Exploring the relationship between newspaper coverage of vaccines and childhood vaccination rates in Spain

ABSTRACT

Background: Despite the effectiveness of vaccines being well established and recognized by the research community, eleven European countries have adopted mandatory vaccination programs because of vaccine hesitancy. Lack of information and fake news are considered the main reasons. The media are a powerful tool for spreading vaccine-related information. The study of media effects on vaccine uptake has received little attention in Europe.

Objective: To explore the association of childhood vaccination rates in Spain with vaccine-related coverage in print media.

Methods: A content analysis of newspaper coverage of vaccines was conducted. The study variables were: national vaccination rates, article publication dates, tone and main theme of the articles. We conducted a correlation analysis to assess the association between media coverage and childhood vaccine uptake.

Results: While vaccine coverage with positive and neutral tones significantly increased during the study period (p < .001), the number of articles with a negative tone remained unchanged (p = .306). There was a significant and inverse correlation between negative newspaper coverage and childhood vaccine uptake (r = −.771, p < .05). During 2016 and 2017, although the media reporting declined, vaccination rates kept increasing. The most frequent themes were about the development of the Ebola vaccine, and the chickenpox and meningitis vaccine crises.

Conclusions: Our findings expand the understanding of media role on vaccination and suggest that the media need to be considered as an important player during vaccination campaigns. The study points to the important educational role of the media in public health.

Introduction

Although the effectiveness of vaccines is well established and recognized by the research community, there remain some issues regarding vaccine confidence and trust among the population,^1-3 as well as low vaccination rates for some vaccine types and geographical regions.⁴ Vaccine hesitancy is an individual behavior, but also the result of broader societal influences in the historical, political and socio-cultural context in which vaccination takes place.⁵ Parental decisions to use or avoid vaccination for their children are complex and multi-dimensional, including contextual determinants related to the vaccination services and individual determinants, such as parents’ knowledge, attitudes, and beliefs or sociodemographic characteristics.⁶ Factors that may influence vaccination rates include access to health-care services, risk perceptions concerning the disease or the safety of the vaccine, social models, and trust.^7-10 These factors are influenced by a few high profile anti-vaccination campaigns which have had a harmful effect, to the extent that vaccine uptake is considered a public health challenge¹¹ and that eleven European countries now have mandatory vaccinations for at least one of the following: diphtheria, tetanus, pertussis, hepatitis B, poliovirus, haemophilus influenzae type b, measles, mumps, rubella, and varicella.¹²

Lack of information and fake news are actually recognized as being among the main reasons contributing to low vaccination coverage.¹² A recent national survey in Spain showed that citizens are not well-informed about health-related issues.¹³ However, the general public is highly interested in health news and the media are often used as the first source of information.^14,15 In this regard, the media are considered to be a powerful tool for spreading information and increasing awareness about vaccines and opinions from both vaccine supporters and opponents. In fact, the traditional media coverage and the rapid growth of the Internet and social media have made it easier to find and disseminate vaccination-related concerns and misperceptions.¹⁶ Indeed, narrative information is readily available on the Internet and actively searched for by parents aiming to gather information on health-related questions, such as information about adverse events following vaccinations. With these regards, previous research has showed how affect and emotions seem to play a role in the process, and that more emotional narratives lead to greater perceived risk and that this effect does not disappear with statistical information in an enhanced graphical manner.¹⁷

The topic of vaccines has attracted extensive media attention in recent years, owing in large part to now-discredited claims about safety. Scholars have studied how the topic of vaccines has been covered by the media. A recent systematic review¹⁸ found that negative messages and inaccurate information were found to be a common pattern in media coverage of vaccines. The majority of previous media analyses about vaccines were carried out in newspapers, especially in the United States; another study¹⁹ showed a lack of this research field in other geographical areas. The review also suggested the need to further analyze media effects on vaccine uptake because previous studies have mainly examined the focus of media coverage or its influence on perceptions of risk.²⁰ In relation to this, vaccine uptake has been reported to vary by media coverage^20-23 and by the use of mass media.^24-26 To our knowledge, only one study²⁷ has been made on the association between media coverage use and vaccination rates in Europe, which only focused on the HPV vaccine uptake and related media coverage in Denmark. In this context, there is a research need to further investigate the association between vaccine rates and media coverage for other types of vaccines and other geographical regions, especially in Europe where evidence is still limited. In the present study, we considered the media and vaccinations in Spain and analyzed the vaccines for Poliomyelitis, DTaP (diphtheria, tetanus, and pertussis), Hib (haemophilus influenza type B), Hepatitis B, MMR (measles, mumps, and rubella), and all doses of HPV (human papillomavirus). Therefore, building on previous research, the aim of the current study is to explore the association of childhood vaccination rates in Spain and vaccine-related coverage in the print media.

Methodology

The present study used quantitative and qualitative content analysis of print media coverage of vaccines published in Spain. In order to create the categories and conduct the analyses, we followed a similar research method of a previous study.²⁰ A content analysis, using a standardized data-collection instrument, was used and included the following variables: publication date, tone of the article, and main theme. For coding ‘tone’, we followed a previous paper²⁸ where the positive tone focused on vaccine benefits, such as disease prevention; the neutral tone referred to if they were not in favor or against vaccination; and a negative tone implied they focused on risks, such as adverse events and discouragement of the vaccination. Examples of tone coding can be found in Table 1. We also conducted an inductive thematic analysis to contextualize the data. Finally, we performed an analysis of correlation between vaccine articles and vaccine rates in Spain. The codebook is available upon request to the corresponding author (DCM).

Table 1.

Examples of tone coding.

Tone type	Examples (translated into English)
Positive	“A safe vaccine for Hepatitis C” (El Mundo, 6/11/2014) “The refusal to vaccinate minors spreads measles in Disneyland” (El País, 23/01/2015)
Neutral	“The vaccine against cancer is being developed this way” (El Pais, 24/03/2017) “Serum and vaccines will come to Africa in a few weeks” (El Mundo, 22/10/2014)
Negative	“Current immunization is poorly effective in prevention” (El Mundo, 18/11/2015) “Jim Carrey criticizes the use of vaccines in Twitter” (El Pais, 02/07/2015)

The newspapers El Pais and El Mundo were selected because both are flagship national newspapers in Spain (El Pais has a daily readership of 1.08 million readers and El Mundo has 0.662 million daily readers). The online database MyNews was used to search the articles by using the following search string in the Spanish language [vacuna* OR inmuniza*]; these were present in the headlines or sub-headlines from October 1, 2012, to October 1, 2017. The analysis period began in 2012, coinciding with the publication of the WHO Global Vaccine Action Plan, which was approved in the 65th World Health Assembly,²⁹ where, for the first time, it was recognized that: (a) some reasons for hesitancy are undoubtedly amenable to improved communication designed to counteract growing anti-vaccination lobby groups and to increase understanding of the value of vaccines or of the danger of diseases, (b) governments should engage in dialogue with communities and media and use effective communication techniques to convey messages about vaccines and to address safety concerns, and c) the media should understand the benefits of, and concerns about, immunization in order to accurately report on and effectively promote immunization programs. The inclusion criteria for article types selected were news articles, features, short articles, opinion articles (including editorials and letters to the editor), interviews, biographies, and obituaries. Our exclusion criteria were duplicate articles and those using the term ‘vaccine’ with a metaphoric meaning. The vaccination rates were compiled from the vaccination health information system of the Spanish Ministry of Health.³⁰ Vaccination rates for each year from 2012 to 2017 show the average rates of the following vaccines: first dose of Poliomyelitis, DTaP (diphtheria, tetanus, and pertussis), Hib (haemophilus influenza type B), Hepatitis B, MMR (measles, mumps, and rubella), and all doses of HPV (human papillomavirus). These vaccines are recommended for childhood, considering this age group until 12 years old. Microsoft Excel software was used as the data-collection instrument.

In order to ensure reliability in coding, data were coded first by one author (DCM), followed by a second coder (CSO). After coding was completed, changes were made to the coding scheme to reflect any disagreements that had been identified and all discrepancies, when necessary, were resolved with the support of a third researcher (CPS). With the aim of reflecting the impact that vaccine articles had on vaccination rates in Spain, a weighting factor was created based on the daily readership of the selected newspapers. In this regard, El Pais had the highest weight of 0.62 (i.e., 62% of the total circulation of the two newspapers included in the analysis). The newspaper El Mundo was given the remaining weight of 0.38. The weight was applied to the number of articles about vaccines by year in each newspaper to create a weighted index of the potential impact of the vaccine articles among the selected newspaper articles. The analysis of correlation between vaccination rates and the vaccine articles in the media was calculated using a one-year time lag in recognition of the delayed impact that media reporting might have had on people’s behaviors toward vaccination.²⁰ Since vaccination rates were only published until 2017 at the time of data analysis, vaccination rates for 2018 were estimated considering the vaccination rates from 2012 to 2017 (see Table 2). Therefore, for the analysis of correlation, the estimated vaccination rate was 94.9 for the year 2018. For data analysis, we used Excel (Microsoft Corporation, Redmond, WA, USA) and SPSS, 24th edition (SPSS Institute, Inc., Chicago, IL, USA). These programs were used to conduct the data descriptive analyses and to find p values to check for the significance of results.

Table 2.

Vaccination rate, number of articles, and risk messages for Spain (2012–2017).

	Vaccination ratea	Articlesb	Positive tone articles (weight)c	Neutral tone articles (weight)c	Negative tone articles (weight)c
	Spain (%)
2012	92.1	8	1 (0.62)	2 (1.24)	5 (2.62)
2013	92.0	20	8 (4.72)	8 (4.24)	4 (2.24)
2014	92.5	22	7 (3.62)	13 (7.10)	2 (1.24)
2015	93.6	52	28 (14.00)	19 (9.86)	5 (2.38)
2016	93.9	15	6 (3.24)	8 (3.76)	1 (0.38)
2017	94.4	14	8 (3.52)	5 (2.38)	1 (0.62)
Total	93.1	131	58 (29.72)	55 (28.58)	18 (9.48)

^aFrom statistics of the Ministry of Health, Spain. Data show average vaccination rates for first dose of Poliomyelitis, DTaP (diphtheria, tetanus, and pertussis), Hib (haemophilus influenza type B), Hepatitis B, MMR (measles, mumps, and rubella), and all doses of HPV (human papillomavirus).

^bTotal number of articles reporting on vaccines from two major newspapers in Spain.

^cTotal number of articles by tone and a weight factor representing an index of the potential impact of articles based on circulation rates of newspapers.

Results

Overall, the initial search in MyNews yielded 159 articles. Of these, 28 were not considered because they did not meet the inclusion criteria. Therefore, the final sample included 131 articles. El Pais carried 75 articles and El Mundo carried 56, with no significant differences among them (χ² = 2,756; p = .97; df = 1). Figure 1 shows the flow diagram. Table 2 shows the distribution by year of vaccination rates in Spain, the number of articles about vaccines in the selected newspapers, and the tone, including the weight factor based on circulation rates. In relation to the vaccination rate, although there was a slight decrease in 2013, a yearly continuous increase can be found since 2014. Regarding the articles, there was one particularly significant heavy period of press coverage about vaccines in 2015 (χ² = 55,550; p < .001; df = 5) during which time the selected newspapers printed 52 articles (El Pais n = 27, El Mundo n = 25). The tone analysis revealed that 44% (n = 58) of articles were positive, 42% (n = 55) were neutral, and 14% (n = 18) negative. Therefore, the overall proportion of pro-vaccine articles was significantly higher than that of anti-vaccine in the total sample period. However, we found that, in 2012, negative articles (n = 5) were more frequent than either neutral (n = 2) or positive (n = 1) articles, and that the number of negative articles remained similar throughout the study period with no significant differences (χ² = 6,00; p = .306; df = 5). In contrast, the number of both positive and neutral articles became significantly more frequent than negative ones since 2013 (positive articles: χ² = 45,241; p <.001; df = 5; neutral articles: χ² = 19,945; p <.001; df = 5).

Figure 1.

Flow diagram.

The findings of the inductive thematic analysis are described in Table 3. We can see that the most frequent theme was about the development of the Ebola vaccine (10%, n = 13). The crises of the chickenpox (9%, n = 12) and meningitis (6%, n = 8) vaccines were also extensively covered by the selected newspapers. Other trending themes were articles about the decrease of vaccination in European countries (6%, n = 8) and the obligatoriness of vaccination (5%, n = 7). The other frequent themes focused on the influenza vaccine (5%, n = 7) and the development of the malaria vaccine (5%, n = 7) (see Table 3 for further information).

Table 3.

Most frequent trending themes in newspaper articles included in the analysis.

Coverage dates (dd/mm/yy/)	Trending themes	Theme description	Frequency of articles, n (%) N = 131
03/08/2014–18/12/2015	Development of the Ebola vaccine	Coverage about the development of the Ebola vaccine, which was intensified after the first case of Ebola infection outside Africa which took place in Madrid, in October 2014	13 (10%)
04/09/2013–09/03/2016	Chickenpox vaccine crisis	The Ministry of Health limited chickenpox vaccine storage in pharmacies due to overuse. After pressure from the pharma industry and some professional associations, the Ministry decided to unblock this vaccine.	12 (9%)
10/05/2014–05/04/2017	Meningitis vaccine crisis	Firstly, in 2014 and 2015, the coverage focused on the Ministry decision to not dispatch the meningitis vaccine to pharmacies. After some pediatric associations criticized this decision, the Ministry decided to allow the delivery of this vaccine. Secondly, in 2017, the coverage focused on a lack of provision of this vaccine in Spain and the death of some children who had not been vaccinated.	8 (6%)
03/06/2015–5/08/2017	Decrease of vaccination	This coverage focused on the alarming decrease of vaccination in some European countries. Articles recalled the positive aspects of vaccination, especially in childhood.	8 (6%)
24/04/2015–21/05/2017	Obligatoriness of vaccination	Due to the decrease in vaccination rates and laws in other countries (Italy, France) about making vaccination obligatory, the Spanish media covered these news items and included some opinion articles about the obligation to vaccinate.	7 (5%)
26/12/2012–26/08/2015	Influenza vaccine	In 2012, a stock of influenza vaccines had to be taken out of market due to unexpected side effects. In 2014, coverage focused on the low uptake of the influenza vaccine in Spain. In 2015, the media covered a research project to find a universal influenza vaccine.	7 (5%)
10/11/2012–24/10/2015	Development of the malaria vaccine	The research into a vaccine against malaria was popular in Spain due to studies conducted by Dr. Alonso, a Spanish scientist who has conducted large projects in African countries about Malaria.	7 (5%)
15/02/2013–06/07/2017	Development of cancer vaccines	Media attention was given to research developments toward different research projects about new vaccines for different types of cancer.	6 (4%)
24/02/2013–24/02/2017	Vaccine supply	In this theme, articles about vaccine supply issues were included, such as the new vaccination schedule for children and delivery issues in low-income countries.	6 (4%)
06/06/2015–30/06/2015	Diphtheria vaccine outbreak	The death of an unvaccinated child due to diphtheria brought media coverage of this event and the importance of vaccination to prevent these lethal infections.	6 (4%)
28/10/2015–24/11/2015	Whooping cough outbreak	Media attention was given to a child infected with whooping cough because there was no supply of the vaccine in pharmacies and the child’s mother could not get the vaccine. It was the first case since 1987 in Spain.	6 (4%)
04/02/2016–14/07/2017	Zika alarm	The Zika alarm, especially in South American countries, was reported by the media in relation to the development of a vaccine.	6 (4%)

Using the data from Table 2, the vaccination rates in Spain were mapped against the number of articles about vaccines or vaccination (see Figure 2). Data suggest that vaccination rates increased since 2014. From 2013 to 2015, there was a rapid increase of the total number of articles. During 2016 and 2017, although the media reporting declined, vaccination rates kept increasing. Figure 3 shows the relation between vaccination rates and the articles according to the tone toward vaccination. We can see that articles with negative tone were more frequent in 2012, and that the vaccination rates decreased the year after, in 2013. Since 2013, articles with positive and neutral tones increased and were more frequent than negative ones. Since 2014, vaccination rates consistently increased. In the analysis of correlation, we found a significant and inverse correlation, revealing that vaccination rates were correlated to reporting of negative articles toward vaccination (r = −.771, p < .05), suggesting that the decrease of negative tone articles might have a positive effect on the vaccination rates in the following year. We did not find significant correlations between vaccination rates and positive or neutral articles.

Figure 2.

Vaccination rate in Spain by number of articles in the two selected newspapers (2012–2017).

Note: Adapted from Meyer et al.²⁰

Figure 3.

Vaccination rate by tone of articles weighted by circulation (2012–2017).

Note: Adapted from Meyer et al.²⁰

Discussion

The findings of this study reveal key facts about news articles’ tone patterns toward vaccination, the most trending themes about vaccines, and the association between vaccine media coverage and the uptake of childhood vaccines in Spain. The key results that are relevant to our study’s aim are as follows: (a) the proportion of positive and neutral articles increased significantly since 2012; (b) the tone of the majority of articles shifted from negative in 2012, to positive and neutral during the following years; (c) the most commonly identified themes included the development of the Ebola vaccine, the crises of the chickenpox and meningitis vaccines, as well as the topic of the decrease of vaccine uptake in Europe; (d) a significant and inverse correlation was found between the reduction of articles with negative tone and vaccination rates; and, finally, (e) despite the volume of vaccine articles decreasing after 2015, vaccination rates increased. The spike in media reporting in 2015 may be explained by (a) the diphtheria and whooping cough outbreaks, (b) the crises of the chickenpox in relation to the decision from the Ministry of Health when limited chickenpox vaccine storage in pharmacies due to overuse, and (c) the meningitis vaccine (meningococcal) due to a supply shortage, and (d) the development of the Ebola vaccine that was very often commented on by the media because, in 2014, the first Ebola infection case outside Africa happened in Madrid.

Our study confirms other previous analyses, which also found a majority of positive messages toward vaccination.^31-35 However, recent systematic reviews revealed that there is a majority of negative articles in the traditional media.^18,36 The reason for this might be that the analyses included in the reviews were conducted in earlier years than the years chosen for our study. In this regard, our data show how journalists might have been persuaded to write more pro-vaccination articles. Further studies should analyze whether the public health community is carrying out more outreach to journalists or whether they were simply better educated than their predecessors.

Perhaps the most important finding of our study is that we found significant associations between media coverage and childhood vaccine uptake, as shown in recent studies.^20,21 The bulk of articles with a negative tone about vaccination had a significant and inverse correlation with vaccination rates. A previous study that analyzed the relation between the seasonal flu vaccine and vaccination rates in Canada²⁰ found that any media publication about vaccines, regardless of content, influences an increase in vaccine uptake. Our study adds, for the first time, that the tone of the article might guide people’s behavior toward vaccines. Nevertheless, we would need a larger prospective study to specifically investigate this correlation to determine a more robust conclusion. In this regard, this preliminary data suggests the need for further research projects to reach a better understanding of the relationship between the characteristics of the work of journalists and vaccination rates.

Another important finding in our study is that, since 2015, reporting declined although vaccination rates kept increasing. Meyer et al.²⁰ found that seasonal flu vaccine reporting is correlated with the increase in flu vaccine uptake; a decrease of this reporting might lead to vaccination decline. Our contrary findings might be due to three possible facts: 1) negative tone articles were less frequent than positive and neutral articles toward vaccination; 2) since 2015, the media frequently reported on the positive effects of vaccination and on new laws about obligatory vaccinations in some neighboring countries (i.e., Italy and France); and 3) in 2015, there were diphtheria and whooping cough outbreaks in Spain, and it has been demonstrated that media exposure may have a role on public behavior specifically during infectious diseases outbreaks.²¹

We should acknowledge important limitations related to our study. The main limitation of our study is that, due to the ecological nature of study, we could not obtain a reason for vaccine uptake. We did not consider other additional factors and media formats that may play a role on vaccination. In the last decade, there has been an important shift from print to digital news, and social media are crucial for spreading information and misinformation about vaccines. In this regard, prior research has focused on how vaccines were represented in social media^37-39 and how misinformation is spread.^40-42 However, we should be cautious and acknowledge that this study is based on a content analysis and therefore it does not allow any conclusions in terms of causal relationships. With these regards, a study to understand the relation between actual exposure and influence on behavior would need to be conducted with methods such as surveys, in-depth interviews or focus groups. Consequently, additional research is required to analyze these new digital formats and their relationship with vaccination uptake. Another limitation is that we did not conduct the actual exposure or readability analysis of the newspaper articles, so we cannot ensure how accessible and understandable the press reporting was for readers. We also must acknowledge that our study analyzed just two national newspapers in Spain during 5 years of coverage; therefore, our findings cannot be generalized. Nonetheless, it was not our intention to review all media in this study. Rather, we aimed to follow this novel method to analyze the association between vaccine media coverage and childhood vaccination rates. Despite these limitations, we believe that our results may show the relevance of mass media in promoting childhood vaccine uptake in Spain, as well as suggesting further research which could elucidate causal relationships among the study variables.

In conclusion, this study stresses the added-value of analyzing the media effects on vaccination and suggests that during vaccination campaigns the media need to be considered as an important player. Nowadays, eleven European governments have enforced mandatory vaccination programmes and others are considering adopting similar strategies. In this regard, our study shows that media monitoring by public health departments could be also included as an effective tool in future vaccination programmes, as previously suggested by Suppli et al.²¹ For this, collaboration between public health officials and media staff is important in order to develop accurate and effective information in the media about vaccination. We believe that the present study expands the current understanding of the media role on vaccination and it can contribute to and inform further vaccination campaigns by pointing to the important educational role of the media in public health.

Funding Statement

This study has been financially supported by the Research Group of Health Sciences CTS-451, University of Almeria, Spain, and by the Ministry of Science, Innovation, and Universities from the Spanish Government, project code number RTI2018-097709-B-I00.

Acknowledgments

The authors would like to express their gratitude to lecturer Dr. Carlos David Santamaría Ochoa for his kind support in the article screening and analysis process.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.