‘It’s got metals in it!’: testing an inoculation intervention in order to reduce resistance towards narrative persuasion against child vaccination

‘It’s got metals in it!’: Testing an inoculation intervention in

order to reduce resistance towards narrative persuasion

against child vaccination.

Name:

Kofi Nimako

Studentnumber:

0312169

Track:

Persuasive Communication

Supervisor:

Dr. S.Mollen

Abstract

Declining child vaccination rates in the EU and US have led to an outbreak in measles (Clemmons, Gastanaduy, Fiebelkorn, Redd, & Wallace, 2015; Schuster, Eskola & Duclos, 2015). According to The World Health Organization (WHO), one of the major contributors to declining vaccination rates is parents lack of trust in the safety of vaccines. This lack of trust is fueled by people who are against child vaccination. They make use of a persuasive technique called narrative persuasion in order to persuade parents (to be) not to vaccinate their children. The aim of this study is to test the effectiveness of an inoculation intervention in inducing resistance against narrative persuasion. Expectations were that narrative persuasion would protect parents with neutral or positive attitudes and intentions towards child vaccination. It was expected that these attitudes and intentions would be mediated through the resistance strategies counter-arguing and reactance. However, no significant results were found. The implications of these results are being discussed in this study.

1. Introduction: Inoculating against declining vaccination rates

Recent outbreaks of measles in the US and EU illustrate the dangers of declining vaccination rates among young children (Clemmons, Gastanaduy, Fiebelkorn, Redd, & Wallace, 2015; Schuster, Eskola & Duclos, 2015). Having 95% of the children vaccinated can prevent these types outbreaks (van Lier et al. 2017). However, in the Netherlands these standards put in place by The World Health Organization (WHO), have not been met for at least three consecutive years (van Lier et al. 2017). Preventing outbreaks like the measles, requires more parents vaccinating their children (Clemmons, Gastanaduy, Fiebelkorn, Redd, & Wallace, 2015; Schuster, Eskola & Duclos, 2015).

The spread of misinformation on vaccine adverse effects (VAEs) of child vaccination leads to parent’s lack of confidence in the safety of vaccines (MacDonald & The SAGE working group, 2015; Wong, 2015; Ward, Peretti-Watel, Larson, Raude & Verger, 2015; Haase, Smith & Betsch, 2019). This in turn leads to lower vaccination rates (MacDonald & The SAGE working group, 2015; Wong, 2015; Ward, Peretti-Watel, Larson, Raude & Verger, 2015; Haase, Smith & Betsch, 2019). Generally, the spreading of this misinformation comes from people who belief vaccines to be harmful and unbeneficial (anti-vaxxers). Even though, the misinformation spread by anti-vaxxers does not have a malicious intent per se, it does have the goal of persuading parents not to vaccinate their children. Narrative persuasion is a key strategy in this process.

Narrative persuasion has the possibility to persuade parents through the immersion of the parent into the narrative being presented to them. This in turn leads to more susceptibility to the arguments presented in the narrative (Moyer-Gusé 2008; Moyer-Gusé & Nabi 2010). Narrative persuasion’s ability of not being perceived as a persuasive attempt, bypasses the resistance strategies of reactance and counter-arguing (Moyer-Gusé 2008; Moyer-Gusé & Nabi 2010). Were the person to perceive a persuasive attempt, they would trigger the resistance strategy reactance (Moyer-Gusé 2008; Moyer-Gusé & Nabi 2010). A strategy through which the receiver would get into an emotional state of anger due to the feeling of its

attitudes and intentions being under attack (Moyer-Gusé 2008; Moyer-Gusé & Nabi 2010; Rains, 2013). Reactance also entails counter-arguing (Rains, 2013). A strategy of generating thoughts that disprove the arguments presented in the message (Rains, 2013). The strategy of counter-arguing itself, is employed when the person perceives the content of the message to be deceptive (Moyer-Gusé 2008; Moyer-Gusé & Nabi 2010). It is reactance without the affective component of anger (Moyer-Gusé 2008; Moyer-Gusé & Nabi 2010). However, without perceiving the persuasive attempt of the narrative, both strategies won’t trigger (Moyer-Gusé 2008; Moyer-Gusé & Nabi 2010). The following example will illustrate this in more detail. When searching the internet for information on child vaccination a parent in favor of child vaccination can come across a story of someone’s negative experience with child vaccination. This parent’s negative experience after vaccinating their child is being conveyed in a vivid manor, with the storyteller vividly explaining the complications the child faced and the emotional effects this had on the parent. Due to the parent’s relatability to the character, situation and its immersion in to the narrative, the parent does not perceive the persuasive attempt. This can lead to changes in attitudes and intentions towards child vaccination, if not directly, over a longer period of time.

Inoculation interventions have been proposed in order to counter misinformation in the field of child vaccination due to its ability to empower resistance strategies like reactance and counter-arguing (Haase, Smith & Betsch, 2019; Wong, 2015). Like the vaccination analogy it derives its name from, an inoculation intervention exposes people to a ‘weak form’ of the arguments being used in the persuasive attempt (Mason & Miller, 2016). When exposed to future persuasive attempt, receivers will engage more in resistance in order to protect their attitudes and intentions (Banas & Rains 2010; Mason & Miller, 2016; Wong, 2015; Haase, Schmidt & Betsch, 2019).

An inoculation intervention starts of, with a threat message about an upcoming persuasive attempt (Banas & Rains 2010; Mason & Miller, 2016; Fransen & Mollen, 2017; Wong, 2015; Haase, Schmidt & Betsch, 2019). The aim of the threat message is to elicit the

threat of a persuasive attempt in the receiver. After the threat message is presented the receiver is exposed to easy refutable counter-arguments in the form of a persuasive attempt. This process is known as refutational pre-emption (Banas & Rains 2010; Mason & Miller, 2016; Fransen & Mollen, 2017; Wong, 2015; Haase, Schmidt & Betsch, 2019). The final stage of the intervention is exposure to a persuasive attempt containing different arguments to the receiver’s position. This is persuasive attempt is defined as the attack message (Banas & Rains 2010; Mason & Miller, 2016; Fransen & Mollen, 2017; Wong, 2015; Haase, Schmidt & Betsch, 2019). Inoculation has proven to be successful in other health care interventions (Banas & Rains, 2010; Wong, 2015; Fransen & Mollen, 2017). It has shown favorable results in protecting women’s attitudes and intentions towards child vaccination, by inducing resistance through counter-arguing (Wong, 2015). However, no studies have been done testing inoculation’s ability to heighten receiver’s ability to engage in reactance.

Reactance is one of the key strategies that indicates that the receiver perceives a persuasive attempt (Rains, 2013). Therefore, engaging in reactance might indicate that the receiver perceives narrative persuasion as a persuasive attempt (Rains, 2013).

This study’s contribution to the scientific literature is that it tests inoculation’s ability to expose narrative persuasion as a persuasive attempt to the receiver by triggering reactance.

Something that has not been studied before. The societal relevance is that, if successful inoculation can be a means of inducing resistance towards narrative persuasion of anti-vaxxers. In doing so it can be meaningful in stopping the decrease in vaccination rates. The following research question forms the foundation of this research:

Research question:

To what extent does an inoculation intervention induce reactance and counter-arguing, in (new) parents who have pre-existing neutral or positive attitudes towards child vaccination, against a negative narrative message. And to what extent does this result in a more positive attitude and intention, compared to when no inoculation intervention is provided?

2. Theoretical Framework

Narrative persuasion has generally been used by health care practitioners in order to

promote public health (Slate & Rouner, 2002; Moyer-Gusé, 2008; Moyer-Gusé & Nabi, 2010; Kim, Bigman, Leader, Lerman, & Cappella, 2012; Ma, Nan, Qin, & Zhou, 2018). However, anti-vaxxers use narrative persuasion to present their arguments against child vaccination (Rodriguez, 2016; Haase, Betsch & Renkewitz, 2015; Haase, Schmid & Betsch, 2019). In doing so they effectively manage to disseminate their persuasive messages which can ultimately lead to hesitant vaccination intentions and negative attitudes towards vaccination (Wong, 2015; Haase, Schmid & Betsch, 2019). A study has shown that inoculation strategies can be effective in inducing resistance towards narrative persuasion (Wong, 2015). Here an explanation will be given why an inoculation intervention might be the most effective

treatment to induce resistance and how this might come about.

2.1 Narrative persuasion and vaccination intentions

In order to understand why an inoculation intervention is expected to be effective in inducing resistance towards the narrative persuasion used by people against vaccination, it is

necessary to understand how narrative persuasion works. Therefore, it is also necessary to have some understanding of resistance towards persuasion. An explanation of the workings of both resistance and narrative persuasion will be given here.

2.1.1 Narrative persuasion and resistance towards persuasion

Resistance is defined as a motivational state in which the audiences are when protecting their attitudes and/or behavioral intentions against persuasive attempts (Zuwerink Jacks & Cameron, 2003; Knowles & Linn, p.5 2004; Fransen & Mollen, 2017). Being in the state of resistance leads audiences to employ resistance strategies in order to protect their attitudes and/or behavioral intentions (Zuwerink Jacks & Cameron, 2003; Fransen, Smit & Verlegh, 2015; Fransen & Mollen, 2017). The type of resistance strategy a person uses depends on the motivation of the person to resist the persuasive attempt (Fransen, Smit & Verlegh,

2015). For example, if the person perceives a threat to its freedom it will engage in the reactance strategy (Fransen, Smit & Verlegh, 2015). However, when the receiver perceives the persuasive message as deceiving he or she will engage in counter-arguing (Fransen, Smit & Verlegh, 2015).

The aim of narrative persuasion is to reduce the activation of resistance strategies and thereby resistance in general (Moyer-Gusé & Nabi, 2010). Through not perceiving the narrative as a persuasive attempt, audiences do not engage in resistance and don’t employ resistance strategies (Moyer-Gusé & Nabi, 2010). This in turn leads to audiences being more susceptible to the arguments presented in the narrative as they do not perceive the narrative as a threat to their attitudes and intentions (Moyer-Gusé & Nabi, 2010). The process of transportation is fundamental in audiences not perceiving the persuasive attempts (Moyer-Gusé & Nabi, 2010). Transportation is the immersion of the audience in a narrative, through focusing all of its cognitive and sensory capabilities on the story in the narrative (Moyer-Gusé & Nabi, 2010). Due to the focus of these cognitive and sensory capabilities on the story, audiences are not capable of conferring resistance (Moyer-Gusé & Nabi, 2010). Hence, they become more susceptible to the arguments presented in the narrative (Moyer-Gusé & Nabi, 2010).

It is not without reason that the aforementioned resistance strategies were given as an example. Studies on the use of narrative persuasion in order to promote healthy behaviors has shown that narrative persuasion can effectively bypass two resistance strategies reactance and counter-arguing (Moyer-Gusé & Nabi, 2010; Niederpeppe, Heley & Barry, 2015; Quintero Johnson & Sangalang, 2017; Ma, Nan, Qin & Zhou, 2018). In order to understand how narrative persuasion bypasses reactance and counter-arguing an explanation will be given of both resistance strategies.

Reactance is known as a state in which the receiver feels anger and engages in counter-arguing. It is a state consisting out of an affective component (anger) and a cognitive

component (counter-arguing) (Rains, 2013; Fransen, Smit & Verlegh, 2015). People engage in reactance when they feel their autonomy and independence is at stake (Rains, 2013; Fransen, Smit & Verlegh, 2015). The theory of reactance states that people generally see themselves as autonomous beings (Rains, 2013; Fransen, Smit & Verlegh, 2015). When this autonomy is under threat they will therefore engage in reactance (Rains, 2013; Fransen, Smit & Verlegh, 2015).

However, narrative persuasion is capable of not triggering reactance (Moyer-Gusé & Nabi, 2010). This due to the fact that people engaged in narrative persuasion are less aware of the persuasive attempt than people in engaged in other forms of persuasive communication (Moyer-Gusé & Nabi, 2010). The following example will illustrate this process in more detail. Consider two website promoting anti child vaccination views. Website number one’s starting page starts of, with disclaiming that this website will convince you why you should not use child vaccination. However, website number two starts off with a narrative on child

vaccination. The first website is according to Reactance Theory more likely to set of the reactance strategy then the second website (Rains, 2013). The reason for this being that people on the first website are likely to understand that they are on website aimed at

persuading them. People entering the second website might think they are reading narratives and testimonials and do not perceive the persuasive attempt (Moyer-Gusé & Nabi, 2010). Even if the narratives and testimonials contain arguments against child vaccination, people on the second website are less likely to engage in reactance. This is due to a process called parasocial interaction (PSI) (Moyer-Gusé & Nabi, 2010). The process of PSI is a process through which a person perceives the person in the narrative or testimonial as part of its own social world. They form parasocial relationships with the person in the narrative due to perceived similarity, likeability, attitudes and background (Moyer-Gusé & Nabi, 2010). The trust that is established through PSI will lead to less reactance when exposed to an argument

in the narrative (Moyer-Gusé & Nabi, 2010). The character is now part of the persons network and therefore not someone who is perceived as threatening to the individuals freedom (Moyer-Gusé & Nabi, 2010).

Counter-arguing is the second strategy narrative persuasion is capable to bypass (Moyer-Gusé & Nabi, 2010; Niederpeppe, Heley & Barry, 2015; Quintero Johnson & Sangalang, 2017; Ma, Nan, Qin & Zhou, 2018). It was already mentioned that counter-arguing belongs to the cognitive part of reactance (Rains, 2013). Therefore, people applying reactance will also engage in counter-arguing (Rains, 2013). However, counter-arguing can also occur without the threat of freedom (Moyer-Gusé & Nabi, 2010; Niederpeppe, Heley & Barry, 2015; Quintero Johnson & Sangalang, 2017; Ma, Nan, Qin & Zhou, 2018). This goes back to the motivation of the person on why he or she wants to resist the persuasive attempt (Fransen, Smit & Verlegh, 2015). A person might not see the persuasive message as a threat on its own freedom, but as deceiving (Fransen, Smit & Verlegh, 2015). Therefore, the person may engage in counter-arguing in order to proof that the message is deceiving (Fransen, Smit & Verlegh, 2015). Counter-arguing is the generation of thoughts that dispute the argument of the persuasive message.

However, narrative persuasion has the possibility to reduce counter-arguing due to a process called transportation (Moyer-Gusé, 2008; Moyer-Gusé & Nabi, 2010). This process is also known as narrative involvement and entails a person being completely involved with the events occurring in the narrative. In doing so all mental capacities are occupied with the narrative leaving little space to engage in counter-arguing (Moyer-Gusé, 2008).

Having reduced the strategies of reactance and counter-arguing, people are more

susceptible to the arguments presented (Moyer-Gusé & Nabi, 2008; Moyer-Gusé & Nabi, 2010; Niederpeppe, Heley & Barry, 2015; Quintero Johnson & Sangalang, 2017). Ma, Nan, Qin & Zhou (2018) have proven that narrative persuasion is useful in creating more positive attitudes towards depression. Their study was held among both American and Chinese students with a narrative of a student being depressed. The aim was to see if there were

cultural differences between the two student populations when it comes to the effects of narrative persuasion (Ma, Nan, Qin & Zhou, 2018). In both student populations students were either assigned to the control group or the experimental group (Ma, Nan, Qin & Zhou, 2018). Both populations showed students in the experimental group to engage less in counter-arguing then students in the control group (Ma, Nan, Qin & Zhou, 2018). Also, students in the experimental group had more positive attitudes towards depression then students in the control group (Ma, Nan, Qin & Zhou, 2018).

Similar results have been found in studies on other (health) behaviors (Moyer-Gusé & Nabi, 2008; Moyer-Gusé & Nabi, 2010; Niederpeppe, Heley & Barry, 2015; Quintero Johnson & Sangalang, 2017). Ma, Nan, Qin & Zhou (2018). Moyer-Gusé & Nabi’s (2010) study on safe sex attitudes and intentions saw similar results, with students exposed to narratives

advocating for safe sex having more positive attitudes and higher intentions to practice safe sex than students not exposed to the narrative. A study on smoking cessation has shown the similar results (Kim et al. 2012). Therefore, it is assumed that narrative persuasion by anti-vaxxers will follow a similar trend.

2.1.3. Resistance strategies and anti-(child) vaccination narratives

Remarkably, empirical studies assessing anti- (child) vaccination narrative persuasion are explorative in nature (Joley & Douglas, 2014; Haase, Betsch & Renkewitz, 2015; Ward et al. 2015; Rodriguez, 2016; Haase, Schmidt & Betsch, 2019; Meppelink, Smith, Fransen & Diviani, 2019; Bradshaw et al. 2020). For example, multiple studies look at the arguments used in the narratives of anti-vaxxers (Ward et al. 2015; Rodriguez, 2016; Bradshaw et al. 2020). However, none of them explain if the underlying processes as explained by Moyer-Gusé and Nabi (2010) are at work in the anti-child vaccination narratives.

It is therefore expected that narrative persuasion in a child vaccination context will follow the same principles as in other fields of healthcare. These assumptions will be tested in this

study by checking how an inoculation intervention can induce resistance through the resistance strategies reactance and counter-arguing.

2.2 Inoculation interventions and anti-child vaccination narratives

In order to induce resistance against narrative persuasion, it is assumed that the resistance strategies reactance and counter-arguing must be activated. An inoculation intervention seems to be the most suitable intervention in order to activate these resistance strategies. First an explanation will be given on how an inoculation intervention works, after which the arguments for the use of it and expected hypotheses will be given. At the end of this part a model will be displayed explaining the workings of the experiment.

An inoculation intervention consists out of two components. (Banas & Rains, 2010 ;

Compton, 2013; Fransen & Mollen, 2017). The first component is the threat component. This component warns the target audience of a persuasive message that might lead to attitude and/or intention change (Banas & Rains, 2010; Compton, 2013; Fransen & Mollen, 2017). The second component consists of exposing the target audience to the persuasive message warned about in the threat component that contains an argument against the receivers’ attitude and/or intention that is easy to refute. (Banas & Rains, 2010; Compton, 2013; Wong, 2015; Fransen & Mollen, 2017; Ma, Nan, Qin & Zhou 2018). This component is known as refutational preemption (Banas & Rains, 2010; Compton, 2013; Wong, 2015; Fransen & Mollen, 2017; Ma, Nan, Qin & Zhou, 2018). After this intervention people are expected to be more resistant towards future persuasive attempts on one’s attitude and intention (Banas & Rains, 2010; Compton, 2013; Wong, 2015; Fransen & Mollen, 2017). It is also expected that these groups will come up with more counter-arguments than those not exposed to the intervention (Banas & Rains, 2010; Compton, 2013; Wong, 2015; Fransen & Mollen, 2017).

Inoculation has indeed shown to be successful in interventions on smoking cessation, in protecting attitudes towards HPV vaccinations, drinking etc. (Banas & Rains, 2010; Wong, 2015; Fransen & Mollen, 2017). Therefore, expectations are that it will be successful in

inducing resistance towards narrative persuasion against anti-child vaccination narratives as well. However, it is still not clear what the effects of inoculation are on reactance.

No study has tested if an inoculation intervention induced reactance. In order to test for reactance not only the cognitive component of counter-arguing should be assessed, but also the affective component of anger (Rains, 2013). Therefore, an aim of this study is to assess if there is an induction of reactance when participants are being exposed to the inoculation intervention. It is expected that an induction in reactance will increase after the intervention due to the threat component. The threat component warns the participant of a persuasive attempt (Banas & Rains, 2010; Wong, 2015; Fransen & Mollen, 2017). Expectations are that participants will be motivated to resist the persuasive attempt and will do this through

engaging in reactance. It is based on the assumption that narrative persuasion deactivates this strategy due to narrative persuasion not being recognized as a persuasive attempt (Moyer-Gusé, 2008). However, when experiencing a threat to their autonomy and freedom due to the threat component, participants will most likely opt for using reactance in order to resist the coming persuasive attempts (Smit, Fransen & Verlegh, 2015). Therefore, the following hypothesis has been formulated:

H1: Participants exposed to an inoculation intervention against narrative persuasion from anti-vaxxers will have higher levels of reactance than participants not exposed to the inoculation intervention

Multiple studies have shown that people exposed to an inoculation intervention become more resistant towards novel arguments in future persuasive attempts (Banas & Rains, 2010; Wong, 2015; Fransen & Mollen, 2017). However, very little is known about inoculation treatments and its effects on narrative persuasion. Based on theories on resistance

strategies we can make assumptions. Participants’ motives to engage in counter-arguing are due to concerns of deceit (Fransen, Smit & Verlegh, 2015). One of the ways people deal with perceived concerns of deceit is through contesting the content of the message (Fransen, Smit & Verlegh, 2015). This is also known as counter-arguing and is a commonly used

resistance strategy (Fransen, Smit & Verlegh, 2015). Prove of this might be found in a study on HPV-vaccination attitudes and intentions (Wong, 2015). Wong (2015) has studied the effects of an inoculation intervention on persuasive messages advocating against the HPV-vaccine. The inoculation treatment proved effective in protecting women’s positive attitudes and intentions towards HPV vaccination. Women in the inoculation condition also showed more counter-arguing then those in the control condition (Wong, 2015). This would mean that women in the inoculation condition produced more counter-arguments than those in the control condition (Wong, 2015). Based on research of Wong (2015), it is expected that concerns of deceit will result in participants contesting the message resulting in more counter-arguing. This has led to the following hypothesis:

H2: Participants exposed to an inoculation intervention will come up with more counter-arguments against an anti-vaccination narrative than participants not exposed to the inoculation intervention.

The difference with this study and the study of Wong (2015) is that he used news articles as persuasive messages that did not contain any narratives. Likewise, Wong (2015) did not assess if reactance was triggered due to the persuasive attempt in the intervention. It is expected that attitudes and intentions are mediated through both counter-arguing and reactance. These assumptions come from a previous study on narrative persuasion (Moyer-Gusé & Nabi, 2010). In their study on narrative persuasion Moyer-(Moyer-Gusé and Nabi (2010) found reactance and counter-arguing mediating change in attitude and intentions towards safe sex behavior. They used narrative persuasion in the form of a TV show in order to make attitudes and intentions towards safe sex more positive (Moyer-Gusé & Nabi, 2010). They found that levels in which participants engaged in reactance and counter-arguing mediated the attitudes and intentions towards safe sex (Moyer-Gusé & Nabi, 2010). Participants in the inoculation condition showed lower levels of reactance and counter-arguing, and as a result more positive attitudes and intentions towards safe sex than participants in the control group

(Moyer-Gusé & Nabi, 2010). Therefore, we assume that inoculation can have a similar result in a reversed manner. Meaning, that participants in the inoculation condition will engage more in reactance and counter-arguing resulting in more positive attitudes and intentions towards child vaccination. This leads to the final hypothesis:

H3: Participants in the inoculation group will have higher levels of reactance and counter-arguing which leads to more positive Attitudes and intentions toward child vaccination. The study and expectations can be summarized in the following model:

H1(+) H3(+)

H2(+)

Model 1: Model of effects of inoculation on attitude and intention. Reactance Inoculation Intervention Attitude & Intention Counter-Arguing

3. Methods

3.1 General outline of the experiment

Design

The current study is an experiment in the form of a between-subjects factorial design. The

experiment has a control group and an inoculation group. The group in the inoculation

condition is exposed to the inoculation treatment and the attack message while the control

group is only being exposed to the attack message. The attack message consists out of a

narrative in which a mother shares her VAE. A more detailed description of the attack

message will follow in the paragraph on experimental stimuli.

Participants

The sample was a convenience sample consisting out of 66 participants. These participants

were selected through the researcher’s personal network. Fifty-three percent of the

participants where male (35) and 47% of the participants where female (31). The

participants’ age ranged between 23 and 71 (M = 33.50, SD = 6,62). On average participants

had one child ranging between the ages of zero and fourteen (M = 4.02, SD = 6.81). Four of

the sixty-six participants were expecting a child. The majority of the participants finished an

education at a university of applied sciences (HBO) (48.5%). Participants with a masters’

degree where ranked second (25.8%) followed by participants having a vocational education

degree (10.6%).

Procedure

After inviting participants for the experiment, the participants were asked to fill in an

informed consent. This was followed up with questions asked about their attitude towards

child vaccination through the Rijksvaccinatieprogramma. This the official vaccination

program of the Dutch government. Children are being vaccinated against vaccine

preventable diseases over a period fourteen years, when completing the entire trajectory.

This attitude was measured on a 6-point Likert scale with 1 = Very Bad to 6 = Very good.

Inoculation only works with participants who already have a positive or neutral attitude

towards the behavior being advocated (Wong, 2015). In this case that behavior is child

vaccination. Therefore, people scoring their attitudes from 3 = Neutral or higher are eligible

to take part in the experiment.

After the selection of eligible participants, participants were asked for some information on

their demographics as mentioned above. Completing this phase would lead to random

assignment of participants to either the control condition or inoculation condition.

Participants in the control condition got to see the attack message after which their

counter-arguing, reactance, attitudes and child vaccination intentions were measured.

Participants in the inoculation condition entered the threat stage in which they first got to

read a threat message. This threat message gave an explanation about the possibility of

narrative persuasion to affect an individual’s attitude and intention. Following the threat

message was a narrative with weak arguments. After reading the narrative participants in

the inoculation condition got to see a refutation of the narrative they read. This is the stage

of refutational preemption. Following the stage of refutational preemption was exposure to

the same narrative as participants assigned to the control condition. Finally, like participants

in the control condition, participants in the inoculation condition were asked questions that

measured counter-arguing, reactance, attitude and intentions. The experiment ended with

an explanation of the experiment and a fact sheet on child vaccination. The fact sheet on

child vaccination answered all arguments used in the attack message which participants saw

in both the control and inoculation condition.

3.2 Experimental materials

Threat message

Participants in the inoculation condition got to read a message about the possibility of an

attack on their positive attitudes and intentions towards child vaccination. The message also

gave them information that the persuasive attempt will be convincing due to it being

delivered as a narrative. The message was depicted in the following manner:

‘Even though, you have a positive opinion towards the Dutch National Immunisation

Program, you will encounter a lot of messages of organisations targeting your attitude and

opinions towards this program. It is very likely that you will encounter these arguments in

the near future. Some of these arguments are so convincing that you might have doubt your

own opinion. You will now see an example of such an argument.’

Inoculation message

The inoculation message was a narrative as seen on a social media platform. The following

text was displayed in the message:

‘I vaccinated my son as per the Dutch National Immunisation Program. After the first set of

vaccinations my son got diagnosed with autism. I almost know for a fact that there is a link

between autism and vaccinations. I then stopped participating in the program on my own

accord. After quitting the program, I noticed a significant improvement in my son’s

behavior.’

The message was accompanied by an explanation of the fallacies in the story told by the

person. This message read:

Explanation of the aforementioned story

Even though, the aforementioned story might sound troublesome, no scientific proof has

been found that shows a connection between child vaccination and autism. The Dutch Board

of Health and Hygiene as well as the WHO came to this conclusion. Vaccines have been

tested rigorously and continuously on vaccine adverse effects and no links are found

between autism and child vaccination.

The idea that there is a link between child vaccination and autism dates back to 1998. It is in

this year that the doctor Andrew Wakefield came to this conclusion in his research.

However, this doctor was later caught for faking the results in his research. The doctor was

therefore not allowed to practice medicine anymore. His research was therefore retracted.

Attack message

The attack message was a narrative that came from an online forum that promotes anti-child

vaccination narratives. This attack message contained three arguments.

‘All vaccines of the Dutch National Immunisation Program are produced in the

pharmaceutical industry. This industry earns a lot of money with this program. Everybody

knows that this industry’s main priority is to make money and without paying attention to

the welfare of other people. How can we than trust the Dutch National Immunisation

Program?

I’ve always had my doubts, but still vaccinated my first child. After the vaccinations my

daughter continued screaming. This can’t be right! During conversations with some

girlfriends, I learned that their children also responded strange to vaccines. Contrary to my

child, their children became less responsive. Their children also seemed to estrange

themselves. They we’re looking for less contact than before.

The doctor couldn’t understand why I didn’t want to continue with the second phase of the

Dutch National Immunisation Program. I already gave my child three vaccinations. I said that

I was better informed now than before, after which I gave her two arguments. First of all,

vaccination don’t work for 100%, because children can still become ill. Secondly, vaccines

contain deadly metals like aluminum. This was enough for me to end the conversation with

the doctor with my head up high. No more vaccinations for my children!’

3.3 Measures

The foundation for the measurements in order to measure the dependent variables come

from previous studies on inoculation and the way it induces resistance towards persuasion.

Attitudes towards vaccination

Attitudes towards vaccination where measured with five items on a 7-point Likert scale. This

Likert scale has been proven to be an accurate instrument in previous research on attitude

assessment (Wong, 2015; Mason & Miller, 2016; Ma, Nan, Qin & Zhou, 2018). A statement

was followed by polar adjective pairs. The statement: ‘I find child vaccination through the

Dutch National Imunisation Program to be’ was followed by the pairs: 1 = Very Bad/ 7 = Very

Good, 1= Very Negative/ 7 = Very positive, 1 = Very Unnecessary/7 Very Necessary. The

reliability of this scale proved to be good (M = 5.60, SD = 1.42, α = 0.96).

Child vaccination intentions

The measurements used in order to measure child vaccination intentions have been adopted

from the study of Mason & Miller (2016). These probability measurements have proven to

have good reliability in former inoculation studies (Mason & Miller, 2016). The probability

scale ranged from 0-100. It assessed the statement: ‘I would enroll my children in the child

Counter-arguing

Counter-arguing was assessed through thought listing measurements. Participants were

obliged to fill in at least one of eight boxes with thoughts on the attack message. After filling

in the counter-argument(s), participants were asked to rate their thought as either negative,

neutral or positive. In this way participants coded their own thoughts. This made the

identification of thoughts as counter-arguments less erroneous. Previous inoculation

research has proven this method of measuring counter-arguing to be reliable (Wong, 2015).

Reactance

Rains (2013) tested the nature of the concept of reactance in a meta-analysis. Like previous

studies, Rains’ (2013) study concluded that reactance is best measured based on six items

(Moyer-Gusé; Moyer-Gusé & Nabi, 2010; Quintero Johnson & Sangalang, 2018). Four items

assessed the affective component of reactance. These items where measured on a 7-point

Likert scale. The following questions where asked: ‘How irritated were you after reading the

narrative?, How frustrated were you after reading the narrative ?, How angry were you after

reading the narrative ? and How restless were you after reading the narrative?’. All four

questions ranged from one to seven: 1 = Not at all/ 7 = Very Much. The cognitive component

was assessed through two items: ‘The story forced me to think in a certain way’ and ‘The

person in the story forced its opinion on me’. Like the affective component the cognitive

component was measured on a 7-point Likert scale with 1 = Not at all/ 7 = Very Much. The

combined scales showed good reliability (M = 3.73, SD = 1.43, α = 0.84).

4. Results

Main analyses

To test the hypothesis that the effect of experimental condition (inoculation vs control) on attitude and intention towards child vaccination is mediated through reactance and counter-arguing,

mediation analyses were done following the steps outlined by Baron & Kelly (1986). According to this method the analyses were executed in four steps. The first step is assessing a correlation between the independent variable condition (Inoculation x Control) on the dependent variables (Attitude and Intention). Step two was assessing the correlation between the independent variable condition (Inoculation x Control) and the mediators (Reactance and Counterarguing). Step three consisted out of assessing the correlation between the mediators (Reactance and Counterarguing) with the

dependent variables attitude and intentions. The final step is assessing the degree through which the main effects of the independent variable condition (Inoculation vs Control) on attitude and intention are mediated through the mediator variables reactance and counterarguing.

Step 1. Effect of Condition on Attitude and intention

Attitude. A T-test was executed with attitude as dependent variable and experimental condition (Inoculation vs Control) as independent variable. The test showed no significant results t(48)=-3.76 p = .709. Therefore, the conclusion is that experimental condition had no effect on participants attitude towards child vaccination.

Intentions Similar results were found for the T-test conducted with child vaccination intention as a dependent variable and experimental condition as an independent variable. No significant results were found for the effect of experimental condition on child vaccination intentions t(47)= -0.67 p = .510.

Expectations where that participants in the inoculation condition would have higher levels of positive attitudes towards child vaccination. It was also expected that participants in the inoculation

condition would have higher intentions towards vaccinating their children. Based on the two

aforementioned t-tests no significant results were found. The specific means and standard deviations are described in Table 1.

Dependent measure Condition M (SD)

Inoculation Control Attitude towards child

vaccination

5.67 (1,50 ) 5.52 (1,35)

Child vaccination intentions 87.48 (23,55) 83.50 (17,86)

Attitude was measured on a 7-point Likert scale and Child vaccination intentions on a 0-100 point scale.

According to previous studies on inoculation interventions, these interventions affect counter-arguing (Wong, 2015). However, it is argued in this study that inoculation can also induce the

resistance strategy reactance. H1 and H2 consists out of these assumptions. Even though, there were no direct effects of experimental condition on attitude and intention towards child vaccination, it is still important to test H1 and H2. It can still give insight in the effects of experimental condition on the resistance strategies counter-arguing and reactance. However, the T-tests did not give any significant results for both counter-arguing t(49)= -1.47 p =.147 and reactance t(48)= 1.24 p = .223. Therefore, H1 and H2 are rejected.

It was expected that higher levels of reactance and counter-arguing would lead to more positive attitudes and intentions towards child vaccination. Due to expectations being that participants in the inoculation condition would have higher levels of reactance and counter-arguing, expectations were that this group would have more positive attitudes towards child vaccination and higher levels of child vaccination intentions. It can now be concluded that H3 can be rejected based on the previous analyses. However, it is still not clear if reactance and counter-arguing affect attitudes and intentions toward child vaccination. Therefore, regression analyses were executed.

The first regression analysis was executed with attitude as a dependent variable and reactance as an independent variable. No significant effects were found (Β=.012; t = 0.85, p = .993). Due to lack of a significant regression equation R² = .000, F(1, 48) = .007, p = .933, the regression model has no predictability.

A simple linear regression analysis was also executed in order to predict attitude with counter-arguing as its foundation (Β=-.014; t = -0.99, p = .328). Like the previous regression analysis, this regression model also lacks predictability R² = .020, F(1, 48) = .976, p = .328.

Simple regression analyses were also executed for the dependent variable intention with reactance and counter-arguing as independent variables. The simple linear regression for child vaccination

intention with reactance as independent variable did not show any significance (Β=-.198; t = -1.381, p = .174). Again, the regression model did not show any predictability R² = .039, F(1, 47) = 1.908, p = .174.

Finally, the last simple linear regression analysis for child vaccination intention with counter-arguing as independent variable was not significant (Β=.001; t = .004, p = .997). Therefore, the regression model did not show any predictability R² = .000, F(1, 47) = .000, p = .997.

Expectations where that participants in the inoculation condition would have higher levels of

reactance and counter-arguing which would lead to more positive attitudes towards child vaccination and higher levels of vaccination intentions. However, based on previous analyses it now be

concluded that H3 can be rejected.

5. Conclusion and discussion

The aim of this study was to test if an inoculation intervention can induce resistance in parents (to be) with neutral and positive attitudes and intentions towards child vaccination against anti-child vaccination narratives. In doing so it might be possible to find an

intervention capable of halting the general trend of child vaccination hesitancy as reported by health organizations like the WHO (Clemmons, Gastanaduy, Fiebelkorn, Redd, & Wallace, 2015; Schuster, Eskola & Duclos, 2015; MacDonald & The SAGE working group, 2015). The scientific value of this research would be to acclaim insights in how inoculation affects resistance strategies used by people to ward of persuasive attempts by narratives. Previous studies have shown that narratives can overcome the resistance strategies reactance and counter-arguing (Moyer-Gusé; Moyer-Gusé & Nabi, 2010). Even though, previous studies have shown that counter-arguing can be induced through inoculation, little is known of its effects on inducing reactance (Wong, 2015). Therefore, this study also ads to the scientific literature in testing inoculation’s effects on the resistance strategy reactance, as well as studying these strategies in a child vaccination context.

Expectations were that participants in the inoculation condition would have higher levels of reactance then participants in the control condition (H1). This hypothesis was rejected due to no significant results to be found. Expectations for the second hypothesis were that

participants in the inoculation condition would engage more in counter-arguing than

participants in the control condition. Due to no significant results (H2) was also rejected. For our final hypothesis expectations were that counter-arguing and reactance would mediate between the independent variable condition (inoculation x control). Again no significant results were to be found. Therefore, the final hypothesis (H3) was rejected.

Theoretical limitations

Aside from the sample size there might be limitations in the experimental stimuli. Specifically, the threat message used in the inoculation condition. Due to the covert persuasiveness of narrative persuasion resistance strategies like reactance were not triggered. An explanation of the workings narrative persuasion in the threat message might lead to this strategy being triggered. This would let the threat message besides acting as a forewarning, and also attain an educational function. However, this would mean that the intervention is an inoculation intervention and would be more a media literacy intervention. Threat messages in original inoculation interventions do not have an educational element in them. They operate based on heightening the fear of a persuasive attempt (Banas & Rains, 2010; Wong, 2015; Banas & Rains, 2017).

These limitations have to do with the resistance strategies people use to ward of persuasive attempts. The foundation of this study where the propositions proposed by Fransen, Smit & Verlegh (2015). They proposed that the resistance strategy used by people depends on the motivation for resisting the persuasive attempt. Yes, when there are threats to freedom people will engage in reactance. In fear of deceit people do result to counter-arguing. However, these are not the only resistance strategies available to people when in the two aforementioned motivational states. People can also result to source derogation when they have concerns of deception. Likewise, people can also engage in attitude bolstering when experiencing a threat to freedom. It could be possible that these strategies have also been employed. Zuwerink Jack and Cameron (2003) have studied and tested the use of resistance strategies in people. They concluded that there is a high possibility of the use attitude

bolstering and source derogation. However, they did not find reactance being used as a resistance strategy in their sample (Zuwerink Jack & Cameron, 2003).

Methodological Limitations

No significant results where found when it comes to main effects. It is obvious to state that this could be ascribed to the sample size (N=66). Statistically speaking, the larger the sample size the larger the chance on significant results.

Future research

More study in the use of resistance strategies against narrative persuasion should be done. Current studies focus on the use of narrative persuasion in order to promote health behavior. In these studies, the main strategy studied is counter-arguing. However, other resistance strategies may be at play.

The relationship between reactance and inoculation have not been proven. However, this is one of the view studies in which this relationship was tested. As a result, it can be concluded that the role of reactance might not be as large, as studies on narrative persuasion suggest. As for the societal relevance, it is advised that future research should focus on the education of parents (to be) in the workings of narrative persuasion in order to protect their attitudes and intentions.