What is different about COVID-19 vaccine hesitancy, in comparison to hesitancy about other vaccines?
It's an interesting question that hasn't been asked in the realm of vaccine hesitancy. What distinguishes COVID-19 hesitancy from that of other vaccines? One interesting point is that it isn't about the vaccine itself. It's not even about hesitancy itself. It is about the circumstances in which it has developed, and in which it continues to evolve. The inherent dynamicity of the pandemic means that the associated hesitancy will also evolve. Therefore there is a very specific context to COVID-19 vaccine hesitancy which does not apply to hesitancy about other vaccines. In this context; COVID-19 vaccine hesitancy is worth thinking about in terms of what makes it different. With this, it is possible to identify trends in drivers of vaccine hesitancy in the modern world. This in turn can help us develop and implement effective strategies to address it in the future.
Now, one might argue that the development of vaccines for pandemics historically also caused hesitancy. That is certainly true. Hesitancy circulated in response to the development of the Salk vaccine during the 1918 H1N1 influenza pandemic and the smallpox vaccine by Edward Jenner in 1796 (read more about this here). For example, English satirist James Gillray famously depicted cows emerging from the bodies of terrified people being given cowpox vaccine. Not only this; in 1885, over 80,000 vaccine dissenters marched through Leicester carrying banners, a child’s coffin and an effigy of Jenner. Dissent spread to the US and Canada. Eventually, the success of Jenner’s smallpox vaccine silenced the anti-smallpox vaccination movement. Also, in 1982, National Broadcasting Company (NBC) affiliate WRC aired a programme called Vaccine Roulette that caused mass panic among parents, the formation of a group called Dissatisfied Parents Together (now the influential National Vaccine Information Centre), and an increase in lawsuits filed against vaccine manufacturers.
It is therefore clear that vaccine hesitancy is not a new cultural phenomenon, but an evolving one. However, such changes in culture have involved more recent, key advances that define the modern anti-vaccine movement. Most notable among these is rapid information sharing, by which I of course mean the Internet. The aforementioned anti-vaccine movements did not have the capacity for exponential information spread that we have today. In that sense; information spread follows the same pattern that the virus itself does when it circulates. It is also very much analogous to the virus spreading because once it has begun replicating and spreading; it's very difficult to impossible to reverse the damage done. There are a multitude of ways misinformation can be discreetly shared. This makes it very difficult to track all misinformation being shared and remove it. This dangerous feature of misinformation is well worth discussing, and that's what I'll do in the next section.
For example; a 2022 study by Ingjerd Skafle and colleagues found that misinformation on COVID-19 is still thriving on social media platforms. Further, they add this does not even account for information shared in closed groups, and that preventing anti-vaccine content from surfacing in searches won't prevent it from being commented; on or other types of misinformation being posted in comment sections. I would also add that direct messaging, private group chats or “Lists'' on Twitter also have the potential for misinformation sharing. Further, other mediums such as blogs, websites, and other platforms may be owned by the individual spreading misinformation themselves; meaning there may be limited to no fact-checking. Further, when they own their platforms it is possible to restrict or outright ban those with accurate information about COVID-19 vaccines from it. Another issue is that many key anti-vaccine voices use multiple channels to disseminate their falsehoods; and may use symbols, slang or other “code” to refer to vaccination so it is not flagged by fact-checking software. Not only this; they may use screenshots or images to avoid text-based moderation.
Thus despite measures being taken to eliminate misinformation; misinformation may continue to spread under the radar across multiple platforms. For instance, an article published on theconversation.com in August 2022 describes how some anti-vaccine groups predict moderation techniques that social media sites use; and then adjust their posting guidelines so as not to get their content flagged. In other cases, content will remain posted for a short period and then deleted before it can be flagged by social media sites. They may also misspell or omit words directly related to the anti-vaccine movement such as “anti-vaccine”. Satire and sarcasm are also used to misdirect moderators and fact-checkers. The challenge is that the advancement of techniques to evade moderation is outpacing the progress of the moderation software itself. This causes mass propagation of misinformation and mistrust of vaccines on a large scale.
This becomes evident when one looks at studies of misinformation and its links with hesitancy. Data shows that regions, where misinformation was more prevalent, experienced more lethal COVID-19 pandemic waves despite the availability of effective vaccines. Also, in the U.S., a news programme that downplayed the pandemic was linked with increased COVID-19 illness and deaths. Not only this; a 2022 study by Francesco Pierri and colleagues states that “considering variability across regions with low and high levels of misinformation, the best estimates from our data predict a ~ 20% decrease in vaccine uptake between states, and a ~ 67% increase in hesitancy rates across Democratic counties, across the full range of misinformation prevalence. “
This allows not only misinformation and disinformation to travel exponentially, but the detrimental effects to spread too. According to the website of the World Health Organization, as of January 2024, there have been a total of 774,395,593 reported COVID-19 cases as well as 7,023,271 deaths globally. It is therefore unsurprising that the WHO named vaccine hesitancy one of the top 10 threats to global health in 2019, along with Ebola and other high-threat pathogens, climate change, and antibiotic resistance. Further, according to the website of the Centre for Disease Control and Prevention, there have been 6,793,622 COVID-19-related hospitalisations globally.
For some, the effects persist beyond the initial infection in a condition colloquially known as “Long COVID”, or post-COVID conditions. According to the website of the World Health Organisation, “studies show that around 10–20% of people infected by SARS-CoV-2 may go on to develop symptoms that can be diagnosed as long COVID. Although exact numbers of those living with the condition are uncertain, it is believed that more than 17 million people across the WHO European Region may have experienced it during the first two years of the pandemic (2020/21)”. It may last weeks, months or even years following initial infection. Not only this; in some cases, it can result in a disability that renders the patient unable to carry out daily tasks; let alone work. The advice from WHO is that the best way to protect oneself from Long COVID is to avoid COVID-19 infection in the first place; meaning accepting vaccination and boosters. What this means is that for this population of people; the consequences of falling prey to misinformation about vaccination can have long-term consequences. With misinformation being a significant contributor to COVID-19 vaccine hesitancy, a case could also be made for misinformation in itself being a threat to global health. However, that is beyond the scope of this article, though I may address it in a future article.
That said; misinformation is not the only new cultural change that has defined COVID-19 vaccine hesitancy. COVID-19 vaccines were developed in a time of patient-centred care, not so much physician-directed care. Previous anti-vaccine movements (ie smallpox, polio) occurred in eras where physicians were more seen as authorities on health matters including vaccination. However, that dynamic has changed. Now, one can find endless articles, posts, tweets, blog posts, and so on advocating for patient-centred care. Generally, this is a positive advancement. According to an article from theconversation.com published on August 9th, 2022, it leads to better patient outcomes and lower health costs. It frames the patient as a key stakeholder in their medical decisions; in contrast to past centuries when patients were expected to be passive and accept medical advice without question. This helps establish a strong doctor-patient relationship and builds trust. This provides a foundation on which future healthcare decisions can be made and is particularly important in cases where serious medical decisions need to be made.
However, this more liberal approach can have negative impacts. Sometimes, it can make people who do not have backgrounds in relevant areas more vulnerable to falling prey to misinformation about COVID-19 vaccines. In this way, patient-centred care can have the unintended consequence of negatively impacting vaccination rates. This doesn't mean patient-centred care should be eradicated; rather, it should be adjusted. That is, where do we draw boundaries on patient autonomy, or should that ever happen? When does the risk of harm to the patient outweigh their right to make their own medical decisions; or does it ever? I discussed this more in-depth here, but these questions will become increasingly important in future pandemics (which can and will come). So, it's important to reflect on how the patient-centred care movement impacted the COVID-19 vaccine hesitancy so that its benefit to patients is maximised and any harm minimised in the future.
A huge contributor to the patient-centred care movement is the fact that we now have a culture of more open communication about healthcare, as well as all aspects of life. Many people openly shared their experiences of the pandemic on various online platforms. I`d argue that in-person conversations are now also more open. Again; this has benefits. People can form communities, share experiences and get advice. However, this can provide a platform for misinformation disguised as seemingly innocent questions and/ or concerns to spread.
Therefore because of this, misinformation isn`t always evident at first glance. This is true even for those with an analytical eye. Sometimes all it takes is for a seed of doubt to be planted by seeing others posting questions or concerns online. When that is combined with one or many past negative experiences with health authorities or healthcare providers; it can be the perfect circumstance for mistrust and doubt to grow. I'll discuss this in the context of COVID-19 vaccine concerns here, but it can apply to any topic.
There is also another reason why misinformation may not be easily identified. Generally, people search for evidence that confirms what they already believe and disregard what we don`t believe or don't accept. With that, we conceal ourselves within an echo chamber online. That is; we will only see what we agree with rather than accurate depictions of what the reality of a topic is. That is actually how the majority of algorithms work - we are shown more of what we engage with and less of what we do not. As humans, we are prone to confirmation bias (read more about this here ) and we don't form opinions from facts. Our pre-existing opinions and emotions dictate the facts we search for and accept. For that reason; if we see facts that contradict our beliefs, it can cause mental discomfort called cognitive dissonance.
As we continue this over time, such opinions become further and further ingrained. Eventually, this is so much so that we entertain certain opinions we hold as fact. Of course, these opinions may not necessarily be about vaccines. They may be about masks, social distancing, or other healthcare topics like infectious diseases, and the false statement that 5G impacts health, among many others. Some misinformation even relates to health at all. Politics for instance is another area rampant with misinformation, especially in charged times like elections.
Not only this; but those who pose questions that are genuine run the risk of falling prey to misinformation. When one is seeking medical advice, it tends to be more vulnerable than when we are seeking more standard everyday advice. For instance, let's take a case where an individual is concerned about a family member. Perhaps it's a child. For a myriad of reasons, they are not able or willing to speak to their physician. One can imagine how vulnerable they may be feeling in such a scenario. Enter the emotional messages anti-vaccine groups often circulate online, and one can see how easily it would be for anyone to be enticed by information. Certainly, they may come across some pro-vaccine messaging, but generally, that involves statistics and facts and tends not to be comforting. And besides; perhaps they`re already biased. Possibly they`ve already had negative experiences with healthcare providers in the past. Also, more extremist online anti-vaccine groups are a minority, but they are vocal and recruit new members easily. The point is; that being emotionally primed can make people more vulnerable to believing misinformation.
Summary and Conclusion
SARS-CoV-2 has undoubtedly been one of the most impactful public health events in the modern era. It occurred at a time when we had virtually unlimited potential for information sharing - and thus for misinformation sharing. In addition, the shift to patient-centred care has caused changes in the physician-patient dynamic. Patients are encouraged to take more active roles in their healthcare decisions. Although there are well-documented benefits to this; it can make patients rely on inaccurate sources of information and make health decisions that are not in their best interests. Finally, more liberal sharing of questions, experiences, and concerns on online platforms can carry the risk of misinformation circulating under the guise of being framed as questions or concerns. This in turn causes mass-propagation of misinformation and mistrust of vaccines on a large scale. This can be detrimental to COVID-19 vaccination coverage; and also to vaccine coverage for future pandemics. Clearly; there will not be a single solution. That said; identifying unique features of COVID-19 vaccine hesitancy will help identify trends in what drives hesitancy in the modern world. This, in turn, can guide the development and implementation of strategies to improve vaccine coverage and save lives. Thanks for reading