Psychology suggests that when we are told we are wrong about something, particularly if we lack education or knowledge of the subject, we are more likely to dig in rather than to adjust our thinking (Salali & Uysal, 2020; Schmidt et al., 2017)). If we look at the recent history since Andrew Wakefield and his now well-known fabricated research on childhood immunization dangers, the percentage of the population opposed to vaccines has increased significantly (Hussain et al., 2018). While some are well-meaning albeit misinformed, others are manipulating ignorance and a lack of understanding in science for financial gain. Politicians who promote disproven quack treatments for pandemic viruses because they own stock in those companies are but one example (Ball & Maxmen, 2020).
A review of history reveals that as long as there have been vaccinations towards disease there have been a small percentage of the population opposed to them for a number of manufactured reasons, most often based on misunderstanding or ignorance of the science (Walloch, 2015); however, those ignorant of science, medicine, or psychology did not have social media with which to spread misunderstanding, falsehoods, and fake news and their numbers were relatively low. Social media has created fear and distrust, rampant false news stories, and with virtually universal access to the Internet, resulting in those who do not understand actual research falling for confirmation bias, and moreover, they are easily able to find others who are equally ignorant of science and medicine to confer with and confirm their beliefs. And this population is growing and becoming a greater danger to public health. Measles is resurging in Washington state, and in Europe tens of thousands of children and adults were affected in the last few years. How do we explain this?
Few people alive today, certainly not the majority of the population, have experienced such a deadly pandemic in their lifetimes. I remember getting a polio vaccine as a child. No one sent a note home, no parents showed up to protest, we simply lined up and got the inoculation. As a result, we did not get polio. I have met a handful of people who had survived polio. Most of them have limited use of their limbs, some suffered significant neurological damage. If vaccines are so effective, why the resistance? One suggestion is that vaccines have become too successful, and most people have no living memory of how deadly infectious diseases can be. We have all seen photographs or documentaries, commercials about Third World countries where people were dying of diseases like Malaria, Dengue, Ebola. The argument, at least for many Americans, was that it was not happening here, and therefore there was some psychological distance. But Sars2-CoV19 is a global pandemic that is happening here. How do we explain the fact that people are dying by the minute all around us, and yet there are still large populations who refuse to acknowledge the necessity of vaccination, adamantly argue against the reality of the infectious agent, and will go as far as mental gymnastics to avoid even considering verified science? Addressing hesitancy to vaccines is certainly not a new challenge for those of us in public health, but aside from a simple cognitive inability to reason out the necessity of vaccination, which is not possible to surmount, how do we address this phenomenon?
Flavors of vaccine hesitancy
While vaccine hesitancy has been defined as either a delay in obtaining a vaccine or a refusal to become vaccinated, the reasons for these decisions are not quite so black and white. According to the World Health Organization there are three factors at play in the minds of those hesitant to receive a vaccination: complacency, convenience, and confidence in the science. Complacency speaks to the perceived risk of preventable disease. The Health Belief Model (HBM) suggest that not only is an understanding of the disease necessary to spur prevention, but also an accurate perception of the risk. Many who lack an understanding in basic biology, let alone virology, epidemiology, statistics, or vaccine research may be able to identify the risk even when it is occurring all around them. Convenience, or as often described, barriers to the treatment or information, may be a far bigger issue for vaccinations than for other healthcare decisions. The HBM outlines convenience as the ability to overcome physical limitations, financial limitations, or other barriers to obtaining healthcare. I believe the model must be altered somewhat, as convenience may suggest more of a cognitive limitation of understanding the importance of public health in general, and vaccination in particular. Individuals who have the means to obtain vaccinations may be limited in their convenience through an inability to cognitively reason out the reality of the threat of COVID-19. As a simple example, in 2014, when Ebola was in the news, there were people in America who were demanding a vaccine for an infectious disease that was highly unlikely to ever emerge, even in a limited fashion, in the United States (Kilgo et al., 2018). It is likely that that confidence in vaccination has decreased significantly in this population. And while this is reasonably clear based on social media, we need to try to understand why.
The anti-intellectual Society
In an anti-intellectual society, there is no value in education or expertise; those individuals who are untrained and uneducated falsely believe they have the ability to understand often complicated subjects, and now they have a platform on social media, and this anti-intellectualism has been recognized and used by politicians to control these groups. The historian Richard Hofstadter described this phenomenon as a character flaw, one championed by religion and fostered by Americanism, particularly the belief in the rugged individual, complete with a distrust of authority. Unless of course that authority agrees with what they already believe to be true (Brown 2008). This was well outlined by Dunning and Kruger in their research (1999); however, as clearly evidenced by public health and the rapidly rising incidence of cardiovascular disease, childhood mortality, and obesity, the distrust and misunderstanding of modern science, health institutions, and medicine is proving highly detrimental to the average American’s life and life span. The challenge of vaccine delivery requires solutions that will address these reasons for vaccine hesitancy, beginning with addressing issues of complacency, establishing confidence, and improving the convenience of vaccine delivery. It will be difficult to get many to accept the reality of the science behind the vaccine until they are forced to deal personally with a tragic outcome of infection. And for some, not even then. As public health professionals we owe it to society to present the information in a digestible and comprehensible form. After this, there is little that can be done to increase acceptance until the vaccine becomes a universal mandate as well as polio and smallpox, to infectious diseases which brought devastation for generations and were effectively eliminated from our population.
Presenting the facts to those who neither understand them or care to hear them
One argument is that the vaccine is not tested. The reality is that this vaccine was thoroughly tested, although quickly. Rather than run a series of trials, the vaccine trials were run concurrently. The science behind the new vaccine is well known and has been used in animal husbandry and pet care as prevention for a number of communicable diseases. Even if the previous statement was not factual, at this point there have been over 100 million vaccines administered and data has been thoroughly analyzed. So, the argument that the vaccine is not tested at this point is patently false, even by the most rigorous standards. Another argument is that the side effects can be worse than the infection. Actually, because the vaccine does not contain the coronavirus, the side effects are proof of the effectiveness of the vaccine as it has triggered an immune response from your system. Once you are vaccinated your system should be able to recognize a viral infection of SARS-2, the coronavirus that causes COVID-19 disease. Another argument is that because there are variances involving the vaccine will eventually be useless. The current COVID-19 vaccines help your immune system recognize an infection including variants such as Delta. Perhaps more importantly, viruses only mutate and evolve in a host who is unprotected. The more people who are unvaccinated, the more opportunity the coronavirus has to mutate into new forms. The best way to prevent variants from emerging is for everyone who can to get vaccinated. Another often misunderstood comment on social media is that natural immunity is favorable to a vaccine. Natural immunity does not occur for many diseases, especially viral diseases that are able to overwhelm the host. One good example is chickenpox caused by the varicella zoster virus. While it is unlikely you will get chickenpox a second time, you are susceptible to a condition known as shingles which is caused by remnants of the virus which can hide out in the cerebral spinal fluid. Evidence has shown that even if you have a previous infection from COVID-19, getting a vaccine will boost your immune response for extra protection. Perhaps the greatest reason to get the COVID-19 vaccine is to help others in the community who cannot be vaccinated due to chronic conditions, those undergoing cancer treatment, or immunosuppressive therapies. The more people vaccinated, the less likely these people will be exposed to infection. Another reason that society should become vaccinated is the chance to get back to normal. In the last year, closures, cancellations, postponements, business losses, and a host of other social impacts of the pandemic have significantly altered the way many of us live. More vaccinations mean a chance to get back to some semblance of normal day-to-day life. And while we know that people hesitate to get vaccines for a number of reasons, fear, ignorance, and politics seem to be the prevailing motivations.
One of the most cited reasons for vaccine resistance is a belief in one’s own ability to do research. We have all heard how people with no clinical or research skills go on Wikipedia or YouTube and after scrolling for a few minutes believe that they have come to some scientific reason to do what they wanted to do when they started. Those of us who have spent a dozen or more years in graduate study learning how to conduct dispassionate research often find such a statement amusing, or mind-boggling. Confirmation bias is not research, unfortunately most people are not trained or educated in research methodology, clinical research, quantitative statistics, and therefore do not understand the difference.
How do we move forward? Social listening is one strategy, we can attempt to understand the concerns and priorities of communities, both for vaccinations and other health information. Providing better data and making it more accessible to the public is another possibility and presenting the information, not in tables, data lists, or graphs, but in effectively tailored communications that will make a strong case for vaccination. It is also important to address those issues identified by HBM particularly making vaccinations accessible to the public, communicating the reasons why the vaccines are necessary, and addressing the disinformation pandemic on social media. Why is it illegal to yell fire in a crowded theater when there is none, but spreading blatantly false information on a life-threatening virus is acceptable?
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