Uppsala Reports Long Reads – Convincing the vaccine hesitant

Fuelled by disinformation and an array of other cultural and economic factors, vaccine hesitancy is one of the greatest global health communication challenges of our times. But to craft the empathetic and tailored communication strategies required to boost confidence in vaccines, we first need to understand the difference between anti-vaccination belief and vaccine hesitancy.

This episode is part of the Uppsala Reports Long Reads series – the most topical stories from UMC’s pharmacovigilance magazine, brought to you in audio format. Find the original article here.

After the read, we speak to Uppsala Reports editor Gerard Ross about the dangers of polarising the conversation on vaccines, the role of social media, and how it all boils down to trust.

Tune in to find out:

• Why having questions or worries about vaccines is not the same thing as being anti-vaccination
• Why directing appropriate communication at the vaccine hesitant is more effective than attacking the vaccine deniers
• How cultural sensitivity and emotional intelligence can benefit pro-vaccine communication

Want to know more?

The World Health Organization provides resources on vaccine communication in general and COVID-19 vaccines in particular.

The University of Queensland’s online course on Antivaccination and Vaccine Hesitancy is available to people anywhere in the world.

For more on vaccine safety and confidence, check out these episodes from the Drug Safety Matters archive:

• Keeping vaccines safe
• Substandard and falsified COVID-19 vaccines in the Americas
• Vaccination errors risk harm and damage trust

Finally, don’t forget to ­subscribe to the monthly Uppsala Reports newsletter for free regular updates from the world of pharmacovigilance.

Transcript

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Federica Santoro 0:10

Welcome to Drug Safety Matters, a podcast by Uppsala Monitoring Center where we explore current issues in pharmacovigilance and patient safety. Vaccine hesitancy is one of the greatest public threats in the ongoing fight against COVID-19. But to neutralize that threat, we need to start differentiating between the anti-vaccination movement and vaccine-hesitant people and adapting communication strategies accordingly. I'm your host, Federica Santoro, and this episode is part of the Uppsala Reports Long Reads series, where we select the most topical stories from our magazine, Uppsala Reports, and bring them to you in audio format. Our pick for today is the article Countering Narratives of Distrust, Key to Convincing the Vaccine Hesitant. Written by Uppsala Reports editor Jared Ross and published online in June 2021. After the read, I sit down with Jared to unpack the thorny issue of vaccine hesitancy even further. So make sure you stay tuned till the end. But first, let's hear the article. For many countries battling the current COVID-19 pandemic, supply of vaccines is the major hurdle to be cleared before societies and economies can fully reopen. But for other countries where vaccination programs are already well advanced, the emerging problems have shifted to the demand side of the equation. Fueled by anti-vaccine disinformation and an array of other cultural and economic factors, vaccine hesitancy looms as one of the primary global health communication challenges of the coming years. Getting vaccine communication right will be a key ingredient to boosting vaccination rates to a point where the world can return to some sort of normal. While there are obvious overlaps between the anti-vaccine movement and vaccine-hesitant people, they are very different groups, and the strategies for dealing with them need to be informed by an understanding of their differences. Dr. Tom Eckner is a senior lecturer in the Faculty of Humanities and Social Sciences at the University of Queensland in Australia.

SPEAKER_01 2:45

The terms anti-vaccine or anti-vaccination usually refer to those who express ardent vaccine denial and an outright refusal to be vaccinated. It refers to the active rejection of scientific consensus on vaccines. And what's key is that this area of anti-vaccination doesn't suitably describe a lot of people who might simply have questions or worries about vaccines.

Federica Santoro 3:12

The questions and concerns of the vaccine hesitant, he explains, are wide-ranging and can include misunderstandings about what ingredients are in vaccines, reservations about how many vaccines someone should receive in any given period, or concerns about whether vaccines could harm their children. Also, in the current context, many people who are otherwise pro-vaccine express concern that the new COVID-19 vaccines were developed too quickly or rely on untested technologies. Fears that, while ill-informed, are understandable. And beyond those concerns, there are many others for whom the perceived benefits of receiving a vaccine are outweighed by the logistical or financial impediments to getting a shot.

SPEAKER_01 4:04

Vaccine hesitancy is much broader than the classification of anti-vaccine. Research has also found that around the world, the percentage of people who might be truly anti-vaccine is actually quite small, around 2-3%. But a much larger proportion of the population expressed vaccine hesitancy, anywhere from 20 to 40%.

Federica Santoro 4:26

This distinction has profound implications for public health communication strategies. The anti-vaccination movement is almost as old as vaccines themselves. Indeed, there was prominent organized opposition to the very first cowpox inoculations. And counterintuitive as it may seem, a lack of information is not necessarily the problem. In fact, explains Eckner, anti-vaxxers often have deep knowledge about the science and practice of vaccination, and they are often armed with considerable information about perceived harms that people believe were inflicted by vaccines. But as they filter information through their own cognitive biases, their conclusions fall outside the scientific consensus. Motivated then by distrust in government or pharmaceutical companies, social cultural values including anti-establishment sentiment among other drivers, the impact of anti-vaccination voices often far exceeds their numbers. From a purely public health standpoint, lack of vaccination among the few true anti-vax proponents is not in itself a major concern, but it's the disproportionate effect their messaging has on the vaccine hesitant that can pose a significant threat. The question then is how to defuse that messaging. While the temptation for the scientifically minded is to confront the anti-vaxxers head on and dismantle their arguments with facts, Eckner warns that the evidence runs against this approach, and that directing appropriate communication efforts at the vaccine hesitant receivers of misinformation is more effective than attacking the vaccine-denying senders.

SPEAKER_01 6:25

Researchers have concluded that health communicators should actually avoid trying to convert anti-vaxxers or ardent vaccine deniers. That's because fervent anti-vaccinators are really the least open to impartial argumentation, scientific evidence, and discussion. Expending your energies to reach people who are committed anti-vaccinators is unlikely to have much benefit. Instead, health communicators should really be more concerned with trying to reach what we call the fence sitters, people who are vaccine hesitant but still undecided. They represent a much larger segment of the population, and they are likely to still be open to some discussions.

Federica Santoro 7:09

The fence sitters, he says, may have been exposed to vaccine misinformation or disinformation, and may even have strong opinions, but they have not yet made the leap to identifying as anti-vaccine. The research on how to reach fence sitters suggests that success comes not from lecturing them or telling them they are wrong, Eckner says, but rather finding their desires, identifying their values, and leading them to a solution that works for what they want, which is in most cases the safety of their children or some other rational goal. Key to achieving that success, therefore, comes from understanding the vaccine hesitant and the communities to which they belong, and speaking in a language that is understandable to them. In practice, the lesson for health communicators is that scientific knowledge and evidence-based arguments frequently need to take a backseat to cultural sensitivity and emotional intelligence. While there will always remain a need to build a foundation of accurate factual information and resources for those genuinely searching for answers, the work of turning around the vaccine hesitant relies heavily on persuasive cues and emotional appeals, the very techniques that anti-vaxxers deploy so successfully. While Eckner concedes this can be uncomfortable for medical and academic practitioners, he argues that the rhetorical tools themselves are value neutral and that it is ethical to deploy them honestly within a factual framework. Even so, pro-vaccine communicators remain at a disadvantage to the anti-vaxxers in the battle to win over the hesitant.

SPEAKER_01 9:00

Misinformation isn't bound to scientific facts. It can be sensational and misinformation tends to spread and be sticky.

Federica Santoro 9:09

Vaccine misinformation and disinformation also taps into a deeper history and language of other fringe beliefs.

SPEAKER_01 9:17

It's amazing how so much of it goes back to the small group of tropes that crop up in conspiracy theories of all types. In the end, much of it boils down to narratives of distrust. We just can't trust who's in charge. And there's good reason why people have that distrust. We've been let down by government, by pharmaceutical companies and industry. So it plays upon a kernel of truth, and the pre-existing distrust makes these messages so sticky.

Federica Santoro 9:45

In the past, traditional media gatekeepers had more power in setting the agenda for public discussion. And it was harder for fringe views to reach a mass audience. But social media changes that balance.

SPEAKER_01 10:00

In theory, social media can certainly be a powerful tool for pro-vaccine, pro-science messages.

Federica Santoro 10:07

Unfortunately, the algorithms of many social media platforms reward engagement, which too often simply means conflict. This is another reason why arguing with anti-vaxxers online is a bad idea. Fighting them sometimes adds fuel to the conflict, and disagreements may spread the misinformation more widely.

SPEAKER_01 10:30

The researchers found that misinformation is reshared more frequently in social media than actual data, and researchers have also found that people who get their news primarily from social media sources tend to be more likely to be exposed to and believe the misinformation they hear.

Federica Santoro 10:49

If all these pro-vaccination communication challenges feel insurmountable, there is help at hand in the form of a growing body of research and evidence-based resources. The World Health Organization is a good starting point both in terms of vaccines in general and COVID-19 vaccines in particular. For his part, Ekner, who holds a research fellowship examining how to improve vaccination rates in Australia, has also launched an open online course to help people understand vaccine hesitancy and respond to anti-vaccination claims. The course, Anti-Vaccination and Vaccine Hesitancy, is hosted by the University of Queensland through the edX platform and is available to people anywhere in the world. Interest in the course is encouraging. Ekner explains that enrollments so far include more than 1,200 people from around 80 countries, representing many occupations such as journalists, science communicators, educators, and public health workers. The diversity of participants is important. With trust and community being such powerful factors in determining the impact of information, it's important that pro-vaccine messaging is not all coming from establishment voices. In this context, Eckner points to pharmacists and nurses as underutilized resources in health communication. Research shows they are highly respected and credible professions, whose members work closely with patients, often as sounding boards for patients seeking more information than they feel able to seek from their doctors. Pharmacists, in particular, are especially experienced in speaking to patients about medications in general. Now, as more pharmacists are becoming involved in administering vaccinations themselves, the seeds of trust they have sown within the community can be valuable in bringing fence hitters down on the side of vaccines. The persistence of real anti-vaxxers and the stickiness of their disinformation will likely always be with us. As frustrating as that can be, the research on vaccine hesitancy provides a sense of perspective on how limited they are in number, allowing health communicators, and indeed anyone who trusts science and evidence to counter dangerous myths and reduce hesitancy with empathy, honesty, and understanding. Hi Jared, and welcome to Drug Safety Matters. It's really fun to have you on the show. How are you?

SPEAKER_00 13:41

Hi Fedo, I'm great. Uh it's uh really nice to be on the show.

Federica Santoro 13:44

We just heard the article you wrote for Upsala Reports, and I thought I could ask you a couple questions about the main issues that came up in the article so we can dive deeper into the topic of vaccine hesitancy.

SPEAKER_00 13:59

Sure, let's get into it.

Federica Santoro 14:00

Let's start with this. The conversation on vaccines has become really polarized over the years. To the point that when you think about people's stance on vaccines, you tend to classify them as either pro-vaccine or anti-vaccine. But as you and your interviewee in the article Tom Eckner rightly point out, the reality is much more nuanced than that. What are the consequences of this black or white thinking? What are the consequences of calling everyone who expresses the slightest doubt or hesitation about vaccines, an anti-vaxxer?

SPEAKER_00 14:42

Yeah, this is a really key point because uh, as you indicate, there is a spectrum of belief from the people who are very hardcore anti-vaccine and who are probably not going to be swayed by any arguments or any facts through to the people who, for one reason or another, and often for very reasonable and understandable reasons, have hesitancy, concern, questions about whether or not they or their children should get vaccinated. Now, some of those reasons can be based on fear of things that they've read from anti-vaccine propaganda, or from bad experiences that they've had with health services in other ways, or mistrust of government for a lot of very understandable reasons. But there can also be, for example, people who are basically pro-vaccine, but who don't get vaccinated because it's very hard logistically for them to fit that into their job, their life, their family commitments. Different health services in different parts of the world operate in various degrees of efficiency. And for some people it can be extraordinarily difficult to access the vaccines. Now, if we treat all of those people as anti-vaxxers, then there's a very strong chance that we will be alienating people, that we'll be offending them, patronizing them. And nobody likes that. Nobody likes to be offended and alienated and patronized. And so if we treat everyone as an anti-vaxxer, then not only do we risk them shutting down and not listening to any more good information, we also risk having them dig in, get stronger in their beliefs, and perhaps move up the spectrum towards the anti-vaxx end. And I think that's a tremendous danger. And so as frustrating as the true anti-vax information can be, we always need to think about the person that we're dealing with and the reasons that they have for their beliefs and communicate to them appropriately, not because we want to win an argument with them, but because there's a greater goal that we're trying to achieve together.

Federica Santoro 16:50

There's a theory we often hear about around vaccine hesitancy, that we've been so good at vaccinating people that we no longer see or appreciate the danger that infectious diseases can pose. And so people struggle then to grasp the benefits of vaccination. But COVID has sort of overturned that in the sense that the disastrous consequences of this new disease have been right there under our nose. And yet we've seen lots of misinformation, lots of distrust around vaccines. Why do you think that is?

SPEAKER_00 17:31

And the context that we entered this pandemic in is that we had gone in many countries for a long time without seeing the specter of these horrible diseases. And yet in that time, a rhetoric of anti-vaccination issues had sprung up and filtered out in many ways and become become intermixed with a lot of other political identities. And so I think that's there in the background. But another thing worth noting in terms of the theory of not seeing the dire consequences is that the current pandemic is different to some of the other ones that we've dealt with, which had far more obviously physical manifestations. Smallpox, for example, you know, left horrible marks on people's skin all over their bodies. Polio left people with limps or other debilitating physical problems. With the current pandemic, unfortunately, the disease itself manifests initially in something that is quite familiar to everybody, flu-like symptoms. And then when it becomes serious, people are in isolation. They're in an ICU ward. And most people in society are not seeing much of that. So I think even though it's more about the broader circumstances of anti-vaccine ideology becoming politicized, which has caused this vaccine hesitancy to stick, we also do need to think about the physical manifestations of this particular pandemic are quite different to some of the other ones that we've seen.

Federica Santoro 19:04

That's a good point. Let's go back to the actual number of anti-vaxxers in the world. It's estimated that about 2-3% of the worldwide population holds a true anti-vaccination stance. That's really not much. But the problem is they make a lot of noise. So how much of their power relies on modern communication technology? And I'm thinking especially of social media. And as pro-vaccine communicators, can we ever hope to sort of drown out that noise?

SPEAKER_00 19:46

I think we can't drown out that noise. And even thinking in those terms is part of the problem. You're right to point to the to the nature of communication platforms now as really contributing to this situation. Anti-vaccine ideologies have been around basically as long as vaccinations, but in the early days, to spread that, you had to stand on a street corner or put pamphlets up around or have small meetings. These days, those messages can be spread across the world at the speed of light, and they're amplified by social networks which share them. Now the social networking companies themselves obviously have a large part to play in this, and each of the major platforms has certain approaches to deal with anti-vaccination information. They probably need to be stronger and to be doing more because that information is still out there and is still spreading. But it's also worth understanding that the business model of any of those companies is to favor engagement, and engagement means people talking about things and people talk about things more when they're fighting about things, when they're angry about them. The word you use noise is a key part of this. These discussions create noise, and fighting them creates more noise, and that drives the bad information further. So I think trying to drown them out is not what we as responsible health communicators need to be doing. We need to be focusing not on the people who are not going to listen to the truth, but focus on the people, that vast majority of the spectrum of the vaccine hesitant, who haven't made up their minds, who still want to do the right thing, but need more guidance as to what that is. And I think we need to be communicating in ways that give them a way to join in with the greater community good and to accept vaccinations as a way out of this pandemic.

Federica Santoro 21:40

And a common theme in vaccine hesitancy is trust or lack thereof, we should say. So many of those who refuse vaccines or have doubts about vaccines seem to lack confidence in the authorities, broadly speaking. People might Not trust the pharmaceutical companies who produce the vaccine, they might not have trust in the healthcare system that administers them, they might not trust the government who rolls out the policies. So the million-dollar question is: Can the public's trust ever be regained, in your opinion, once lost? And what should these actors be doing to maintain it?

SPEAKER_00 22:28

Yes, well, that is a big question, and probably significantly above my pay grade. Like many good things, it's much easier to break trust than to build it. And once it's gone, once it's damaged, it can be very hard to restore it. So it is really up to everybody in positions to promote vaccination to always think about what they need to maintain the trust that they've built up and to continue to build that. And there's no magical solution to that. It's about being honest, it's about being open, it's about trusting the people who you want to invest their trust in you, not talking down to people. It's about listening to the concerns that they have, understanding why they don't trust. There are often very good reasons for all of the groups that you named that uh can be distrusted by people. There are often very good reasons why people distrust them. And those are things that need to be remembered and addressed. And again, it's important to just stay on message, to be honest with people, to not go out beyond what you know as well. I think one of the things we've seen, for example, in the current pandemic is that uh in many countries at many different levels, experts have made very confident statements about a range of different things, whether it's when vaccines would come, the role of masks, the role of ventilation or hand washing or other things. And the quality of the way that those recommendations have been made has varied from place to place. Now the danger is that as new facts come in and we need to change the guidelines that we give, that people can feel as though the experts don't know what they're doing, or they're making it up as they go along, or they're patronizing people. What we need to be able to do, and this is this is a tricky thing, is to communicate in ways that make it clear that part of working with science and translating scientific knowledge into public policy is understanding that you have to work with the best evidence that you have now, and that can change. And when it changes, the policies, the recommendations may need to change. And that requires, I think, communicating with a certain degree of humility at all stages so that people in the public can understand that you're you're doing the best with the information that's there, that you're not talking down to them, you're not trying to mislead or lie, but preparing them for the fact that we are learning about this as we go. We have a certain amount of knowledge that we can build on from other pandemics, from other health knowledge, but that there are certain facts here that are evolving rather rapidly. So again, it's a it's tricky, it's a balancing act. There's no magic way of doing this, but again, I think it's that humility when giving out recommendations to let people know that this is based on the best we have now, and to be able to bring people along on that journey rather than confuse them with contradictory edicts from time to time.

Federica Santoro 25:38

And a lot of what you say, the importance of being transparent and honest and not talking down to people, this applies not only when authorities talk to individuals, but also when individuals talk between them. And I personally have found it difficult and at times frustrating when talking to people who express hesitation about vaccines. I found it difficult to keep my cool and not bombard them with facts and try to stay empathic. It's not an easy thing to do. So, what is your best advice when dealing with those who express doubts about vaccines? How would you say you will go about in your everyday life? You know, showing them the understanding and the empathy they need and at the same time trying to say the things they need to hear, so they decide to get their shot.

SPEAKER_00 26:34

Yeah, I think the key word that you used there was empathy. It is personally extraordinarily frustrating, maddening to see the same debunked arguments come up again and again, to hear people just ask questions, even though those questions have been answered thousands of times over many decades. But what you need to remember is it's not about you, it's not about me, it's not about how that frustration can affect us. We have a broader goal here, and part of getting there is staying empathetic to the people that we're interacting with, to understand that they're at different stages of the journey towards knowing about this issue and that we need to help guide them in the right way. I mean, again, as the course that we wrote about uh made clear, and as the research has shown again and again, there's a small number of people who will never take that journey, who are set on being anti-vaccination, and that's that. And there's nothing really to be gained from us in engaging with them. And in fact, if we do try to engage with them, we risk spreading their ideas further. But with those who are hesitant, other places on the spectrum, we need to stay empathetic. We need to talk to them, engage with them, find out why they think the things that they think, what are the concerns that are behind their hesitancy, and see what we can do to help there. It's not going to be about overloading them with facts and arguments, because that's been done. And facts and arguments have never actually been a particularly strong way of changing the way that people feel. And when people feel very deeply about things, and when they have some cultural identity tied up in those feelings, then facts and logic and argument are not going to be the way to dislodge that. Empathy, understanding, narratives, telling stories, these are important tools that we can use. We need to still be telling the truth. We need to be factual, but that doesn't mean listing facts. It means finding the ways to express our feelings for what we believe, finding the stories that illustrate what we believe is the truth about the role of vaccines and vaccination.

Federica Santoro 29:00

So keep calm, take our time, and use our heart, I guess.

SPEAKER_00 29:05

Yes, that's true. And also at times know when not to engage. Engage where it can be useful. Stay out of arguments that will go nowhere except spread uh bad information further.

Federica Santoro 29:19

Aaron Ross Powell And choose the right ways to do it as well. I think these issues will not be solved over a bunch of tweets, but you need to take the time to have these conversations with people, preferably face-to-face.

SPEAKER_00 29:30

Well, yes, definitely that can be the most powerful way of getting to people. And Twitter is definitely not going to be um the way of changing the feelings of uh everyone that you know in an empathetic way. It it's simply not built for doing that. This is not to say that we don't use those tools. Having good information out there is important. It's not sufficient, but it is important. And so engaging on various platforms, providing a source of reliable information and positive stories and positive reinforcement for what we're trying to achieve, those are still very important things to do. But we need to understand the limits of those approaches and to continue to really just do the hard, continuous, day-to-day work of engaging with people in a positive way and setting examples.

Federica Santoro 30:27

That makes a lot of sense. One last thing before I let you go. You took the course on vaccine hesitancy yourself. Did you find anything particularly surprising or unexpected there?

SPEAKER_00 30:41

Yes, I've completed the course, and I have to say it really was a very worthwhile course with a lot of great uh references to get people researching the topic in a positive way. Working in the field myself, it wasn't so much that there were a lot of surprises there for me, but um it was a reminder, a constant astonishing reminder of just how persistent bad ideas and wrong beliefs can be. That the things that we're dealing with now have been dealt with since vaccines existed. There are some new particular twists to the arguments, but the basic approaches are still there. One thing that I did find really valuable in the course in particular was its focus on looking at the various modes of vaccine denial and uh anti-vax ideology that are spread by the anti-vaxxers but then filter through the vaccine hesitant population as well. The different techniques that are used to undermine the value of vaccines and vaccination programs, tactics such as just asking questions or raising fears about the ingredients within vaccines. I thought some of that focus was really very valuable because it allows you to quite quickly identify where somebody's coming from when you're engaging with them. And an example of that was actually in the course itself, in the discussion forums when I did the course. There was, in fact, an anti-vax person who was, let's say, lurking within the course, who was using those techniques at first in a fairly subtle way, and and then as as he was called out, it became more and more blatant that he was cherry-picking certain studies and data and throwing doubt on established things. And it's very time-consuming and uh and frustrating to deal with, but it was quite instructive to actually look at the course uh coordinators deal with that. I thought that was uh really quite a useful practical example of the course in action while it was going on.

Federica Santoro 32:35

That's interesting. Thank you, Jared, for your time. I thought the conversation we had was really inspiring, and hopefully our listeners will be tempted now to sign up for the course on vaccine hesitancy. Thanks again and have a good day.

SPEAKER_00 32:51

Thanks, Fed. It was a pleasure to be on. Bye-bye.

Federica Santoro 33:00

That's all for now, but we'll be back soon with more long reads, as well as our usual in-depth conversations with medicine safety experts. If you'd like to know more about vaccine hesitancy or Tom Ekner's online course on the topic, visit uppsalareports.org or check out the episode's show notes for useful links. For more stories like this one delivered straight to your inbox every month. Sign up for our free newsletter at upsalareports.org slash subscribe. And of course, if you don't want to miss future episodes of Drug Safety Matters, subscribe to the podcast in your favorite player and help us spread the word on social media so other listeners can find us. In our archive you'll find a few other episodes on vaccines. So if you haven't done so already, do check them out. We've spoken about how medication errors and falsified products can impact confidence in vaccines. And we've also looked at how side effects of vaccines are studied. You'll find links to all those episodes in the show notes. If you'd like to get in touch, the easiest way to do that is on social media. Look for Uppsala Monitoring Center on Facebook, LinkedIn or Twitter, and come talk to us there. For Drug Safety Matters, I'm Federica Santoro. I'd like to thank Graham Nadassi for reading Tom Ekner's quotes in the article, Jared Ross for taking the time to talk to me, Matthew Barwick for production support, and of course you, as always, for tuning in. Take care and till next time.