Here is the newly published decision aid helping you decide whether to get vaccinated against covid-19. It comes from OptionGrid (now with Ebsco) led by Glyn Elwyn. In this blog I would like to offer some feedback on how the aid is written.

Let me start by saying that I commented on a few decision aids and, as they go, I think the one I am about to dissect is a useful one. Also, I want to make it clear that my comments do not (and are not by any means meant to) undermine the effort and the product. I think it’s good to have the decision aid. That said, I also think some more reflection on how to phrase the document would have been useful. At least in my opinion. Also, a reservation is necessary. What I am about to write is a reasonable account of the linguistic form of the document. However, I do not wish to make any claims as to how the document will be received or understood. I have no idea; it depends on too many things.

Let me start with the introduction. There are some interesting choices there. First, the aid refers some people to a healthcare professional. I started wondering about who exactly I should speak to. Wikipedia lists quite a number of people as health professionals. So, will it be OK to talk to a nurse? What about a pharmacy technician? A psychologist? A physiotherapist? Right from the start, the aid actually has confused me. Of course, you could argue that people are cleverer than me, so they will not speak to a physiotherapist, but are nurses already trained to talk about the evidence on the vaccine? I’ll do one better – are all physicians on the ball?

Anyway, let’s not fuss over health professionals….Let’s fuss over this:

The information below is based on the published information for available mRNA vaccines

There are couple of problems with the sentence. It talks about mRNA vaccines as if they had already been introduced, i.e., the readers already know that the vaccine they are choosing is an mRNA vaccine. But that’s actually not the case and, again, instead of helping, the aid may well be confusing. I would also pose the question of how useful the information is.

The second problem with the sentence is that it seems to tell me that the document is not saying much about the vaccine I am about to get (or not), but only about the like vaccines. And yet, the document very clearly refers to the vaccine in question. So, what exactly am I reading here? I must admit that I am more and more confused here, and I am apparently fairly well educated and with a decent IQ….

But all that pales away when you come to the next point. What options do I have? Well, there are two. First, I can get the vaccine:

You will get a total of 2 shots in your arm. The shots will be given 3 or 4 weeks apart. Getting both shots is important for the vaccine to work. You should continue to distance, avoid gatherings, wear a mask, and clean your hands often

Second, you can decide not to have the vaccine:

You should continue to distance, avoid gatherings, wear a mask, and clean your hands often

And if you started wondering why on earth you should get the damned thing, you’re not alone. What difference does getting the vaccine bring? Well, judging by the two options, it brings a total of absolutely nothing. I hope you have noticed that that the third sentence in the first option is repeated verbatim in the second option. It basically tells me that I go through all the trouble of getting the vaccine and nothing changes! Like nothing, nada, zilch. If you pardon the expression, the vaccine seems to get me sh.t. And if that’s supposed to help me decide, the document pretty much decides for me. However implicitly, it tells me that the vaccine ain’t worth it.

And here I would like to point to something more ‘systematic’ in the document. Consistently, I think, not getting the vaccine is represented in a more positive way. Let me compare a few sentences from the get-the-vaccine column and its opposite one.

Benefits.

• • For: You will be much less likely to get COVID-19.
  • Against: You will not have the side effects that are common with the COVID-19 vaccine.

Can you see the caution in the first sentence and the certainty in the other? Get the vaccine, well, something good may happen. Don’t get the vaccine, something good will definitely happen. Similarly, the good things in the society are even less certain.

Harms.

• • For: Common side effects within the first 3 days include:
    • feeling tired
    • headache
    • fever or chills
    • muscle aches or joint pain
    • soreness, redness, and swelling from the shot.
  • Against: You will be at higher risk of getting COVID-19. This could result in serious illness, long-term symptoms, hospital care, or death.

This time, the document tells us about bad things. So, the certainty moves to the getting-vaccine option. The document tells you: these are the side effects, no two ways about it, no ‘mays’, no ‘mights’. They are so certain to come that the document doesn’t even tell you what you might be getting, it just lists them.  And the bad things in the against option? Oh well, there’s a risk, things could happen. In other words, if you take the shot, this is what you’re looking at; if you don’t, this is what you might be looking at. Again, the invisible anti-vax option is grabbing hold of me….

But that’s not all! When the document moves to good things in the second part of the box, the uncertainty comes back. Look:

These effects are more likely with the second shot. They are normal effects of your body doing what it should after getting the vaccine. They typically go away in a day or two.

Good things are more likely, and they happen ‘typically’. As I am finishing the read, I am gasping for some definitely good news on the vaccination side. Hit me, please!

I hope it’s quite clear that the document is asymmetrical. The two options are represented linguistically as different. Consistently, they are represented with different degrees of uncertainty, with the no-vaccine option consistently represented in a more positive light.  If this was the intention of the authors, that’s great, congratulations, you’ve done a wonderful job. Somehow, however, I think this was not the intention behind the document. And if so, the document could and probably should be re-worked to offer a more (linguistically) balanced view of the Covid-19v vaccine.

This asymmetricity of representation continues in the section on the less common side effects. Compare, for example, the representation of the symptoms with those in the common-side-effect section, as I discussed it above. Can you see the hesitation in the former and certainty in the latter section?

Now, despite reading the aid, I will be getting my vaccine as soon as it is available to me. But I understand vaccination, I have been vaccinated before, my children have, I think that anti-vax movements and ideas are dangerous, should not be supported, should opposed socially and politically. So, to be honest, my decision has already been made. That’s probably (at least partly) why the document has done nothing to undermine my belief in the benefits of vaccination.

But it’s also supposed to help those who are not so certain, and we know that such people are legion. And I wonder about what it will do to them. Given that it is a piece of communication that is explicitly aiming to get you to do something, I think the document could be improved. I think that there is at least some chance that someone undecided will think that the vaccine does you no good at all, as your life will continue to be rubbish. This is why I think that more care should be taken to create a document which represents the two options more symmetrically.

I want to stress that I do not advocate manipulation (not that there isn’t, I think, a case for some debate here), as a linguist I only advocate a different phrasing, one which introduces symmetry of representation. At the moment it’s not there and that, in my opinion, is counteruseful.

A later addition.  I think it’s worth adding that the analysis of the document focuses on its lexical material in a minor way. In other words, yes, words matter, but here they matter considerably less than the grammatical structures (in this case, modality, in particular). It’s important to underscore this, as most comments on language in medicine I come across, concern replacing a word here or word there, while being oblivious to other features of the linguistic form. Yes, words matter, sometimes more, sometimes less, but, importantly, grammar matters too. Sometimes, it matters considerably more than individual words.