By Elizabeth Duffy, BA in Microbiology, Trinity College, Dublin.
Disclaimer: Please note I am not a medical professional and am not an authority on the issue, I am expressing my own opinions in this article. This is not a substitute for medical advice. For accurate scientific information about vaccines, please visit the WHO website.
You look at your child in the physician’s waiting room. They’ve been up all night again. You got no sleep, and also have a work deadline to manage. Raising a child is a huge emotional burden, and healthcare decisions can be particularly emotionally charged. So scientific education, although vital, is not the only predictor of vaccine acceptance. Or indeed other healthcare interventions. So, what are the other factors, and how can we address them to increase vaccination rates specifically? In this article, I’d like to explore why this isn`t just an important issue to address, it’s an urgent one.
2. What is vaccine hesitancy?
Consider the term ‘hesitant’. It’s a distinct word from ‘anti’, which implies a very polarized, negative view of an issue. The WHO website captures this complexity in their definition of vaccine hesitancy as a “delay in acceptance or refusal of safe vaccines despite availability of vaccination services”. It is important to note that ‘acceptance’ or ‘refusal’ can be selective. According to a 2015 paper by Noni E. McDonald, and the SAGE Working Group on Vaccine Hesitancy, a minority may accept or delay some vaccines, but are unsure about the decision. Therefore, like personality traits, vaccine hesitancy is present in varying degrees among people. It is therefore represented as a continuum, ranging from completely resisting all vaccines, to hesitant, to completely accepting all vaccines.
3. Why our current approach towards it is wrong
I have a background in microbiology, and it’s true that the scientific/medical community can be guilty of classifying anyone questioning vaccines as ‘anti-vaxxers’, dismissing them, and invalidating their concerns. They are stigmatized as uneducated, scientifically illiterate, and stubborn. I know I have been guilty of this at times. However, these people are not unidimensional. They are scientists, educators, scholars. They can be found in all sectors, and in all echelons of society. Not having an intellect or curiosity is not true for most vaccine-hesitant patients.
In what is perhaps the most hurtful stigma of all, they are seen as callous and uncaring. They are accused of being unempathetic parents. Of neglecting their children’s, family’s, and even their own health. However, the most common reason for parents for being vaccine hesitant is that they are worried about their child’s and family’s health. In fact, the reason that people are vaccine hesitant is because they want to make the best decision for their child’s and family’s health. People are vaccine hesitant because they care about the health of their families so much. Arbitrary information and statistics are unlikely to help here. All this shows that the cliché of the ignorant ‘antivaxxer’ is not the reality.
Therefore, it is time to stop presenting this cliched idea of them in media, comedy, and promoting this damaging rhetoric. It is time we change our approach to discussion with vaccine-hesitant people, and those unsure about any medication or medical procedure.
4. Why is this important, and what are the underlying issues driving vaccine hesitancy?
However, why is this important? Vaccines have such a large-scale impact on people`s lives, and indeed during the pandemic we experienced life without just one vaccine. People lost jobs, and businesses closed permanently. We were isolated and lonely; couldn’t access our friends and other support networks. Family members became ill, and hospitalized. Other loved ones passed away. Although sounding dire, these can be the consequences of making decisions related to vaccination. Lack of a vaccine can impact every aspect of everyone’s life. If we don’t address the hesitancy issue, this scenario is likely to keep repeating itself in future pandemics.
It will therefore impact the health of not just this generation, but the health and wellbeing of future generations. During climate, political or economic crises, trust erosion also fuels conspiracy theories. Therefore, re-establishing trust between the public and government and other authorities will also impact other sectors of society.
It should now be clear that vaccine hesitancy is not solely about vaccines. Complacency, convenience, and confidence are cited by the World Health Organization website as key reasons for not vaccinating. Of course, these are valid. Time off work, cost, and access to transportation may be an issue. This is particularly true for those in more isolated rural areas, and those who are elderly and/or disabled, and cannot access health services. This can lead to a domino effect in that lack of access to healthcare services can prevent access to accurate information. What these communities rely on in these circumstances is internet resources, with no way to differentiate accurate from inaccurate information. Added to this is the fact that scientific papers can use inaccessible language, creating further division between them and scientific/medical circles.
These pragmatic challenges are valid and are key to address. However, it is also about people, their cultures, identities and value systems. These factors can make the decision to vaccinate very emotionally charged. If someone has grown up in a community where natural medicine was a heavy part of their culture, they will be reluctant to accept anything that might conflict with that. If the social group that a person engages with every day is hesitant about vaccines, the likelihood is that they will develop a similar attitude over time. If a family member has had an adverse reaction to a vaccine in the past, that can make the decision particularly complicated. This problem is worse if they have had bad experiences with doctors or other healthcare professionals. Like any relationship, if someone feels they have been mistreated repeatedly, mistrust will grow. Scale that up to the level of millions, and you get the phenomenon of vaccine hesitancy.
This can also cause stigma against certain vaccines. During my undergraduate degree, I wrote an essay on HPV vaccination. There is controversy around that vaccine – a belief that it would make girls promiscuous, and irresponsible around their sexual health, a claim not supported by numerous studies. My personal theory for this is that if someone is considering getting the vaccine to protect them against contracting HPV, they are likely careful about their sexual health anyway. Why invest time, energy and resources into getting a vaccination against an STD, if sexual health is not a priority?
In this case, however, the underlying issue was that human papillomaviruses are a sexually transmitted disease, and people feel vulnerable discussing sexual health. So perhaps normalizing dialogue around sexual health could be one factor in addressing this issue. This is particularly an issue in developing nations and among certain religious groups. In other words, the information people were receiving isn’t always the problem. It is often the stigma and cultural context in which people are receiving it. This is a critical point.
If we are to look in the past, science was always politicized. It doesn’t exist in a vacuum, so to speak. Think of why the first caveman discovered fire. It cooked food, and possibly scared off predators. It served the interests of the group. We need to stop detaching science from politics, law, and sociology. Society defines what areas of science are most relevant, and resources are directed into it. Again, there is a pattern. Scientific research addresses the most important interests of society at the time.
Further, people may also feel that their sense of freedom, or personal autonomy is being compromised. Few things frustrate people more than lacking control over their lives. Some people are pro-vaccination, but against vaccine mandates. This is an important distinction to make, as it distinguishes those who are against the formulation itself from those who feel that their freedom is restricted. This is highly relevant. Approaches to conversations with them should differ hugely. As the underlying cause of the issue is different, the solution should be different.
Therefore, vaccine hesitancy is a multifactorial problem. The factors in people’s lives making them vaccine hesitant can differ between people. Following on from that, it is not logical to group all vaccine hesitant individuals together, or to try to make comparisons between them. An important part of addressing the issue is addressing concerns on an individual basis, and tailoring the approach to each person accordingly. This requires the ability to relate to a variety of people. Which means considering their situation in an objective way to prevent emotional involvement. Remember, frustration at individual doctors, scientists, or vaccine advocates is often frustration at the institutions they represent. It is rarely personal. This is key in regulating your emotions when engaging with people.
5. How can we address it?
So how do you have a conversation where you can discuss controversial issues? In my experience, what you give is what you get. If you express empathy and understanding to people, they respond in kind. They will be more receptive to hearing new ideas and facts, and this principle is generally true of people. Being genuinely empathetic can really open doors, in terms of the quality of relationships you can form. It`s vital to have genuine curiosity about their perspective and experience, as opposed to wanting to jump to spreading your information and sharing your perspective. This allows you to connect with people with diverse experiences and backgrounds, no matter where in the world you are.
Empathy is a universal language. In my opinion, it is an underutilized skill in our current culture, which can be individualistic. It is for these reasons that it is so applicable to this topic, because vaccines affect the lives of everyone. When you do this, people can be vulnerable with you, and are comfortable discussing sensitive issues. It validates them. This is absolutely key in establishing positive long-term relationships. I believe that this is a principle that could be applied between vaccine hesitant groups and scientific/medical, and governmental authorities. This is easily achieved with our hyper-connected society. It simply requires a willingness to shift perspective on both sides. If we can use our technology to divide, we can use it to unify.
Communication style and language are also really important when discussing controversial issues. Using language that affirms their concerns rather than criticizes them is key, and also letting them know that you understand their perspective “I know what you mean…etc”, shows a genuine desire to understand. Now people are receptive to hearing information. In some cases, they may be open to scheduling an appointment with their healthcare provider to discuss vaccines, whether they do or don’t accept the vaccine. Even in the case where they do not engage with the information at the time, it plants the seed for them to think about it more. They may then possibly spread the information to others in the community. Never underestimate potential for large-scale effects from small acts of empathy. The butterfly effect also applies to human behaviour. In fact, this process can be accelerated with the rapid transmission of data, information, and ideas online.
Sharing your own experience can also engage people in a conversation. This is particularly true if you focus on emotive language by explaining how much relief it gave your family to finally be vaccinated. Also, if a member of your family is immunocompromised or at high-risk of contracting disease, mentioning them can be helpful. The reason for this is that it makes the risk of disease and the benefits of vaccination relatable and relevant to them in a context everyone understands. Family. The same can also apply to explaining how many people in your local community or school got vaccinated, or are planning to. Both of these approaches resonate with people much more deeply than facts and statistics.
People are also much more comfortable discussing sensitive topics when they feel integrated into a community. This can be achieved by engaging with their cultural background. Engaging with religious leaders, and culturally sensitive messaging have all been successful in increasing vaccination rates for precisely this reason. In addition, including members of a hesitant community in discussion panels, and campaign brochures are also a culturally-sensitive way of engaging them. People need to hear voices they can relate to. Cultural sensitivity is a hugely under-addressed aspect of the issue. However, I believe it is a vital element of any successful vaccination campaign, regardless of where in the world it is used.
Also, giving people a sense of control over healthcare-related decisions will be important in addressing the problem. Few things frustrate people more than lack of control. Informational interviewing involves asking the person questions that prime them to think about how their behaviour will affect their future. It involves guidance-based communication, rather than authoritarian-steering by physicians and scientists. Therefore, this patient-driven approach addresses the freedom element of the issue.
This is a serious issue that impacts the health of our families, communities and countries. It will continue to do so if we do not address the problem. It is a psychological, and by extension, a social issue. Understanding social dynamics around vaccine discussion is critical. This does not mean we reject scientific facts. It simply means an acceptance of the fact that it is a multidimensional issue. This means addressing the cultural background and past experiences of the vaccine-hesitant, and validating their concerns. Even language use and communication style play a key role in how we interact with vaccine hesitant patients. Of course, we can’t always control other people`s reactions. There are a proportion of people who are dogmatic, and have attitudes that may never shift.
However, spreading stigma and shame that are so common against these groups is unlikely to be successful. Divisiveness between pro and anti-vaccine groups will never solve the issue of vaccine hesitancy. You cannot reach a common goal (i.e. high vaccine uptake rates) by dividing people. So, we have to stop taking this dogmatic attitude towards the vaccine hesitant as it will only create more division.
We cannot get a different result using the same approach. I am confident this will be key to addressing the hesitancy issue, not creating more division between ‘pro-vax’ and ‘anti-vax’ groups. This is a trust issue. An empathy issue. A very human issue, as opposed to a scientific one.