Growing Immunization Resiliency in the Digital Information Age
Noni MacDonald - Professor of Paediatrics (Infectious Diseases)
The decision to accept a vaccine is influenced by many factors that can vary across time, place, vaccine and context (1). In Canada, like other countries around the globe, the online immunization information avalanche is having a major impact on vaccine uptake. In the early digital age, public health information online consisted of static “read-only” materials. With Web 2.0, information online evolved into a multidirectional, user-generated communication characterized by participation, collaboration, and openness. Web 2.0 and social media have become the major modern platform for self-directed learning – a bottom-up user reaching out, not a top-down expert delivering approach.
Most Canadians seek health information online, including information on immunization. This information-seeking behaviour also includes many seniors, even though they came of age long before Web 2.0. However, only some of the immunization information on Web 2.0 and social media is science/evidence-based, while much is opinion, speculation and/or dramatizations that are often untrue, repeated vaccine-adverse event stories, all presented as “alternative facts.” Such vaccine misinformation can spread widely on social media (2), burying science-based comments. Exchanges may spread widely, where comments may be vigorous and may become increasingly polarized over time (3).
Exposure to immunization misinformation and fake news is now very common. A 2018 study of United Kingdom parents found that over 40% had been exposed to negative vaccine messages on social media (4). This is not a trivial issue, as we are at risk of confirmation bias when we search for information (5). We seek, select and retain the information that confirms our existing beliefs and are biased in how we evaluate information. Furthermore, with social media platforms, people can now be exposed to vaccine-critical messages even if they are not seeking this type of information. Negative vaccine information may stimulate and/or reinforce a vaccine hesitancy view. Only 5-10 minutes on a vaccine-critical website can negatively influence decisions to accept a vaccine (6).
Many who are very active online have very firm opinions that evidence and facts are unlikely to shift. Some see themselves as experts, albeit with “expertise” often based solely upon misinformation gathered online from those holding similar world views. Many are only too willing to share their “knowledge” through YouTubeTM videos, TwitterTM, FacebookTM groups and websites that readily pop up on GoogleTM searches. Misinformation can indeed negatively influence vaccine decisions (7) and even adverse event reporting (8).
This digital information age has also changed the patient-healthcare professional relationship. Shared decision-making is becoming normative; top-down paternalism is disappearing. Shared decision-making is good when decisions are underpinned by sound scientific evidence, but bad when the decision is influenced by misinformation. The plethora of immunization misinformation online is also negatively impacting people’s trust in healthcare professionals and in public immunization programs. Sadly, online bullying and trolling of evidence-based vaccine experts by those with polarized opposite views are also problems that are increasingly being recognized.
Growing immunization resiliency in this context means ensuring that vaccination programs are adapted to the current communication environment and are able to maintain vaccine acceptance and trust over time.
What can public health do to grow immunization resiliency?
There are no simple solutions, but there are some evidence-based strategies that can help. Remember that these strategies involve the complex art of individual persuasion, but coming from the public level. This requires a blend of different and multipronged strategies. Public health professionals should always bear in mind that “while data tells, stories sell” – a well-executed lesson of those promulgating vaccine misinformation. As well, the “what”, “how”, “where”, “when” and “who” always matter.
- Listen to patients and parents. Learn what the issues of concern are in different communities. Listen to reports directly from frontline health care workers, but also from the analyses of social media channels (9).
- Be aware that words do matter. Be respectful, never disparaging or demeaning, whether in public or with a patient. The term “vaccine deniers” may work well in academic discourse but is unhelpful in public and patient discussions.
- Develop multipronged campaigns that fit the subgroup, with the target of improving vaccine uptake. Some strategies may involve online media. Listening while working with communities and community leaders builds trust in immunization through multipronged campaigns that explicitly support local values and are respectful of their context (10) (11). These tailored programs can help shift the narrative in the community.
- Consider an online presence – but beware when engaging in social media. Many online forums are very polarized and anti-vaccine; joining in may not be helpful (3).
Knowledge dumps (i.e. putting up a large quantity of information) are frequently overly technical and not easily understood; posting online in an attempt to overwhelm misinformation on a social media site often only adds fuel to the fire.
Getting into a debate on the merits of immunization is not usually helpful, as such discussions just go on and on and on. While the evidence is clear that vaccines are safe and effective, and that diseases with serious consequences and even death can occur when immunizations are not received – this does not convince those with strongly held opposing views.
Recognize the tactics often used by those opposing immunization: conspiracy, fake experts, selectivity, demanding that vaccines be 100% safe and effective, misrepresentation, and false logic (12). Draw attention to these, but only if they are used in a forum where there is a bigger audience (i.e., in a FacebookTM group) and only if the platform is not so polarized that the comments will be buried. Alerting people to these tactics and correcting misinformation can be salutary for those without confirmed negative views on immunization (12). This technique has been shown to be helpful in growing resiliency against science misinformation of many kinds including immunization and climate change (13,14).
Do not fall into the persuasion trap – i.e., the “yes, but” never-ending dialogue cycle – when trying to correct repeated examples of selectivity or misrepresentation being raised, as all this does is raise more and more “yes, but” examples. Stick to your message and provide details on where to find more information, and exit the conversation.
Do correct misinformation – refuting misinformation is effective and does not necessarily backfire as had been previously suggested (14).
- Despite the warnings above, public health does need to have a presence on the internet. Be proactive – promote positive messages about vaccination, as this is likely more effective than trying to counter every new piece of misinformation online.
- Make the public health immunization website appealing, easily searchable, and ensure that there is a place where questions can be asked. Static websites are dated. Having a question component does not mean that the questions asked are public – but rather, having no place for inquiries is frustrating for users. Public health needs to determine if it has the resources to answer the questions, in what depth they will be answered, and whether any questions and answers will be posted. Be careful not to enter into a debate with the question poser.
- Exploit some social media opportunities. Tailored and targeted messages and information can help shape attitudes and improve uptake in some instances (15-16). However, bear in mind the comments noted above.
- If you choose to enter into a conversation on a social media site, be thoughtful. Succinctly get the point across – remember that stories may be more powerful than facts – and steer readers to reputable sites for high-quality information.
- Work with social media platform providers, not to stifle freedom of expression, but to help ensure that misinformation is not favoured in searches (17) (https://www.cnn.com/2019/04/10/tech/facebook-integrity-updates/index.html).
- Educate children and youth.
- Work with the Department of Education to develop a curriculum that can help to improve students’ understanding of the benefits and safety of immunization, and risks of disease. Remember that our young people have only ever lived in the digital information age, hence online games and cartoon stories have appeal. While many groups, both in Canada and elsewhere, are developing online student immunization educational materials (18), it is important to ensure that these fit the context of the students.
- Vaccine-specific curriculum is not enough to help grow immunization resiliency. Students need well-developed critical thinking skills and much higher levels of science and digital literacy than what is seen now if they are to see through the vaccine misinformation and con-artist techniques being used by many on the internet. These skills are needed for assessing for more information than just immunization, but immunization makes an excellent case example. There are resources available to help with this such as Media Smarts – the Canadian Centre for Digital and Media Literacy (www.mediasmarts.ca).
Misinformation and polarization of immunization information on the Internet and on social media are not going to go away. For public health, the work to grow immunization resiliency is only going to become even more complex. Public health and health care professionals need to better understand why misinformation is so appealing and why polarization is to be expected. People need to be listened to. Immunization concerns need to be assuaged. Over time, all must become more discerning about what information is credible and what is not, whether the subject is about health, climate change, the economy or politics. While growing critical thinking skills and digital and science literacy amongst our young people is a major step forward for tomorrow, today, we also need to focus on how to connect better with communities and how to reframe the immunization messages so they are better heard and appreciated.
- MacDonald NE, SAGE Working Group on Vaccine Hesitancy. Vaccine Hesitancy: Definition, scope and determinants. Vaccine. 2015; 33: p. 4161-4.
- Bauch CT, Galvani AP. Social Factors in Epidemiology. Science. 2013 Oct 4; 342: p. 47-49.
- Meyer SB, Violette R, Aggarwal R, Simeoni M, MacDougall H, Waite N. Vaccine hesitancy and Web 2.0: Exploring how attitudes and beliefs about influenza vaccination are exchanged in online threaded user comments. Vaccine. 2019; 37(13): p. 1769-1774.
- Royal Society for Public Health. Moving the needle: promoting vaccination uptake across the life course. [Online]. 2018. Available from: https://www.rsph.org.uk/uploads/assets/uploaded/f8cf580a-57b5-41f4-8e21de333af20f32.pdf.
- Meppelink CS, Smit EG, Fransen ML, Diviani N. “I was Right about Vaccination”: Confirmation Bias and Health Literacy in Online Health Information Seeking. Journal of Health Communication. 2019; 24(2): p. 129-140.
- Betsch C, Renkewitz F, Betsch T, Ulshöfer C. The influence of vaccine-critical websites on perceiving vaccination risks. J Health Psychol. 2010; 15(3): p. 446-55.
- Dunn AG, Surian D, Leask J, Dey A, Mandl KD, Coiera E. Mapping information exposure on social media to explain differences in HPV vaccine coverage in the United States. Vaccine. 2017; 35(23): p. 3033-3040.
- Faasse K, Porsius JT, Faasse J, Martin LR. Bad news: The influence of news coverage and Google searches on Gardasil adverse event reporting. Vaccine. 2017; 35(49 Pt B): p. 6872-6878.
- Müller MM, Salathé M. Crowdbreaks: Tracking Health Trends Using Public Social Media Data and Crowdsourcing. Frontiers in Public Health. 2019; 7: p. article 81.
- Attwell K, Freeman M. I Immunise: An evaluation of a values-based campaign to change attitudes and beliefs. Vaccine. 2015; 33: p. 6235–6240.
- Dubé E, Leask J, Wolff B, Hickler B, Balaban V, Hosein E, et al. The WHO Tailoring Immunization Programmes (TIP) approach: Review of implementation to date. Vaccine. 2018; 36(11): p. 1509-1515.
- MacDonald NE. When science meets Google: Reflections on research and evidence in the age of science deniers. Clinical and Investigative Medicine. 2018; 41(suppl): p. 35-37.
- van der Linden S, Maibach E, Cook J, Leiserowitz A, Lewandowsky S. Inoculating against misinformation. Science. 2017 Dec 1; 358(6367): p. 1141-1142.
- Schmid P, Betch C. Effective strategies for rebutting science denialism in public discussions. Nature Human Behaviour. 2019 June 24;(Online).
- Glanz JM, Wagner NM, Narwaney KJ, Kraus CR, Shoup JA, Xu S, et al. Web-based Social Media Intervention to Increase Vaccine Acceptance: A Randomized Controlled Trial. Pediatrics. 2017; 140(6): p. e20171117.
- Mohanty S, Leader AE, Gibeau E, Johnson C. Using Facebook to reach adolescents for human papillomavirus (HPV) vaccination. Vaccine. 2018; 36(40): p. 5955-5961.
- Allcott H, Gentzkow M, Yu C. Trends in the Diffusion of Misinformation on Social Media. [Online]. NBER Working Papers 25500, National Bureau of Economic Research, Inc; 2019 [cited 2019 May 9]. Available from: https://web.stanford.edu/~gentzkow/research/fake-news-trends.pdf.
- Wilson K, Atkinson K, Crowcroft N. Teaching children about immunization in the digital age. Human Vaccines and Immunotherapeutics. 2017; 13(5): p. 1155-1157.