A funny thing happened during a May 2015 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, they often see and frame issues in fundamentally different ways. So it should probably go without saying that the federal government would prefer it that people in Vancouver’s Downtown Eastside not die of heroin overdoses, but facilities that use evidence-based interventions to help addicts reduce the health risks associated with injection drug use are just not on. Likewise, the government is concerned about the rise of obesity among children but loath 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 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 “irresponsible.” Extolling vaccines as a “miracle of modern science” and expressing her frustration in having to “hold back my emotions,” she proclaimed: “You’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 workshop participants were asked: “Is 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 “yes.” Such sentiment is reflected in a changed public debate on vaccination.
In recent years, communication strategies to help tackle the vaccine hesitancy problem, 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. For example, according to the model: don’t start with the question “What are we going to tell the vaccine-hesitant so they do the right thing?” but rather with “What are they going to tell us so that we can better understand their worries and concerns?” From this perspective, patience and understanding, not finger-pointing, are what physicians and medical professionals need in order to address the problem of parental anxiety or disbelief about the importance of vaccination.
The emerging hardline approach suggests a shift away from trying to better understand the fear and concern of vaccine-hesitant individuals, toward strategies built around powerful emotional tools that call people to account. For example, this might involve sharing personal stories about the consequences of vaccine hesitancy, as happened recently in a high profile Ottawa case involving a family with several unvaccinated children who developed whooping cough. More commonly, it includes the use of strategies that can be best described as public shaming and blaming.
Signs of this transition are evident in examples spilling out of the health sector. For example, New Jersey Governor Chris Christie was broadly attacked in the Huffington Post in June after making statements on vaccine choice that were interpreted as pandering to the antivaccine and vaccine-hesitant communities. The potential Republican presidential candidate beat a hasty retreat — reflecting the power of the backlash. In February late-night- talk-show host Jimmy Kimmel tapped into the changing public mood — as the best comics always do — 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 is matched by the profound mistrust of -ardent antivaxxers 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 toward vaccination are not a binary model in which you are either for or against immunization. Although news headlines frequently decry a rising tide of “antivax” sentiment, attitudes toward 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 a 2014 study by Dubé et al. puts it, “Vaccine-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 well-being. A recent poll by Toronto-based Mainstreet Technologies found that the majority (65 percent) of Canadians who do not vaccinate their kids cite “health 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.
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 well-being.
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 (for example, governments, physicians, drug companies, public health organizations) and its stakeholders (for example, patients, voters, citizens, shareholders). The communicator takes informed decision-making as its main objective. Risk communication works to support the broader risk-management ideal of the partners — organizations and individuals — with diverse perspectives and priorities coming together to comanage a risk. By extension, this ideal has to be substantive. It’s not enough to simply “feel people’s pain”; the communication has to respond and adapt.
This comes as a profound disappointment for too many leaders, scientists and experts. They imagine risk communication to be 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 that this is not necessarily the case.
Indeed, for those who oppose vaccines, additional scientific explanation is likely to only harden their views. Research from the United States by Brendan Nyhan and Jason Reifler has found that when presented with information that contradicts their beliefs, people actually become more, not less, convinced that they’re correct. Shaming meanwhile is risky, not only because it heightens anxiety and leads people to seek security in already consonant perspectives, but also because politically it may force many on the vaccine sidelines to withdraw from the debate altogether or side with those they may perceive to be under attack.
So let’s be clear: a hardline approach which aggressively takes on the antivaccination and vaccine-hesitant communities is not a risk communication strategy. In fact, quite the opposite is true — without dialogue, negotiation and understanding, it represents the abandonment of a risk communication strategy.
The hardline approach may well be an appropriate policy option. But it’s an option that may have serious implications, and if the Minister of Health and other authorities are truly serious about “taking off the gloves” in how to communicate about vaccines, they had better make sure they have something more than just emotionally compelling pleas founded on the politics of frustration. As one of the Carleton workshop experts noted: “What we’re doing is just not working.”
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 the absence of a risk communication strategy, there needs to be serious action in other areas. One possibility would be to develop a national immunization strategy that would include making mandatory school-entry vaccination laws nationwide, which could entail enacting legislation like that recently introduced in Oregon and California. This legislation would all but eliminate nonmedical exemptions to ensure compliance, or involve 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 is an expression of provaccine frustration and passion, and this is playing an important role in sustaining the support of that position in the public health and medical communities, but it may also have significant repercussions in the future, since aggressive shaming and blaming strategies do very little to change risky behaviour. If health authorities are truly serious about taking a hard line in communicating the importance of vaccines, they will have to back it up with bold policy action.