How Do Experts and Nonexperts Want to Promote Vaccines? Hepatitis E Vaccine as Example

"Low- and middle-income countries receive limited guidance from external entities about how to introduce vaccines."

The hepatitis E (HepE) vaccine has little recognition in the one country where it is on the market, China. In attempting to promote its uptake, officials need to relay a concise set of details about the vaccine and disease to the public. The aims of this qualitative study are to identify which attributes of the HepE disease and vaccine are considered important, and to compare desired promotion methods between different stakeholders.

Sixty-three stakeholders from Shanghai and other parts of China participated in in-depth qualitative interviews between October 2017 and August 2018. Experts (35) included staff at various levels of the Centers for Disease Control and Prevention (CDC), vaccination providers, infectious disease doctors, vaccine researchers, and vaccine company employees. Nonexperts (28) included members of high-risk populations (pregnant women, slaughterhouse workers, and family caregivers of HepE cases), HepE cases, and individuals who have previously received the vaccine.

Select findings:

• Knowledge of HepE was low among the general population and even among the experts.
• Although disease severity was the main disease attribute that both experts and nonexperts considered when making vaccine decisions, the general population was more likely to be influenced by personal experiences with the disease than by knowledge about its severity in general.
• Transmission route was the second most important attribute, according to all participants.
• Disease burden encompasses money and time costs, but many individuals also related it back to measures of disease severity like physical and mental health costs or quality of life.
• Experts thought the general population would conceive of a disease's importance by the number of cases they personally knew, though they also believed that hearing about outbreaks in the media could increase the general population's understanding of importance/incidence.
• Experts emphasised that vaccine safety information should be included in promotion materials and believed that the best type of safety information was data from clinical trials and other statistics. The general population also was highly concerned about safety, but they framed their concerns negatively, as in they had a gut feeling that vaccines might not be safe.
• Effectiveness was the second most important attribute to interviewees.
• Both experts and nonexperts mentioned that price was important to consider when making vaccine decisions, but it was secondary to effectiveness and safety.
• Experts, particularly government public health workers, believed the general population would trust the government as a source of information about attributes. However, it was also thought that personal anecdotes about the vaccine or cases of disease from acquaintances could be powerful ways to disseminate information.
• Social media, like WeChat, was an important source for news and could be a way for members of the general population to learn about attributes of the HepE vaccine or disease.

Overall, the study revealed that the vaccine decision-making process among the general population would involve, first, evaluation of exposure risk to HepE based on the transmission route and the importance (prevalence) of the disease. If an individual considered herself as having a substantial risk of being infected, he or she would perform a simplified cost-benefit analysis based on perceptions of disease severity and disease burden (i.e., social and economic costs). Broadly, these inputs correspond to constructs in the Health Belief Model.

Based on these findings, recommendations for promoting the vaccine to the general population are offered. They include:

• Information, education, and communication (IEC) materials could focus on severity, transmissibility, and the safety and effectiveness of the HepE vaccine.
• Government sources were thought to be particularly reliable, and presenting information about the vaccine during an outbreak would be one way to tie information about the disease to the availability of a vaccine.
• Participants valued hearing from others in the community and from those with experience with the disease, so showcasing the experience of HepE cases - perhaps in part using social media to convey anectodes - could be valuable.
• An overreliance on statistics (related to effectiveness, for example) may not be persuasive, so imparting individuals with a memorable idea (a "gist") and using emotions could have long-term impacts on vaccine decision-making.