Vaccine Hesitancy and Administrative Burden in the Australian National Immunisation Program: An Analysis of Twitter Discourse

"Positive aspects of public vaccination programs, messaged by public health professionals, may not successfully enter into the discourse on vaccinations."

In Australia, the requirement of vaccination in order to receive public services aligns government and medical interests, but a less-than-trusting public may see conspiracy in such requirements. Misinformation spread on social media can deepen the public's apprehension of costs and exacerbate vaccine hesitancy. This paper uses Twitter posts as a corpus to explore the administrative burden of vaccinations, with costs in compliance, learning, and psychological elements, in a complex policy environment, with the hope of understanding how communicators can respond when public health benefits are weighed against individual freedom.

The paper begins with a review of literature on the concept of administrative burden, which refers to government requirements, such as vaccine mandates, that people experience as onerous. Despite the many benefits vaccinations confer, the imposition of a vaccination programme involves expenditure of resources, such as a need to access information about vaccinations, and may be perceived or experienced as a burden. In addition to the cost of compliance, compelling citizens to do something can have psychological implications. Such requirements can pose significant hardships to lower-income populations other those otherwise disadvantaged, for example. Failure to engage with citizens around these burdens can have dire effects. "[E]ven when compliance with a rule makes sense for the public as a whole, inattention to the experience of individual citizens can be perceived as hurtful or worse, a violation of fundamental rights and personal autonomy. Perception is a key point - what is seen as red tape is a movable target, depending on one's perspective..."

As outlined here, vaccine mandates reduce the need for the government to act in the role of educator who would engage in serious discussion of burdens and hesitancy in ways that can be understood by diverse stakeholders of varying capacity. Further, coercive strategies "may not allow for the compassion, respect, and information sharing needed to make a difference for parents, reducing barriers and the potential that they will avoid or refuse vaccines....This can limit effectiveness of communication, increasing the potential for hesitancy behaviour....When discussion of burden of a program - vaccination or otherwise - is avoided, this might further undermine public trust and confidence."

In such a context, people wondering about vaccination often turn to the internet, which represents a source of both knowledge and misinformation. "It has been shown that it is worthwhile for officials to respond to misinformation, but the crafting of messages to counterbalance the misinformation must be appropriate to the platform and its users. The original misinformation message often has much more traction and readership than any subsequent response, even if the official answer corrects the record."

The paper continues with an overview of the Australian National Immunisation Program (NIP), which was established in 1997 in response to insufficient vaccination rates of children. Nationwide campaigns were undertaken, including television advertising efforts and registering children with a central database. There was concern at the time that the marketing effort may have created concern among parents about the state's efforts around vaccination. There was also discussion, in the 1990s experience in Australia, of a variety of barriers to vaccination compliance, such as trouble remembering whether children had been vaccinated, lack of awareness about vaccination schedules, belief that the diseases immunisation was meant to prevent were not too serious, and concern about side effects.

Searches conducted by the researchers to understand communication around the NIP on Twitter yielded 5,599 subject tweets from 2015 to 2019. Sentiment analysis showed that the corpus is skewed with a negative sentiment for the topics searched (2,390 very or moderately negative, about 64%, compared with 1,352 moderately or very positive, or 36%, out of a total of 3,742 separately coded sentences). Fifty-nine tweets received more than 100 retweets each. These tweets included: risk comparisons (e.g., to mass shootings); examples of dread illness (e.g., whooping cough); reports of measles outbreaks and how individuals were unvaccinated; and tweets imploring vaccination ("vaccinate your kids so babies don't die of whooping cough" in light of the "no jab no play" rule). "From the perspective of administrative burden experienced as learning, there were some tweets that sought to share information and dispel myths and misinformation, but these were not as widely retweeted and shared.

The researchers also found that Australia's 2017 flu epidemic "provided an inflection point in discussion about immunisation and vaccines. As a focusing event, the epidemic may have changed some minds among the population, and created a more welcoming environment, at least as expressed in the narrow window of online social media, for vaccine uptake."At this time, "official messages appear to have gained some traction, so users of the network may have seen these tweets."

Notably: "When information is not shared via relatable and entertaining formats like Twitter, the additional burden of finding information, and even knowing what questions to ask, becomes more apparent. What ends up being shared speaks to a problem (among others) of social networking in the public space."

In reflecting on the findings, the researchers observe, in part, that "the thoughts that tend to stick about vaccination programs are those that have emotional weight. Appeals to belief stick, as do emotional stories. Misinformation is insidious and resists rectification; responses from official sources that fail to engage individuals positively and proactively as autonomous in their health decisions..., may simply encourage individuals to remain mired in their views, biased against fact and science. There is support in the literature for engaging the feelings and thoughts of individuals to encourage vaccination acceptance... - shaping behaviour rather than relying on coercion and punishment."

The researchers stress that "the burdens of policy, and notably immunisation program policy, should be top of mind for policymakers, who seek to engage science to provide greatest benefit for the public. While those that spread misinformation are doing a disservice to the public, government agencies that fail to acknowledge and respond to questions from the public are doing themselves no great favour....On the side of institution-led vaccination efforts, imposition of coercive means to force compliance has a negative aspect, in that it might undermine the very goal government seeks in ensuring public health. Coercion results in the creation and maintenance of an implicit viewpoint, unfair or not, that the science is not good enough to stand on its own, that the public is too ignorant to understand, and that rights and freedoms are under attack by institutions in place ostensibly to help protect the public."

In conclusion: "[S]imply recommending that information be provided to parents ignores an important aspect of the discussion - namely that the distrust in public institutions has already been ingrained, leading to the prospect that certain segments of the public may go to grey sources of information for matters of public importance, rejecting government perspectives based upon science. When the government itself embraces an anti-science perspective, it becomes even more difficult for the public to simply trust and abide by what they are being told. Adding coercion to the mix may press individuals beyond their willingness to accept the burden, yielding vocal dissent, if not open conflict....When societal norms and ethical commitments are compromised, trust can be difficult, if not impossible, to regain."