שנת סיום: 2021
כותרת עבודת הדוקטורט: Decision-Making in Arab and Jewish Society about the Human Papillomavirus (HPV) Vaccination and the Seasonal Influenza Vaccination
מנחים: פרופ' ענת גסר-אדלסבורג ופרופ' גוסטבו מש
Abstract
Research Framework: Examining the behavioral, cognitive, social, cultural and logistic factors that affect health behavior and influence decision-making has become more and more important in the field of public health. Most studies indicate that Arab minority groups in Western countries are usually less compliant in vaccinating their children. On the other hand, an examination of vaccination compliance among the Arab population of Israel before the coronavirus crisis reveals a different picture marked by very high vaccination compliance, even relative to the Jewish majority. According to recent figures from the Ministry of Health (2019), the compliance rates in the Arab sector for the seasonal influenza vaccination and the human papillomavirus (HPV) vaccination are almost twice as high as the compliance rates in the Jewish sector for the same vaccinations. In addition, it is interesting to note that prior to the coronavirus crisis no groups in Arab society exhibited vaccination hesitancy, in contrast to the situation in Jewish society.
Objective: The current study seeks to investigate the decision-making process of mothers in Arab society with respect to two vaccinations: the HPV vaccination and the seasonal influenza vaccination. Further, it seeks to examine the variables related to this process and their correlation with the emotional and cognitive considerations manifested in the process of making decisions about vaccinations.
Research methodology: This study is based on a sequential explanatory design. The first stage entailed gathering and analyzing the qualitative data: a) content analysis of 18 explanatory materials published by the health maintenance organizations and the Ministry of Health that were designed to promote the HPV vaccination in the Arab society; b) conducting in-depth interviews with mothers from Arab society and health professionals (N=70 mothers and N=20 nurses from Arab society). Based on this stage, a quantitative questionnaire was constructed and answered by different subgroups from the representative sample of the investigated population: N=693, comprising six subgroups (Muslims, Christians, Northern Bedouins, Druse, secular Jews, religious Jews).
The mixed research method adopted in this study facilitated integration of the perspectives and means for understanding the relevant considerations in vaccination compliance (Creswell, 2013). Data triangulation made it possible to achieve better cross-checking of the data and to develop strong and validated arguments backed up by data collected from subgroups in the Arab population, while using the Jewish population as a control group (Creswell, 2013).
Main findings: The research findings indicate that for the most part the decision-making process of mothers in Arab society relies upon an automatic system (as defined by Kahneman, 2011) based on various emotional heuristics emerging from this study. We described the research findings along two paths: 1) variables we referred to as internal social-cultural variables that are inherent in the social structure of the Arab population; 2) variables we called external variables that are related to how the health system conveys information on the issue of vaccinations to Arab society.
Several variables are included in the internal social-cultural path. The findings indicate that most of the ethnic subpopulations in Arab society identify trust as the most significant factor in their decisions about vaccinations. Mothers in Arab society place high trust in professionals from Arab society, i.e., family doctors and even more significantly, nurses working in the Tipat Halav Family Health Centers. It is reasonable to assume that this trust in professionals is tied to the Dunning-Krueger effect, according to which people who do not possess the skills needed to assess their own knowledge vis-à-vis experts tend to rely on experts’ opinions. At the same time, in Arab society the level of trust in the medical system and the medical establishment is low. The study also found that participants saw vaccinations as a means of ameliorating discrimination. That is, they saw vaccinations as a privilege given to the Arab population as equals to the Jewish population. This perception is associated with the affect heuristic in decision-making, i.e., the mechanisms that affect acceptance of an issue. Moreover, the research findings also point to the role of perceived risk in the mothers’ decision-making process: Most of the mothers in Arab society perceive vaccinations as a means of preventing dangerous diseases and pay less attention to the risk of side effects or health implications. The decision to be vaccinated because of perceived risk of disease is related to the type of vaccination, such that different heuristics play a role. The ambiguity aversion heuristic describes the preference for complying with a vaccination to prevent an illness that is relatively unknown to parents. In this study, this heuristic is manifested in the mothers’ decision-making process regarding the HPV vaccine. In contrast, the omission bias heuristic, which describes the tendency to prefer damage caused by omission over taking action, found expression in the study in the mothers’ decision-making regarding the seasonal influenza vaccine. Another variable associated with decision-making is health literacy, which is also related to level of education. The research findings show that Arab mothers have more difficulty searching for information about the studied vaccinations than do Jewish mothers. Their low health literacy prevents Arab mothers from being exposed to materials describing topics of scientific controversy. Thus they rely almost exclusively on the information provided by the health establishment.
The external variables are related to the means used by the health system to convey information, including both the content of the information and the strategies employed to convey it. The findings of the current study revealed three main points: 1) A lack of transparency in materials geared to Arab society. Content analysis of the explanatory materials published in Arabic on the Ministry of Health website and the websites of the different health maintenance organizations promoting the HPV vaccine showed that these materials did not make any mention of the sexual context of the vaccination, while this context was mentioned in materials written in Hebrew targeting the Jewish population. 2) Incompatibility with the health literacy level of Arab society, which made it difficult for the mothers to read and understand information on the HPV vaccination. 3) Explanatory materials intended to promote vaccinations in Arab society do not alleviate the fears and concerns of mothers in Arab society. 4) Framing vaccinations: The explanatory materials frame the HPV vaccination as a vaccine that prevents cervical cancer and not as one that prevents a virus transmitted by sexual relations. 5) Providing legitimacy by introducing the two vaccinations into the school-located vaccination program. The research findings show that mothers in Arab society tend to believe that giving a vaccination into the school setting testifies to its high level of safety.
Scientific contribution: This is a pioneering study. To the best of our knowledge, it is the first to offer an in-depth examination of the variables influencing decision-making processes among various subgroups in Arab society rather than referring to the entire society as a single entity. The study’s theoretical contribution lies in its proposal of two main decision-making models among mothers in Arab society. The study found that at present, decision-making is based primarily on an automatic system (emotions, experience, intuition, framing and the like) (Kahneman, 2011). The alternative decision-making model proposed in the study is a culturally appropriate and analytic risk communications model to help mothers in Arab society make intelligent and knowledge-based decisions.
Practical implications: Current risk communications literature clearly indicates that if health authorities do not provide full and transparent information and do not take the public’s fears and concerns into consideration, this communication will most likely be ineffective and have a boomerang effect. That is, such communication will cause the public to doubt whether the information is reliable or suspect that the authorities are hiding information from them. In the current age of new media, the public is exposed to a great deal of information. Hence, if the public does not receive what it needs from the official authorities, it will seek other sources of information. Moreover, it is important to make information accessible to various population subgroups in accordance with their needs, literacy level and trust, rather than to treat them as a single entity. The practical contribution of this research to public health lies in its exposure of a deeper foundation that will facilitate developing health communication programs geared to different subgroups in the population.
Conclusion: improving the ways in which the authorities communicate information to the Arab population will help build trust, not only in the agents (nurses working in the Tipat Halav Family Health Centers and doctors) but also in the entire health system. This trust is extremely important in achieving cooperation in present and future epidemiological crises, such as the current coronavirus crisis in Israel.