This is the fifth instalment of Paula Jardine’s six-part investigation into the planning behind ensuring vaccine acceptance and countering vaccine ‘hesitancy’. You can read Part 1 here, Part 2 here, Part 3 here and Part 4 here.
By Paula Jardine
THE starting point for universal vaccination is that virtually everyone is (indeed, needs to be) a suitable recipient. This has proved the case for the Covid-19 vaccines even though they are still technically under emergency use authorisations pending the completion of clinical trials, and even though the disease is a serious mortality risk for only a minority of the older demographics.
This presumption is at odds with the fallout from the 1976 landmark US judgment in Reyes v Wyeth Laboratories. The parents of a child who was paralysed by polio caused by the Sabin oral polio vaccine she had been given sued the manufacturer and won. In affirming the decision the Federal Court of Appeal said the manufacturer had a duty to market and inform potential customers of the dangerous vaccine and that this duty was heightened since the manufacturer had knowledge of the vaccine’s harmful potential.
In the wake of the case the US Centers for Disease Control (CDC) added a ‘duty to warn’ clause to all its vaccine purchase contracts which required that ‘vaccines be administered only after an individualised medical judgment by a physician, or after “meaningful warnings related to the risks and benefits of vaccination” were provided in understandable language.’
Today the CDC advocates what it calls ‘medical provider vaccine standardisation’, saying offering vaccination should be a default option at patient visits. Ideally, the vaccine is available to be administered then and there, for the sake of convenience, and lest upon further reflection there be a change of mind.
Informed consent guidelines require that an explanation of both the risks and the benefits is provided, that the decision is voluntary and is not influenced by pressure from medical staff or others. Vaccine confidence literature, however, suggests the trusted health care practitioner’s role is to influence decisions by presenting vaccine-positive information so that patients or parents will choose vaccination. Safe and effective is the familiar mantra.
The World Health Organisation technical advisory group on behavioural insights and sciences for health have considered the ways in which vaccination decisions can be influenced. They say that ‘anticipated regret’ – when people expect that an unpleasant outcome would lead them to wish they had made a different decision – ‘shows promise as a predictor of intentions and behaviour’. They go on to suggest that ‘leveraging regret’ is a strategy that can be used ‘to tackle motivational barriers to vaccine acceptance and uptake’.
Dr Heidi Larson, a professor of anthropology, risk and decision science, who set up the ‘Vaccine Confidence Project’ at the London School of Hygiene and Tropical Medicine but is not a member of the behavioural insights advisory group, offers the same advice saying, ‘Regret is an important dimension in conversations with parents, but the important thing is to shift the anticipated regret towards how they might feel if their child is not vaccinated and becomes seriously ill or even dies from a vaccine preventable disease rather than being more focused on the potential side effects of the vaccine.’
Another strategy that this advisory group has recommended to help increase vaccine uptake is to emphasise the social benefits (or disadvantages of not) such as being able to stay in the workforce or provide for your family. Lisa Fazio, a psychologist who participated in the US National Institutes of Health (NIH) Covid communications expert group, also recommends leveraging altruism. What was required for Covid vaccines, she said, was ‘a call to action beyond “getting” the vaccine for yourself, but using emotions via an aspirational approach. The call to action is something that is elevated and aspirational and focused on the benefits and that sense of normalcy. The call to action is not getting a vaccine that is available to you. The call to action is, “Protect your family, protect your loved ones. Help the world get past this crisis”.’
Another pitch offered by yet another NIH adviser, Paul Slovic, a psychologist who studies risk perception, was that being vaccinated could help people feel that they’re taking back control. ‘One of the things that makes Covid scary is that it’s difficult to control,’ said Slovic. ‘It’s invisible, people can carry and transmit the disease without showing symptoms, and there are limited treatment options. People have profound discomfort with uncertainty, and so offering the vaccine in the context of regaining control could be quite powerful.’
Persuasion isn’t left on its own to do the work. The 2019 Global Vaccination Summit endorsed behavioural nudging to increase uptake: ‘Interventions which focus directly on supporting individual behaviour and making vaccination as easy and convenient as possible have more impact than interventions attempting to modify attitudes and beliefs. In other words, “nudging” and behaviourally-informed strategies can trigger vaccine confidence.’
The idea behind nudging (though a doubtful science) is that it works to increase uptake by making people feel as though they are making a free choice. ‘Offer a default option that’s determined by experts, with an opt-out possibility. This retains people’s sense of freedom, but default architecture will guide them into the experts’ recommendations.’
The Covid-19 vaccination campaign in the UK used this presumptive approach by inviting people to vaccination appointments rather than asking people to request them. It may have been the fear/urgency factor that worked. But that does not lessen the manipulative intent.
Regardless, anyonetrying to sell you an investment product by inflating past performances, failing to ascertain its suitability for you as an individual, and using manipulative talk while providing insufficient information for you to make an informed decision in order to make a quick sell, would be deemed to have engaged in unethical practice. Depending on the nature of the misinformation, it could even be illegal.
Vaccines are biological pharmaceutical products, and in the case of mRNA Covid vaccines gene transfer therapies, ones that permanently and irreversibly alter the physiology of healthy people. Having claimed that the case for universal vaccination is a moral one, for the greater good, the strategies employed in pursuit of coverage targets to increase uptake have been and are to varying degrees ethically suspect.
As Covid vaccination uptake figures show, most people do accept vaccines but, despite all the nudging and the hard sell, the 100 per cent coverage that is meant to deliver a disease-free utopia remains elusive. Demand generation at that level would require universal uncritical acceptance of vaccines.
Larson likened people exercising their right to refuse the medical procedure of vaccination to an epidemic requiring crisis management. The various vaccine confidence projects describe their aim as helping populations become more resilient against what they call rumours or misinformation, a nebulous category of anything that might threaten the War on Microbes, that cause people to reject vaccination.
‘We need to be more sophisticated and to build strong transnational networks to pick up rumours and misinformation early and surround them with accurate and positive information in support of vaccination,’ said Larson, chillingly.
The World Economic Forum (WEF) provided the Vaccine Confidence Project with research assistance to support its Covid vaccination work. In the six months from November 2020, NetBase Quid technology was used to ‘scrape’ online forums and social media for conversations about vaccines “to get a deep understanding of the obstacles to vaccine adoption, barriers to building trust and the communication strategies that move people to action”.
No fewer than 66million conversations were identified and analysed to provide insights on how to target communications for Covid vaccines. It enabled a market segmentation of messaging, microtargeting different messages for different audiences.