Vaccination Communication Strategies: What Have We Learned, and Lost, in 200 Years?

"Advocates for childhood vaccination need to employ greater pathos in their communication - simply stating 'these are the scientific facts...' is not, and never will be, enough."

This study compares the modes of rhetoric and frames that Australian government officials used in different historical periods - the early nineteenth century (1803-24) and the early twenty-first (2016) - to encourage parents to vaccinate their children and alleviate public fears. The analysis shows that modern campaigns rely primarily on scientific fact, whereas 200 years ago, personal stories and emotional appeals were more common. The authors argue that a return to the old ways may be needed to increase Australia's immunisation rates, which are relatively high and stable at 90–93% but less than the national aspirational immunisation coverage target of 95% - a level exceeding that needed to ensure herd immunity against measles, the most infectious vaccine-preventable disease - as well as to address vaccine hesitancy around the world.

Though vaccine hesitancy is not a new phenomenon, it is possible that vaccine hesitancy is increasing because of what some researchers have cited as greater access to, and more rapid dissemination of, vaccine-critical messages via digital networks. The news media, both "new" and "traditional", play a role in communication of vaccination messages, as are social media sites such as Facebook. "This suggests that government agencies seeking to promote vaccination need to use these outlets to help disseminate their message....In addition..., the literature suggests government agencies need to shift away from merely reiterating safety and efficacy messages....[P]ublic health organizations cannot control how people will respond to a message, but simply describing recent advances or scientific information will not engage their target audience. They need to attempt to connect the emotions their audience may feel, such as fear or uncertainty about vaccine safety, to the information they provide, and genuinely attempt to address those fears without goading further negative emotional response."

For their analysis, the researchers studied 46 Sydney Gazette articles about vaccination and/or smallpox between 1803 and 1824; this paper wwas primary channel through which colony officials campaigned for vaccination and represented the endorsed government position on smallpox. For the 2016 dataset, 19 texts were collected from national, state, and territory government websites. The researchers used 3 analytical approaches to characterise each period's campaign strategy, identifying the presence or absence of the following in each article or text:

1. logos (fact-based logical arguments), pathos (emotive arguments), and ethos (argument by asserting expertise) - Aristotle's modes of rhetoric - in each article or text;
2. Nisbet and Scheufele's [2007] 8 frames; and
3. the 3 types of objection (public fear) Boddice [2016] identified, in order to understand how the government in each period implicitly characterised the vaccine hesitancy problem.

The researchers then describe the major trends that emerged for each of the 2 eras, comparing them to evaluate what has changed in 200 years and the significance of those changes. In brief:

• With regard to modes of rhetoric, logos (e.g., a simple factual statement such as "Immunisation is a simple and effective way of protecting children and adults against certain diseases") was the rhetorical mode most commonly employed in both eras. Ethos was used to persuade readers in 64% of Gazette articles and in 53% of 2016 texts. There was a striking difference in the use of pathos between the 2 eras. Pathos appeared in 61% of Gazette articles, manifesting itself in an emotive turn of phrase praising vaccination and/or strong negative language appealing to colony residents to vaccinate their children when losing the vaccine was a risk. In contrast, when pathos was employed in 2016, it was generally more restrained. Eight texts (42%) used it, but half of those were Victorian video transcripts.
• Of the 8 potential frames identified by Nisbet and Scheufele, 4 were coded present in both datasets, appearing regularly in both eras: social progress, public accountability/governance, morality/ethics, and scientific/technical uncertainty. For example, the morality/ethics frame appeared in 68% of 2016 texts; for example, the Victorian 'Immunity for Community' campaign used this frame in many of its videos: "What I want to say to parents is thank you for immunising your children because it keeps my children safe as well" (Ros' story). In the Gazette dataset, the frame appeared in 27% of articles, and was always accompanied by pathos rhetoric.
• In neither era did the campaigns address extensively the 3 types of objection listed by Boddice (ignorance; political ideology regarding individual liberty or mistrust of establishment interests; and/or "moral panic or ethical misgivings related to religion, sex and class"). Ignorance, however, was the objection type most commonly addressed in both eras. Thirty percent of Gazette articles overtly noted public ignorance as a source of resistance to vaccination, or explicitly set out to present "the facts". Half the 2016 texts (47%) appeared to address ignorance; for example, the Queensland website had a section called "Doing Further Research", aimed at people who wish to know more about vaccination safety or necessity, cautioning them about what constitutes credible information sources ("Be wary of people who proclaim that they, and only they, have discovered the 'hidden truth'.")

"These results suggest that despite 200 years of progress in both vaccination science and communication studies, Australian government strategies in vaccination campaigns have not changed much, and in some cases appear to have gone backward....The dominant approach taken by historical and current Australian governments has relied on facts-based, or logos, arguments to convince people to vaccinate. While an important element, this ignores a growing understanding within science communication that facts alone are not enough to convince someone to adopt behaviours or accept ideas." With that statement, the researchers reflect on the findings of their study, noting that, while a predominantly logos approach may have made sense when the science was new and knowledge minimal, the "facts" that dominate present-day approaches are more likely to get lost in the plethora of pro- and anti-vaccine information sources available today. Furthermore, in both eras, in addition to being emphasised via logos arguments, the scientific perspective was communicated through ethos endorsement from establishment bodies and social progress frames linking vaccination successes to public well-being. In neither era were issues of trust or identity-based objections dealt with often (though more often in the 1800s). It is notable that this general approach has not changed in 200 years except in non-governmental organisation (NGO) materials, despite widespread understanding of this point among communications researchers.

In making actionable recommendations to emerge from this study, the researchers delve more deeply into the striking difference in the use of pathos between the 2 eras. "Principal Surgeon Jamison had no qualms about reaching out to parents with deeply emotional appeals in the 1800s. In 2016, pathos was largely reserved for people's personal stories in a single jurisdiction (the Victorian Immunity for Community videos) - the 'government voice' in all jurisdictions generally lacked pathos. The absence of pathos in most governments' current approaches may be a shortcoming of the campaign....Social media platforms are notably not restricted to logos-type information provision, but are venues for emotional expression and personal conversations. Intelligent social media interventions by governments may parallel Principal Surgeon Jamison's personal appeals to the public, and his use of pathos, logos and ethos together for maximum impact....They must acknowledge not only the scientific arguments, but the other factors which influence personal perceptions of risk and decision making. These include ideological disagreements about state power versus individual rights, and feelings of disenfranchisement in the face of establishment authority. Governments and their scientific representatives need to think seriously about how to present themselves in light of this."

In conclusion, the authors note that the findings presented here are derived from the Australian context, but are echoed in the international literature. This literature suggests that "[p]ublic health campaigns, especially on social media, need to invite emotional dialogue to be more successful, acknowledging and respecting the real fears of an audience who have doubts about the ability of the medical profession to help them....Governments must adopt communication processes that build rapport and trust, particularly with parents, and 'recognize that parents' trust in the source of information may be more important than the information itself' [Danchin and Nolan, 2014, p. 71]. Government vaccination programs have diversified in the past two centuries, changing with developments in research, and it is time their communication strategies did too."