Optimizing communication tools to address vaccine hesitancy
Ève Dubé - Medical Anthropologist, Researcher
Author: Ève Dubé1-2, Dominique Gagnon1 and Maryline Vivion1
1- Institut national de santé publique du Québec, Québec (Québec)
2- Centre de recherche du CHU de Québec-Université Laval, Québec (Québec)
Vaccine hesitancy (the reluctance to accept recommended vaccines) is a complex issue that poses risk communication problems for public health agencies. Studies have shown that providing information and communicating evidence of vaccine safety and efficacy to those who are vaccine-hesitant has done little to stem the growth of hesitancy-related beliefs and fears. In this CANVax in Brief, we highlight good practices informed by research evidences in developing communication materials to address vaccine hesitancy.
Addressing vaccine hesitancy requires tailored strategies that are tested, evidence-informed and that take into account that vaccine hesitancy is complex and context specific, varying across time, place and vaccine type.1 Previous research has shown that messaging that too strongly educates and advocates vaccination can be counterproductive for those who are already hesitant.2 Providing too much information can also generate hesitancy.3 However, being informed about which vaccines are needed, for whom, why and when is the basis of the vaccination decision-making process and informed consent.
More information alone is unlikely to dramatically change vaccine acceptance, but the communication of information is one of the primary tools at the disposal of public health professionals. Given the amount of financial and human resources invested in developing and diffusing communication materials about vaccination, it is critical to optimize these tools to ensure that they work as intended.
In this CANVax in Brief, we highlight some good practices in developing communication materials to address vaccine hesitancy. This work is based on the review of research evidence of what works (or not) in health risk communication compiled by Fischoff and colleagues4 and endorsed as a good practices by the Council of Canadian Academies Expert Panel on Health Product Risk Communication Evaluation (see Table 1 for a summary).5
Providing evidence-based information about vaccination
“All we have to do is give them the numbers”.4 Providing information about the risk and benefits of vaccination is not as simple as it might look like. When developing your communication material, you need to be sensitive to the complex ways that people process and value information. We cannot assume that “numbers will speak for themselves”. How you develop your message is as important as the content that you wish to deliver.6 While the content of the tools should be evidence-based, the development should be based on risk communication science evidence.7
Provide numeric likelihood of risks and benefits of vaccination
- Tools should clearly define the risks and potential consequences of not being vaccinated (risks of vaccine-preventable diseases) and the risks of adverse events after vaccination using numbers – not only words. Keep denominators constant (e.g., 1 in 10,000; 25 in 10,000) and use whole numbers rather than fraction or decimals.8
Use visual aids (icon arrays/pictographs, infographics, etc.)
- Graphs make numeric information easier to understand and pictographs are the best graph for communicating both gist (meaning) and verbatim (exact details) knowledge9 (Figure1).
Figure 1. Visual aids to support the effectiveness of vaccination, from the Public Health Agency of Canada
Provide qualitative information
- Your material should not only indicate how large vaccination risks and benefits are, but should also present the evidence supporting these estimates. You also need to provide the information that people need to know if they are to understand the processes creating the risks and benefits that could follow from their decisions (e.g., people might not be aware that their individual vaccination decision has an impact on herd immunity or parents may think that postponing vaccination is not a decision).
Addressing myths around vaccination
One of the main objectives of most communication tools on vaccination is to “correct” misconceptions about vaccination. But this needs to be carefully designed, as debunking a myth could actually reinforce it.10 When developing your communication material, put the emphasis on the facts, not the myth. The goal is to increase people’s familiarity with the facts, not the myth.10
The often-seen technique of headlining the debunking with the myth in big, bold letters is the last thing to do. As people will remember the myth, not the fact. Instead, communicate your core fact in the headline. When myth is debunked, a gap in the person’s mind is created. To be effective, the debunking must also fill that gap by providing another explanation (Figure 2).
Figure 2. Addressing vaccination myths
Test your communication prior to launch to make sure it’s working as intended in the target population
Studies have shown that as many as one out of two adults do not have the necessary skills to interpret probabilities and other mathematical concepts.11 For example, a study showed that information given in frequency formats (e.g., 1 out of 10 infants will have fever after the vaccination) were perceived as more risky than the same information conveyed in probabilistic terms (e.g., 10% of infants will have fever after the vaccination).12 It is critical to test your messages in your target audience to ensure that they are correctly understood.
Make sure your communication is clear and easy to understand
Use simple language, short sentences, subheadings and paragraphs. Avoid dramatic language and derogatory comments that alienate people. Stick to the facts and ensure that the numbers are accessible to all individuals.13
Reduce affective input
For those who are strongly fixed in their views, being confronted with counter-arguments can cause their views to be strengthened.13 Even carefully crafted efforts to influence individuals holding factually incorrect beliefs may in fact reinforce these beliefs (i.e., backfire). However, messages can be framed in ways that reduce this resistance.13 For example, when HPV vaccination is framed as a cancer-prevention vaccination, it may generate less resistance than when it’s framed as a means to prevent a sexually transmitted infection.14
In conclusion, risk messaging cannot be ‘one-size-fits-all,’ but must be tailored and targeted to take into account for the realities of community-driven knowledge systems, and the unique information needs and preferences of particular communities.15-16 “Communication is a two-way process”, writes Goldstein and MacDonald, “it is in equal measure a process of listening and telling. Understanding the perspectives of the people for whom immunization services are intended, and their engagement with the issue, is as important as the information that experts want to communicate”.17
Table 1. Risk communication good practices supported by scientific research
- MacDonald NE, Sage Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4.
- Nyhan B, Reifler J. Does correcting myths about the flu vaccine work? An experimental evaluation of the effects of corrective information. Vaccine. 2015;33(3):459-64.
- Scherer LD, Shaffer VA, Patel N, Zikmund-Fisher BJ. Can the vaccine adverse event reporting system be used to increase vaccine acceptance and trust? Vaccine. 2016;34(21):2424-9.
- Fischhoff B, Brewer N, Downs J, editors. Communicating risks and benefits: an evidence-based user's guide. Silver Springs: US Department of Health and Human Services; 2011.
- Council of Canadian Academies. Health product risk communication: Is the message getting through? The expert panel on the effectiveness of health product risk communication Ottawa: Council of Canadian Academies, 2015.
- Parrish-Sprowl J. Vaccine hesitancy communication: What counts as evidence. Vaccine. 2018 Oct 22;36(44):6529-30.
- Thomson A, Vallee-Tourangeau G, Suggs LS. Strategies to increase vaccine acceptance and uptake: From behavioral insights to context-specific, culturally-appropriate, evidence-based communications and interventions. Vaccine. 2018 Oct 22;36(44):6457-8.
- Downs J, Fischhoff B. Chapter 8: Qualitative Information. In: Fischhoff B, Brewer N, Downs J, editors. Communicating risks and benefits: an evidence-based user's guide Silver Springs: US Department of Health and Human Services; 2011.
- Fagerlin A, Peters E. Chapter 7: Quatitative Information. In: Fischhoff B, Brewer N, Downs J, editors. Communicating risks and benefits: an evidence-based user's guide. Silver Springs: US Department of Health and Human Services; 2011.
- Cook, J. & Lewandowsky, S. The debunking Handbook. 1–7 (University of Queensland, 2011).
- Peters E. Numeracy and the perception and communication of risk. Annals of the New York Academy of Sciences. 2008;1128:1-7.
- Peters E. Beyond comprehension: The role of numeracy in judgments and decisions. Current Dir Psychol Sci. 2012;21(1):31-5.
- Kahan DM. Social science. A risky science communication environment for vaccines. Science (New York, NY). 2013 Oct 4;342(6154):53-4.
- Vorpahl MM, Yang JZ. Who Is to Blame? Framing HPV to Influence Vaccination Intentions among College Students. Health communication. 2018;33(5):620-7.
- Gray L, MacDonald C, Mackie B, Paton D, Johnston D, Baker MG. Community responses to communication campaigns for Influenza A (H1N1): A focus group study. BMC Public Health. 2012;12:205.
- Hutchins SS, Fiscella K, Levine RS, Ompad DC, McDonald M. Protection of racial/ethnic minority populations during an influenza pandemic. American Journal of Public Health. 2009;99(S2):S261-S70.
- Goldstein S, MacDonald NE, Guirguis S. Health communication and vaccine hesitancy. Vaccine. 2015;33(34):4212-4.