News & Views: Vaccine Communication (Part 1) — The Recipient

Editor’s note: This is the first of a two-part series related to vaccine communication. It is based on a presentation originally developed by Charlotte Moser for the Wilkes University Kimball Lectureship. Part 1 focuses on the recipient of a vaccine-related message, and part 2, which will be published in the May issue of Vaccine Update, will focus on the message and the messenger.

Vaccine communication can be complicated. Like any topic based on science, we often have knowledge gained from experimentation — the facts — but when we attempt to share that knowledge, we may be met with confusion, hesitation or resistance. These reactions are easier to understand when we realize that the facts are being considered through a series of filters the individual already has in place. For the recipient, the information is not the only ingredient that matters. So, let’s consider three areas that will contribute to an individual’s reaction to a message: personal relationship to knowledge, feelings, and assessment of risk.

Personal relationship to knowledge

The decision to get vaccinated is complex in part because it does not have one straightforward (correct) answer. As such, individuals will approach the vaccine decision differently. When they are making decisions, their relationship with knowledge matters. This relationship is known as cognitive processing. Three levels of cognitive processing have been defined.

Cognition: The most basic form of gaining knowledge; it is present from birth. Cognition allows us to learn content-based information, like language, reading, numbers and math.

Metacognition: This form of cognitive processing allows us to consider how we acquire knowledge. For example, cognition allows elementary school children to memorize their spelling words, but metacognition allows them to understand how they must study to memorize the spelling words (e.g., writing the words five times each, spelling out loud to an adult, etc.). This type of processing typically develops during the early years of school and increases over time as people better understand how they learn.

Epistemic cognition: The most mature and most complex type of cognitive processing, a person’s epistemic cognition is characterized by three components:

1. Epistemic disposition refers to how open-minded a person is to new information and uncertainty. One’s epistemic disposition is contextual, meaning a person may be open-minded about uncertainty related to the effectiveness of a cancer treatment, but less so when it comes to a prevention measure like a vaccine.
2. Epistemic skills refers to how a person justifies information as being valid. A scientist is likely to look at an experimental design to determine whether the findings are valid; however, a mathematician will study a proof or theorem, and an historian may triangulate from multiple sources. As such, people will determine the validity of information differently based on their training and previous experiences.
3. Epistemic beliefs refer to a person’s relationship with knowledge. Everyone begins as a realist during childhood. In this phase, individuals view knowledge as unchanging and believe they just need to ask someone to find out information (Have you ever been with a young child that keeps asking “Why?” — this is why!). People will progress to other stages at different rates. The next phase is absolutist in which knowledge is viewed as direct and objective, but the individual realizes that people can be wrong, so they understand that information may need to be checked. This phase still relies heavily on experts and authority as primary sources of information, so in a school setting, a student in this phase may struggle to evaluate information from different sources. The third phase is multiplist. In this phase, people view knowledge as “a construct of reality” that can change over time. To them, all knowledge is subjective and uncertain. (You may have heard this in the form of “You have your facts, and I have mine.”) The most mature stage of epistemic belief is the evaluativist phase. In this phase individuals realize that knowledge is imperfect but that subjective and objective information can be reconciled into useful models of the world. People in this phase rely on evidence and evaluate the quality of an argument when they consider information.

Feelings

How someone feels is also going to affect how they receive a vaccine message. For example, if a person is without a home or consistent meals, they are probably not going to be very concerned about getting vaccinated. Likewise, if a new mom is coming for their child’s first sick visit, it may not be a good time to discuss getting vaccines, even though the illness may be minor and vaccines could be an option. In these examples, the individuals have both a low motivation and a low ability for considering a vaccine message. In this case “ability” does not refer to one’s intellect (e.g., cognitive processing), but rather the availability of attention, time, relevance and focus, among others. In the two examples, the message recipients have higher priorities at the moment.

Motivation and ability are factors that affect a theory of attitude change known as the Elaboration-Likelihood Model (ELM). Developed in the late 1970s to early 1980s, Richard Petty and John Cacioppo were trying to understand conflicting findings related to the effectiveness of persuasive messaging and the persistence of attitude changes. The ELM model they created suggests that because we can’t carefully consider every message that is presented to us, we have two message processing pathways: central and peripheral. Only if our motivation and ability are high do we use the central processing route, a route that causes us to evaluate arguments and carefully consider the message. As a result, central processing leads to enduring attitude change. But, in most cases, we use the peripheral processing route, which is based on cues, triggers and pre-existing biases. The peripheral processing route does not lead to enduring attitude changes. For example, people are more likely to use the central processing route when they are at a life-stage that makes the message relevant, such as a parent of an adolescent more carefully considering a message about HPV vaccine because they are aware that their child is of the age to get the vaccine. In contrast, a retired person without grandchildren would be more likely to process an HPV-related message using the peripheral route.

Assessment of risk

Another consideration related to a person’s decision on vaccines is their assessment of risk. A person’s assumptions about vaccine risk are different than what we describe as vaccine safety. A 2008 paper by Macpherson did a nice job of describing the difference between risk and safety using bears and bridges. For our purposes, consider that safety is what we measure when we do clinical trials or post-licensure surveillance. We know that certain side effects are likely, and we know at what rate to expect those side effects to occur. That is the information we often give to families, but what they are really concerned about is risk. They are considering whether the risk is worth the benefit. If they feel the disease is not likely, even a very small risk may feel like too much. Risk is subjective, whereas safety is not.

Side effect rates do not change, but feelings about those rates can. Indeed, risk varies across both individuals and time. Take the 2014-2015 Disneyland measles outbreak as an example. Prior to the outbreak, many studies had shown that the MMR vaccine did not cause autism, but for some parents the risk was still too great. When the Disneyland outbreak occurred, it was covered extensively by the media. As a result, some of the parents who previously opted against the MMR vaccine changed their mind. Their risk calculation had changed. The safety profile of the vaccine had not changed.

A final point in talking about risk is one made by Thompson in a 1999 paper. When people consider something to be risky, they are more compelled to be deliberative in considering it. Today’s parents view vaccines as risky, so they are more likely to carefully consider the vaccination question using the central processing route — as long as they have the motivation and ability to do so.

Summing up part 1

Whether to vaccinate is a complex and very personal decision affected by a variety of factors. As such, when we deliver vaccine messages, we need to consider the recipient more than ourselves. Understanding one’s relationship with knowledge, their feelings, and their interpretation of risk will all play a role in how they receive a message and whether they will act on it.

With this said, while vaccine communication is complex, the social norm is to vaccinate. Only about 1% of children in this country receive no vaccines by 2 years of age according to the National Immunization Survey, albeit this rises to 6% among uninsured children. This means most parents opt in for at least some vaccines when other barriers do not get in the way. So, while we need to understand and apply the nuances of communicating around vaccines, we also need to remove barriers that work against the motivation and ability of our population to get vaccinated. Most parents are not anti-vaccine — 99% of parents have demonstrated that.

References (Part 1)

Greene JA, Yu SB. Educating Critical Thinkers: The Role of Epistemic Cognition. Behavioral and Brain Sciences. 2016; 3(1):45-53.

Hill HA, Chen M, Elam-Evans LD, et al. Vaccination Coverage by Age 24 Months Among Children Born During 2018–2019 — National Immunization Survey–Child, United States, 2019–2021. MMWR Morb Mortal Wkly Rep. 2023 Jan 13;72(3):33-38.

Kitchener KS. Cognition, Metacognition, and Epistemic Cognition: A Three-Level Model of Cognitive Processing. Human Dev. 1983 July-Aug;26(4):222-232.

Macpherson JA. Safety, risk acceptability, and morality. 2008. Sci Eng Ethics. 14:377-80.

Muis KR, Chevrier M, Denton CA, Losenno KM. Epistemic Emotions and Epistemic Cognition Predict Critical Thinking About Socio-Scientific Issues. Frontiers in Education. 2021 April 14;6:669908.

Petty RE, Cacioppo JT. The Elaboration Likelihood Model of Persuasion. Adv in Exp Social Psych. 1986;19:123-2-5.

Thompson PB. The Ethics of Truth-Telling and the Problem of Risk. 1999. Sci Eng Ethics. 5(4):489-510.