The Backfire Effect Part 1:
Motivated Reasoning

Have you ever had a difficult time convincing a patient to do what you said? I'm sure the answer is an almost universal "yes." For example, you sit there counseling your diabetic patient about how he should check his blood sugar and check his feet, only to see him later with an acute ulcer and infection. You instruct your postop patient to remain nonweight bearing only to observe dirt and holes in the cast bottom. Sometimes it seems that not only is your advice ignored, but your patients actually become further entrenched. Sometimes our very well intentioned advice has the opposite effect – it backfires. Why does this happen?

Recently, I was introduced to an interesting research study in the journal Pediatrics.¹ Researchers studied the effectiveness of vaccination education on patient views of vaccination policies. The authors studied 1759 parents age 18 years and older. They first surveyed parents for their attitudes toward vaccination and if they had ever delayed or refused a recommended vaccine.

Respondents were then randomly assigned to receive one of four pro-vaccine messages or a control. The interventions were:

• Correcting misinformation
• Presenting information on disease risks
• Dramatic patient narratives
• Displaying visuals to make risks more salient

The actual material used were CDC education materials correcting autism caused by (#1) vaccines misinformation; (#2) information on measles, mumps, and rubella; (#3) a patient narrative; (#4) and pictures of children with these diseases. The control was text information about the costs and benefits of bird feeding.

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The authors looked at three primary outcomes:

• Misconceptions about vaccinations causing autism
• Perceptions about MMR side effects
• Likelihood parents would vaccinate their children in the future

Demographic distribution of the randomly sampled study population was representative of the United States as a whole. The results can be quickly summarized as follows:

• After intervention #1 (correcting misinformation) respondents were less likely to vaccinate their children
• No other intervention significantly increased respondent intent to vaccinate

Interestingly, when the researchers looked at the results separately they found that after viewing Autism disinformation corrections those respondents who already had a low opinion of vaccination were even less likely to vaccinate in the future. The likelihood to give MMR actually decreased from 70% in the control group to 45% in those given Autism debunking information! Providing education with the intent to inform parents that Autism is not caused by vaccination actually caused many of the parents to dislike vaccination even more – a backfire effect if there ever was one.

The researchers concluded that these patient education methods "do not always work as intended" and that message effectiveness depended on prior attitudes. The authors explain this phenomenon as follows: "This finding suggests respondents brought to mind other concerns about vaccines to defend their anti-vaccine attitudes."

Psychologists call this type of response motivated reasoning, in which people form and cling to false beliefs despite overwhelming evidence to the contrary. This effect was discussed by psychologist Ziva Kunda as occurring for three primary reasons²:

• Reducing cognitive dissonance (psychological stress brought on by holding two contradictory opinions or beliefs)
• Beliefs about others upon whom one's own outcomes depend
• Evaluation of evidence relating to one's own outcomes

In essence, many of us are hardwired for a rapid, emotionally-based attitude about certain beliefs we hold very strongly.  When exposed to information that contradicts attitudes or beliefs we hold strongly we will harden our attitudes and disbelieve even more strongly the new contradictory (and possibly correct) information.

How can we, as healthcare workers that care about the well being of our patients, communicate most effectively with those patients likely to use motivated reasoning and not listen to our advice? More on this to come next week.

Best wishes,

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References:

1. Nyhan B, et al. Effective Messages in Vaccine Promotion: A Randomized Trial. Pediatrics. April 2014; 133(4):e835-e842.
2. Kunda Z. The Case for Motivated Reasoning. Psychological Bulletin. 1990;108(3):480-498.

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