Although health communication encompasses diverse fields, it also involves research on vaccine hesitancy, referring to the act of postponing or rejecting inoculations due to the denial of its usefulness, even when one is in a situation where vaccination services can be useful.1 Because the ratio of the population receiving vaccinations at an appropriate time must remain high at all times to ensure the effective control of diseases that can be prevented with vaccines, this issue is important in relation to the health of populations overall.2 Of course, despite the safety and effectiveness of vaccines, on the Internet, numerous are information conflicts regarding vaccines and differences in perspectives between experts and ordinary citizens as well.
Because the media today easily amplify information, as false information about vaccines is circulated or conflicting information surfaces, the confusion of the general public is aggravated and the phenomenon of vaccine hesitancy can be intensified. Of course, the phenomenon of doubts about and rejections of vaccines on the part of certain members of the public is one as old as the history of vaccines itself. However, this issue has become even more important with the recent addition of even more vaccines to the essential vaccination program. Consequently, active discussions are underway on whether or not the absence or insufficiency of communication is a decisive factor affecting hesitancy with regard to vaccines.
The World Health Organization Working Group on Vaccine Hesitancy views communication as a tool rather than a decisive factor of vaccine hesitancy.3 However, insufficient communication can promote vaccine hesitancy and amplify the negative effects on vaccination rates. Regardless of their forms, low-quality services such as insufficient communication can lead to an increase in the population postponing vaccinations in countries without deficiencies in vaccine procurement. For example, in the early stage of the influenza A (H1N1 flu) pandemic in 2009, the unpredictability of this virus failed to receive sufficient attention. In most cases, medical institutions failed to properly convey to the public not only the gravity of the situation but also the fact that the potential risk of the spread of the new virus and the efficacy of the prospective vaccine could not be predicted accurately. Consequently, the vaccine was supplied only after the pandemic reached its apex in many cases. The public’s perspectives on and responses to such risks are likely to follow the logic of the mass media rather than that of epidemiology.4 In addition, the result was a continuation of distrust on the part of the public and the medical personnel in countries impacted by the pandemic.
At present, internationally underway are discussions on priorities and challenges related to the vaccination system.5 These discussions have included the need and opportunities for the implementation of new vaccination and communication strategies, the inducement of participation by major authorized personnel and the public during the initial stage of decision making, and organization and performance of important activities such as the introduction of new nationwide vaccination programs.6 With a focus on new media and the case of the Zika virus (ZIKV), this study examines the strategies and tasks of health communication in relation to vaccinations.
New media communication and the Zika virus
Social networking services (SNSs) are major channels of health communication in responding to infectious diseases.7 New videos posted on the Internet attract considerable amounts of attention from SNS users and increase traffic to certain Web sites. For example, YouTube is so influential that it accounts for no less than one-quarter of all SNS traffic in the United States.8 However, although the view counts for YouTube videos on the outbreak of diseases amount to several million, most of these videos are produced and uploaded by nonexperts.9,10 In other words, although medical institutions have striven to convey key messages concerning infectious diseases to the public, in the SNS space, contents differing from scientific evidence acknowledged as the established theory have been disseminated as well.11 This has led to confusion among the public and the danger of reducing the effects of health communication.
The recent global spread of ZIKV was a great cause for fear. Zika virus causes microencephaly among newborns and is related to the development of Guillain-Barré syndrome among certain infectees as well.12 Because there still exist no vaccines against or treatments of ZIKV, important measures in response consist of killing mosquitoes and the virus’s carriers, and health communication. In recent years, online health communication research on ZIKV has been conducted with a focus on Twitter and Facebook.13,14 Indeed, SNSs present simultaneously opportunities and challenges in responding to new infectious diseases, including ZIKV. Many people obtain medical information on pregnancy and child health from SNSs.15,16 Consequently, SNSs can become health information communication channels that are more effective than the classic mass media by making use of their advantages of high accessibility and two-way communication.17
However, SNSs can also amplify any unnecessary anxiety about infectious diseases.18 If and when reports surface of microencephaly in some pregnant women infected with ZIKV, which detrimentally affects the brain development of fetuses, it causes anxiety in other pregnant women who may have been exposed to ZIKV, possibly motivating them to have abortions.19 In fact, there also exist on YouTube videos that address anxiety and fear in relation to the ZIKV “infection” and pregnancy avoidance due to the risk of ZIKV infection during pregnancy. If and when such uncertain risks and the exaggerated levels of anxiety spread, the health of both pregnant women and fetuses can be seriously affected by erroneous information. Of course, reading about others’ public health experiences on SNSs can strengthen the experience of homogenization and social support and enhance medical common sense regarding infectious diseases. However, a task faced by health authorities is prompting the public to filter out erroneous information that can cause excessive fear and to select instead accurate information.
Implications and challenges
The knowledge-insufficiency model, whose premise is that the public is insufficient with regard to their ability to understand key public health knowledge and to make related decisions in crisis situations, is the model most widely used by public health personnel.20 To fill such information gaps, medical communicators therefore have pursued two-way communication in which both nonexperts and experts participate.21 By providing medical authorities with the necessary information through such efforts, it is possible to contribute to the development of public participatory policies encompassing two-way communication. Future challenges are discussed hereinafter.
First, because the outcome of health communication is a joint responsibility, a comprehensive exchange of information is necessary. Communication encompasses all elements and behaviors that make possible the circulation of information through relational processes. The word “communicate” signifies exchanges of information and opinions among all of the parties involved. Consequently, it is necessary to pay attention to the public’s perspectives when establishing and applying plans for communication regarding vaccinations.22 However, the capacity to induce changes in the behavior of those who are hostile to vaccinations still appears to be insufficient.23,24
Second, it is necessary to improve vaccination acceptance through strategies that integrate new and old media.22 Although being based on evidence, communication must occur in an appropriate manner that is most conducive to a proper understanding of vaccinations. To achieve this, it is necessary to seek advice from communication experts and to promote collaborations among different forms of media and the integration of these forms. In addition, it is important to grasp and develop new tools through projects on national and local levels and to encourage not only the medical personnel but also the public to use communication channels among peer groups.25
Third, it is necessary to establish customized public health education for the public, vulnerable groups, and experts. To raise the public’s vaccine literacy, it is necessary to include consistent and continuous education on vaccinations in the curricula of primary and secondary schools. School education regarding the importance of disease prevention is a fundamental measure for improving the entire population’s vaccine awareness. In addition, because the role of medical personnel is important with regard to prompting the public to accept vaccinations, training and education for experts must be strengthened.26,27 However, there still are cases where vaccine acceptance is limited by individuals’ convictions based on prejudices or insufficient training. Such a phenomenon is likely to result in a failure to either receive or even avoid vaccinations among groups who are relatively more vulnerable to infectious diseases. Consequently, the scientific community must take measures to establish concrete educational programs and to invest in expert training and lifelong education.28
Fourth, it is necessary to understand the public’s desire for information and to mitigate vaccine hesitancy through communication training. Government authorities and experts must continuously monitor the public’s perspectives, knowledge, attitudes, and opinions through diverse Web tools.29 With the goal of recovering mutual trust among public (government) agencies, medical personnel, and the public, it is necessary to establish a communication basis that supports the conveyance of necessary information and then to use this to deliver appropriate messages and to activate beneficial discourse on this subject. Communication based on effective shared strategies and consistent behavior can change attitudes toward vaccinations and can serve as a key element among global strategies against vaccine hesitancy.
In the end, to promote communication regarding vaccinations, it is simultaneously necessary to grasp major measures to be considered and implemented first on the state level and then to improve communication among public agencies, the scientific community, the medical personnel, and the public.30 In addition, social trust must be raised so that the public will smoothly implement recommendations from government authorities and medical staff in the event of new infectious diseases.31 Physicians who reject vaccinations or prevent their own family members from receiving vaccinations spread distrust of inoculations, and distrust thus formed cannot be eradicated with any type of verbal communication.
1. Hickler B, Guirguis S, Obregon R. Vaccine special issue on vaccine hesitancy. Vaccine
2. Salmon DA, Dudley MZ, Glanz GM, Omer SB. Vaccine hesitancy: causes, consequences, and a call to action. Am J Prev Med
. 2015;49(6 suppl 4):S391–S398.
3. MacDonald NE. the SAGE working group on vaccine hesitancy. Vaccine hesitancy: definition, scope and determinants. Vaccine
4. Reintjes R, Das D, Klemm C, Richardus JH, Keßler V, Ahmad A. Pandemic public health paradox: time series analysis of the 2009/10 Influenza A/H1N1 epidemiology, media attention, risk perception and public reactions in 5 European countries. PLoS One
5. Signorelli C, Odone A. Advocacy communication, vaccines and the role of scientific societies. Ann Ig
6. Bonanni P, Azzari C, Castiglia P, et al. The 2014 lifetime immunization schedule approved by the Italian scientific societies. Italian Society of Hygiene, Preventive Medicine, and Public Health. Italian Society of Pediatrics. Italian Federation of Pediatric Physicians. Italian Federation of General Medical Physicians. Arezzo Service of Legal Medicine. Epidemiol Prev
. 2014;38(6 suppl 2):131–146.
7. Fung IC, Duke CH, Finch KC, et al. Ebola virus disease and social media: a systematic review. Am J Infect Control
9. Basch CH, Basch CE, Ruggles KV, Hammond R. Coverage of the Ebola virus disease epidemic on YouTube. Disaster Med Public Health Prep
10. Towers S, Afzal S, Bernal G, et al. Mass media and the contagion of fear: the case of Ebola in America. PLoS One
11. Pathak R, Poudel DR, Karmacharya P, et al. YouTube as a source of information on Ebola virus disease. N Am J Med Sci
12. Rasmussen SA, Jamieson DJ, Honein MA, Petersen LR. Zika virus and birth defects: reviewing the evidence for causality. N Engl J Med
13. Southwell BG, Dolina S, Jimenez-Magdaleno K, Squiers LB, Kelly BJ. Zika virus-related news coverage and online behavior, United States, Guatemala, and Brazil. Emerg Infect Dis
14. Sharma M, Yadav K, Yadav N, Ferdinand KC. Zika virus pandemic—analysis of Facebook as a social media health information platform. Am J Infect Control
15. Bernhardt JM, Felter EM. Online pediatric information seeking among mothers of young children: results from a qualitative study using focus groups. J Med Int Res
16. Wong WH, Li SL, Fu K-W, Tinsley H, Chow C-B, Ip P. The importance of online resources for parents of children with special needs in Hong Kong: South China’s experience. J Health Med Info
17. Moorhead SA, Hazlett DE, Harrison L, Carroll JK, Irwin A, Hoving C. A new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication
. J Med Int Res
18. Fung IC, Tse ZT, Cheung CN, Miu AS, Fu KW. Ebola and the social media. Lancet
20. Ziman J. Not knowing, needing to know, and wanting to know. In: Lewenstein B, ed. When Science Meets the Public
. Washington, DC: American Association for the Advancement of Science; 1992:13–20.
21. Hulme M. Why We Disagree About Climate Change: Understanding Controversy, Inaction and Opportunity
. Cambridge, UK: Cambridge University Press; 2009.
22. Goldstein S, MacDonald NE, Guirguisc S. The SAGE Working Group on Vaccine Hesitancy. Health communication
and vaccine hesitancy. Vaccine
23. Bedford H. Pro-vaccine messages may be counterproductive among vaccine-hesitant parents. Evid Based Med
24. Nyhan B, Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: a randomized trial. Pediatrics
25. Odone A, Ferrari A, Spagnoli F, et al. Effectiveness of interventions that apply new media
to improve vaccine uptake and vaccine coverage. Hum Vaccin Immunother
26. Giambi C, Del Manso M, D’Ancona F, De Mei B, et al. Actions improving HPV vaccination
uptake. Results from a national survey in Italy. Vaccine
27. Di Gregori V, Franchino G, Marcantoni C, Simone B, Costantino C. Logistic regression of attitudes and coverage for influenza vaccination
among Italian public health medical residents. J Prev Med Hyg
28. Costantino C, Mazzucco W, Azzolini E, et al. Influenza vaccination
coverage among medical residents: an Italian multicenter survey. Hum Vaccin Immunother
29. Fadda M, Allam A, Schulz PJ. Arguments and sources on Italian online forums on childhood vaccinations: results of a content analysis. Vaccine
30. European Centre for Disease Prevention and Control (ECDC). Communication on Immunization: Building Trust
. Stockholm, Sweden: ECDC; 2012.
31. Diekema DS. Improving childhood vaccination
rates. N Engl J Med