The Human Factor: How Our Nature Is Linked to Vaccine Hesitancy
Authors: Federica Franceri, Alessandra Magazzino, Marta Beatrice Sciunnach
Last January the Italian Government announced the start of an awareness campaign on COVID-19 vaccines, realized with the support of the Oscar-winning director Giuseppe Tornatore. Around the world, similar communication strategies are taking place.
Is this the right approach to convince people to get vaccinated?
Recent studies in social sciences have demonstrated that irrational mental mechanisms can influence individuals’ judgements and beliefs. In turn, these convictions rapidly spread, by causing the creation of rumors and misleading information. But have you ever thought about the story behind a rumor? Have you ever considered the magnitude of its impact?
If you are doubtful about answers, then keep reading. In this article, we explore the power of rumors and cognitive biases in conditioning vaccination decisions and the world’s health. From the identification of these effects, we finally propose some innovative tools to contrast them. A more empathetic and transparent path is needed to bring people together around a single fundamental purpose: lead this dramatic outbreak to an end.
Rumor Has It
According to anthropologist Heidi Larson, rumors have a story and usually an important one. They cannot be considered as facts or just wrong because of their intrinsic value that should not be underestimated. During TEDMED 2020, she reported one of the most alarming rumor episodes she encountered in her career while working for UNICEF’s Global Immunization program in Northern Nigeria. The local population as well as political leaders suspected that the polio vaccine was actually a contraceptive, that it could cause AIDS and that the CIA was spying and counting patients. As a matter of fact, it was 2003, only two years after 9/11, and they were convinced that the West, especially the United States, was at war with Muslims. Consequently, knowing that the US was the strongest supporter of the vaccination initiative, they had legitimate reasons to be suspicious. Nevertheless, it is worth noting that this lack of trust cost the polio eradication program 500 million dollars to save the progress done until then and stop polio from spreading.
Yet, the Nigeria episode is not history of the past. As of this writing, more than 2.3 million people have died from SARS-Covid-19, 105 million have been infected and every single individual on Earth is coping with the long-term consequences of this pandemic. Vaccines and community immunity are the only solutions on the horizon. With record times, technological efforts made great success: today two vaccines have already been approved and more than 50 candidates are in trial. However, this scientifical coup was based on a critical assumption: people will get vaccinated as soon as a dose is available. But humans are not as simple as viruses. People have their own stories, needs and desires and most of all, their beliefs are embedded in networks that shape their vision of reality. Furthermore, we live in a hyperconnected environment where sharing views, concerns and anxieties is only a matter of seconds. It follows that vaccines are not excluded from the political and social turmoil that arises around them and the Covid-19 outbreak will not come to an end if vaccination campaigns are bound to fail. Therefore, to reach immunization and convince people to accept vaccines, health professionals, politicians, and media experts should cooperate in contrasting rumors from spreading, starting from their identification.
Cognitive Biases
Fascinating results that facilitate the comprehension of vaccination decisions are provided by cognitive psychology, a branch of psychology that explores internal mental processes.
Prof Daniel Kahneman, from Princeton University, has elaborated a revolutionary theory about “cognitive biases” and their influence in individuals’ beliefs and choices.
Cognitive biases, also known as cognitive distortions, are mental patterns that an individual systematically uses to make decisions and select pieces of information from everyday reality. This set of rooted convictions — deeply influenced by strong emotions and memory — is employed to respond automatically to complicated domains and high-level reasonings. For this reason, humans are defined as “cognitive misers”. Empowered by fear and prudence, cognitive biases are often considered as the intuitive thoughts that enabled our ancestors to quickly escape from risky situations and, eventually, to survive. However, when they are activated to make a judgement about complex medical subjects — such as vaccine efficacy — they tend to generate irrational and dangerous outputs to the whole society. Psychology researchers emphasize the effects originated from the following ones.
The confirmation bias acts as a filter for the collection of new information: it is the tendency of recalling, searching for and believing those pieces of information that are aligned with pre-existing beliefs. It is considered as the most impactful bias in the case of vaccination. As an example, we cite the fraudulent paper of Andrew Wakefield about the presumed correlation between MMR (Measles, Mumps and Rubella) vaccine and autism — merely based on 12 samples — published more than 20 years ago. In the last 15 years, more than 25 studies have confirmed the lack of such a relationship; in 2010, The Lancet officially withdrew the article. Regardless of scientific research, lots of individuals kept on refusing scientific and certified results: the suspect and, ultimately, the confirmation bias had been already stimulated.
In an uncertain, unclear, and stressful situation, a “non-decision” is preferred to a decision. In the case of vaccination, the apparent chance of side effects leads people to choose inaction over action. This is what psychologists call “omission bias”. The defense of the status quo comes from the unwillingness to study in deep complicated topics, despite the risk that this behavior produces to the entire community.
Omission bias occurred during Wakefield’s controversy as well, causing a fall of vaccinations in the early 2000s and a rise of measles cases from a few hundred in the late 90s to over two thousand in 2012.
Finally, an illusory correlation takes place when a person perceives a relationship between two variables that are not in fact correlated. Again, Wakefield’s thesis had led individuals to use any incidence where autism and MMR co-occur to confirm their opinions.
The acknowledgement and the subsequent extirpation of cognitive biases is only the first step to reduce the skepticism of some groups about vaccines effectiveness.
Solutions
From the previous analysis, it emerges that vaccine hesitancy — defined as the refusal or the delayed acceptance of vaccines even when they are available — is a major issue to be dealt with by policy-makers. This holds in general and, even more so, during the current outbreak.
While the arguments used to oppose vaccines have always existed, what has changed is the media coverage that they can reach thanks to digitalization. Indeed, social media play a key role in helping the spread of false myths against vaccination. One of the main strategies adopted so far in addressing hesitancy, namely the attempt to correct those myths through the provision of medical evidence, has proven to be mostly ineffective. Therefore, it is crucial to develop alternative ways of conceiving the right messages concerning vaccines. To this purpose, scientific evidence coming from the social sciences may provide sound tools meant to positively affect policy in this field.
Promoting trust seems to be the common denominator in the relevant literature. The term may be interpreted in different ways. In societal terms, vaccination is an act of collective responsibility and solidarity. More efforts should be made to let people perceive it as such. Indeed, marginalized groups may not feel supported by society and bear the duty to make decisions to protect their families — and stereotypes about people who are concerned about vaccines only increase their uncertainty and isolation. By adopting a more empathetic approach and enhancing openness and transparency, governments and their health policies may appear more trustworthy to the eyes of citizens.
The creation of trust also takes place at the practical level, and technology may help in having it backed up by robust evidence. Some scholars suggest that data could be made available simply and clearly through user-friendly means such as apps and community networks. These would include information on, for instance, the number of people who have already been vaccinated or who are experiencing adverse effects after vaccination. This may also contribute to creating viral effects thus triggering virtuous cycles.
Finally, in specific contexts, absence of trust derives from the perceived lack of expertise of health workers — who might, for example, be unable to answer questions and doubts by parents on their children’s vaccination. Providing technical knowledge and educational materials would represent a solution to this problem.
In general, more investment should be made in education. It has been argued that science-based training on vaccination should be given to kids early in school. For further credibility, this should be done not only during outbreaks but, rather, on a constant basis.
Besides, communication represents a research area that is worthwhile exploring for its great potential in overcoming hesitancy. Experience from studies on the psychology of science denialism produced a five-point technique to avoid the repetition of myths on vaccination. This is meant to deconstruct impossible expectations (e.g. full certainty of vaccines’ safety and effectiveness), false logic (including reasoning that links what does not come from nature to evil), undue claims of technical expertise, conspiracy theories and selectivity (i.e. evidence drawn from isolated sources).
Moreover, confusion arises from conflicting evidence and reports from a variety of media sources like radio, television and newspapers. Building a consistent message at the public level may serve the purpose of creating consensus around the topic. It has also been suggested that rumors and misinformation should be challenged as soon as they arise.
In concrete terms, a superlative patient experience before, during and after vaccination may be pivotal. The set of strategies may range from making it simple to sign in — also through the adoption of nudges — to celebrating who gets the shot, and then supporting the recovery (e.g. through the possibility of getting in touch with the healthcare provider) and maintaining engagement.
Finally, each country is different and significant variation also exists within countries. Hence, local contextualization (for instance, by providing personalized information) would play an important role in effectively stimulating confidence towards vaccines.
Conclusions
People will ask questions. This does not necessarily mean that they are uneducated or mad, they might just be worried. And even if conversations may be uncomfortable, that confidence needs to be built.
To conclude, we want to share the story of Ethan Lindenbergen, a young activist who created a global youth movement in favor of vaccines. It all started with a post that rapidly became viral: “My mother doesn’t believe in vaccines. She’s really worried they cause autism. In fact, she strongly believes that. But I’m 18. I’m a senior in high school. I can drive a car, I can vote and I could go get my own vaccine. Can someone tell me where to get it?”. In 2019, he was invited to the Global Vaccine Summit to share his story in front of world leaders. “You know, everybody talks about misinformation, but I want to tell you about a different kind of misinformation, and that’s misinformation that says that people like my mother, who is a loving mother, is a bad person because she doesn’t give me vaccines. Well, I want to tell all of you that she didn’t give me a vaccine because she loves me and because she believed that that was the best thing for me. I think differently and I will never change her mind, but she’s not a bad person”.
This message clearly demonstrates that we have a relationship problem that does not only need scientific solutions but rather empathy, kindness and understanding.
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