A funny thing happened during a recent workshop at Carleton University — a room full of public health experts and practitioners all but stood up and cheered for the federal Minister of Health.

Well, it wasn’t exactly a blanket endorsement. It’s fair to say the current federal government and much of the country’s public health community do not see eye-to-eye on many, if not most, issues. From fairly narrow issues like supervised injection sites, to broader challenges like regulating sugary drinks, the two often see and frame issues in fundamentally different ways. So it should probably go without saying that the federal government would prefer people in Vancouver’s Downtown Eastside didn’t die of heroin overdoses, but facilities which use evidence-based interventions to help addicts reduce the health risks associated with injection drug use is just not on. It is likewise concerned about the rise of obesity among children, but loathe to strengthen regulations around junk food or tell Canadians what they should feed their kids.

But during the workshop in question, a professional program on vaccine hesitancy communication, the moment of consensus focused on the health minister’s recent public statements in the wake of a spike in measles cases in Canada and the United States. The minister chose to speak directly to parents who reject vaccination when she stated that they were being ”œirresponsible”. Extoling vaccines as a ”œmiracle of modern science,” and expressing her frustration in having to ”œhold back my emotions,” she proclaimed, ”œyou’re putting other children at risk if you don’t immunize your child and you send them to school”.

The tone of the minister’s comments was one of exasperation. Like many in the public health community, she’s had enough. And here, she was giving voice to the beliefs and feelings among a majority of our workshop practitioners and experts. These were medical professionals, health policy analysts, and public health researchers and communicators who have spent years trying to better understand the motivations of vaccine-hesitant individuals, and to try to better explain the science of vaccination to them.

Frankly, they’re fed up too.

Indeed, in an anonymous poll workshops participants were asked: ”œIs it time to adopt a more aggressive tone in our communication to people who are vaccine-hesitant? For example, emphasizing the irresponsibility of exposing others to vaccine preventable disease risk.”

The response was an emphatic ”œyes.” Such sentiment is reflected in a changed public debate on vaccination.

The Emerging Hardline

In recent years, communication strategies to help tackle the vaccine hesitancy problem, and which build from risk communication theory and practice, emphasized the importance of better understanding parent concerns and engaging in a substantive dialogue to address them. The best examples – according to the model — don’t start with the question, ”œwhat are we going to tell the vaccine-hesitant so they do the right thing?” But rather, with: ”œwhat are they going to tell us so that we can better understand their worries and concerns?” Seen from this perspective, patience and understanding, not finger-pointing, are what physicians and medical professionals need to address the problem of parental anxiety or disbelief about the importance of vaccination.

In contrast, the emerging hardline suggests a shift from an effort to better understand the fear and concern of vaccine-hesitant individuals, towards strategies built around powerful emotional tools calling people to account. Examples range from the positive, sharing personal stories about the consequences of vaccine-hesitancy, to those better described as public shaming.

Signs of the transition are evident in examples spilling out of the health sector. For example, New Jersey Governor Chris Christie was broadly attacked following statements on vaccine choice, interpreted as pandering to the anti-vaccine and vaccine-hesitant communities. The potential Republican presidential candidate beat a hasty retreat – reflecting the power of the backlash. Late night talk show host Jimmy Kimmel – as the best comics always do – tapped into the changing public mood through a series of video skits mocking those who would challenge the science supporting vaccination. So much for empathy and the search for mutual understanding.

The frustration driving the search for different communication approaches is understandable. Public health’s profound belief in the phenomenal benefits of vaccination may only be matched by the profound mistrust of ardent anti-vaxxers in the very same intervention. Stuck somewhere in between these views are segments of the population we now describe as vaccine-hesitant.

One of the problems with the Kimmel videos, entertaining as they may be, is how poorly they explain the nature of vaccine hesitancy. We know from public health research that attitudes to vaccination are not cast in a binary model in which you are either for or against immunization. Although news headlines frequently decry a rising tide of ”œanti-vax” sentiment, attitudes to vaccination actually range from one end of the spectrum (total acceptance) to the other end (complete refusal) with a large number of people and positions falling somewhere in between. As one recent study puts it, ”œvaccine-hesitant individuals may refuse some vaccines, but agree to others, delay vaccination or accept vaccination although doubtful of doing so…The phenomenon is complex and context-specific, varying across time and place and with different vaccines.”

We also know that people who are most likely to oppose vaccination do not arrive at this view because they are uneducated, poor, or unconcerned about their health and wellbeing. A recent Canadian survey found that the majority (65 percent) of those who do not vaccinate their kids cite ”œhealth reasons” as their primary concern (19 percent cite religious reasons). Education and income don’t factor into their positions either – nearly 40 percent of vaccine-hesitant parents surveyed have household incomes greater than $100,000 and more than two-thirds (66 percent) have completed post-secondary education.

Ironically, in many ways the vaccine-hesitant cohorts could be characterized as a public health planner’s dream. They are educated, health conscious and economically advantaged. They are the very demographic that would, under many other circumstances, be willing and able to make positive behavioural change to improve both their own health and that of their communities.

In its simplest form, risk communication entails a process of ongoing and evolving dialogue and negotiation between a communicator (government, physician, drug company, public health organization, etc.) and its stakeholders (patients, voters, citizens, shareholders, etc.) and takes informed decision-making as its main objective. Risk communication works to support the broader risk management ideal of partners – from organizations to individuals —  with diverse perspectives and priorities coming together to co-manage a risk. By extension, it has to be substantive. It’s not enough to simply ”œfeel people’s pain,” it has to respond and adapt.

This comes as a profound disappointment for too many leaders, scientists and experts. They imagine risk communication as a kind of specialized public relations that will, at the end of the day, make sure everyone agrees with them and allow them to manage a risk as they see fit. In this interpretation, communicating risk is a matter of simply explaining the science better or more persuasively. With most serious risk, however, evidence suggests explanation is not necessarily the problem.

Indeed, for those who oppose vaccines, additional scientific explanation is likely to only harden their views. U.S. research has found that when presented with information which contradicts their beliefs, people actually become more convinced, not less, that they’re correct. Shaming, meanwhile, is risky not only because it heightens anxiety and leads people to seek security in already consonant perspectives; politically, it can also force many on the vaccine sidelines to withdraw from the debate altogether or to side with those they may perceive to be under attack.

So let’s be clear on what we are doing.  A hardline approach, aggressively taking on the anti-vaccination and vaccine-hesitant communities is not a risk communication strategy. Quite the opposite – without dialogue, negotiation, and understanding, it represents the abandonment of a risk communication strategy.

That may well be an appropriate policy option. As one of the Carleton workshop experts noted: ”œwhat we’re doing is just not working”. But it’s an option that may have serious implications, and if the Minister of Health and other authorities are truly serious about ”œtaking off the gloves” in how to communicate about vaccines, they better make sure there is something more than just emotionally compelling pleas founded on the politics of frustration.

There is evidence to suggest that without a legitimate risk communication strategy, the vaccine hesitant cohort will only grow in size, increasing the health threat of vaccine-preventable diseases to the larger population. In its absence, there needs to a serious action in other areas.  For example, developing a national immunization strategy that would include extending mandatory school-entry vaccination laws nationwide, enacting legislation such as that recently introduced in Oregon and California to all but eliminate non-medical exemptions to ensure compliance, or investing in robust surveillance and electronic record keeping. But that would require not only a significant investment of financial capital, but also the symbolic capital associated with shouldering some political risk.

A hardline communication approach on vaccine hesitancy gives voice to pro-vaccine frustration and passion, and this plays an important role in both constituting and sustaining support from the public health and medical communities, but it may also have significant repercussions in the years to come since we know that more aggressive, shaming and blaming strategies do very little to change risky behaviour. If health authorities are truly serious about taking a hardline in communicating the importance of vaccines, it will have to be backed up by bold policy action.

Photo by Sanofi Pasteur and Eric Larrayadieu / CC BY-NC 2.0 / modified from original 

John Rainford
John Rainford is the Director of The Warning Project. He is the former Director, Emergency and Risk Communications for Health Canada and Global Project Lead, Risk Communication Capacity Building for the World Health Organization.

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