Writing for a vaccine-hesitant reader

Vaccine hesitancy involves more than missing information. Effective writing starts with the reader's reasons for hesitation, uses respectful and consistent messages, and recognises that a single correction may be only one part of changing a decision.

The reader's position and concerns

Vaccination decisions may involve emotional, cultural, social, spiritual and political factors as much as cognitive ones, so supplying facts alone is insufficient. ^{1, 2, 3, 4} Addressing hesitancy requires identifying and diagnosing barriers and tailoring the response rather than assuming one strategy fits all. ^{1, 3}

Vaccine attitudes form a spectrum through which parents may move without following a fixed sequence. ⁵

1. Unquestioning acceptance.
2. Cautious acceptance.
3. Hesitance.
4. Delaying or selective vaccination.
5. Declining all vaccines.

⁵

Only a handful of those declining all vaccines are vocal anti-vaccination activists, and hesitant parents are most likely to change their position because they can be reassured. ⁵ Legitimate concerns among individuals, parents and carers should be distinguished from outright anti-vaccine sentiment and met with positive engagement. ⁶

Reasons people may avoid beneficial actions include the following. ⁷

• Science is difficult to understand.
• Understanding science is not innate.
• People distrust pharmaceutical companies and government.
• Poverty.

⁷

Two prominent themes in COVID-19 hesitancy were fear of the unknown, including long-term side effects, unfamiliar ingredients and pregnancy risks, and loss of control over personal choice, bodily ownership and freedom. ⁷ Anger and frustration can accompany these concerns, making respectful understanding important to avoiding arguments. ⁷

Listening, courtesy and trust

Communication requires listening as well as telling; understanding the intended audience's perspective and engagement matters as much as the information experts wish to convey. ⁸ Vitriol, passive aggression and hate speech widen the divide. ⁸ Three courtesy principles apply. ⁸

• Acknowledge the other person's belief or mindset without implying agreement.
• Communicate empathetically, listening before sharing a perspective.
• Match the tone to the audience.

⁸

Further strategies address the reader's decision and sources of concern. ⁸

• Reinforce the importance of the decision.
• Ask which blogs and other content influence the decision.
• Understand the source of the reader's fears.
• Explain the risks of not vaccinating.
• Explicitly acknowledge a caring parent trying to make the best health decisions for their child.

⁸

A study of misperceptions and corrections found that people completing a self-affirmation exercise were more likely to accept corrected information. ⁸ Hesitant people should be treated as potential allies, not dismissed as ignorant or their concerns rejected out of hand. ⁷

For responding to vocal vaccine deniers in public, WHO's 2016 guidance recommended the following. ⁸

• Stay calm.
• Do not demean the other person.
• Focus on the category of argument, such as safety or fear.
• Provide evidence respectfully.
• Use appealing language.

⁸

Parents' decisions respond to personal experience, values and trust in healthcare professionals; building community relationships and encouraging clinicians to listen without judgement may help restore trust. ⁹ Vaccine messages should avoid appearing dictatorial or dogmatic. ⁹ Credible community members already trusted by an audience, including clinicians, scientists, teachers, celebrities and influencers, may increase confidence when communicating on familiar platforms. ¹⁰ Earlier social media marketing studies for human papillomavirus (HPV) vaccination did not report increased vaccination rates, despite suggesting potential for education and trust-building. ¹⁰

Targeted and consistent responses

Targeted communication is more effective than generic communication, and questions about people's reasoning help identify what they need to know. ⁷ Different stages of hesitancy need different messages, but each particular concern needs a consistent response: receiving a different answer repeatedly can increase confusion and hesitation. ⁷ Mixed Australian COVID-19 vaccine messages in 2021 illustrated the problem: advice about AstraZeneca for people under 60 differed between states, and Queensland's later change was not accompanied by an explanation of its earlier position. ¹¹

Three principles guide discussion of vaccination benefits. ¹²

1. Understand the reader's reasons for hesitation.
2. Form an effective, evidence-based response using fear with hope rather than frightening messages, short messages focused on immediate gains, and narratives or real-life success stories.
3. Keep communication targeted to relevant communities or age groups.

^{12, 13}

Writers should continue examining what worked in previous pandemics and campaigns and what is increasing vaccination in real time, while keeping communication consistent, clear and courteous. ¹⁴

Harms, hope and stories

A University of Illinois research team moderated anti-vaccination beliefs by reminding people of the harms of not vaccinating. ¹⁵ Fear-based strategies have also worked in other public health interventions, including cigarette-label imagery. ¹⁵ However, fearmongering, sensationalist headlines and speculation can create confusion and worsen hesitancy. ¹¹

Fear alone is discouraged in the 2021 approach. ^{16, 7} Fear combined with hope helped inspire behaviour change in a 2017 skin-cancer prevention campaign, suggesting that a consistent fear–hope vaccination message might help if it is not too threatening. ^{7, 16} Smoking-prevention research favoured short messages about immediate gains over highly threatening messages, while a separate study found deception and disgust could provoke defensive responses. ⁷ These findings support targeted, evidence-based and considerate responses. ¹⁶

Embedding facts in a story can be more persuasive than presenting facts alone, and accounts of hesitant people who changed their minds may help. ⁷ One formerly anti-vaccination mother said opposing evidence and derision had not changed her mind, whereas a friend with similar parenting values posted respectfully, explained vaccination decisions and gently challenged misconceptions, leading her to follow reliable information. ^{17, 18} Such accounts also show how peer relationships can draw people into anti-vaccination groups. ^{17, 18}

A conversational approach adapted to writing

A four-step conversational approach proposes building empathy and trust before presenting the benefits of change. ^{19, 20, 21, 22, 23}

1. Respect comfort zones. Acknowledge that maintaining the status quo requires less effort, worry and struggle; listen to why the person distrusts vaccine science and see the issue from their perspective.
2. Discuss the costs of changing. People already consider these costs, including leaving a comfort zone, unlearning information and learning new information. Acknowledge concerns about rapid vaccine development, potential reactions and the need for boosters and appropriate timing; transparency helps the communicator seem relatable.
3. Discuss the costs of not changing once empathy and trust are established. Use missed opportunities and a story of what inaction cost to consider the future, emphasising people rather than systems or buildings. Seek an acknowledgement such as “that's right” before moving on.
4. End with hope. Discuss the benefits of change and a positive future, ask how the other person feels, and explain personally living with less fear after vaccination, even if they have not volunteered to be vaccinated.

^{20, 21, 24, 22, 23, 25}

Although developed for speech, the approach can inform writing through intellectual and personal respect, acknowledgement of concerns, attention to the future opportunity cost of inaction and an ending that offers hope, using language appropriate to the audience. ^{26, 25}

Practice with concerns and motivations

A 2021 writing exercise asks for an empathetic, short response combining fear and hope to each of these hesitations. ²⁷

1. The AstraZeneca vaccine is not as effective.
2. The vaccine will not stop me getting the virus.
3. Why vaccinate if it can still be passed to other people?
4. Fear of blood clots.
5. Fear of immediate death after vaccination.
6. Nobody I know has had COVID-19.
7. Wanting to wait and see.
8. Worry about fertility.
9. An experimental vaccine rushed to market.

²⁷

A second exercise uses reasons people gave for vaccination to prepare a response to a hesitant individual, since sharing others' motivations may persuade. ²⁸

1. Keeping family safe.
2. Not wanting to die of COVID-19.
3. Caring about the community and public health.
4. Wanting to travel and live normally again.
5. Having seen vaccination benefits over many years and seeing no reason this vaccine should differ.
6. Worry about spreading the virus.
7. Wanting peace of mind.
8. Wanting to live without anxiety and fear.
9. Protection against long COVID-19.

²⁸

The limits of a written correction

Correcting misinformation is important but needs to be part of a multifaceted, individualised and contextualised response. ²⁹ Evidence-aligned health communication should help readers make decisions that benefit health and public health rather than present unsupported views as equally valid. ¹⁴