Vaccine 33 (2015) 4212–4214

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Health communication and vaccine hesitancy

a r t i c l e i n f o a b s t r a c t

Article history: Health communication is an evolving field. There is evidence that communication can be an effective
Available online 18 April 2015 tool, if utilized in a carefully planned and integrated strategy, to influence the behaviours of populations
on a number of health issues, including vaccine hesitancy. Experience has shown that key points to
Keywords: take into account in devising and implementing a communication plan include: (i) it is necessary to
Vaccine hesitancy be proactive; (ii) communication is a two-way process; (iii) knowledge is important but not enough to
Health communication
change behaviour; and (iv) communication tools are available and can be selected and used creatively
Vaccine communication
to promote vaccine uptake. A communication strategy, incorporating an appropriate selection of the
available communication tools, should be an integral part of every immunization programme, addressing
the specific factors that influence hesitancy in the target populations.
© 2015 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/3.0/).

There is no vaccine against resistance or refusals that are information, ideas, and methods in order to influence, engage,
rooted in social, cultural, religious and political contexts. No sup- empower, and support individuals, communities, health-care profes-
ply chain can overcome issues of gender-based decision-making in sionals, patients, policymakers, organizations, special groups, and the
households. Medical approaches alone cannot address certain com- public so that they will champion, introduce, adopt, or sustain a health
munity concerns...These challenges demand effective communication or social behaviour, practice, or policy that will ultimately improve
action...(Obregan et al., 2009 [1]) individual, community, and public health outcomes” [4].
Health communication is an evolving field that has shifted from There is less information in the literature about communication
an emphasis on health education towards behaviour and social interventions for promotion of vaccination, although community
change. The evidence that communication can help people adopt dialogues and mass media have received some attention [1,3,5–9].
positive health behaviours and create demand for preventive and The Strategic Advisory Group of Experts on Immunization
curative services is growing. Much of the growth in this field was (SAGE) Working Group on Vaccine Hesitancy (WG) [10] consid-
stimulated by the AIDS epidemic starting in 1985 when there was ered whether poor communication was a determinant of vaccine
no antiretroviral treatment and the only tool for prevention was hesitancy and concluded that communication was a tool to address
social and behaviour change. Lessons from communication experi- vaccine hesitancy, rather than a determinant. The WG also noted
ences for improving child survival [2] and for encouraging family that poor communication can undermine vaccine acceptance in
planning [3] underpinned these early HIV prevention communi- any setting. For example, in 1999, the rationale for the decision
cation strategies. Given this breadth, not surprisingly, definitions to minimize the use of thimerosal as a preservative in some vac-
of health communication are neither simple nor brief. In 2013, cines in the USA was poorly communicated. As a consequence,
Schiavo defined health communication as “A multifaceted and mul- public confidence in vaccines and the vaccine delivery system
tidisciplinary field of research, theory, and practice concerned with decreased, leading to increased vaccine hesitancy and refusal. In
reaching different populations and groups to exchange health-related middle and low income countries, sparse communication resources
limit the capacity to counter negative information about vaccines
and achieve community support for vaccination programmes. For
example, the Independent Monitoring Board on polio eradication
∗ Corresponding author.
noted deep concern about “the Global Programme’s weak grip on
E-mail address: [email protected] (S. Goldstein).
1
Member of SAGE Working Group on Vaccine Hesitancy.
the communications and social mobilization that could not just neu-
2
Members of SAGE Working Group on Vaccine Hesitancy are listed in Appendix. tralize communities’ negativity, but generate more genuine demand.

http://dx.doi.org/10.1016/j.vaccine.2015.04.042
0264-410X/© 2015 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/3.0/).
 S. Goldstein et al. / Vaccine 33 (2015) 4212–4214 4213

Within the Programme, communication is the poor cousin of vaccine attitudes to vaccines and the influence of online social networks,
delivery, undeservedly receiving far less focus. Communications exper- both for adults and children and within different social networks.
tise is sparse throughout and needs to be strengthened” [11]. Thus, Mass communication campaigns – both online and offline – may
regardless of the setting, poor communication to promote vacci- be more effective in building support for vaccination programmes
nation needs to be addressed generally, in addition to developing or maintaining revaccination social norms. They may also prove
quality targeted communication to specifically address hesitancy counterproductive with subgroups which are ardently opposed to
and improve vaccine uptake. The WG also noted that commu- vaccination [7]. For any communication approach to be successful,
nity engagement and social mobilization have an important role it is critical that it be grounded not only in theory, but also in social
in encouraging and fostering trust in vaccines and vaccination data that informs accurate targeting of subgroups.
and that communication is an essential tool in accomplishing this. A concern about communication on vaccine hesitancy raised
Where and who the messages come from is significant when lack by some in the immunization community is that public discus-
of trust is a driver of hesitancy. sion of hesitancy may, by drawing attention to it, “legitimize” it
In the past two decades, a number of lessons learnt about effec- through familiarity so that it becomes a self-fulfilling prophecy,
tive health communication from other fields, as well as a few thus aggravating the situation. In addressing this, the WG stressed
from immunization, have highlighted cautionary points that need the importance of reinforcing public perception of immunization as
to be considered as communication plans concerning vaccination a social norm. They also reviewed data from UNICEF and the Global
and vaccine hesitancy are formulated. These points are elaborated Polio Eradication Initiative on community and individual concerns
below. raised about polio immunization in Nigeria and India. Noteworthy
Firstly, it is necessary to be proactive. A communication strategy findings were that by 2014, only 1.2% of unvaccinated children in
should be integrated into the planning of any immunization pro- Nigeria were not vaccinated because of refusal, and the refusal rates
gramme from its inception. Last minute communication planning were highest where insecurity and social strife were highest. Many
compromises the quality of the communication, the immuniza- of the unvaccinated children had been missed, i.e. not at home when
tion intervention and its impact. Lack of communication at the called, rather than having refused the vaccine (although in some
outset can lead to serious problems with implementation of the settings this was interpreted as a “silent refusal”). When organized
programme, and leaves open the space for communication by peo- resistance to polio immunization was present, it was typically cor-
ple and organizations with vested anti-vaccine interests or religious related with political opposition to the government or an outside
convictions. group seen to be supporting immunization, and the resistance usu-
ally had a dynamic leader at the centre of the movement. Grievances
The need for a methodical and proactive communication
were often linked to lack of other services and amenities (i.e. immu-
strategy to respond to misinformation and anti-immunization
nization provided a bargaining chip to leverage access to other
activities was recognized in the European region [12].
services or demands for political actions of government or interna-
Secondly, communication is a two-way process. It is in equal tional players such as “stopping the drones”). Addressing vaccine
measure a process of listening and telling. Understanding the hesitancy, especially through building the trust of the local lead-
perspectives of the people for whom immunization services are ers and community communication did lead to increases in polio
intended, and their engagement with the issue, is as important vaccine acceptance in communities and reduce vaccine hesitancy.
as the information that experts want to communicate. Formative Thus, the evidence from the Global Polio Eradication Initiative does
research is therefore an essential component of communication not support the hypothesis that discussing/addressing hesitancy
planning. This creates opportunities to engage people in discussion makes the situation worse.
and debate and provides opportunities for listening and learning. In conclusion, there is evidence that communication can be an
Formative research can also involve consulting existing epidemio- effective tool, if utilized in a planned and integrated strategy, to
logical and social data about the specific population being targeted. make a significant difference to the behaviours of individuals and
Mobilizing populations through their religious and community populations on a number of health issues including acceptance of
leaders has proven to be an effective communication tool to pro- vaccination. Despite the complexity of vaccine hesitancy and the
mote polio eradication efforts in endemic countries [11]. broad range of its determinants, a carefully devised communica-
Thirdly, knowledge is important but is not sufficient to bring tion strategy should be an integral component of any immunization
about changes in health behaviours or to ensure their adoption programme, addressing the specific factors that influence vac-
[13,14]. Different change models have been developed and vali- cine uptake in the targeted population. The incorporation and
dated, and may be appropriate in different contexts [15,16]. While implementation of a well thought-through immunization commu-
the merits of each model can be debated, the importance of under- nication plan should be a regular – and inextricable – part of good
pinning a communication strategy on one or a combination of immunization programme practice. Given their vast experience in
validated models cannot be overestimated. Communication is more the field of polio and expertise in civil society organization, in com-
effective when it is based on theory. munications and in behavioural change, UNICEF is encouraged to
Fourthly, many communication tools are available. They include continue its work with WHO and member states to ensure compe-
mass electronic media, digital media, print media, social mobiliza- tencies in the field of vaccine hesitancy worldwide. Communication
tion, mobile technology, and service-based communication. These strategies can and should be harnessed for vaccination, as a means
tools can be selected and used creatively together to engage tar- of counteracting vaccine hesitancy and promoting optimal vaccine
get groups in dialogue. The appropriate mix of mediums and tools uptake.
should be determined based on a thorough analysis of media pat-
terns. All tools need to be used thoughtfully, monitored for their
impact, constantly honed and refined, and discarded if they are not Conflict of interest statements
achieving their objectives. The use of social and other new media
needs to be embarked upon with care and monitored for impact in The LSHTM research group “Project to monitor public confi-
view of the complexities of these media, as well as those of vaccine dence in Immunization Programs” has received research funding
hesitancy. The role social media plays in individual and community from Novartis as well as funding from GSK to host a meeting on
vaccine decision-making is still not fully understood. The con- vaccine confidence. Heidi Larson has done consulting on vaccine
tent of social media needs to be better monitored with respect to confidence with GSK.
4214 S. Goldstein et al. / Vaccine 33 (2015) 4212–4214

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