Potential consequences of invoking ‘natural’ in health promotion: Part 2 of 2

Source: United States Breastfeeding Committee.

When this conversation about breastfeeding being natural and its implications started, I thought a lot about how many families, including mine, get a good dose of parenting advice and health care information on the internet. Because I tend to distrust medical professionals, I almost always consult other resources (trusted individuals and the internet) for supplementary information when making choices that impact my children’s health.

But the internet is saturated with articles that claim this and that and the other thing, and there’s “evidence” to prove it all. Many parents, including myself, don’t have the expertise to recognize good research design or truly grasp the abstract nature of statistics. Other things happen when we seek out information on the internet and elsewhere: confirmation bias and the backfire effect. These terms are used by cognitive scientists and psychologists to describe the following reactions:

Confirmation bias is our drive to prefer information that appears to affirm our core beliefs.

On the other hand, when we are exposed to information that runs counter to our core beliefs, we may have one of the following responses:

  • Motivated skepticism: examining information with doubt that it is true, actively looking for flaws in the information
  • The backfire effect: rejecting information that challenges our strongly held beliefs; research indicates that being overwhelmed with a good deal of such information may actually strengthen the belief it is meant to challenge.

Turner-Maffei provides a few examples from the lactation world.

“The first news about Vitamin D deficiency in breastfed babies resulted in motivated skepticism on the part of breastfeeding advocates,” she begins. “Many dug into the research looking for problems and oversights, demonstrating motivated skepticism. The fact that we are motivated to attack information that seems to run counter to our beliefs (in this case, breast is best, why would babies need extra vitamin D?) shows how deeply held these beliefs are, close to our personal and group identity. We are less likely to be skeptical about findings that appear to confirm our core beliefs, such as studies showing a link between breastfeeding and positive health outcomes.”

On confirmation bias: When the World Health Organization’s guidance on safe preparation of infant formula was first added to the Baby-Friendly Hospital Initiative guidelines in 2009, many lactation professionals expressed a belief that instructing parents of newborns about how to safely prepare powdered infant formula to protect the infant might actually “scare” some new parents into breastfeeding to avoid Cronobacter, a potentially fatal infection. However, the current understanding of the backfire effect indicates that this viewpoint may be flawed. (Meanwhile this information triggers confirmation bias on the part of lactation activists, as it aligns with the strongly held belief that ‘breast is best.’)

A You Are Not So Smart podcast (about 28 minutes in) offers insight into these phenomenon covering research about the belief that vaccines can cause autism. It demonstrates how we are more heavily influenced by stories than by complex research.

It is easy to understand that parents might feel autism is a greater risk than the common diseases that childhood vaccination protects against: whooping cough, pertussis, measles, mumps, rubella, etc. The media is replete with stories of autism on the rise (up from one child in 150 in 2000 to one in 68 in 2012) while outbreaks of these diseases are reported sporadically in limited geographic locations.

While there are rare side effects to vaccinations, high level research has not found a causative link between vaccination and autism (IOM, CDC, WHO). Some have suspected that mercury found in the preservative, thimerosal may be linked to autism; not only does research deny this linkage, but the originator of this theory was found to have engaged in ethical misconduct.  Nonetheless, the U.S. government recommended removing this preservative from vaccinations in 1999 (although it is still used in some multi-dose vials of flu vaccine.)

When expert opinion regarding lack of linkage between vaccination and autism is shared with concerned parents, research indicates that the backfire effect may cause those who are most against vaccination to accept the lack of evidence, but also to strengthen their commitment to avoid vaccinating their children, as shown in Effective Messages in Vaccine Promotion.

As a side note, the low incidence of things like hemorrhagic disease as described in Dekker’s article means that most parents have not seen or heard of a family member or friend with this outcome . The likelihood of a child contracting a vaccine-preventable disease in the U.S. is relatively low too, in this case thanks to herd immunity or community immunity.

Turner-Maffei points out that the CDC reported that 667 people in the U.S. had measles in 2014, and the last death in the U.S. from measles occurred in 2015 for instance.

“With 4 million children born annually, the risk of contracting measles whether one vaccinates or not is incredibly low,” she explains which might explain a false-sense of security against disease among those who choose not to vaccinate. “But the more people who decide not to vaccinate, thinking they’re safe from this risk, the greater the potential spread of the disease in the unimmunized pockets of the community, thus the greater the risk to children as the trend grows. The safety of not vaccinating decreases with the herd immunity.”

Today, health officials are dealing with the largest outbreak of measles in Minnesota in almost 30 years after a population “fell under the sway of anti-vaccination activists.”

The same type of risk/benefit ratio pertains to the risk of a newborn contracting a Cronobacter infection from contaminated infant formula, Turner-Maffei reports. Again, the occurrence of these infections is low. (CDC reports that it learns of four to six cases per 4 million infants annually, although they note that many cases are likely not reported.)

Expectant parents who are made aware of the potential contamination of infant formula may also be falsely reassured by the rarity of this infection, she suggests.

Is it possible all humans are prone to believe we’re protected from rare negative outcomes associated with our core values?

The release of WHO recommendations on infant feeding by HIV-positive mothers, based on new evidence, suggests that HIV-positive mothers or their infants take antiretroviral drugs throughout the period of breastfeeding. This means that the child can benefit from breastfeeding with very little risk of becoming infected with HIV, Breast is always best, even for HIV-positive mothers reads.

Over 1,000 words earlier I quoted, “The term natural has a lot of values packed into it.” And here we are about 1,000 words later still with much to consider. When we engage in activities designed to convince people something is best, or the natural choice, we are entering into complex endeavors that may trigger sophisticated cognitive responses, including the backfire effect, in some individuals.

So what can we do to propagate evidence-based thinking, we wonder. In response to a question from You Are Not So Smart’s Dave McRaney, Jonas Kaplan states that currently science can’t tell us how to make others accept the facts we consider unassailable (around 37:00 minutes), Turner-Maffei reiterates. Rather, Kaplan proposes that we strive to be more flexible when encountering information that runs counter to our beliefs, to be aware of the tendency toward motivated skepticism, and to learn to distinguish our beliefs from our identity as individuals.

Turner-Maffei suggests, “Perhaps in this way we can model cognitive flexibility while becoming more open to the beliefs of others, less centered in our own worldview, and hopefully less likely to contradict the beliefs of others since contradicting core values may trigger the backfire effect.”

Research which suggests a delay in breastfeeding at the time of the oral rotavirus vaccine to “overcome [breastfeeding’s] negative effect” on the potency of the vaccine has been met with outrage by some breastfeeding advocates.  As an exercise in cognitive flexibility, we invite you to read the publication and take note of your feelings and cognitive process.

Also for your consideration, a list of common misconceptions that corrects erroneous, widely-held beliefs.

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