Using campaigns to improve perceptions of the value of adult vaccination in the United States: Health communication considerations and insights

Contributions and Impact of Health Communication Research to Vaccination Efforts and Acceptance

Vaccines (a medical product) and vaccination recommendations (expert advice on who should receive, when, and how often) have grown in importance and prominence in the past 15 years, including because of a recent COVID-19 pandemic. This essay highlights contributions from vaccine and vaccination-related health communication research since 2010. This research has had significant impacts - that is, visible and discernible positive effects - on the ways health communication is undertaken broadly (e.g. at the campaign level) and at the health care provider-patient level (e.g. conversations with parents and patients regarding vaccine benefits, risks, and safety). As this essay illustrates, health communication research has resulted in greater use of formative research to guide vaccination campaign and education efforts, better identification and understanding of the factors behind vaccination delay and declination, and greater recognition that communication efforts can fail to achieve desired outcomes or generate unintended consequences. Health communication research has also documented the powerful influence of healthcare provider communication on parent and patient understanding and compliance with immunization recommendations. Importantly, this research has also shown the characteristics of provider-patient communication matter much. Healthcare providers must have or establish a high degree of trust, be well-versed in vaccine efficacy and safety, and be adept at using their personal experiences, information tailoring/personalization, and evidence-based communication strategies to increase the likelihood of success.

Modelling the Public Health Burden of Herpes Zoster and the Impact of Adjuvanted Recombinant Zoster Vaccine in Five Selected Countries in Southeast Asia

INTRODUCTION

Herpes zoster (HZ) can cause substantial patient morbidity and lead to large healthcare costs. However, the disease burden of HZ in Southeast Asia may be underestimated. This study aimed to estimate the public health burden of HZ and the impact of vaccinating adults aged ≥ 50 years old in five Southeast Asian countries (Indonesia, Malaysia, Philippines, Thailand, and Vietnam), with adjuvanted recombinant zoster vaccine (RZV) compared with no vaccination.

METHODS

For each country, we adapted a static multicohort Markov model developed with a 1-year cycle length and lifetime horizon. Demographics were obtained from the World Health Organization, HZ incidence from a worldwide meta-regression reporting Asian-specific values, proportions of postherpetic neuralgia (PHN) and non-PHN complications from local/regional studies, and vaccine efficacy from a long-term follow-up trial. First-dose coverage and second-dose compliance were assumed to be 30% and 70%, respectively. A one-way deterministic sensitivity analysis (OWSA) and probabilistic sensitivity analysis (PSA) were performed to assess the robustness and uncertainty of inputs for each country.

RESULTS

Without RZV, it was estimated that there would be a total of approximately 10 million HZ cases, 2.1 million PHN cases, and 1.4 million non-PHN complications in individuals aged ≥ 50 years included in the model. Introducing RZV under 30% coverage could avoid approximately 2.2 million (22%) HZ cases, almost 500,000 (21%) PHN cases, and around 300,000 (22%) non-PHN complications. OWSA showed that first-dose coverage and initial HZ incidence had the largest impact on the estimated number of HZ cases avoided. The number needed to vaccinate ranged from 15 to 21 to prevent one case of HZ and from 68 to 104 to prevent one case of PHN across each country.

CONCLUSIONS

This study demonstrated that there is substantial HZ disease burden in older adults for the five selected countries in Southeast Asia, negatively impacting national healthcare systems. Introducing RZV could potentially reduce this burden. A graphical abstract is available with this article.

The language of vaccination campaigns during COVID-19

Understanding what makes communication effective when designing public health messages is of key importance. This applies in particular to vaccination campaigns, which aim to encourage vaccine uptake and respond to vaccine hesitancy and dispel any myth or misinformation. This paper explores the ways in which the governments of Great Britain (England, Scotland and Wales) promoted COVID-19 vaccination as a first-line strategy and studies health message effectiveness by examining the language of official vaccination campaigns, vaccine uptake across the different nations and the health message preferences of unvaccinated and vaccine sceptic individuals. The study considers communications beginning at the first lockdown until the point when daily COVID-19 updates ended for each nation. A corpus linguistic analysis of official government COVID-19 updates is combined with a qualitative examination of the expression of evaluation in governmental discourses, feedback from a Public Involvement Panel and insights from a nationally representative survey of adults in Great Britain to explore message production and reception. Fully vaccinated, unvaccinated and sceptic respondents showed similar health messaging preferences and perceptions of health communication efficacy, but unvaccinated and sceptic participants reported lower levels of compliance for all health messages considered. These results suggest that issues in health communication are not limited to vaccination hesitancy, and that in the future, successful vaccination campaigns need to address the determining factors of public attitudes and beliefs besides communication strategies.

Attitudes and Beliefs around the Value of Vaccination in the United States

Despite the benefits of immunization, differences in attitudes persist toward vaccines. We captured individuals’ perceptions of vaccines and vaccination across the United States (US) to inform vaccine-related policy development. A survey was completed by 5000 respondents from 10 states. Respondents were screened for inclusion, which included individuals ≥ 18 years of age that had received a vaccine or were unvaccinated but indicated a favorable or neutral attitude towards vaccinations. Participants were excluded if they indicated they did not support the idea of vaccinations. Questions explored perceptions of vaccines for all age groups. Among unvaccinated individuals, the most common concerns were about safety (38%). Most respondents (95%) highlighted the importance of state immunization programs for disease prevention. Access to health and immunization records and immunization information systems were important to 96% and 88% of respondents, respectively, for future health planning. Doctors and healthcare professionals (HCPs) were considered trusted sources for vaccine information (95%). Overall, respondents recognized the importance of vaccination, but documented concerns among the unvaccinated indicated a need for greater promotion regarding vaccine safety. Doctors and HCPs, as trusted information sources, should continue to and increasingly advocate for the importance of immunization to increase vaccine uptake.

The Value(s) of Vaccination: Building the Scientific Evidence According to a Value-Based Healthcare Approach

Objectives

To provide a new value-based immunization approach collating the available scientific evidence on the topic.

Methods

Four value pillars (personal, allocative, technical, and societal) applied to vaccination field were investigated. A systematic literature review was performed querying three database from December 24th, 2010 to May 27th, 2020. It included studies on vaccine-preventable diseases (VPDs) that mentioned the term value in any part and which were conducted in advanced economies. An in-depth analysis was performed on studies addressing value as key element.

Results

Overall, 107 studies were considered. Approximately half of the studies addressed value as a key element but in most of cases (83.3%) only a single pillar was assessed. Furthermore, the majority of papers addressed the technical value by looking only at classical methods for economic assessment of vaccinations whereas very few dealt with societal and allocative pillars.

Conclusions

Estimating the vaccinations value is very complex, even though their usefulness is certain. The assessment of the whole value of vaccines and vaccinations is still limited to some domains and should encompass the wider impact on economic growth and societies.

Vaccine perceptions in a free urban clinic for underserved, uninsured adults

BACKGROUND

Adult vaccine rates remain low despite public health efforts. Despite the likelihood that underserved patients face more barriers to vaccination, little is known on the perceptions underserved patients have about vaccines as a whole. Additional information could guide health care providers in efforts to improve adult vaccination rates in the medically underserved population.

OBJECTIVES

The primary objective of this survey was to assess perceived susceptibility to and severity of vaccine-preventable disease (VPD) and perceived safety and effectiveness of vaccines in a medically underserved population.

METHODS

This cross-sectional, descriptive study evaluated vaccine perceptions using a self-administered paper survey in a free clinic providing care to uninsured, low-income adults. All patients with scheduled appointments in the clinic were eligible to participate. Two Likert-type items were used to define responses regarding trust and beliefs. Level of trust was defined as "Not at all" (1), "A little" (2), "Not sure" (3), "Some" (4), and "A lot" (5). Responses to vaccine belief items were defined as "Strongly disagree" (1), "Disagree" (2), "Neither agree nor disagree" (3), "Agree" (4), and "Strongly agree" (5). Statistical analyses were descriptive in nature.

RESULTS

Final analysis included 131 surveys. Health care providers were the most common patient-reported vaccine information source (73.3%) and the most trusted (median: 5). Despite clear agreement among respondents that vaccines are safe (median: 3.94) and effective (median: 4) in adults, with similar results regarding children, the results regarding personal risk from VPDs were less definitive (median: 3).

CONCLUSION

Overall, survey responses in this uninsured, low-income population indicate that vaccines are perceived as safe and effective, but there is less consensus regarding the individual risk patients face from VPD. Focusing patient education on individual risk as much as overall vaccine safety and efficacy may help improve low adult vaccination rates in the medically underserved.

Evaluating the effects of vaccine messaging on immunization intentions and behavior: Evidence from two randomized controlled trials in Vermont

The effectiveness of vaccines in reducing child morbidity and mortality worldwide relies on public acceptance. However, relatively little is known about the effects of vaccine communication on vaccine attitudes and immunization behavior. Previous research suggests that common communication approaches may be ineffective or even counterproductive, especially among vaccine-hesitant parents. However, these studies typically rely on observational data or self-reported measures of vaccination intention. Using novel research designs, we tested the attitudinal and behavioral effects of messages encouraging vaccination in both a survey experiment conducted among a large sample of parents in Vermont who expressed hesitancy about childhood immunizations and a field experiment among parents whose children were overdue for vaccines. We find that neither a message promoting immunization as a social norm nor a message correcting common misperceptions about vaccines was measurably more effective than a standard public health message at improving parents' attitudes toward vaccines, intention to vaccinate their children, or compliance with the recommended vaccine schedule. Our results highlight the need for more research on approaches to successfully reducing vaccine hesitancy among parents.

Attitudinal Correlates of HPV Vaccination in College Women

This study examined associations between general attitudes toward seeking medical care, attitudes about vaccines/fear of shots, and human papillomavirus (HPV) vaccine uptake and intentions in college women. Hypothesized associations were framed by the Theory of Planned Behavior (TPB). Participants (N = 330, mean age = 18.9 years, 75% White) completed a one-time survey. The majority (61%; n = 201) had received ≥1 HPV vaccine dose. Hierarchical logistic regression examined relationships between attitudes and vaccine uptake. Pearson correlation coefficients and Kruskal-Wallis tests examined associations between attitudes and vaccine intentions. Results were partially consistent with the TPB. In the final model, perceived benefits, but not fear of shots, were associated with vaccine uptake. Among the unvaccinated, perceived benefits, but not fear of shots, were associated with vaccine intentions. Provider recommendation was the strongest predictor of vaccine uptake. Findings suggest interventions incorporating discussion of perceived benefits and provider recommendation may improve HPV vaccine receipt among college women.

Identifying Missed Opportunities for Routine Vaccination among People Who Use Drugs

In the US, adult immunization coverage remains low, especially among vulnerable populations, as recent hepatitis A outbreaks have demonstrated. We studied the vaccination history variation among the US adults who use drugs by implementing a community-engaged research survey to identify reported immunization coverage, missed opportunities (MO), and places where immunizations might be delivered. Our analysis of a sample of 1127 participants recruited at community syringe exchanges in three cities identified higher overall vaccination receipt in Los Angeles compared to Atlanta or Las Vegas (e.g., HAV receipt 52.2% LA, 42.1% LV, 41.4% Atlanta). Overall, fewer participants reported having received HAV (45.9%), HBV (47.5%), or influenza (47.6%) vaccines than MMR (57.1%) or Td/Tdap (61.1%). Across sites, HAV receipt was higher for participants incarcerated ≥ 5 years (54.2% vs. 43.6% for those incarcerated < 5 years, 49.4% no incarceration history, p = 0.02). HBV receipt was higher among participants who were not intravenous drug users (56.1% vs. 46.0%, p = 0.03). Additionally, income >$20k predicted higher rates of MMR receipt (67.0% vs. 56.5%, p = 0.009), as did stable housing (62.8% vs. 54.3%, p = 0.01). To address the need to expand vaccine coverage among vulnerable adults, delivering vaccine at sites where persons who use drugs access services, or in correctional facilities, may be warranted.

Using immersive virtual reality to improve the beliefs and intentions of influenza vaccine avoidant 18-to-49-year-olds: Considerations, effects, and lessons learned

OBJECTIVE

Only one-third of adults 18-49 years old in the United States receive a recommended annual influenza vaccination. This study examined whether supplementing vaccine information statements (VIS) with an immersive virtual reality (VR), short video or electronic pamphlet story designed to convey the community immunity benefits of influenza vaccination would improve influenza vaccine avoidant participants' influenza-related perceptions as well as their influenza vaccination-related beliefs, confidence and intentions.

METHOD

A one-way between-subjects experimental design compared the effects of adding a supplemental education experience prior to VIS exposure with flu vaccine avoidant 18-to-49-year-olds. The 171 participants recruited from the community were randomly assigned to one of three modality treatment conditions [VR, video, or e-pamphlet (i.e., story board presented via electronic tablet)] or a VIS-only control condition.

RESULTS

Compared to the modalities, the VR intervention created a stronger perception of presence (i.e., feeling of "being there" in the story), which, in turn, increased participants' concern about transmitting influenza to others and raised vaccination intention. Increased concern about transmitting influenza to others was associated with positive effects on influenza vaccination-related beliefs, including confidence that one's flu vaccination would protect others. Neither the e-pamphlet nor the video intervention were able to elicit a sense of presence nor were they able to improve the impact of the VIS on the outcome measures.

CONCLUSIONS

Immersive VR has much potential to increase understanding of key immunization concepts, such as community immunity, through creative executions that increase a sense of presence. Given the need to increase influenza vaccination uptake among 18-to-49-year-olds, and the projected growth in VR accessibility and use, additional applications and assessments related to vaccination communication and education are needed and warranted. By increasing the ability to convey key vaccine and immunization concepts, immersive VR could help address vaccination hesitancy and acceptance challenges.

A Rational Explanation of Limited FMD Vaccine Uptake in Endemic Regions

Vaccination for foot-and-mouth (FMD) disease remains low in parts of Africa despite the existence of vaccines. In East Africa, the presence of multiple virus serotypes and sub-types makes matching a vaccine with the circulating virus type in the field, or providing a high potency vaccine, a challenge. In this paper we use game theory to show that the resulting vaccine uncertainty associated with these vaccination conditions in an endemic setting help explain the low vaccine uptake. We evaluate vaccination for FMD in the context of East Africa due to FMD being endemic in the region, the diversity of FMD virus types, and barriers to implementing other disease control measures, such as controlled movements. We incorporate these conditions into a vaccination game setting and compare the payoffs to those of a traditional vaccination game for seasonal influenza and commercial livestock vaccination in a developed country context. In showing that vaccination provides households with a lower payoff than not vaccinating, our simple game theoretical explanation supports existing evidence calling for improved vaccine quality and efforts to enhance surveillance to provide early information on disease status.

Interventions to Increase the Rate of Influenza and Pneumococcal Vaccination in Patients with Chronic Obstructive Pulmonary Disease: A Scoping Review

Background and Objective: Current evidence suggests that patients with chronic obstructive pulmonary disease (COPD) should receive influenza and pneumococcal vaccinations. Despite international guidelines recommending vaccination in patients with COPD, many patients remain unvaccinated. Reasons for vaccine non-acceptance are multifaceted and are likely to be influenced by multiple psychosocial factors and pre-existing health beliefs. The aim of this review was to identify interventions which have been shown to effectively increase vaccination rates in patients with COPD. Materials and Methods: A structured search of PubMed returned 491 titles. Following title and abstract screening, seven full-text articles reporting on 6 unique interventional studies were extracted for narrative synthesis. A variety of interventions were investigated which, for the purposes of this review, were grouped into patient-focussed, clinician-focussed and mixed interventions. Results: Three papers reported findings from clinical trials (2 unique studies) and 4 papers reported findings from before-after studies. Two studies were conducted in the primary care setting, the remaining studies were conducted in secondary and tertiary care. Most studies reported both influenza and pneumococcal vaccination rates. These studies suggest that multimodal interventions, which target multiple aspects of evidence-based care and use both patient-focussed and clinician-focussed techniques, may have the greatest impact on vaccination rates in patients with COPD. Conclusions: Further, adequately powered, high quality studies are needed. It is crucial for individual institutions to monitor their own vaccination rates to determine if there is scope for performance improvement.