I’m currently putting the finishing touches on a presentation for the The Ontario Public Health Convention next week, where I’ll be speaking, with occupational therapist Kim Hébert, about the anti-vaccine movement and social media (SM): how antivaccine advocates use it, and the challenges and opportunities for public health advocates. I’m pleased to see Seth Mnookin, author of The Panic Virus, is one of the keynote speakers – his perspective will be valuable for the public health crowd which has traditionally relied on fairly static “key messages” for disseminating information on vaccine safety and effectiveness. The panel discussion of which I am a part will be an examination of challenges and opportunities presented to public health advocacy, and particularly vaccine advocacy, in a Web 2.o environment. What seems clear is that the old public health channels don’t cut it anymore: these methods are distant and insufficient to address the wide and rapid spread of misinformation in an era of social media. We all remember the anxiety over H1N1 just a few years ago – and judging by the poor uptake of the vaccine, it seemed the anti-vaccine movement had some success in propagating fear, uncertainty, and doubt. I’d almost forgotten about this chestnut from the Health Ranger himself:
In about two minutes, Mike neatly compiles most of the still-common anti-vaccine gambits in use. It’s not keyboard cat popular, but almost 200,000 views is likely greater than any pro-vaccine video produced. But is it effective? I looked to the medical literature for any current articles on the tactics of the antivaccine movement. In contrast to the wealth of information online, particularly at Science-Based Medicine, there is a much smaller set of papers in print. Orac at Respectful Insolence covered one recent paper back in January, Anna Kata’s Anti-vaccine activists, Web 2.0, and the postmodern paradigm – An overview of tactics and tropes used online by the anti-vaccination movement. Kata neatly categorizes the disingenuous tactics and messaging used by the antivaccine movement. Tactics include:
- Skewering the science of vaccine safety and efficacy, while trying to create legitimacy for unfounded or discredited theories of harm.
- Shifting the hypotheses and the villain, from MMR, to thimerosal, to other “toxins”, and more recently, “too many, too soon”.
- Censoring criticism, whether it’s at Age of Autism, Mothering.com, or other antivaccine sites that delete comments or restrict access to their events.
- Attacking the opposition, whether it’s Science-Based Medicine Editor David Gorski or lawsuits against Paul Offit or Amy Wallace.
And then there are the tropes, some of which I’ve covered, others have been covered at Science-Based Medicine:
- “I’m not anti-vaccine, I’m pro-safe vaccine”
- “Vaccines are toxic!”
- “Vaccines should be 100% safe”
- “You can’t prove vaccines are safe”
- “Vaccines didn’t save us”
- “Vaccines are unnatural”
- “Choosing between diseases and vaccine injuries”
- “Galileo was persecuted too”
- “Science was wrong before”
- “So many people can’t all be wrong”
- “Skeptics believe…”
- “You’re in the pocket of Big Pharma”
- “I don’t believe in coincidences”
- “I’m an expert on my own child”
I’m sure there are more than a few missing, as the spin continues despite the overwhelming evidence that vaccines, on balance, are safe and highly effective. Kata points out that the anti-vaccine movement has been around as long as there are vaccines: It exists despite the evidence, so no amount of evidence will ever cause it to disappear. She summarizes with a list of some potential solutions to arresting the propagation of this misinformation, noting the potential opportunities for social media campaigns to “immunize” against misinformation.
And that’s where a second article picks up, a more detailed examination of “Web 2.0” as the newest battlefield for both the antivaccine movement and for public health advocates. From Betsch et al, it’s entitled Opportunities and challenges of Web 2.0 for vaccination decisions and was published earlier this year in the journal Vaccine. The paper is a summary of a conference on vaccination decisions held in 2011. As someone who discusses vaccines directly with patients, but also via the interwebs, I found the paper discussed some of my personal questions about vaccine advocacy:
- What is the most effective way for me, as a health professional, to identify and address antivaccine sentiment among my patients?
- What is the most effective way I can use social media to present science-based information in a way that maximizes its usefulness to the largest audience?
The paper focuses on the impact of impact of Web 2.0, a term which may sound trivial to those who already contribute on a blog, as you’re already in a 2.0 environment. Briefly, any technology that facilitates user-to-user interaction can be thought of as Web 2.0. Social media (e.g., Facebook, Twitter, etc.) is any 2.0 technology that facilitates sharing, adapting, and crowd-sourcing material. Compared to the static websites of several years ago, most of the internet is now squarely 2.0. The key feature relevant to vaccines and web 2.0 is the ability to add a personal narrative to data. That is, users can adapt, promote, support and personally contextualize internet content easily now – sharing this article to your own Facebook feed, perhaps prefaced with your own comment on its merits, is one click away.
The emerging consequence of social media as it relates to vaccination decisions is the ability to attach a personal narrative to vaccine information.
Betsch summarizes the considerations that go into vaccination decisions, which include recommendations from health professionals, social norms, previous experiences with, and beliefs about, vaccines, trusted individual and organizations, and related background knowledge. The key drivers of the decision are believed to be those that have an effect on risk perception – that is, the perceived risks and benefits of vaccinating, and also of not vaccinating. Both the frequency or likelihood of an event, and the severity of that event, may be considered.
And here’s where it gets interesting with Web 2.0. As I’ve noted before, it takes only a few minutes of reading anti-vaccine information to shift perceptions of relative risk and benefit, and to lower vaccination intentions. And social media makes it that much easier – by effectively using the power of a simple narrative. And narrative is among the most potent tactics of the antivaccinationist.
I take great pains as a health professional to give the proper context for my recommendations. If questioned about MMR vaccines and autism, I might provide a response like, “Numerous studies have demonstrated that there’s no relationship between the MMR vaccine and neurodevelopmental disorders”. While that may be accurate, it may not be most effective way to address the underlying uncertainty. The individual benefit of vaccination may be hard to see (though it’s easier when there are outbreaks to point to.) The harms, whether real (injection pain) or just attributed to vaccines, may be more tangible. The antivaccine response, while wrong, is far simpler: “MMR has been linked to autism. The vaccine is dangerous.” The ability to link a personal, emotional narrative to an antivaccine trope is facilitated by Web 2.0 technologies – it can personalize impersonal information. Emotional appeals can push the actual evidence into the background. The producers of the Greater Good movie used this approach to deliver their antivaccine message: Three narratives of harm attributed to vaccines, around which all of the antivaccine tropes described above were packaged and delivered.
Betsch points out how the narrative, or anecdote, is a powerful communication device. It’s easily understood, concrete, seemingly credible, and emotional. Whether or not they’re causally linked to the vaccine isn’t relevant – narratives increase the perception of harm and of the resultant risk of vaccination. While there have been some attempts to compile narratives of consequences of vaccine avoidance (What’s the Harm? comes to mind), on balance, negative personal narratives on vaccines seem far more prevalent.
So the challenge for public health advocates in a Web 2.0 environment is twofold: We must be accurate and effective. Accuracy may mean more complexity and nuance to our messaging. Plus we need to be able to rapidly respond to emerging concerns, ideally in a way that facilitates dissemination and sharing via social media to the same recipients of antivaccine messages. And here’s where we come to the third paper, one which explores theories of risk perception and decision-making: fuzzy-trace theory. It’s examined in detail in a 2011 publication by Valerie Reyna, Risk perception and communication in vaccination decisions: A fuzzy-trace theory approach. According to this theory, we integrate information in two distinct ways:
- Verbatim memories: the precise details of the facts
- Gist memories: the essential meaning of the facts
Based on this theory, gist memories are derived not from verbatim facts, but are developed in parallel with verbatim memories. Because they’re subjective, they incorporate existing biases and understandings. Reyna argues that gist memories are relevant to reasoning and decision-making – and that gist is in fact preferred when exact answers are not required. Importantly, meaning is at the core of gist memories. She argues that traditional public health messaging, designed to warn and persuade, doesn’t provide the necessary meaning to support the development of a pro-vaccine gist. From this perspective, anti-vaccine messages can create strong gist memories: they provide meaning to adverse events related to vaccinations – even where no true relationship exists. The narrative is coherent, even if it’s not rational. Positive vaccine communication needs to do the same, appealing to values, such as how vaccinating protects those that cannot be vaccinated. Emotional resonance counts, too – messages can be resonant while remaining accurate and distilling risk perceptions in ways that support positive gist interpretations.
Social media has changed the way we share information on the internet, presenting challenges and opportunities to public health advocates. The ability to attach a personal narrative to vaccine communication has the potential to shift risk perception about vaccines. While research on best practices continues to evolve, it seems safe to conclude the following: Make the gist of your pro-vaccine message easy to extract, and make it memorable.
Betsch C, Brewer NT, Brocard P, Davies P, Gaissmaier W, Haase N, Leask J, Renkewitz F, Renner B, Reyna VF, Rossmann C, Sachse K, Schachinger A, Siegrist M, & Stryk M (2012). Opportunities and challenges of Web 2.0 for vaccination decisions. Vaccine PMID: 22365840
Kata A (2011). Anti-vaccine activists, Web 2.0, and the postmodern paradigm – An overview of tactics and tropes used online by the anti-vaccination movement. Vaccine PMID: 22172504
Reyna, V. (2011). Risk perception and communication in vaccination decisions: A fuzzy-trace theory approach Vaccine DOI: 10.1016/j.vaccine.2011.11.070