On Tuesday 3rd July I was in Copenhagen attending the 107th Global Health Histories seminar with Sanjoy Bhattacharya (Director of the WHO Collaborating Centre for Global Health Histories at the University of York), who was chairing the session. The seminar showcased two excellent speakers: Robb Butler, Programme Manager for Vaccine-preventable Diseases and Immunization at WHO Europe, and Heidi Larson, Director of The Vaccine Confidence Project (VCP) and Professor of Anthropology, Risk and Decision Science at London School of Hygiene and Tropical Medicine.
To start, Robb Butler gave a very interesting overview of some of the factors affecting decision making, and how this applies to vaccination. He made the point that behaviour, as well as diseases, can be contagious (think of yawning!), and that in order to anchor the population into making positive decisions around vaccinations we need to move to a position where people are making well-informed decisions, rather than just following the crowd.
Robb discussed the ‘mental toolbox’ of tools we use to make decisions, including affect heuristics (i.e. being affected by emotions, a factor particularly used by anti-vax lobbyists) and negativity bias (i.e. people are more likely to make a decision based on the avoidance of negative side effects rather than gaining any positive benefits).
Vaccine hesitancy is affected by confidence, complacency and convenience. Examples were given of populations both of the general public and of healthcare professionals who had never experienced diseases such as measles, and therefore did not feel vaccination was necessary (‘complacency’). Other difficulties included the ease of getting the vaccine, with an example given of French healthcare that required multiple GP/pharmacy trips for a single vaccine (‘convenience’), and poorly-responsive technology (e.g. the failure to progress from fear-inducing needles).
Overall, Robb argued that vaccine hesitancy is complex, context-specific and varies across time, place and type of vaccine.
Following on from Robb’s discussion of how decisions around vaccination are made, Heidi addressed historical and cultural attitudes to vaccine hesitancy from across the globe. She started with the point that not only can we not prevent all vaccine hesitancy, but that we shouldn’t be trying to prevent all vaccine hesitancy; parents with children should quite rightly be asking questions about what is best for their children. She highlighted two key themes that most often lead to vaccine hesitancy: purity (i.e. ‘natural is better’) and liberty (i.e. ‘who are you to impose this on me?).
Heidi highlighted that discussions on vaccine hesitancy can be difficult, particularly when there is emotive polarisation of pro- and anti-vaccination groups (‘they’re stupid’ vs. ‘they’re lying to us’). She argued that we have to be better at how we discuss vaccines with the public – stock phrases like ‘its 100% safe’ and ‘vaccination is the most cost-effective intervention’ (not necessarily – depends on the vaccine/disease) can be unhelpful.
As a case study Heidi also referred to a particular incident involving HPV vaccination in Columbia, where full vaccine coverage in an area decreased from 88% to 5% after an ‘outbreak’ of anxiety symptoms in this area. This case also highlighted the fact that symptoms are not spread evenly throughout the vaccine-taking population; this leads to ‘clusters’ of vaccine hesitancy, linking back to Robb’s concept of behaviour as contagious.
The Q&A session also addressed some important issues. The first question raised the point that people’s first port of call when they have a medical (or other) question is usually Google, and responses are therefore particularly influenced by the top ‘hits’ (and by extension the companies that sponsor them). Robb acknowledged that challenging/working with ‘Dr Google’ was an area the medical profession had not spent enough time on, as well as emphasising the sizable impact a single individual could have on social media to counteract all the work done by health professionals.
Heidi also had advice for a medical student asking how healthcare professionals should discuss vaccination with their patients. Giving them the opportunity to ask questions and listening to their concerns is very important, particularly in maintaining the trust between patient and professional. However, making sure clinicians are confident in answering these questions (ideally with better training, e.g. at medical school) would also help.
The final take home message on improving our approach to vaccine hesitancy was that we all need to put down the guns, engage stakeholders and understand and address their perspectives if we want to move forward.
