Meeting the Challenge of Vaccination Hesitancy

"The reasons for declining vaccine uptake in a given community or country will vary; what is key is to gain an understanding of them and take action. This moment offers a solemn opportunity to confront the problem of mistrust in a resolute way..."

The Sabin-Aspen Vaccine Science & Policy Group (the Group) observes that the end of the COVID-19 pandemic will depend on our ability to address vaccine hesitancy: reluctance or opposition to vaccination. The papers in this compendium look at the multiple layers and root causes of vaccine hesitancy, laying out actionable steps that leaders across healthcare, research, philanthropy, and technology can take to build confidence in vaccines and vaccinations, to strengthen vaccine acceptance, and to promote timely immunisation.

The report emerges from the second annual meeting in September 2019 of the Group's 22 members, who represent both domestic (United States - US) and global perspectives and bring professional experience across disciplines including public health, medicine, philanthropy, venture capital, biotechnology, biology, ecology, ethics, and journalism. In brief, the Group's deliberations focused on improving demand for vaccines. The Group examined findings on why people accept or delay vaccines, or reject them altogether, and explored ways to shape education, communication, and methods of behavioural change to maintain vaccination as a social norm. It also discussed strategies to counter misinformation as it arises in different contexts.

Their discussions, informed by background research papers and expert presentations, are presented in the Group's consensus paper that constitutes Part 1 of this compendium, Getting Back on Track: Restoring Vaccine Confidence and Confirming Vaccination as a Social Norm. Three key assumptions underlie the paper: (i) vaccination levels, after reaching record heights, have plateaued or even declined slightly in many countries; (ii) various factors have undermined confidence in or contributed to complacency about vaccination; and (iii) the vaccination enterprise needs new knowledge and tools to overcome challenges to vaccine acceptance.

Some of the topics explored in this report include:

• Trust: Community Immunity Versus Herd Mentality - "Trust in vaccination depends not only on the nurse, doctor, or mobile team that administers the vaccine, but also on the authorities who enable and drive vaccination. Thus, vaccine uptake may be threatened in any country, region, or community where there is waning confidence in the government, doctors, or public health officials who recommend, oversee, and mandate vaccination..."
• Social Networks and Social Norms - "Developing strategies to counter vaccine hesitancy will require the public health community to engage with new disciplines, especially from the social and behavioral sciences, and to improve its communication strategies, building on a base of expanded research into the nature and volume of the hesitancy problem..." For example, the Global Demand Hub - an international effort involving the United Nations Children's Fund (UNICEF), the World Health Organization (WHO), GAVI, the Vaccine Alliance, and other organisations - has been gathering data on vaccine demand and hesitancy in low- and middle-income countries (LMICs) in order to use this knowledge to nudge and support national programmes.
• The Mechanization of Doubt - "Changes in how people gather and digest science and health information have fed vaccination hesitancy. As local and regional newspapers disappear, internet sites of varying intent and quality provide an increasing percentage of the public's news intake....[Furthermore, p]ublic health scientists have demonstrated little expertise in creating stories that generate emotion and engage popular attention, and vaccine foes have manipulated internet search engines to steer people toward false information - in the United States and Europe, as well as in Pakistan, the Philippines, Brazil, Egypt, India, and Nigeria..."
• Communication and Education - "Research is underway to assess how people encounter and evaluate sources of vaccine information and to test communication strategies in different settings. This research is beginning to yield valuable information, but a great deal remains to be learned....[T]here will be no magic-bullet communication strategy....The best results will be obtained by framing the vaccination decision and focusing on vaccination uptake rather than philosophical transformation."
• Behavioral Change and Mandates - "The most direct way to increase childhood vaccine uptake may be to require it....[Yet, v]accination proponents are leery of mandates in countries where vaccine laws are associated with authoritarian regimes....[, and, c]learly, mandates are also not appropriate in countries where steady and consistent supplies of vaccines are not always available....Some pediatricians in the United States have resorted to dismissing families that refuse vaccination....The segregation of non-vaccinating families poses a quandary on a community-wide scale because it may push them to outlier practices where anti-vaccine opinions and behaviors may become further entrenched, while sharpening the risk of vaccine-preventable illnesses among these groups."
• Building a Movement for Vaccines - "Before engaging in the effort to bolster vaccine confidence, clear objectives are needed. Campaigns to counter hesitancy must consider whether their aim is to blunt the reception of anti-vaccine messages; strengthen the number, type, and volume of pro-vaccine voices; or simply bypass negativism or skeptical voices about vaccination and push to increase uptake in communities where vaccination is still the trusted norm among large majorities..."

The Group puts forward a set of principles as the foundation for new efforts to counter vaccine hesitancy and strengthen the vaccination enterprise:

• Vaccine hesitancy is a troubling global phenomenon.
• There is an urgent need to better understand the causes and dimensions of vaccine hesitancy.
• Efforts are needed to address hesitancy, even as efforts to understand it are incomplete.
• The focus should be on improving vaccination services and reducing access barriers.
• A dedicated media strategy - targeted on the role and impact of social media - is needed.
• Vaccine use should be viewed as a key, lifelong component of a healthy lifestyle.
• Mandates, incentives, and other measures aimed at directly affecting behaviour should be used with care.
• Efforts to boost vaccination coverage and reduce hesitancy must be coordinated.

The Group proposes three "big ideas" to help reverse the trend toward vaccine hesitancy and reestablish full uptake of vaccines as a social norm. They are detailed in the paper but, in brief, include: (i) create a new collaborative partnership between the vaccination community and social media platforms; (ii) develop a prioritised research agenda to generate knowledge about sources of vaccine hesitancy and the evidence to inform mechanisms to counter it; and (iii) craft a strategy to shift the conversation around immunisation to one that focuses on its many benefits. The latter involves reaching beyond traditional public health and vaccine advocacy groups to find and engage non-traditional players who are passionate about the value of vaccination for personal reasons, including local activists, entertainers, politicians, patients, and members of disease advocacy groups.

The commissioned papers included in Part 2 of the compendium explore potential barriers to vaccine acceptance and identify solutions. They: clarify many of the reasons for vaccine hesitancy; consider how social movements emerge and succeed and how to build such a movement to broaden vaccine acceptance; and examine the value of activities that foster behaviour change to drive vaccine use. Brief excerpts follow:

1. The Challenge of Vaccination Hesitancy and Acceptance: An Overview, by Arthur Allen and Robb Butler - Excerpt from the paper's Conclusion: "...Global vaccine agencies and non-governmental organizations increasingly frame vaccination acceptance as 'demand promotion.' Demand promotion aims to ensure that all parents, caregivers, and other key partners value and trust immunization; have the necessary information, capacity, and motivation to seek out services; and actively pursue immunization for their children. The goal of demand promotion is to help build up vaccination as a positive social norm - one that embodies resilient and sustained demand across the life-course of individuals and throughout the community. Most people in any setting passively accept vaccination as a normative behavior. In general, this serves society well by maintaining high levels of vaccination. However, passive acceptance is vulnerable to vaccine safety fears, poor service quality, out-of-pocket expenses, misperceptions and myths, any of which can lead to hesitancy or outright refusal to vaccinate....Scholars who have recently examined the hesitancy issue agree that vaccination programs and providers need more evidence-based tools to efficiently convince vaccine-hesitant patients and parents. This clearly requires communication strategies that consider the context of science and vaccine literacy, social media, and other sources of popular information and influence....While few strategies have been evaluated, there is a growing consensus about the need to bolster awareness of the positive impact of vaccination....Recognizing that context is crucial to any action plan, public health officials, clinicians, and others dedicated to the benefits of vaccination need to deepen their outreach to affected groups as they continue to pursue new strategies for rebuilding confidence in vaccination."
2. What Do We Know About Movement Emergence and Success? by Doug McAdam - Excerpt from the paper's Conclusion: "...The vaccine hesitancy movement did not emerge because of an increase in the objective risk posed by vaccines, but because specific groups constructed an account of increased risk and began acting collectively to counter that perceived threat. And what of the equally important question of movement success? While the characteristic features and typical dynamics of insider and outsider movements tend to be quite different, the long-term success of either generally reflects the interaction of two factors. On the one hand, the prospects for movement success are powerfully shaped by the environments in which they are embedded. As we have seen, successful movements typically benefit from prior, destabilizing change processes that render their opponents more receptive to movement influence. And they also depend critically on the capacity of movement actors to recognize and respond strategically to the evolving opportunities and constraints afforded them by environmental changes. This ongoing interaction between movement groups and the broader strategic environment ultimately shapes the relative impact of the movement."
3. What Works to Increase Vaccination Uptake, by Noel T. Brewer - Excerpt from the paper's Conclusion: "Direct behavior change is clearly the most promising approach to increasing vaccination uptake, and research supports the use of many different techniques....No single intervention is effective on its own, however, making it necessary to adopt more than one....In contrast, interventions to change what people think and feel are often expensive and hard to sustain, and they may not be especially effective....An important caveat here is that interventions by providers in clinical settings may be influential if they effectively use communication approaches based on information, persuasion, and engaged listening. Interventions targeting social processes are promising insofar as they build on multiple nodes of social networks or happen in clinical settings....Thinking more broadly about public support for vaccination, work is needed to understand how to ensure resilience in the face of safety scares. Interventions to boost vaccine confidence may not increase vaccination uptake directly, but they may have a side benefit of increasing support for effective policies and programs..."
4. The Complex Contagion of Doubt in the Anti-Vaccine Movement, by Damon Centola - Excerpt from the paper's Conclusion: "...A possible viral epidemic is a distant risk, but the perceived danger from vaccination is that it can cause immediate harm, which encourages people to recoil into a position of safety - that is, a position of inaction....The complexity of social contagion is that it requires social reinforcement to spread. But, if the contagion of doubt spreads most effectively through clustered networks of peers, it may be possible to counteract that contagion with the same strategy. Creating networked communities - online and offline - in which social reinforcement is strategically harnessed to delegitimize the anti-vaccine arguments, is one promising approach. The strategies of complex contagions provide useful guidance for targeting places in the social network where reinforcement can either increase the credibility of the anti-vaccination movement or decrease its legitimacy."
5. Online Misinformation about Vaccines, by Renée DiResta and Claire Wardle - Excerpt from the paper's Conclusion: "It is important to understand that social media is fundamentally a peer-to-peer form of communication....User participation facilitates the development of personal connections and in many communities is considered a breach of social norms to challenge or attempt to contextualize a personal narrative....Furthermore, social media design choices have provided a dispersion mechanism for stories that eliminate traditional gatekeepers (such as fact-checkers and editors). While online platforms have begun to take meaningful steps to combat vaccine misinformation, the anti-vaccine narrative endures. The ability of the pro-vaccine community to tell a more compelling story more persuasively and to spread its evidence-based message to broader audiences online is an imperative for public health."

Going forward, the Group plans to share the ideas articulated in the report (which, along with the second meeting, was funded by the Bill & Melinda Gates Foundation) through the networks of the Group, the Sabin Vaccine Institute, the Aspen Institute, and many partners, as well as to advocate for strategies that will hopefully turn them into action.

Editor's note: Click here to read an op-ed on the report, "How to Counter Vaccine Skepticism if a Coronavirus Vaccine Becomes Available" (June 9 2020, Fortune), by Sabin-Aspen Group Co-Chairs Harvey Fineberg and Shirley Tilghman. They write, in part, "The gravity of the current COVID-19 pandemic, ongoing measles outbreaks throughout the world, the hard last mile of polio eradication, and the resurgence of other vaccine-preventable diseases reinforce the need to act now to bolster vaccine acceptance everywhere."