Jun 05 2012

Education and Vaccine Uptake

A new study, not published but to be presented at a meeting, purports to show that after the infamous Andrew Wakefield 1998 Lancet article alleging a connection between the MMR vaccine and autism, vaccination rates in the US declined by about two percent. This may seem like a small amount but has an effect on public health, and vaccine refusal typically occurs in pockets that bring vaccination rates below the level needed for “herd” immunity, allowing for outbreaks.

This, however, is all old news. There are two other pieces of information in the study that are interesting. The first is that the decrease in vaccination rates did not rebound after Wakefield and his Lancet study were thoroughly refuted. That genie was out of the bottle, and correcting the misinformation did not have the desired effect of putting it back in. This too is in line with other research and experience. It is easier to spread fear than reassurance. Once rumors are spread the damage cannot be undone.

The study also purports to find that the there was an inverse relationship between education level and vaccine use – college-educated mothers were less likely to vaccinate their children. Further, in the 8 years after the Lancet study this gap increased. This education-gap is also in line with previous research, but needs some explanation. We need to distinguish unvaccinated from undervaccinated, and vaccine non-compliance from vaccine refusal. When looking at the undervaccinated, and specifically those who missed scheduled vaccines, this correlates with lower socioeconomic status and less education. This is in line with a more general pattern – the fewer resources a family has the less likely they are to avail themselves of available health care.

However, if you look at those who refuse or delay vaccines as a deliberate choice, there is a positive correlation with the education level of the parents, especially the mother. This may seem paradoxical at first – higher education leading to bad health care decision making, but actually it makes perfect sense. First, let me say that I am taking as a premise that refusing vaccines is a bad decision. For reference just plug in “vaccine” into the search box on this blog and you can read dozens of articles explaining my position.  In short, the evidence overwhelmingly supports the conclusion that vaccines are safe and effective and a net health benefit for the vaccinated. Fears over vaccines causing autism or other neurological damage are based upon soundly refuted pseudoscience. So why, then, the reverse correlation with education?

The typical hypothesis, which is plausible but untested (as far as I know), is that higher education levels leads to greater access to information, specifically on the internet, where vaccine fears have largely been spread. If you are not exposed to misinformation about vaccines then you cannot act on that misinformation.

I also think, however, that this is part of a larger phenomenon – a direct relationship between education level and general acceptance of pseudoscience. Prior surveys have found a correlation between higher levels of education and belief in ghosts, ESP, and alien visitations. Education superficially seems to make us more gullible. However, the interpretation of this result, in light of other psychological research, is different than just gullibility. Access to information is likely part of the reason for the correlation between education and belief. Another factor is likely that as we get smarter we get better at justifying our own beliefs. Having an education can make someone more confident in defending their offbeat beliefs, and better able to defend those beliefs from the skeptics.

This is a sobering realization. It is partly the result of human psychology, but also partly an indictment of our educational system. We cannot change human nature, but we can transcend it by understanding that nature and developing methods to compensate for it. We would call these methods critical thinking, or perhaps metacognition. We need to teach students not only how to access information, but how to think about it critically, and how to examine their own thought processes for flaws and pitfalls.

The relationship between education and paranormal belief is more complex than the study I linked to above would suggest. A Finnish study found that the areas of study made a difference. University students and those studying psychology and medicine had less belief in the paranormal while vocational students and those studying education and theology had higher beliefs. The authors interpreted this as those having a more analytical style of thinking had less belief in the paranormal than those with an more intuitive style of thinking.

This all goes along with one of the major premises of the skeptical movement – that education alone is not enough, you have to teach students how to think critically and be more skeptical. This is increasingly true in the internet age. We are exposed to all sorts of information, which appears to be counterproductive and lead to greater misinformation than accurate information, unless we also have the scientific literacy, critical thinking and metacognitive tools to properly assess that information.

23 responses so far

23 thoughts on “Education and Vaccine Uptake”

  1. LTerry says:

    Dr. Novella,

    A great post, as usual. I might add, as someone who teaches in a university in the humanities, that many of my colleagues are perhaps the most likely of all to avoid vaccinations. When questioned, most of them respond with a post-modernist brand of relativism in which the sciences are simply an ideology akin to capitalism that seek nothing other than to perpetuate themselves and their profits. The brand of post-modern or post-colonial suspicion that is very much a part of the general humanities education in North America today is deeply hostile to science in general, and many people, after reading Foucault, Adorno, and Derrida, take up the deconstructionist toolbox to resist what they see as the ideological construct of scientific discourse. Many of these people, while ‘educated’ in the basic sense of the term, know nothing about science, while still considering themselves enlightened and critical thinkers. I think that the rise of this “hermeneutics of suspicion” since the 1960s is largely responsible for the intense grip of conspiracy theories among those educated in the humanities, especially if their education involves a post-modern suspicion of science in general.

  2. wfr says:

    A small nit:

    …an inverse relationship between education level and general acceptance of pseudoscience…

    Wouldn’t that be a direct relationship?

  3. Granis says:

    I don’t think so, wfr.

    As education level decreases (relative to some average), general acceptance of pseudoscience increases. That’s an inverse relationship. Both would have to increase or decrease to be a direct relationship.

  4. wfr is correct. I meant direct relationship. I think I started the sentence one way and then finished another. It’s correct now.

  5. Sanclus says:

    A good article on a topic that I have discussed numerous times with those opposed to vaccines; often to little or no avail. The dismissal of the tested and tried science behind vaccines definitely smacks of post modernism. You hit the proverbial nail with your discussion of critical thinking. The lack thereof is a danger to us all. The advancement of critical thinking is, perhaps, our most important task as skeptics. How we will do that is the story yet to unfold.

  6. Sastra says:

    Is there such a thing as “identity science?” Meaning, you start with the assumption that true “science” is whatever you experience for yourself: thus, one picks and chooses the “scientific” or empirical viewpoint not based on objective assessment of the facts or an understanding of how they are weighed by experts, but in order to express yourself, join a group, or be counted as a certain type of person. You “believe” in pharmaceutical conspiracies, alternative medicine, and anti-vaccination propaganda because you are a concerned mother, empowered equally by a love for nature and a rebel spirit. It’s a signal that you belong to a certain enlightened class of people.

    Identity Science might help account for the hostility to attempts at correction. People are trying to change who you are! You reject vaccination for the same reason you love opera. It is what people like you do.

    I don’t know. Maybe.

  7. SARA says:

    Skeptics (myself included) are convinced that teaching critical thinking skills will help eliminate some of the misconceptions people seem hold. But are we wrong?

    Is there any research that supports our position that learning critical thinking skills will eliminate most of the misconceptions and superstitions. Or does it only help people who already have an entrenched misconception to argue harder for their position?

  8. NewRon says:

    Michael S Roth in the June 6 2012 edition of The Chronicle of Higher Education states:

    ‘The skill at unmasking error, or simple intellectual one-upmanship, is not completely without value, but we should be wary of creating a class of self-satisfied debunkers or, to use a currently fashionable word on campuses, people who like to “trouble” ideas. In overdeveloping the capacity to show how texts, institutions, or people fail to accomplish what they set out to do, we may be depriving students of the capacity to learn as much as possible from what they study. In a humanities culture in which being smart often means being a critical unmasker, our students may become too good at showing how things don’t make sense. That very skill may diminish their capacity to find or create meaning and direction in the books they read and the world in which they live. Once outside the university, our students continue to score points by displaying the critical prowess for which they were rewarded in school. They wind up contributing to a cultural climate that has little tolerance for finding or making meaning, whose intellectuals and cultural commentators delight in being able to show that somebody else is not to be believed.’

  9. NewRon says:

    Sorry, wrong date: should be Jan 3 2010.

  10. ferrousbueller says:


    I think you raise a very good point. I did an undergrad in Physics, and felt that it really helped to hone my critical thinking skills. However, I have a classmate who entered the program as a bit of a conspiracy buff, and left it as a conspiracy nut. During this time, he strengthened his ability to scan the literature for evidence that supported his climate change denial and his anti-vaccination stance, but didn’t develop the ability to objectively examine his own views. I don’t know how much hope there is for people like this. It’s fairly common, especially amongst academics, to lack a sense of self-doubt and capacity for critical analysis of one’s own beliefs.

  11. BillyJoe7 says:

    Michael S Roth in the June 6 2012 edition of The Chronicle of Higher Education states:
    “our students may become too good at showing how things don’t make sense”

    Those students would have no trouble showing how Roth’s article “don’t make sense”.
    It’s rarely a good idea to suppress the truth because the lies are comfortable.

  12. Sanclus says:

    Regardless of the above discussion, critical thinking is essential for the advancement of science as well as the welfare and survival of the human species. To argue against such a positive because certain people employ some of the same skills used in critical thinking to further their own agenda is underwhelming. Anecdotal evidence aside, self-doubt is endemic to humans, and an irrefutable sign of intelligence. I understand what Michael Ross is trying to say, but I see learning as becoming even more efficient when a student has mastered critical thinking as applied to concepts, ideas and historical documents. Inquiry should never be censored by fear of negative result.

  13. ConspicuousCarl says:

    This of course raises a whole bunch of questions, only some of which I can think of:

    Are the more-educated non-vaccinators tilted towards being a “pocket” member (via proximity or communication), drawing from independent conclusions/research, or do they have no special tendency in that way?

    What is the actual range of education involved? (e.g., what level of education above average makes someone 50% more likely not to vaccinate)

    If post-hoc rationalization plays a part, that doesn’t explain the acquisition of the belief. But supposing it is involved (and established evidence of intelligent rationalizers suggests it might), I would suppose that it would have to go something like a certain % of all people believe the rumors, but only those with rationalizing skills are confident enough to refuse vaccines in the presence of a doctor. That leaves the rather sad question: Are there parents vaccinating their kids while simultaneously suffering under a fearful belief?

    Depending on the strength and range of the education/refusal correlation, is the jump from education to intelligence reasonable here? I recall (recklessly not researching here) there being a general correlation between intelligence and education level, but I thought it was inconsistent.

  14. SARA says:

    @NewRon. I don’t see why developing “debunking” skills will adversely affect the ability to learn something. For example, I am not a Buddhist, but I find much of their philosophy very compelling and have incorporated some of it into my own personal world view. Of course that is anecdotal, but I don’t see much evidence that the author’s position is true either.

    @Sanctus. I agree. Particularly regarding the self doubt. I don’t think knowing whether teaching critical thinking helps people make more rational assessments on a daily basis will change it’s value to science. I think (without any evidence) that knowing which lessons help people incorporate critical thinking in their daily life and which don’t is the best chance we have to turn the tide of human ignorance.

  15. Sanclus says:

    @ Sara Good point, I agree. One thing that always surprises me (despite how often I am confronted with it) is the uphill battle that I need to engage in to simply encourage critical thinking. There are times where I feel that I surrounded by a population of witch-hunting, blacklisting fools. Even friends and family with whom I have a life-long association have gone down the road to pseudo-science, false controversy and supernatural fixations.

  16. Cow_Cookie says:

    A bit of anecdotal evidence to challenge the “plausible but untested” is in this article:


    From the article:

    “Somali parents of children with autism and the Minnesota Department of Health are at a standoff over vaccines. The parents suspect vaccines have caused autism in their children, while the Health Department says there’s no evidence of a link. … Measles was once almost wiped out in Minnesota, but so far this year 23 cases have been reported — a third of them among Somalis.”

    I don’t know education rates among the Somali population. But I do know the state has one of the widest “achievement gaps” between white students and minority students (a major concern among educators in the state) and that it is plausible that an immigrant community would have lower education rates than established populations. So it’s, again, plausible that the Somali community has lower education rates than the population at large.

    The 32,000 Somalis in Minnesota accounted for just .6 percent of the state’s 5.3 million people in 2011. Yet they made up a third of the measles cases that year. So we’ve got a population that appears to be going against the trend of more education=greater susceptibility to pseudoscience.

    *My* untested hypothesis would be that humanity as a whole has a fixed level of gullibility. Development of critical thinking skills may reduce that gullibility, but bad education isn’t going to make it much worse — because it’s already so bad. Any relationship we see between belief in a particular pseudoscience and education has more to do with how that pseudoscience meshes with the existing ideology prevalent among that group.

    In this case, anti-vaccination belief stuck among the educated crowd because it aligns so closely with other natural fallacy beliefs prevalent on college campuses. But it would be unlikely to stick among those who reject the natural fallacy — even if they embrace other pseudosciences, such as global warming denial.

    For other pseudoscientific beliefs, you’d see the opposite. The point is that the underlying link is not education; it’s culture and ideology. Education in this case is just one variety of culture and ideology.

    That’s why you see the Somali population embracing a pseudoscience despite what is likely a below average education among that population. There is a significant level of distrust toward the government — hence, they distrust the Health Department’s vaccine recommendations. Similarly, anti-vaxers reject vaccines not because of their education, but because they already have a bias against non-natural remedies.

  17. PharmD28 says:

    Great Post,

    We had a couple we know go down the semi-anti-vax route after reading a quacky anti-vax book (something like what your doctors are not telling you about vaccines).

    The wife was indeed the person motivated about the issue…happened to be some friend of her’s has an autistic child that “got the shot, then had terrible autism”.

    Motivated reasoning indeed! The fallacy in the whole beginnings and fear she experienced that created the initial basis for what became a big series of “research” that consisted of cherry picking sources that confirmed the suspicion she had rooted in the anectdote.

    Most discussion of pseudoscience in soooo many cases gets back around to discussion of anectdotes….and in her case her inability to be properly knowledgeable about the limitations of the anectdote was the root cause.

    She eventually got around to asking me about it…then I quickly learned that she only wanted to validate all the reading, research, and poor decision making made to date. In 2 minutes I effectively invalidated the book…without knowing anything about the book, I asked her if the book cited compelling scientific research that would show evidence based concerns for thiomersal and/or MMR to cause autism….she replied that it did (although I guarantee she never read the references) – then I asked her for the book and very quickly found the like 12 pages on thiomersal and we looked at their references…a) it had like 3 in vitro weird study references and b) zero mention of the RCT’s related to MMR and thiomersal and not even an attempt in the book to address that research.

    After pointing this out, then we had reliance on the anectdote.

    She and his wife also seemed to think this a bit like pascal’s wager…the husband at one point downplayed the significance of getting a viral infection…..I pointed out some of the states pre and post various vaccinations and the sequelae of these….

    Of course, the books and other mis-information, build such massive straw men that a loving caring and otherwise not sufficiently critical parent will think they are making the more prudent decision, and attempts to point out the fallacy in this are viewed as ideological rants from those that are not sufficiently critical (from their viewpoint).

    I offered her to read Paul Offit’s book as giving due diligence to both sides of the argument…seems like a reasonable request for a concerned parent to compare the reason, logic, and evidence…but again, it seemed that motivated reasoning won the day..

    She did end up getting some modified series of vaccinations that the book recommended….bunch of horse shit.

  18. ccbowers says:

    “Or does it only help people who already have an entrenched misconception to argue harder for their position?”

    Well learning critical thinking skills certainly is no guarantee that one will think actually think critically, but it would at least give a person access to the tools to do so. I think this issue is relevant to education in general in that a person may feel more confident that their opinion on a topic is more informed than it really is just based upon that education.

    I think the key in the case of the person with the “entrenched misconception” is that the learned critical thinking skills must also be applied inwards. Perhaps that is an important lesson for teaching such a class… not to just give examples of errors in other people’s arguments, but to force people to look within for errors in thinking. But after such a class is over, each individual must value intellectual integrity enough to continue to apply it to their lives. Realistically most will not, but some will and that is all you can hope for.

  19. Gotchaye says:

    I’m basically with ccbowers.

    Critical thinking should not be taught as a weapon. Its value is not in being able to destroy a target idea. The point is to be able to weigh competing ideas, including taking a stab at weighing hypothetical ideas that we haven’t even had yet (“is this an X, a Y, or something we haven’t even thought of yet?”), and a sense of intellectual “fairness” is absolutely vital to the process. No sacred cows and all that. Unfortunately, it’s often the case that when people develop a bit of sophistication they turn their critical faculties on only the things that they’re predisposed to disagree with.

    “How can you be good without God?” is a great example. The claim is that an atheist has no reason to think that there is such a thing as a moral fact, or at least that an atheist couldn’t discern a moral fact, and therefore those who are committed to moral facts should prefer theism. The first half of that is an interesting and not obviously wrong claim (well, it’d be interesting if it weren’t thousands of years old). But we’ve recognized since the Euthyphro that, really, the theist has no better reason, and so we know that the “therefore” is completely unjustified. That this so often goes completely unrecognized is a failure to think critically (or to have even a basic familiarity with the history of philosophy of religion).

    I’m not sure how you’d go about teaching critical thinking other than by having students debate, with an instructor stepping in to moderate and critique. Students /have/ to have their own ideas challenged and set up as being the same sort of thing as the ideas that they disagree with. Students should be confronted with undeniable examples of their own wrongness, and they have to be made to understand why they were wrong. This could be coupled or introduced with teaching about cognitive biases – set up situations where cognitive biases will often cause students to reach the wrong answer and then pull back the curtain and /show/ them that they were wrong. Probably doing that well would take many semesters, though I think it’s valuable enough to be worthwhile. Unfortunately it’s also going to be very hard to test and see if students are learning well and then if what they’re learning is valuable.

  20. NewRon says:

    For what it is worth, I believe that for good educational outcomes the hermeneutics of suspicion should be balanced with the hermeneutics of restoration. It is a matter of emphasis. It seems to me that critical thinking by itself requires an established point of view, an established ideology perhaps, that allows a standard for the views of the other to be measured against. By itself, then, there is a preclusion of the possibility of an alteration to this established position. Genuine dialogue except that within the world view of those engaged in critical thinking events becomes impossible. I know that volumes have been written on this and one could argue for ever on variations to this theme. No one I know of – including Michael Roth – would say that critical thinking skills should not be taught.

  21. Calli Arcale says:

    Cow_Cookie: for every rule of thumb, there will be exceptions. That vaccine refusal correlates with higher education rates does not mean that it is always true. Homeschooling religious fanatics are often both poorly educated and vaccine refusers, for instance. However, they don’t make up a large percentage of the population.

    The Somalis in Minnesota are an interesting case. I live in the Twin Cities, and I see Somalis every day. We have a disproportionately large Somali population compared to other states. They are a refugee immigrant population, which in and of itself is going to increase the rate of undervaccination simply because of the inherent challenges facing a refugee immigrating to a strange (and cold!) land where they don’t yet speak the language. Like all large immigrant groups, they tend to congregate, for fairly obvious reasons — it’s nice to have somebody to talk to who understands you. When they first came over, they were not generally opposed to vaccination. Nor to education; in fact, Somalis historically are in favor of universal education, including of girls, and historically have had a very high literacy rate compared to neighboring countries, and prior to the collapse of their government and the explosion of civil war, sent a lot of young people to higher education, in Mogadishu and abroad. Today, a lot of them are attending the University of Minnesota.

    So what happened? Well, Andrew Wakefield happened. The timing was spectacularly bad — Somali parents were just coming to grips with the concept of autism (education is revered in Somalia, but mental health care is less than primitive; the mentally ill or developmentally delayed are shunned there) and expressing shock when public school early education screening programs revealed likely problems. (Our public schools screen all children by age 4, preferably 3, to see if they qualify for early intervention, and they will do full-up autism screenings. It is not considered a diagnosis, and they encourage seeking a psychologist for a real diagnosis, but it’s a major boon to those who cannot afford that sort of screening.) So here they were, in a strange land, homesick, and being told their child has autism.

    Then Andrew Wakefield showed up. I don’t recall which of the vaccines-cause-autism groups had arranged his lecture, but he went to one of the major Somali community centers and gave a lecture telling all of these parents how qualified he was and about his research showing that the MMR vaccine causes autism. The results were predictable. It didn’t take long for a backlash; there are already Somali parents furious with him because they trusted his stated credentials, believed his story, didn’t vaccinate their children, and then had to sit in the hospital while the kids recovered from the measles. They were lied to, and many of them recognize it. But it will take a while for the damage to be undone.

  22. BillyJoe7 says:

    This blog post…
    …has been nominated for the “2012 3QD Science Prize”…

    It shows how information gets distorted from research, through op-eds, newspaper articles, and ulimately to the facebook entiries of the lay public reading these articles.

    It gives an example where the research is about the effect of toxins on neurodeveolpment – in which no conclusion is reached except that more research should be done on ten most likely suspects – and ends with the public reading a newspaper article on that research, titled “Top 10 Chemicals Most Likely to Cause Autism and Learning Disabilities”, and concluding that vaccines causes autism in their facebook commentary.

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