expert; Parents
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1. Introduction
Measles remains one of the leading causes of preventable deaths globally among children
(World Health Organization [WHO], 2012). Moreover, in March 2019, the WHO announced
that cases of measles around the world were surging to alarmingly high levels. Childhood
vaccination is the most effective and safest preventive health measure for
vaccine-preventable diseases (VPDs), including measles (Healy & Pickering, 2011). However, the
practice of receiving the Measles-Mumps-Rubella (MMR) vaccine in childhood is still not
meeting the expectation especially in developing countries, which needs to reach or exceed
95% coverage at the district and national levels to prevent the outbreak (WHO, 2012). The
success of MMR vaccination has been challenged by individuals and groups of parents who
refuse to vaccinate their children for various reasons, and are known as vaccine-hesitant
parents (VHPs) (Larson, Jarrett, Eckersberger, Smith, & Paterson, 2014). The reasons for
parents to be hesitant range from parents' education, with refusal being more common among college-educated parents than those with lower levels of education (Gowda & Dempsey, 2013), low socioeconomic status (Bocquire, Ward, Raude, Peretti-Watel, & Verger, 2017), restriction from religion (Ruijs, Hautvast, IJzendoorn, Ansem, Velden, & Hulscher, 2012),
how parents process the information (Betsch, Renkewitz, Betsch, & Ulshöfer, 2010), fear that
the vaccine could cause autism (Hendrix, 2014), and mistrust in the information and
providers of childhood vaccinations (Lehmann et al., 2017).
Indonesia has some of the highest levels of measles cases in the world, with a
vaccination coverage rate of only 89,8% in 2017, which leaves the country prone to develop
an outbreak (Kementerian Kesehatan Republik Indonesia [Kemenkes RI], 2018). As a
Muslim majority country, religion seems to be the most prominent reason for parents not
vaccinating their children, as the MMR vaccine contains pork gelatine, which is considered
3 leaders in Indonesia have agreed that the MR (or MMR) vaccine is permitted for Muslim
people due to the unavailability of other options (Majelis Ulama Indonesia [MUI], 2018). The
agreement was obtained in the form of a letter explaining the information that the vaccine was haram but now allowed until a halal (means acceptable in Islamic law) replacement was found. Unfortunately, the media, primarily via the internet and social media, still highlight just the information about the haram statement, which is why the agreement is not well received by the religious society (Grabenstein, 2013). Other than religious reasons, some parents are still confused and anxious about the risks associated with the vaccine, such as the
misconception that vaccination can cause autism in children (Bedford & Elliman, 2000).
Much research concerning childhood vaccination acceptance has evaluated strategies
for increasing vaccine acceptance, but relatively little is known about which messages are
effective in overcoming parental reluctance to vaccinate their children (Gowda, Schaffer,
Kopec, Markel, & Dempsey, 2012; Nyhan Reifler, Richey, & Freed, 2014). Message-framing
is known as one of the most common strategies to formulate campaign content to persuade
people in the health behavior area. The strategy works by manipulating the valence of
information as either a gain-frame (e.g., 95% survival rate) or a loss-frame (e.g., 5% death
rate) (Ferguson & Gallagher, 2007). However, the evidence of the effectiveness of the
message-framing in the context of childhood vaccination is still limited. On the other hand,
the success of a campaign most likely not only relies on the message content but also on the
person who sends it, later referred to as the spokesperson. A study by Emmers-Sommer and Terán (2019) showed that the type of spokesperson has an effect on people’s intention of undergoing cancer screening; for example, that celebrities have a more significant persuasive
effect than medical experts. By considering the findings of previous research, the current
study aimed to investigate the effectiveness of a campaign that combines message-framing
4 whether the perceived credibility of the source mediates the relationship of the message on
parents' attitudes and intention towards MMR vaccination for their children. The research
questions of this study were:
1. To what extent does a message informing about childhood vaccinations by a celebrity
impact parents' perceived attitudes and intention towards childhood vaccinations,
compared to a message by a medical expert?
2. To what extent does a message containing information about vaccination using gain-frame impact parents’ perceived attitudes and intention towards childhood vaccinations, compared to a message using a loss-frame?
2. Theoretical Background
2.1 The Type of Spokesperson
Displaying faces in advertisements attracts attention better than other stimuli (Hutton & Nolte, 2011) as neural systems in the human brain are exceptionally trained in processing them later. Therefore, the advertising spokesperson's selection should be considered one of the leading indicators of advertising success (Lin, 2011). The spokesperson would create a significant impact on viewers' attention, which develops attitudes and influences intentions to do the recommended behavior (Chang & Chang, 2014). To draw attention to the message, advertisers often use well-known celebrities, such as actors, athletes, and other famous public figures admired by their target audience (Belch & Belch, 2017).
In the field of health communication, Pileliene and Grigaliunaite (2017) found that their study participants had a statistically significant more positive attitude towards the spokesperson as well as the attitude towards the advertisement when the spokesperson in the advertisement is a celebrity rather than non-celebrity. In line with these findings, Emmers-Sommer and Terán (2019) found that women elaborated on the message from the celebrity
5 more than that of the medical expert. A celebrity spokesperson has a more powerful
emotional value to participants in comparison with a non-celebrity. Other than emotional value, celebrities are also often perceived as having authority through their name and face recognition.
Elaboration Likelihood Model (ELM)
The ELM is a “dual process” approach to social information-processing phenomena that is focused specifically on persuasion (Petty & Wegener, 1999). The basic premise of the ELM is that attitude change attributable to message strength depends on the likelihood that an issue or argument will be further considered (Petty & Cacioppo, 1986). Based on the ELM, there are two kinds of routes that involve how individuals process the information to persuade them into believing or doing something, known as the central route (conscious processing) and peripheral route (automatic processing).
Central Route. The central route to persuasion involves careful consideration of the
issue-relevant information generating positive and/or negative thoughts toward the advocated position (Petty, Barden, & Wheeler, 2009). In order to process the information centrally, the recipient of the message should be both motivated and able to think carefully. A person’s motivation can be influenced by the perceived relevance of the message and the need for cognition (Petty & Cacioppo, 1986). Moreover, there are two factors that influence one’s ability to process the message through a central route; less distraction and sufficient
knowledge to understand the message (Baumeister & Bushman, 2011). Persuasion produced by central routes instills a more durable and powerful change in attitudes. In the case of the type of spokesperson, a medical expert/ doctor has a counter benefit to this route. Someone may have high motivation and ability to elaborate the message; however, a subject
6 the presentation of some arguments (e.g., an argument to promote vaccination is just a part of their job as health care provider) (Petty & Cacioppo, 1984).
Peripheral Route. The peripheral route involves emotion or heuristics (using a
mental shortcut to make a decision) (Petty, Wegener & Fabrigar, 1997). The attitude that changes via the peripheral route does not occur because of individual internal motivation or ability; instead, the person associates the attitude issue or object with positive or negative cues or makes a simple inference about the merits of the advocated position (Petty & Cacioppo, 1984). The simple cues, such as the attractiveness or credibility of the source, provide means of maximizing the likelihood that the communicator’s position is correct while minimizing the cognitive efforts to achieve this position (Dong, 2015). In the case of health communication, the medical expert as a spokesperson can give the impression that medical experts are generally correct about health information. That cue can be used to make a
message proceed heuristically. However, as mentioned before, if the motivation and ability of someone to elaborate the message are high, then the source of expertise can make people over-process the message. Increase of this processing generalizes the thoughts that every expert has the same interest that leads to less positive evaluation (i.e., in making people vaccinate their child). (Petty, Wegener & Fabrigar, 1997).
On the other hand, attractiveness can be another heuristic cue that can enhance someone’s attitude towards certain messages. Attractiveness can give a positive association for someone that impacts their attitudes towards the messages. For instance, a person might respond positively (get vaccinated, etc.) to a celebrity message sharing a health testimony because they are attracted to the celebrity (Emmers-Sommer & Terán, 2019). These attitudes are formed when celebrity attractiveness is related to the central merits of the product or campaign (and thus could itself act as an argument), the same variation in celebrity
7 Fabrigar, 1997). To that end, attitudes that form from message elaboration are most likely to result in behavioral intentions that potentially guide future behaviors (Petty, Barden, & Wheeler, 2009). Based on that argument, it is hypothesized that:
H1a: Messages delivered by the celebrity will give a stronger effect on parents’ attitudes than
a message delivered by an expert.
H1b: Messages delivered by the celebrity will give a stronger effect on parents’ intentions
towards childhood vaccination than a message delivered by an expert.
2.2 Message Framing in Vaccination
Message framing is how the information about a health behavior can emphasize the benefits of taking action (i.e., a gain-framed appeal) or the costs of failing to take action (i.e., a loss-framed appeal) (Rothman, Bartels, Wlaschin, & Salovey, 2006). For example, a gain-loss-framed message aimed at increasing flossing teeth might be “Flossing your teeth daily removes particles of food in the mouth, avoiding bacteria, which promotes great breath.”. On the other hand, a loss-framed message might be “If you do not floss your teeth daily, particles of food remain in the mouth, collecting bacteria, which causes bad breath” (Mann, Sherman, & Updegraff, 2004). Those simple kinds of variations in how health information can be framed can influence people to translate their perception of a health concern into action differently (Rothman & Salovey, 1997). Moreover, the influence of gain- and loss-framed messages on health behavior can be derived from the conceptual framework outlined in prospect theory (Tversky & Kahneman, 1981).
Prospect theory assumes that people respond predictably to potential gains and losses. Responses are divided into two categories, risk-seeking and risk-averse. Risk seeking is considered when someone is willing to take risks when there is a potential loss afforded by their decision. Meanwhile, risk-averse is considered when someone is acting to avoid risk
8 when considering the potential gains afforded by a decision. In connection with message-framing, people are seeking when confronted with information about losses but risk-averse when confronted with information about gains (Tversky & Kahneman, 1981).
In the field of health communication, the messages typically focus on advocating people to either engage or not engage in a given behavior. The motivation to engage or not engage in a health-related behavior is depending on the extent to which people perceive the behavior will afford an unpleasant outcome (Rothman et.al, 2006). Abhyankar and colleagues (2008) found that the loss-framed message better encouraged women to obtain the MMR vaccine for their children. Gain-framed also has a very weak persuasive effect on vaccination intentions (Gallagher & Updegraff, 2012). Vaccination is a prevention behavior from the medical point of view, but, from the person, especially parents who are still hesitant to get their child vaccinated, this behavior comes with several things that are considered as a risk. The risk ranging from procedural risks, such as pain from the injection and a sore arm, to serious outcome risks, such as allergic reactions or religion value disagreement, to health risk possibility that might impact their children after being vaccinated. Considering the higher perceived riskiness of vaccination should generally be associated with greater persuasive advantage of loss-framed messages relative to gain-framed messages (Rothman & Salovey, 1997). As a result, the following hypothesis is constructed:
H2a: A loss-framed message will have a more positive effect on parents’ attitudes towards
childhood vaccination than the gain-framed message.
H2b: A loss-framed message will have a more positive effect on parents’ intention towards
9 2.3 Relation between The Type of Spokesperson and The Type of Message-Framing
According to the ELM framework, many variables can influence persuasion, especially when it comes to changing someone’s attitude and intention. Two of the most influential variables are message factors and source factors (Petty, Wegener, Fabrigar, 1997). As explained before, a loss-framed message is expected to have a more positive effect on a parent's attitudes and intention towards childhood vaccination than a gain-framed message. From the ELM point of view, the loss-framed leads to people process the message centrally. Moreover, Nan (2013) stated that loss-frames can trigger negative responses, such as reactance in the person who sees the message. To reduce the reactance that might happen, combining persuasive factors is likely to improve an individual's attitude or behavioral intention related to a particular issue (Diedring, 2008; Kim & Kim, 2013). We have not seen studies investigating the interaction between message framing and type of spokesperson especially in vaccination promotion, so this perspective is worth investigating. Based on Petty and colleagues’ article (1997), when the elaboration likelihood is high, it is better to combine the message with a spokesperson giving simple positive cues. Moreover, a spokesperson that is attractive and likable can increase someone’s intrinsic motivation to process the message compared to a spokesperson who is perceived as someone that is an expert in the field. Accordingly, the following hypothesis was constructed: A message delivered by a celebrity will have a more positive effect on parents’ attitudes and intention towards childhood vaccination, than a message delivered by a medical expert, and this effect will be stronger if the message is using loss-frames than gain-frames (H3).
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Figure 1. Conceptual Model of The Main Hypotheses
3. Method
3.1 Participants and Procedures
Since Indonesia has the highest rate of measles cases and the MMR vaccination is needed for children aged 6 month-5 years old (WHO, 2013), Indonesian parents who have children in that age range were the research participants. They were recruited using non- probability sampling and took part in the study voluntarily; ethical approval was approved by the supervisor and obtained. To reach the participants who matched the study characteristics, the researchers collaborated with local communities to distribute the survey in the form of a link via a WhatsApp group, Instagram, and other online platforms. Potential participants were informed about the study participants' characteristics, the approximate overall duration of the study (10 min), and that data collection was to be done online. Once the participants clicked the link, they were directed to a page that contained the information about the study. The information contained a made-up story that told the participants this study was about evaluating public service advertisements in the field of childhood vaccination. After the participants were informed with the aim of the study, they saw the informed consent. If they agreed to participate, they were asked baseline questions about age, religion, education, and age of their youngest children. After completing the demographic-related questions, they were assigned randomly to one of four conditions that will explain later in the part 3.2 Design and Stimuli. Then, parents answered questions regarding attitude, intention, and perceived
11 source credibility. The last question of the survey was a manipulation check, which was used to ensure all the experiment materials worked as intended. Lastly, parents were thanked for participating in the study and debriefing.
3.2 Design and Stimuli
The experiment was chosen as the study method to find the causal relationship between independent variables (i.e., the type of spokesperson and the type of message framing) and dependent variables (i.e., Parents’ attitude and intention towards childhood vaccination). Bryman (2012) explained that an experimental method can give clearer explanations by having control and strong internal validity. Therefore, this was the most suitable method to find the causal relationship between independent and dependent variables. Moreover, the randomization aspect of this method eliminates potential external threats and heightens the confidence in the causal finding.
A 2 x 2 between-subjects design was used in this study. There were 2 main factors studied: 1) The Type of Message Sender (with 2 levels, namely: celebrity and medical expert) and 2) The Type of Message Framing (with 2 levels, namely: gain-frame and loss-frame). Therefore, four videos were used in this study as manipulations that were made based on this study need in Bahasa, Indonesia. Participants were randomly allocated to one of those
conditions: (1) a celebrity with a gain-framed video, (2) a celebrity with a loss-framed video, (3) a doctor with a gain-framed video, and (4) a doctor with a loss-framed video. Each video had a duration of 60 seconds and consisted of two sections: the first part was background information about mumps, measles, rubella, and the MMR vaccine; then, the second part was the message with the different framing (see Table 1). The purpose of the first part (i.e., general background about MMR) was to set the hypothetical scenario into context and to
12 ensure that all participants were working with the same basic information about the diseases and the vaccine (Abhyankar, O’Connor, & Lowton, 2008).
Type of Sender
Celebrity Expert
Type of Frame
Gain Condition 1: Parents will see a video with general information about vaccination and a celebrity giving a message about the benefits of vaccination and the good things that can happen if their children are vaccinated
Condition 3: Parents will see a video with general information about vaccination and an expert telling a message about the benefits of vaccination and good things that can happen if their children are vaccinated
Loss Condition 2: Parents will see a video with general information about vaccination and a celebrity telling a message about bad things that can happen if their children are not being vaccinated
Condition 4: Parents will see a video with general information about vaccination and an expert telling a message about bad things that can happen if their children are not vaccinated
Table 1. Experiment design and conditions
The scripts that were used for the videos were adapted from Abhyankar and colleagues’ study (2008). There were two kinds of scripts: first, the gain-framed message emphasized the gains or benefits of performing the behavior, and second, the loss-framed message emphasized the losses or disadvantages of not performing the behavior (see Appendix A for the scripts). The message focused on the advantage or disadvantage to the child and parents itself since that information is more influential for parents than the emphasis on societal benefit (Hendrix et al., 2014).
As mentioned before, the spokespersons of this study were a celebrity and a doctor. The celebrity was Alyssa Soebandono, a 29 year old Indonesian female artist with 17.4 million followers on Instagram. She has been in movies, TV series, and commercials since 2000 and also is a mother. The doctor was Bulan Sambowo, a 29 year old Indonesian female general practitioner. Both spokespersons were female and wearing a hijab (scarf to cover hair for Muslim women). Since religion is one of the main reasons of vaccine-hesitant parents,
13 Hijab as a religious attribute might help reduce the reactance of the parents towards the video (Stolz & Usunier, 2014).
3.3 Instruments
After the participants saw the video, they were asked questions about the dependent
variables. All scales were developed based on the Theory of Planned Behavior Questionnaire of Icek Ajzen (2019). See Appendix B for the complete questionnaire.
Attitudes Towards Vaccination. This is how positive or negative the parents judge childhood vaccination. There were four items offered and the answer was given on a 7-point Likert-type scale running from: bad-good, very hesitant-not hesitant at all, extremely
unpleasant- extremely pleasant, extremely difficult -extremely easy. The questions’ example was “In my opinion, giving MMR vaccination twice for my child is…”. We did factor analysis
for the 4 items and the result was item 2 has the least correlation with other items, with .24. Therefore this item was deleted. However, the Kaiser-Meyer-Olkin measure of sampling adequacy was .75, and Bartlett’s test of sphericity was significant (χ2 (6) = 864.81, p < .05).
The cumulative percentage of variance accounted for was 63.25%. On the reliability aspect, Cronbach’s alpha showed the items to reach acceptable reliability (𝛼=.78). Most items appeared to be worthy of retention, resulting in a decrease in the alpha if deleted. The one exception to this was item 2, which would increase the alpha to α = 0 .85. As such, removal of this item was done. For further analysis, this scale also converted into one new variable based on computation of three final items (M= 5.57, SD= 0.96).
Intention to Vaccination. This is about how likely the parents are to have their
children vaccinated. There were four items measured with 7-point Likert-type scales, ranging from 1 (extremely unlikely) to 7 (extremely likely). An example of the questions was “I intend to give MMR vaccination to my child”. Factor analysis was conducted. The 4 items correlated
14 at least .74 with at least one other item, with a cumulative percentage of variance of 87.11%. The Kaiser-Meyer-Olkin measure of sampling adequacy was .85, above the commonly recommended value of .6, and Bartlett’s test of sphericity was significant (χ2 (6) = 1328.47, p < .05). Based on the computation of Cronbach’s alpha, the scale had a very high internal consistency (𝛼=.95). The four items were also computed into a new variable based on the mean (M= 6.06, SD= 1.02).
4. Results
4.1 Pilot Study
A pilot study was conducted to check the performance of the experiment materials. The participants were 40 Indonesian parents with a mean age of 29.30 years (SD= 2.08, range 26-38), of which 27 (67.5%) were mothers. The education was ranging from high school (n=2, 5%), undergraduate (n=19, 47.5%), to graduate (n=19, 47.5%). Regarding the religious affiliation, 29 (72.5%) identified themselves as a Muslim, 6 (15%) as Catholic, 4 (10%) were Protestant, and 1 (2.5%) was Hindu. The majority of the participants had one child (n=27, 67%), 12 (30%) had two children and only one (2.5%) parent had three children. Moreover, 30 (75%) participants reported that they vaccinated their child, 7 (17.5%) did not vaccinate their child, and 3 (7.5%) did not know.
There are two independent variables manipulated that were used in this study: the type of spokesperson (celebrity vs. medical expert) and the type of message framing (gain vs. loss).
The type of spokesperson. Depending on the experimental condition, participants were exposed to either: a) a video with the celebrity as the spokesperson or b) a video with the medical expert as the spokesperson. To check if the manipulation worked, an independent-samples t-test was conducted. The question was “What do you think is the profession of the
15 person in the video?”. The answer was a 10-point Likert-type scale, ranging from 1 (medical expert) to 10 (celebrity). The results were M=8.15, SD=3.17 for the celebrity, and M=1.60, SD=2.04 for the medical expert; t (38) = 7.78, p < 0.001. The results showed that there was a significant difference between celebrity and the medical expert, which means participants can identify the difference between spokespersons.
The type of message framing. Depending on the experimental condition they were in, participants were exposed to either: a) a video with a gain-framed message or b) a video with a loss-framed message. The question to check the manipulation was “What is the message mostly about?”. The answer was a 10-point Likert-type scale, ranging from 1 (the loss from getting a vaccination) to 10 (the gain from getting a vaccination). Manipulation for this variable was checked with an independent-samples t-test. The results showed that there was a significant difference in the scores for the gain-framed group (M=9.45, SD=2.01) and the loss-framed group (M=3.55, SD= 3.98) conditions; t (38) = 5.92, p < 0.001. The results suggest that the manipulations succeeded and the participants have perceived the type of message framing as different.
4.2 Main Results
There were 402 Indonesian parents participating in this study, but 92 of them were excluded because they could not see the video. The mean age of the 310 participants who reliably completed the entire questionnaire was 28.98 years (SD= 3.29, range 21-41 years old) and 92.6% (N= 287) of them were mothers. The majority identified themselves as Muslim and had obtained a bachelor degree. Over 70% of participants had one child and half of the participants’ youngest children were aged between 1-3 years old. Moreover, 61.9% of the participants had vaccinated their child(ren). Table 2 shows the characteristics of the study participants.
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Variable n % Mean SD
Role in the family
Mother 287 92.6 Father 32 7.4 Age (years) 28.98 3.29 Religion Islam 260 83.9 Protestant 22 7.1 Catholic 22 7.1 Buddhism 3 1.0 Hinduism 2 0.6 None 1 0.3 Highest education High school 28 9.0 Bachelor degree 237 76.5 Master degree 45 14.5 Number of Children 1 232 74.8 2 62 20.0 3 13 4.2 More than 3 3 1.0
Age of the youngest Children
0 - 11 month 102 32.9
1 - 3 years old 169 54.5
4 - 5 years old 36 11.6
more than 5 years old 3 1.0 Did any of your children
receive MMR vaccination?
Yes 192 61.9
No 89 28.7
Do not know 29 9.4
17 To check whether the participants’ background has an association to attitude and intention towards vaccination or not, a one-way ANOVA was conducted. The results with regard to vaccination attitude were F (2, 284) = 1.34, p= .26, η2= .009 for education, F (5, 284) = 1.141, p= .34, η2= .020 for religion, F (2, 284) = .99, p= .37, η2= .01 for vaccination status. There was no statistically significant difference in participants’ education, religion, and also vaccination status with regard to the parent's vaccination attitude. Moreover, the effect size in each background is also small.
The results with regard to vaccination intention were F (2, 284) = .22, p= .80, η2= .002 for education, F (5, 284) = 1.08, p= .37, η2= .019 for religion, F (2, 284) = 1.74, p= .18, η2= .01 for vaccination status. There was no statistically significant difference in participants’ education, religion, and also vaccination status with regard to the parent's vaccination intention. Moreover, the effect size in each background is also small.
4.2.1 Randomization Check
Randomization checks were conducted to control for the unequal distribution of background variables across the 2 (the type of spokesperson) × 2 (message framing) conditions.
Distributions of role in the family and vaccination status on each condition were checked on the type of spokesperson and message framing. The result will be mentioned respectively on each factor.
The role in the family. To check whether participation of mothers and fathers were comparable between all conditions, a randomization check was conducted with Chi-square. The results are X2(1, N=310) = 0.12, p = .73 for the type of spokesperson, and x2(1, N=310) = 0.21, p = .65 for the type of message framing. Those results show that there is no significant difference between the distribution of mothers and fathers in all conditions, so all conditions are comparable.
18 Religion. Religion is an important background of participants since the vaccination issue might be influenced by this aspect. The distribution of participants was checked by Chi-square. The results are X2(5, N=310) = 4.77, p = .45 for the type of spokesperson, and x2(5, N=310) = 3.79, p = .58 for the type of message framing. Those results show that there is no significant difference between the distribution of the participants’ religion in all conditions, so all conditions are comparable.
Education. Education is also an essential background that needs to be taken into
account. Therefore, the analysis was conducted with Chi-square. The results are X2(2, N=310) = .85, p = .65 for the type of spokesperson, and X2(2, N=310) = 1.76, p = .45 for the type of message framing. The results were there’s no significant difference between each education background in all conditions.
Vaccination status. This aspect is related to the involvement of the participants with the issue. Thus, the distribution of the vaccination status of the participant needs to be checked with Chi-square. The results are X2(2, N=310) = .30, p = .86 for the type of
spokesperson, and X2(2, N=310) = 2.19, p = .34 for the type of message framing That result shows that there’s no significant difference in vaccination status distribution among
conditions, which means that the randomization was successful.
4.2.1 The Main Effect of The Type of Spokesperson on Parents’ attitudes towards vaccination and intention to vaccinate
To investigate the influence of the type of spokesperson, on parent’s attitudes and intention towards vaccination, a multivariate analysis of variance (MANOVA) was conducted using SPSS 26. The first hypothesis (H1) predicted a stronger effect of celebrity (vs. medical expert) as the spokesperson on parent’s attitudes (H1a). The results for the effect on attitudes towards vaccination revealed F (1, 306) = 19.43, p<.001, which means that the attitudes towards vaccination differ significantly between the message delivered by a celebrity and a
19 doctor. From the mean score, the celebrity (M= 5.81, SD= 0.73) has a stronger effect on the attitudes towards vaccination than the medical expert (M=5.35, SD=1.31). However, for the intention towards vaccination, the result was F (1, 306) = 0.02, p=0.88, which means that the main effect of the spokesperson is not statistically significant on intention towards
vaccination. From the estimated marginal means, the difference in the celebrity condition (M= 6.06, SD= 0.08) is not significantly different from the medical expert condition (M = 6.08, SD= 0.08). These results, thus, partially confirm our first hypothesis.
4.2.2 The Main Effect of The Type of Message-Framing on Parents’ attitudes towards vaccination and intention to vaccinate
The second hypothesis predicted a stronger effect of gain-framed message (vs. loss-framed) on parent’s attitudes (H2a) and intention (H2b) towards vaccination. The result showed a statistically significant result, with F (1, 306) = 11.16, p<.001 for the effect on the attitudes and F (1, 306) = 6.76, p = 0.01 for the effect on the intention. This means that the hypothesis was fully supported. The type of message-framing has a statistically significant effect, both on the parents’ attitudes and intention to vaccinate their children, and the effect was stronger on parents’ attitude when the message is using loss-frame (M= 5.74, SD= 0.91) than using gain-frame (M= 5.40, SD= 0.97). The pattern remained the same on the intention; the effect was stronger when the message was using loss-frame (M= 6.22, SD= 0.95) than using gain-frame (M= 5.92, SD= 1.05).
4.2.3 The Interaction Effect of Type of Spokesperson and The Type of Message-Framing on Parents’ attitudes towards vaccination and intention to vaccinate
The third hypothesis was that messages delivered by the celebrity will improve parents’ attitudes towards childhood vaccination more than a message delivered by a medical expert, and this effect will be stronger if the message is using gain-frame, compared to loss-frame (H3a). The results of the interaction effect were F (1, 360) = 0.79, p= 0.37. There is no
20 significant interaction between exposure to a message involving a celebrity or a doctor as the spokesperson on attitudes towards vaccination, and the message framing (gain-framed or loss-framed). See Table 3 for an overview of the means.
The Type of Spokesperson
The Type of Message Framing Celebrity Doctor Total
Loss-framed 6.03 5.47 5.74
Gain-framed 5.59 5.22 5.41
Total 5.79 5.35 5.57
Table 3. Means on the measure of interaction between the type of spokesperson and message framing
in attitude towards vaccination
Meanwhile for the interaction effect between the type of spokesperson and message framing in intention towards vaccination (H3b), we found the result was F (1, 360) = 1.126, p= 0.290. That means there is no statistically significant interaction between exposure to a message involving a celebrity or a doctor as the spokesperson on parents’ intention towards
vaccination, and message framing (gain-frame or loss-frame). See Table 4 for an overview of the means.
The Type of Spokesperson
The Type of Message Framing Celebrity Doctor Total
Loss-framed 6.15 6.29 6.22
Gain-framed 5.97 5.87 5.92
Total 6.05 6.08 6.06
Table 4. Means on the measure of interaction between the type of spokesperson and message framing
21
5. Discussion
The current study investigated the effectiveness of the type of spokesperson and type of framing in enhancing parents’ attitude and intention towards childhood vaccination,
specifically MMR. Four hypotheses were tested, with one being confirmed and three being partly confirmed. The results demonstrated that messages delivered by a celebrity have a stronger influence on parents’ attitudes towards vaccination compared to messages delivered by a medical expert (H1a). However, the effect of the type of spokesperson was not applied to parents’ intention to vaccinate their children, rejecting H1b. Meanwhile, concerning message framing, loss-framed messages had a stronger effect on both parents’ attitude and intention to vaccinate their children compared to loss-framed messages (H2a and H2b). Textbox 1 provides an overview of the hypotheses and findings.
Textbox 1. Overview of the Hypotheses and findings of the study
Spokesperson effect
As predicted, a message delivered by a celebrity has a stronger effect on a parent's attitude towards vaccination, than a message delivered by a medical expert. Vaccination is considered a high-involvement issue engaging in careful thinking of the information (Frew, et.al., 2016). Therefore, as mentioned before, the existence of a medical expert as a spokesperson can lead
22 to less strong evaluation because people tend to over-process the message and reduce the attitude towards the message (Petty, Wegener, Fabrigar, 1997). However, a celebrity that is known can give a heuristic cue, can enhance someone’s attitude towards certain messages. In the case of high-involvement issues, celebrities can help to reduce barriers to health-related issues and are precursors for people’s motivation to process the message (Hoffman et.al., 2017). The effect of celebrity is not applied to parents’ intention to get their children
vaccinated. In order to perform certain behaviors, especially under high-involvement issues, strong arguments are needed, which celebrities might not be strong enough for people to do the recommended behavior. In the case of vaccination, parents might have another practical reason, for instance, maybe a parent watched the video and tend to have a more positive attitude towards vaccination, but they have hesitancy because they believe about the
information that said that MMR can cause autism. Therefore, they do not intend to get their child vaccinated because of the video.
Framing effect
Furthermore, this current study revealed that loss-framed messages efect parents’ attitudes as well as the intention to vaccinate their children. When the messages show the costs of failing to take the recommended action, parents are more likely to have a positive attitude towards vaccines and more likely to have a strong intention to have their child vaccinated. These results confirm the findings of Abhyankar and colleagues (2008) that found that loss-framed messages were more effective in increasing parents’ attitudes and also intend to give MMR vaccination to their children. This evidence reinforces the understanding that the motivation to engage or not engage in a health-related behavior is dependent on how people perceive risk on the outcome of the behavior (Rothman et al., 2006). In the case of vaccination, even though the aim of the behavior is to prevent someone from getting ill, the parents might
23 perceive this behavior as risky due to fear of side effects that might happen. Therefore,
considering the higher perceived riskiness of vaccination, loss-framed messages will give more persuasive advantages compared to gain-framed messages (Rothman & Salovey, 1997).
Relationship between the type of spokesperson and the type of message-framing
From the study, we found that there was no significant interaction effect between the type of spokesperson and the type of message-framing. In the previous section, we expected that the type of spokesperson can enhance the persuasive effect of the type of framing on parents’ attitudes and intentions. These findings confirmed the result from the Puckett and colleagues’ study (in Petty & Cacioppo, 1984), who found that if the message had a strong argument and the person that sees the message had a high motivation to process the message (i.e., high of issue relevance), they would process the message arguments regardless of the source.
5.1. Conclusion and Implications
This study presented herein demonstrated an effect of the type of spokesperson and the type of message framing on parents’ attitude and intention towards childhood MMR vaccination. Findings showed that parents who were exposed to a celebrity spokesperson for vaccination had a more positive attitude towards vaccination than parents who were exposed to a medical expert. Moreover, parents who were exposed to a loss-framed message about vaccination had a more positive attitude and intention to vaccinate their children than parents who were exposed to a gain-framed message. However, the expected interaction between the type of spokesperson and message-framing was not found.
Our findings hold some theoretical implications for the scientific literature in the field of health communication, especially childhood vaccination. This study enriches a theoretical framework on how the type of spokesperson (celebrity vs. medical expert) and the type of
24 message-framing (loss- vs. gain-framed) can play a role in communicating childhood
vaccination campaigns. In the present study, we created video campaigns dedicated to parallel and comparable manipulation messages. This present study showed clearer results of the relationship between variables compared to the one conducted by Emmers-Sommer and Terán (2019), that used a manipulation with different content (or narrative) for each
condition. This study also supports the findings of a favorable effect of loss-framed messages in vaccination communication that had been proposed by Abhyankar and colleagues (2008). Moreover, this study elucidates formulating messages that can enhance parents’ attitudes and intentions regarding their child’s health-related topic.
Our findings also have practical implications. Healthcare providers or government organizations that want to create a campaign targeting parents to vaccinate their children could use this study’s findings as a recommendation. Using a celebrity as the spokesperson of the campaign can give a benefit to enhance parents’ attitudes towards vaccines. Moreover, loss-framed messages are shown after parents have built a positive attitude to the behavior to make parents more likely to intend to do the recommended behavior (i.e., bring their child to get vaccination). A medical expert appearance as the spokesperson and along with the loss-framed message also can be a good consideration to support a celebrity to enhance the attitude.
5.2. Limitations and Future Directions
This present study includes several limitations in which future researches can improve. First, the sample size was a small percentage of the population. This may limit the extent to which the findings can be generalized to the real world. Secondly, the number of mothers and fathers who participated were not equal, which may not represent how the decision about MMR vaccination may be made, as decisions about vaccinations are usually made by
25 mother and/or father. Thirdly, the celebrity and the medical expert were only women; it is worth noting that the spokesperson gender and age might also play an important role . Fourthly, a technical incident arose where many participants faced trouble accessing the video. Therefore, many of them complained or canceled their participation, which might have impacted their attitude towards the study itself.
This study also does not cover some areas that might still be relevant and worthy of consideration that did not fall within the scope of the current investigation and might offer viable areas of future research. First, the type of delivered message (narrative vs informative) could be considered. Research suggests that combining a narrative in which the celebrity tells a story of her/his personal experience regarding the issue can make people more engaged in health stories (Kim, Bigman, Leader, Lerman, & Capella, 2012; Emmers-Sommer & Terán, 2019). Moreover, a previous study showed that narratives also have a greater persuasiveness when combined with loss-framing (Ma & Nan, 2018). Second, as celebrities show a stronger impact on parents’ attitudes, it might be useful to explore the type of celebrity (athletes, movie stars, models, etc.) and the effect they have on persuading different parents.
Lastly, despite the limitations, our study extends current knowledge about the effect of type of spokesperson and type of message-framing in a meaningful way by identifying its relationship with parents’ attitude and intention towards MMR vaccination for their children. To our best knowledge, this is the first study that investigated the interaction between the type of spokesperson (a celebrity vs. a medical expert) with custom-made manipulations and message framing (loss-framed vs gain-framed) in an MMR vaccination context with Indonesian parents. Together, these data suggest a beneficial combination of message presentations to encourage vaccination of children.
26
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31
APPENDIX
APPENDIX A VIDEO SCRIPT
General information:
Mumps, Measles and Rubella are infectious diseases which affect health in the early life of our children. MMR is a combined vaccine, which is the safest way to protect the children against measles, mumps and rubella. It is given to children at around 15 months and again before they go to school. The second dose protects anybody who did not respond to the first dose.
After that, is the message with different framing.
For gain framed:
Hi, my name is (name of the spokesperson), by vaccinating your child against mumps,
measles and rubella, you will be able to protect your child against contracting these diseases and take advantage of a safe and lifelong immunization, which will make you feel less
anxious and safe.
For Loss framed:
Hi, my name is (name of the spokesperson), by not vaccinating your child against mumps, measles and rubella, you will fail to protect your child against contracting these diseases and will fail to take advantage of a safe and lifelong immunization, which will make you feel anxious and unsafe.
32
APPENDIX B QUESTIONNAIRE SCRIPT AND QUESTIONS
Factsheet
Dear (name of participant) ,
With this letter, I, Fathya Artha Utami, would like to invite you to participate in a research study to be conducted under the auspices of the Graduate School of Communication, a part of the University of Amsterdam.
The study for which I am requesting your cooperation is about evaluating public service advertisements in the field of childhood vaccination. In the online survey, you will see a video of someone explaining childhood vaccination information. You are expected to watch the video to the end. In addition, several questions will be asked about your thoughts towards the video. The goal of this research is to generate insight into how parents perceive public service advertisements.
The study will take about 10 minutes.
As this research is being carried out under the responsibility of the ASCoR, University of Amsterdam, we can guarantee that:
1. Your anonymity will be safeguarded, and that your personal information will not be passed on to third parties under any conditions unless you first give your express permission for this.
2. You can refuse to participate in the research or cut short your participation without having to give a reason for doing so. You also have up to 24 hours after participating to withdraw your permission to allow your answers or data to be used in the research. 3. Participating in the research will not entail your being subjected to any appreciable
risk or discomfort, the researchers will not deliberately mislead you, and you will not be exposed to any explicitly offensive material.
4. No later than five months after the conclusion of the research, we will be able to provide you with a research report that explains the general results of the research. For more information about the research and the invitation to participate, you are welcome to contact the project leader (fathya.artha@gmail.com) at any time.
33 Should you have any complaints or comments about the course of the research and the
procedures it involves as a consequence of your participation in this research, you can contact the designated member of the Ethics Committee representing ASCoR, at the following
address: ASCoR Secretariat, Ethics Committee, University of Amsterdam, Postbus 15793, 1001 NG Amsterdam; 020‐525 3680; ascor‐secr‐fmg@uva.nl.
Any complaints or comments will be treated in the strictest confidence.
We hope that we have provided you with sufficient information. We would like to take this opportunity to thank you in advance for your assistance with this research, which we greatly appreciate.
Informed Consent
I hereby declare that I have been informed in a clear manner about the nature and method of the research, as described in the email invitation for this study.
I agree, fully and voluntarily, to participate in this research study. With this, I retain the right to withdraw my consent, without having to give a reason for doing so. I am aware that I may halt my participation in the experiment at any time.
If my research results are used in scientific publications or are made public in another way, this will be done in such a way that my anonymity is completely safeguarded. My personal data will not be passed on to third parties without my express permission.
√ I understand the text presented above, and I agree to participate in the research study.
34
Pretest Questions
Demographic
What is your age? (in numbers and years, example: 28)
____________
What is your role in the family?
- Mother - Father
Which following religious affiliations do you identify as?
- Islam - Protestant - Catholic - Buddhism - Hinduism - Kong Hu Cu - None - Other
What is your highest achieved level of education?
- Junior High School - High school
- Bachelor degree - Master degree or PhD - other
How many children do you have?
- 1 - 2 - 3 - > 3
35
Age of youngest child
- 0-11month old - 1-3 years old - 4-5 years old
Did any of your children receive MMR vaccination?
- Yes - No
- Don’t know.
Instruction before Video
You will see a video of someone talking about childhood vaccination. Please look at it carefully. You are allowed to pause or replay the video. When you feel you saw enough of the video, you can click next. After you click next, you cannot go back to the video. Please do not record the video. It is confidential.
Instruction After Video
You will see a couple of questions. Please read them carefully. Many questions in this survey make use of rating scales with 7 places; you are to circle the number that best describes your opinion.
Questionnaire
Perceived of source credibility
The spokesperson has sufficient knowledge about the topic of MMR vaccination
1 2 3 4 5 6 7
36
The spokesperson is competent in delivering the message
1 2 3 4 5 6 7
Strongly disagree Strongly Agree
The spokesperson is an intelligent person
1 2 3 4 5 6 7
Strongly disagree Strongly Agree
The spokesperson has the credibility to deliver the message
1 2 3 4 5 6 7
Strongly disagree Strongly Agree
I trust the information about MMR vaccination that is delivered by the spokesperson
1 2 3 4 5 6 7
Not at all Very much
The spokesperson is an expert in the field of MMR vaccination
1 2 3 4 5 6 7
Not at all Very much
Attitudes
In my opinion, getting my child vaccinated against MMR twice is...
1 2 3 4 5 6 7
Bad Good
I feel……... about getting my child vaccinated against MMR twice
1 2 3 4 5 6 7
37
For me, the potential side effect of MMR vaccination is...
1 2 3 4 5 6 7
Extremely unpleasant Extremely Pleasant
For me, deciding whether to vaccinate my child or not is...
1 2 3 4 5 6 7
Extremely difficult Extremely Easy
Intention
I intend to give MMR vaccination to my youngest child
1 2 3 4 5 6 7
Extremely unlikely Extremely likely
I intend to give MMR vaccination to my child twice, as is recommended
1 2 3 4 5 6 7
Extremely unlikely Extremely likely
I plan to give MMR vaccination twice to my child without hesitation
1 2 3 4 5 6 7
Extremely unlikely Extremely likely
I will make an effort to give MMR vaccination twice to my child
1 2 3 4 5 6 7
I definitely will not I definitely will
Manipulation check
You have seen a video about MMR vaccination, please fill the questionnaire below.
What do you think is the profession of the person in the video?
1 2 3 4 5 6 7 8 9 10
38 What is the message mostly about?
1 2 3 4 5 6 7
the losses from not getting a vaccination the gains from getting a vaccination
Debriefing
(This text is to be placed at the end of the Qualtrics questionnaire after the participant click finish button)
Thank you for participating in the present study concerning how parents perceive public service advertisements. The video that you just saw is fictional, and it will only be used for academic purposes. If you know friends or acquaintances who are eligible for this study, we ask you to please not discuss it with them until June 1st, 2020. Prior knowledge of this study can invalidate the result. We greatly appreciate your cooperation.
If I wish to receive more information about the research, either now or in the future, I can contact Fathya Artha Utami (fathya.artha@gmail.com). Should I have any complaints about this research, I can contact the designated member of the Ethics Committee representing the ASCoR, at the following address: ASCoR secretariat, Ethics Committee, University of Amsterdam, Postbus 15793, 1001 NG Amsterdam; 020‐ 525 3680; ascor‐secr‐fmg@uva.nl.
