Rethinking Vaccine Communications
How a radically new approach to COVID-19 vaccine communications could be the key to reopening society
In the last week, Pfizer/BioNTech and Moderna both announced results from two COVID-19 Phase 3 clinical trials showing efficacy of greater than 90 percent. According to company press releases, the trials showed no significant safety issues. (Full publication of the data is yet to come, as is standard practice.)
This is great news. But as with most things in 2020, it’s complicated. Though vaccines will be valuable to frontline healthcare workers and vulnerable populations, they won’t return us to a version of our pre-pandemic existence for some time. In order to achieve that, scientists estimate that 70 percent of people would have to be vaccinated (the actual number varies based on the efficacy of a vaccine and other factors; achieving so-called “herd immunity” via vaccines with lower efficacy would require more people to be vaccinated.) When it comes to how many people actually plan to get vaccinated, the numbers don’t look good. According to one prominent tracking survey, only half of Americans may now be willing to take the first vaccine. (Various polls have offered varying results on this point; a recent poll by STAT and The Harris Poll indicated that 63 percent of Americans said they would get a vaccine if it lowered their risk of contracting coronavirus by 90 percent.)
This spotlights a public health problem that predates COVID-19 – vaccine hesitancy and refusal. While vaccines are widely regarded as the greatest public health intervention in history next to clean drinking water, global vaccination rates have been flattening or declining in many parts of the world for the past two decades. The traditional vaccine communications response has been to speak louder and more emphatically about the importance of broad immunity, to highlight the risks of vaccine refusal on communities. A COVID-19 vaccine offers those of us who do public health communications to radically rethink our approach and adopt one that favors engagement, transparency, education and shared decision-making. For a number of reasons, this is a good moment to consider such an approach. Done well, it may be an essential part of resolving the current pandemic, addressing vaccine hesitancy and bridging the many gaps in our body politic that have deepened in the last decade.
Anxieties about vaccines, particularly among parents, have been on the rise. In 2019, the United States nearly lost its measles elimination status based on an outbreak of 1,249 cases in New York State. Ironically, the answers as to why vaccine hesitancy and refusal are rising are not clear. According to global surveys by the Wellcome Trust, it’s not about lower wealth: higher-income nations tend to be more skeptical about vaccine safety than lower income nations. It’s not about lower education: in some regions, people with a high level of science education produce strong vaccine confidence; in others, the opposite is true. It’s not about a lack of information: again, parents who exhibit greater health-information seeking behaviors are less likely to agree vaccines are safe than those who don’t. (While we have access to more information than ever before, that also means we have more access to contrarian opinions, Reddit subthreads and disinformation.) It’s not even about the developed world v. the developing world: France, where one in three people say vaccines aren’t safe, shows the highest rates of vaccine hesitancy, while Bangladesh, Egypt and Tajikistan show the lowest.
Vaccine hesitancy is a complex phenomenon that touches on a wide range of issues: parental authority; vaccine effectiveness, safety and importance; historical experiences; religious views; relationships with information sources and trust. And vaccine hesitancy is about as old as vaccines themselves. The first anti-vaccination movement was in the 1850s, in response to mandatory smallpox vaccination efforts.
Writing about cases where communities have refused vaccination, Heidi J. Larson, Ph.D., director of the Vaccine Confidence Project and author of Stuck: How Vaccine Rumors Start—and Why They Don’t Go Away says such vaccine revolts “are rarely only about the vaccine.” She writes “(They) unleash underlying sentiments about personal and collective histories, relationships with government, big business and international bodies.” Vaccine hesitancy appears to be an emotional issue, rooted in dynamics of power, control and trust. In this way, it presents a serious challenge to a public health infrastructure that is accustomed to communicating in mostly rational terms and measures success purely in terms of the number of people vaccinated.
The Trump administration has broken nearly every rule in the pandemic playbook: it sidelined doctors and scientists, the most trusted spokespersons; it placed President Trump, Vice President Mike Pence or Health and Human Services Secretary Alex Azar — all political appointees — in the role of spokesmen, where the playbook urges reliance on spokespersons with scientific credentials; it was wildly inconsistent in its messaging, amplifying conspiracy theories and suggesting unproven and dangerous treatments and cures; and it allowed political influence on its leading public health agencies, the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Perhaps most importantly, the considerable lack of clarity that marked the administration’s response – “don’t wear masks” became “wear masks”; “wear masks” became “wear masks, but it’s an individual choice” – deepened the divides among groups of people with very different worldviews about the pandemic.
It should be noted that the administration’s Operation Warp Speed, which was created to support the creation of a vaccine in record time, achieved remarkable success in terms of accelerating vaccine development programs. Prior to this year, the fastest such program in history was the measles vaccine in 1968, which took four years. Never before have so many viable vaccine programs proceeded so quickly from the lab to the clinic. As a consequence, though, many have expressed concerns about whether the science has been rushed.
As a function of all this, trust in the government’s public health infrastructure has been battered. A Kaiser Family Foundation survey prior to the election found that trust in the CDC had declined from 83 percent in April to 67 percent in September, and trust in Fauci had declined from 78 percent to 68 percent. There was a stark partisan divide. Trust in the CDC by Republicans dropped from 90 percent to 60 percent in that time frame and trust in Fauci among Republicans dropped from 77 percent to 48 percent. The same poll showed six in ten adults were worried that the FDA would rush to approve a vaccine without making sure it was safe and effective due to pressure from the Trump administration.
The FDA clearly recognizes the public opinion challenge and is conducting landscape research to better understand how frontline workers and traditionally underrepresented groups – two critical vaccine audiences – are thinking about a vaccine, through the Reagan-Udall Foundation for the FDA. According to a presentation to the FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC), people who have participated in a series of focus groups reported the following concerns (quotes are directly from participants):
- Concerns about speed: “We all know how long vaccines take, so to hear that it will be ready in a few months is concerning”
- Distrust of government: “When I hear the FDA say they have a particular process, but then I hear the White House say they can cut that in half or negate it – it brings more distrust”
- Distrust of the healthcare system: “Doctors are going to be pushed to sell this [vaccine] to our community. I would like you to not sell me, but show me and tell me, educate me.”
- Concern that politics and economics will overshadow science: “A lot of people don’t trust the people who are making the vaccine because they are politically motivated, and we are all a bunch of guinea pigs”
- Fear a vaccine won’t work for me or my community: “Need to know other minorities have taken it. Are other minorities ok? We’re all built different. How do we know?”
- Past experiences: “I firmly believe that this is another Tuskegee experiment.”
Taking in the depth and multiple dimensions of distrust among these audiences reminds us of our checkered past. The Tuskegee experiment was a study of 600 African-American men, 399 of whom had untreated syphilis, from 1932 to 1972 by the U.S. Public Health Service and the CDC, a black mark on public health and biomedical research studies. This deeply unethical and racist study has left a legacy of distrust in minority communities, which not surprisingly have also experienced higher mortality from COVID-19. Vaccine programs themselves have been rife with problems. Mandatory vaccination programs, both historically and globally, have been marked by the use of coercion and force. There are also memories of vaccine programs gone wrong. The 1976 “National Influenza Immunization Program” was dubbed a fiasco at the time due to low efficacy, side effects and the sense that it was – wait for it – rushed for political gain. (That program encountered significant logistical challenges, produced the wrong version of the vaccine strain, was correlated with an increase in Guillain-Barré syndrome, an obscure neurological condition, and immunized just 25 percent of Americans in 10 months, for a version of influenza that did not produce the pandemic as feared.)
Current communications environment
Whatever the legitimacy and legacy of these historical events, the communications landscape of 2020 is primed to create greater challenges to promoting vaccine adoption. The deep divisions in our body politic, on full display in response to our recent election, bode poorly for vaccine communications efforts. COVID-19 has been marked by what the World Health Organization classifies as an “infodemic” of misinformation, with a long list of falsehoods about the disease, its genesis and spread, prevention and treatment.
We can see evidence of these divisions as it relates to attitudes toward COVID-19 and conspiracy theories, as shown in a May study by Annenberg Public Policy Center of the University of Pennsylvania. The 800-person study, which included two surveys to assess both beliefs and the correlation between beliefs and preventive actions, showed 28 percent of people said they believed that the Chinese government created the virus as a bioweapon; 24 percent said they believed the CDC exaggerated the danger posed by COVID-19 to hurt President Trump; and 15 percent said they believed the pharmaceutical industry created the virus to increase sales of drugs and vaccines. It found that those who believed in conspiracy theories were less likely to take the preventive actions recommended by public health authorities to control the spread of COVID-19.
In many categories, the demographic breakdowns of belief in these theories is unremarkable. But with certain audiences, these – again, false – conspiracy theories have a strong foothold. Here are the demographic categories for each theory in which more than a third of the respondents expressed belief in the specific piece of fake news.
- Pharmaceutical conspiracy:
- More than 36 percent of Black respondents
- CDC conspiracy:
- Nearly 34 percent of those who rely heavily on conservative outlets as their main news source
- The Chinese conspiracy theory had the most pockets of belief:
- 35 percent of 18-29 year olds
- Nearly 44 percent of Black respondents
- Nearly 43 percent of those with a high school education or less
- 37 percent of respondents with incomes of less than $30,000 per year
- 37 percent of conservatives
- Nearly 52 percent of respondents who rely heavily on conservative news sources for information
- Nearly 42 percent of those who rely heavily on social media
The social media landscape, which is a key channel for both pro- and anti-vaccination message dissemination, might best be characterized as a vaccine information battleground.
In a study titled “The online competition between pro- and anti-vaccination views” published in Nature in May, researchers conducted a network analysis of 100 million Facebook users who expressed views about vaccinations. The pro-vaccination groups were large, in terms of followers, and drew on a significant amount of positive news media. They were also “monothematic” (i.e., vaccines are safe and effective). Anti-vaccination groups were smaller but more numerous and more dynamic, the researchers said. They put forward multiple narratives: concerns about safety; conspiracy theories; alternative health and medicine theories; causes and cures of COVID-19. This strategy, the researchers said, gives them multiple potential points of traction with undecided users. Interestingly, the pro-vaccination groups had few connections with the anti-vaccination groups, meaning they “may remain ignorant of the main conflict and have the wrong impression they are winning.” According to these researchers, anti-vaccination groups have been focused on COVID-19, often spreading misinformation, since the spring.
Studies have also shown that Russian bots have been particularly active in promulgating COVID-19 disinformation. According to a May study by researchers at Carnegie Mellon University, more than half of all Twitter accounts sending messages about the pandemic may have been Russian bots.
There is a path to rebuilding trust in public health institutions, but it will take time. Before the election, former U.S. Surgeon General Dr. Vivek Murthy, who now co-chairs President-elect Joe Biden’s COVID-19 task force, outlined the shift in focus that would be required on a podcast. “Public trust is one of the most important resources you have,” he said. “And you have to cultivate it at all costs.
“That means being honest with people, even when you’ve done something wrong,” Dr. Murthy said. “That means being open to hard questions, even when you don’t know the answers. It means communicating openly, transparently and regularly with people. And in this moment, it also means allowing them to hear directly from the sources of information, which are scientists. You know, science has to guide pandemic responses. And when scientists aren’t allowed to speak directly, in an unfettered way, with the public, it sows doubt.”
Biden has signaled his plan to rely on scientists – and science — and tamp down the politics. “We can save tens of thousands of lives if everyone would just wear a mask for the next few months,” Biden said. “Not Democratic or Republican lives — American lives.” Masks, it should be noted, have been shown to be highly effective where used properly. Studies have shown masks may even confer some level of inoculation, which further underscores the missed opportunity of promoting mask use more widely than has been done to date.
Murthy’s role in pandemic response planning and in a vaccine rollout bodes well for the reassertion of public health communications norms. He spoke of relying on trusted voices (scientists and doctors), including the FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC). He talked about publishing the data from trials in peer-reviewed journals and creating a robust discussion around these data. He talked about engaging both the medical community and the non-medical community, reaching out to local communities and engaging non-scientific community leaders. He does this while acknowledging that social connections have been in decline, a phenomenon that will not help planned outreach efforts.
There is a sense, however, that the communications around pandemics and vaccines is an exercise more in telling than listening. The Obama administration’s pandemic playbook, focused on pandemic response, contains one page on communications in a 69-page publication, and that page is mostly focused on key planning questions, roles and responsibilities, and coordination mechanisms. The Trump administration’s COVID-19 vaccines plan offers a far more detailed approach and includes an emphasis on listening, engagement and empathy. It’s unclear whether the different plans around vaccine communications will follow this approach.
The Reagan-Udall Foundation’s effort says it is conducting message testing this month. The CDC outlined a similar effort at its Advisory Committee on Immunization Practices in October, emphasizing the need to reinforce trust, empower healthcare providers and engage communities and individuals. The Department of Health and Human Services appears to be moving forward with a $250 million “defeat despair” campaign, which at one point planned to use celebrities and Santa Claus volunteers to send positive messages out about COVID-19. That effort, which was criticized as being overly political, has reportedly been retooled under the guidance of public health leaders. HHS Deputy Assistant Secretary for Public Affairs and Human Services Mark Weber, the campaign’s manager, promises something that looks more like a traditional public health campaign.
Still, if you look at the actual communications plans and pandemic playbooks of the past, there is often a tone that if we just tell people clearly enough, or perhaps loudly enough, vaccine communications will be a success. That’s not what’s recommended by the Vaccine Confidence Project’s Larson: “Vaccine reluctance and refusal are not issues that can be addressed merely by changing the message or giving ‘more’ or ‘better’ information. What is needed is a more fundamental change around the fertile ground which is fueling the concerns, rumors and heated debates.”
A New Model for Vaccine Communications
If vaccine hesitancy is rooted in issues of power and control, this would present an incredible opportunity to do something dramatically different in vaccine communications. An approach that abandons a paternalistic tone in favor of a shared decision-making model.
In July, an interdisciplinary working group convened by the Johns Hopkins Center for Health Security produced a report suggesting that kind of direction. It urged the groups involved in vaccine development to prioritize vaccine rollout planning and take a ‘design thinking’ approach that put the public at the center of the effort. The recommendations emphasized the need to understand public expectations, earn public confidence in the fairness and even-handedness of vaccine allotment and availability, make vaccines available in familiar settings and communicate in meaningful, relevant and personal terms. It is the closest thing to an applied social science approach among all the various plan documents.
Such an approach won’t be easy to adopt. From a messaging standpoint, it requires evolving messaging from an emphasis on things like “herd immunity” to terms that are more personal and meaningful. Things like commerce, dining, travel and other things that are enabled by a vaccine, but not direct outcomes of a vaccine. From a communications standpoint, it requires a dynamic set of outreach and communications strategies that will be rooted not in selling but in education and engagement:
- Vaccine manufacturers should produce robust analyses of their data in peer-reviewed publications and ensure wide distribution of their findings to key opinion leaders (KOLs), relevant medical societies, allied health professionals and patients, in patient-accessible language
- The federal government should lead a strong vaccine distribution effort, prioritizing the places where the vaccine can be most effective in mitigating the spread of COVID-19 and protecting frontline workers and vulnerable populations
- State and local governments, in coordination with federal authorities, should create awareness campaigns that position vaccines broadly as an offer, not a mandate
- Providers should counsel patients with patience, recognizing that in many cases the concerns they express in rational terms may often reflect a hesitancy rooted in emotions
- Insurers and policymakers should set minimal copayments or waive cost-sharing provisions for vaccines to ensure broad access, particularly for the most vulnerable
- Advocacy groups should create tailored communications for their audiences, particularly those with health conditions that put them at higher risk for COVID-19
- Employers, who have found themselves in the unaccustomed position of communicating health-related topics to employees and customers, should embrace an appropriate role in vaccine communications, educating leadership teams on vaccine data and recommending vaccines to employees, particularly those in roles that place them at risk of infection
- Nonprofits that serve at-risk communities should redouble outreach efforts to reach those whom the pandemic has shown are so clearly disproportionately impacted by COVID-19
- Vaccine experts, public health experts and epidemiologists should serve as trusted sources to media outlets and other communities (including social media) to address misinformation in clear but compassionate terms
- Media outlets should write extensively about vaccine issues — the good and if necessary, the bad — and aspire to provide a fully accurate picture of the risks and benefits, knowing that in past vaccine experience there has been an overemphasis on stories that lacked a scientific basis in fact
- Government should make an effort to engage and solicit involvement from influencers, even non-scientific ones, who have a strong following in key communities and on social media. In so doing, there should be an effort to provide them with access to trusted, scientific sources and resources that can help them shape their comments in accurate ways
- Social media platforms should continue to monitor and flag factually inaccurate posts and point participants in the direction of accurate information
In short, it will take a team effort. A big one. One that is less reliant on authority and more invested in transparency, authenticity and two-way communications. Not so much a “vaccine confidence project” as a “vaccine clarity collaboration.” An effort that treats people like they’re smart, have agency and can make their own decisions. Which, after all, they will. Failing to acknowledge this invites efforts on the part of those antivaccine activists and others to demonstrate their power to resist.
It looks like we have at least two strong vaccine candidates that could be approvable in the coming weeks. If the public health authorities charged with communicating about vaccines take an empathetic, engagement-focused approach, complicated as that may be, it may increase the odds that enough people will decide to get one. Which in turn would allow us to move past the COVID-19 pandemic and reopen the economy and our society. If that happens, science won’t be the only winner.