Vaccine Hesitancy: A Vade Mecum v1.0

Noting that vaccine hesitancy has been a constant and steady threat to immunisation programmes since their inception and that there is no quick and easy fix, this reference guide from the journal Vaccine draws upon existing evidence to propose some practical recommendations for healthcare professionals (HCPs) and public health professionals, with the caveat that all of these recommendations should be further tested for efficacy upon vaccination attitudes, intentions, and behaviours. Immunisation partners can start with 3 shared objectives: (i) communicate proactively on immunisation, (ii) prepare for issues that may arise, and (iii) understand the challenge better through existing and future research.

Table 1 includes some rules of thumb for talking vaccination, including: remember importance of your recommendation and example; present vaccination as the default; be alert to local reactions; and address one concern. That said, the HCP should remember to: listen first, beware of debunking myths, use facts sparingly; be careful with fear; maintain your authority; have your own vaccination story; elicit underlying beliefs if there are multiple concerns; minimise pain of vaccine; and remain presumptive to the end.

Specifically, the vade mecum has some tips for immunisation partners (e.g., national immunisation programmes, public health departments, academia, manufacturers, civil society organisations, HCPs, etc.):

• Emphasise the positive - how vaccination protects people and keeps them healthy. Reinforce the social norm of vaccination, as people will do what they think everyone else is doing. But do not try to scare people, as fear can backfire. Be open about local or general reactions such as local redness at the injection site or mild fever. These are relatively common and actually indicate the vaccine is working. It is essential to differentiate these minor effects from serious adverse events which are extremely rare.
• Give the press the information, stories, and answers they need to write about vaccines or possible emerging issues. Provide them with independent science commentary. Help them understand the risks of presenting anecdotal stories as the counterbalance for strong scientific evidence (where the scientific evidence is overwhelmingly in favour of vaccination or other public health measures).
• Effectively engage with social media. Every country should have a trusted hub of resonant, trustworthy information, answers, stories, and videos that is the reference for the public when they have questions about vaccination. Reach comes through effective social media strategies that share content in multiple channels and develop and connect positive voices online.
• Use tools such as the open-access Vaccine Sentimeter to routinely monitor the ongoing public conversation on vaccination in mainstream and social media.
• Plan to be able to listen to and understand an emerging public concern, know who will respond and where they will engage with the media and the public, and prepare for an ongoing conversation not just distribution of short statements and fact sheets. Be transparent and honest, and have the trusted alternative voices ready to speak as well. Key risk management principles include ongoing regular engagement with the media, plain language, empathy, and listening to the public.
• Invest in research, capacity building, and monitoring and evaluation (M&E) of immunisation programmes.
• Empower, equip and galvanise HCPs to help people make healthy decisions like vaccinating.

Medical doctors, nurses, and other HCPs can:

• Establish rapport (look at the person, not the computer) and positive common ground ("It's great to see your baby Joan in good form.").
• Start with a statement that assumes vaccination will occur ("Today we are going to give Joan her shots to keep her fit and healthy"), not a question ("Do you have any questions about today's vaccines?"). If no concerns arise, vaccinate and congratulate ("Well done, together we've helped protect Joan against some pretty nasty diseases."). This reinforces the norm of vaccination and leaves the person with a positive final recollection. Set an appointment for the next shots right away and send a reminder close to the date.
• Prepare the person to identify, manage, and appreciate local reactions or mild fever ("It shows the vaccine is working.") so there are no surprises or unnecessary anxiety.
• If a concern is raised, listen to it without interrupting. Affirmation increases the chance someone will accept correct information ("I can see you are a caring parent who wants to do everything keep Joan healthy and safe."). Respond with a simple, resonant and, if possible, tested answer ("There is more formaldehyde in a pear than in all the vaccines a child receives.")
• Do not repeat a myth, even to refute it; that can lead people to recall it as being true. Acknowledge the presence of a risk with vaccination ("Just as there is a risk taking a bath, driving a car, in everything we do in life..."), and describe briefly the known risks of vaccination; distinguish clearly between local reactions and severe and very rare events.
• "Information and education alone do not change beliefs or behavior. Facts can polarize people, solidify their beliefs, and may actually backfire."
• "To have a positive effect, both the perceived threat and perceived self-efficacy must be high, and this is hard to achieve. Wield fear with great care. Or better still, focus on vulnerability and likelihood of infection."
• "State that through your research and clinical experience you are certain that vaccination is the right thing for the person. Remind the person that they trust you on all other matters regarding their child's health."
• Share a relatable personal story from your experience which illustrates why you vaccinate and why you recommend vaccination.
• If a number of concerns are raised, stop and try to understand the underlying beliefs or fears. Concentrate on securing their trust, which may take more than one consultation.

This practical guide is just a first version (hence the "v1.0"), to be developed and refined by further rigorous research and best practice sharing.