Addressing Vaccine Concerns: A Hopeful Path Forward for Vaccine Confidence

In 2018, Broniatowski et al. found that bot and troll accounts tweeted about vaccination at higher rates than average Twitter users.¹ The authors pointed out that bots and trolls generate discord by promoting both pro- and antivaccine content and that disseminating more provaccine messages from real accounts is likely an inadequate response to these techniques. Although more recent work questions the dominance of bots,² the problem of antivaccine misinformation persists. Health care providers and public health professionals are the most trusted sources of vaccine information for most people and as such have the potential to play an important role in addressing misinformation. Here, we outline some simple principles for how one might do that.

MOTIVATION, CONTEXT, AND AUDIENCE

First, we must understand the motivation of inaccurate health information the public receives. Misinformation includes false or inaccurate information of all types. Misinformation may include content from social media users who have concerns or questions about vaccines. Disinformation describes false, inaccurate, or misleading information that specifically aims to deceive. We should also examine the reasons that disinformation might be shared and what motivates the deception. A recent analysis of vaccine-related advertising on Facebook showed that the number of ads per buyer was significantly higher for antivaccine compared with provaccine ads.³ Several well-funded antivaccine groups use their nonprofit organizations to fund lobbying activities and antivaccine advertisements and documentaries. Understanding the forces behind a large portion of antivaccine disinformation provides context to specific concerns raised in clinical encounters and in public dialogue.

With this backdrop of a social media landscape filled with misinformation and disinformation, individuals may have a variety of questions about vaccines that each require a tailored response. For example, addressing concerns about vaccine safety requires knowledge and acknowledgment of true adverse events including common minor side effects (e.g., fever, pain at the injection site) and rare but potentially serious adverse events such as anaphylaxis. Conversely, addressing vaccine hesitancy among Black Americans requires acknowledging the contextual history and ongoing problem of racism in medicine. Parental concerns about well-studied routine childhood vaccines with long track records of safety may warrant a straightforward discussion of risks and benefits, while uncertainty about a COVID-19 vaccine calls for a more nuanced communication rooted in evolving knowledge about risks of both vaccination and disease. Personal relationships matter too: someone who has had a close personal or family experience with a known or perceived vaccine adverse event may respond differently to communication efforts about vaccines than someone who has heard concerning messages about vaccines but does not share that personal experience.

Just as different questions require different approaches, so do different audiences. Vaccine hesitancy is a spectrum including a small minority of individuals who refuse all vaccines and a larger group of people who have some questions but will receive all or some vaccines.⁴ People who refuse all vaccines may not be interested in engaging in dialogue with a medical or public health professional, whereas those who are vaccine hesitant are more often receptive to new information about vaccines. Discussing vaccines with a patient in clinic is not the same as discussing vaccines with friends or strangers on social media. Positive public communication about vaccines on social media is unlikely to change the mindset of people who are firmly antivaccine but may influence those who simply have questions or concerns.⁵ A more successful approach to combatting social media disinformation about vaccines may be the removal or reframing of vaccine mis- and disinformation by the social media platform, a solution that requires advocacy and organizational change. Some social media platforms have taken steps in this direction, but more work is required.

PRINCIPLES TO ADDRESS MISINFORMATION AND BOOST CONFIDENCE

After understanding motivation, context, and audience, medical and public health professionals can apply several principles to address vaccine misinformation and strengthen vaccine confidence. First, maintaining a respectful and listening attitude is the foundation for responding to questions and concerns about vaccination. This approach is at the heart of motivational interviewing, which has proven to be an effective strategy to improve vaccination uptake and many other health behaviors.⁶ Avoiding assumptions or judgments is particularly important. Respect for concerns and questions is the foundation of individual patient communication and addressing vaccine misinformation in more public forums. Individuals who have encountered or are sharing vaccine misinformation may have underlying concerns that can benefit from an open-minded approach.

In addition to listening respectfully, eliciting the reasons for concerns about vaccines or the motivation for sharing misinformation is another communication tool and principle of motivational interviewing.⁷ For individual patient encounters, asking why someone is concerned about vaccines helps to focus any response on existing questions without bringing up additional types of vaccine misinformation that are not central to an individual’s concerns. For social media, it may be useful to ask why someone chose to share a piece of vaccine mis- or disinformation or what they found interesting about that information. These questions help shape the response by identifying the topic(s) of concern and clarifying an individual’s motivations and where they are on the spectrum of vaccine hesitancy.

After identifying specific concerns about vaccines, rather than simply providing a refutation, which can be counterproductive and turn an encounter into an argument, clinicians can use the powerful motivational interviewing technique sometimes called “asking permission to share.” With this technique, rather than simply denying the misinformation and providing supporting facts, a provider could simply say: “You know, I’ve looked into that concern. Would you mind if I shared with you what I’ve found out?” Use of this technique makes an individual more receptive to the information that will then be shared. After receiving permission, the misinformation can be corrected with a direct and succinct statement of facts.

Clinicians and public health advocates must also consider the potential of a backfire effect in addressing misinformation: presenting someone with information that contradicts a strongly held belief may reinforce that existing belief. Simply repeating the misinformation also runs the risk of perpetuating it. When correcting misinformation, communication should focus on the facts and emphasize the benefits of vaccination and risks of the diseases that vaccines prevent. When specifically addressing disinformation, one must be aware of common disinformation techniques, such as reliance on “fake experts” and invoking conspiracy theories.⁵ Addressing disinformation can include unmasking and responding to the technique of disinformation as well as the content.

A HOPEFUL PATH FORWARD

With all of this in mind, we must remember that, despite all we hear about vaccine hesitancy and refusal, we continue to maintain vaccination rates in the United States well over 90% for almost all childhood vaccines. There are other reasons to be hopeful. While we saw a dramatic decrease in childhood vaccination with the advent of mitigation measures to address the pandemic in March 2020, we are already seeing significant recovery. Anecdotally, we are hearing from primary care pediatricians that they are seeing less vaccine hesitancy since the pandemic began, with stories of complete vaccine refusers coming in to the office and asking, “Can we get caught up on vaccines?” This pandemic offers the opportunity to rebuild the public’s trust in science that has been eroded over the last several decades. Using the principles outlined here, maintaining and increasing confidence in childhood vaccinations seems like a great place to start.