August 20, 2019 – With misinformation and mistrust about vaccines on the rise, the World Health Organization named vaccine hesitancy as one of 10 global health threats for 2019. At Harvard T.H. Chan School of Public Health, Gillian SteelFisher, senior research scientist in the Department of Health Policy and Management, studies people’s concerns about vaccines, with an eye toward developing strategies to lessen them.
Q: You’ve led studies that have surveyed parents and caregivers, in countries such as Pakistan, Afghanistan, and Somalia, regarding their views on vaccination. What are some of the major reasons you’ve found for vaccine hesitancy in those countries?
A: A lot of my research speaks to the importance of trust in the system. In the case of polio campaigns, vaccinators going door to door might be people’s first line of interaction with the health care system. In many places, it might be the only health care system they know.
We have a number of studies that showcase the importance of trust in the vaccinators. For example, one of the key elements seems to be whether or not the vaccinator appears to care about your child—which feels so fundamental, and yet it’s often forgotten. Much of the training for vaccinators and for health care professionals more broadly is technical training. And it’s not that we should ignore that—technical training is certainly an important foundation—but it’s not always sufficient to convince people to accept the vaccine when vaccinators arrive at their door.
We also think that misinformation and rumors can play a role in hesitancy. It’s not that people simply believe every rumor they hear. It’s that people may believe rumors just a little bit or be open to them at first. It’s a seed of mistrust. And so you have to ask, how does that seed of mistrust grow?
One way that seed can grow is that people may have had previously negative experiences with the health care system in their country. In the case of vaccines that parents get at clinics, maybe they had to walk many miles, but then got turned away when the vaccines were out of stock or there wasn’t someone available to vaccinate their child. Or maybe a health care provider told the parents that they wouldn’t open a vial of vaccine for their child until 10 other kids showed up who also needed it. The message can sound like the health workers at clinics think your child isn’t worth it. When parents have these experiences, we worry it can make them receptive to rumors that vaccination programs don’t have children’s best interests in mind. Basically, it gives parents a reason to start believing rumors they might hear back in their village.
Q: How has your research impacted the problem of vaccine hesitancy?
A: The collaboration that I lead has included more than a dozen polls in countries where polio and immunization are priorities, and these data have been used by UNICEF, by the World Health Organization, and by governments to inform on-the-ground communication strategies and global communication strategy around vaccines.
Information from these studies about people’s willingness, or lack of willingness, to accept the door-to-door vaccine has shaped the way that a number of countries developed vaccinator teams. It has shaped not only the interpersonal communication skills that are taught to vaccinators, but also the recruitment and selection of vaccinators. So instead of being teams from different villages, they have become local teams. In Pakistan, for example, in communities where vaccination occurs, more people have been recruited who are part of the community and already hold the community’s trust.
Also in Pakistan, vaccinator training programs have moved from using traditional training manuals to using graphic novels. In one there is an image of a woman, an example vaccinator, and she says, “Our interactions with our community, parents and children should be respectful and demonstrate our concern for the child.” She even models facial expressions and talks about body language that helps communicate the vaccinator’s concern. It’s so basic, but I think this approach can really make a difference.
Q: How widespread is the problem of vaccine hesitancy?
A: I was recently on a panel at the United Nations about the challenges of misinformation and loss of confidence in vaccines. We wanted to bring attention to the problem, but not to suggest that confidence has dramatically fallen—because it’s important to remember that most parents in most places vaccinate their children when they have the chance. And yet we see that there are pockets of mistrust or that confidence can be fragile.
I think what’s different now is that there are more and different kinds of threats to confidence in vaccines. There’s just an onslaught of misinformation. This past spring in Pakistan, for example, rumors spread online that children were getting sick after receiving the polio vaccine. That rumor was linked not only to vaccine refusals but even to violence against the vaccinators. There have been calls to encourage social media companies to be more responsible citizens—to be part of the public health infrastructure that helps support effective decision-making for people, and pull back on misinformation. Facebook was part of the UN meeting, talking about their early efforts to curb misinformation. Their participation was important because it can help catalyze conversations about the responsibility that these large technology companies have to help curb misinformation about vaccines.
I think the sort of data that we gather—about people’s views and experiences—is a really powerful tool because it brings key actors around the table. It brings together governments, non-governmental organizations, big international organizations, and hopefully social media companies to have a frank conversation about what can be done about vaccine hesitancy. That dialogue is really important, because we have to be humble about this. For a long time, the public health message about vaccinations has been, ‘Hey, we have this great service for you, and you should take it.’ But the point is that we actually need to listen to people’s concerns and address them respectfully.
photo: © UNICEF/UN0323717/Nesbitt