Social norms, vaccine confidence, and interpersonal communication as predictors of vaccination intentions: Findings from slum areas in Varanasi, India.

In recent years, India has seen significant improvements in childhood immunization, but rates among the urban poor remain stagnant. Disruptions during COVID-19 pandemic have created further challenges. This paper focuses on how social norms, vaccine confidence, and interpersonal communication independently and jointly affect vaccine intentions among caregivers of infants living in six slum areas in Varanasi, India. Data for this study come from the baseline assessments conducted before implementing the Happy Baby Program, an intervention to improve vaccination attitudes and intentions. In-person interviews (N = 2,058) were conducted with caretakers of children up to two years old. Analyses showed that interpersonal communication about vaccines, descriptive norms, injunctive norms, and vaccine confidence were each associated with intentions to vaccinate in both a bivariate and, except for injunctive norms, a multivariate model. In addition, we found significant interactions among these variables, suggesting that the roles of interpersonal communication and vaccine confidence attenuated the relationship between social norms and vaccination intention. Overall, our model explained 46.2 % of the variance in vaccine intention. Given the strengths of the relationships observed in this study, intervention strategies should focus on enhancing social norms and vaccine confidence to promote vaccination.

Assessing message deployment during public health emergencies through social media: An empirical test of optimizing content for effective dissemination.

BACKGROUND: During an infodemic, the need for timely, reliable, and accessible information is crucial to combat the proliferation of health misinformation. Message testing can provide vital information to make data-informed decisions, but traditional methods tend to be time and resource intensive. Recognizing this need, we developed the Rapid Message Testing at Scale (RMTS) approach to allow communicators to repurpose existing social media advertising tools and understand the full spectrum of audience engagement. OBJECTIVE: We had two main objectives: a) to demonstrate the use of the RMTS approach for message testing, especially when resources are limited and there is a need to act in a timely manner, and (b) to propose and test the efficacy of an outcome variable that measures engagement along a continuum of viewing experience. METHODS: We developed 12 versions of a single video that was created for a vaccine confidence project in India. We manipulated video length, aspect ratio, and use of subtitles. The videos were tested across four demographic groups (women/men, younger/older). We assessed user engagement along a continuum of viewing experience: getting attention, sustaining attention, conveying the message, and inspiring action. These were measured by percentage of video watched and clicks on the call-to-action link. RESULTS: The video ads were placed on Facebook over four consecutive days at the cost of $450 (U.S.) and garnered a total of 3.34 million impressions. Overall, we found that the best performing video was the shorter version presented in portrait aspect ratio and without subtitles. There was a significant but small association between the length of the video and users' level of engagement at key points along the continuum of viewing experience (N=1,032,888; 〖χ^2〗_4=48,261.97; P<.001; V=.22). We found that for the longer video, those with subtitles held viewers longer after 25% video watch time than those without subtitles (n=15,597; 〖χ^2〗_1=7.33; P<.01; V=.02). While we found some significant associations between the aspect ratio, the use of subtitles, and the number of users watching the video and clicking on the call-to-action link, the effect size for those were extremely small. CONCLUSIONS: This test served as a proof of concept for the RMTS approach. We obtained rapid feedback on formal message attributes from a very large sample in a very short timeframe. The results of this test reinforce the need for platform-specific tailoring of communications. While our data showed a general preference for the short video in portrait orientation and without subtitles among our target audiences on Facebook, that may not necessarily be the case in other social media platforms such as YouTube or TikTok, where users go primarily to watch videos. RMTS testing highlights nuances that communication professionals can address instead of being limited to a 'one size fits all' approach.

Correction: Twitter and Facebook posts about COVID-19 are less likely to spread misinformation compared to other health topics.

[This corrects the article DOI: 10.1371/journal.pone.0261768.].

The Be REAL Framework: Enhancing Relationship-Building Skills for Community Health Workers.

Trust plays an integral part in the effective functioning of public health systems. During the COVID-19 pandemic, distrust of public health fueled vaccine hesitancy and created additional barriers to immunization. Although most Americans have received at least one COVID-19 vaccine, the percentage of fully immunized adults remains suboptimal. To reach vaccine-hesitant communities, it is vital that public health be worthy of trust. As trusted members of their communities, community health workers (CHWs) can serve as ideal messengers and conversation partners for vaccination decision-making. We developed the Be REAL framework and training materials to prepare CHWs to work with vaccine-hesitant communities nationwide. Through the four steps of "Relate," "Explore," "Assist," and "Leave (the door open)," CHWs were taught to prioritize relationship building as a primary goal. In this shift from focusing on adherence to public health recommendations (e.g., get vaccinated) to building relationships, the value of vaccine uptake is secondary to the quality of the relationship being formed. The Be REAL framework facilitates CHWs harnessing the power they already possess. The goal of the Be REAL framework is to foster true partnership between CHWs and community members, which in turn can help increase trust in the broader public health system beyond adherence to a specific recommendation.

Corrigendum: LetsTalkShots: personalized vaccine risk communication.

[This corrects the article DOI: 10.3389/fpubh.2023.1195751.].

Evaluation of online videos to engage viewers and support decision-making for COVID-19 vaccination: how narratives and race/ethnicity enhance viewer experiences.

Background: Vaccine hesitancy has hampered the control of COVID-19 and other vaccine-preventable diseases. Methods: We conducted a national internet-based, quasi-experimental study to evaluate COVID-19 vaccine informational videos. Participants received an informational animated video paired with the randomized assignment of (1) a credible source (differing race/ethnicity) and (2) sequencing of a personal narrative before or after the video addressing their primary vaccine concern. We examined viewing time and asked video evaluation questions to those who viewed the full video. Results: Among 14,235 participants, 2,422 (17.0%) viewed the full video. Those who viewed a personal story first (concern video second) were 10 times more likely to view the full video (p < 0.01). Respondent-provider race/ethnicity congruence was associated with increased odds of viewing the full video (aOR: 1.89, p < 0.01). Most viewers rated the informational video(s) to be helpful, easy to understand, trustworthy, and likely to impact others' vaccine decisions, with differences by demographics and also vaccine intentions and concerns. Conclusion: Using peer-delivered, personal narrative, and/or racially congruent credible sources to introduce and deliver vaccine safety information may improve the openness of vaccine message recipients to messages and engagement.

The efficacy of Facebook's vaccine misinformation policies and architecture during the COVID-19 pandemic.

Online misinformation promotes distrust in science, undermines public health, and may drive civil unrest. During the coronavirus disease 2019 pandemic, Facebook-the world's largest social media company-began to remove vaccine misinformation as a matter of policy. We evaluated the efficacy of these policies using a comparative interrupted time-series design. We found that Facebook removed some antivaccine content, but we did not observe decreases in overall engagement with antivaccine content. Provaccine content was also removed, and antivaccine content became more misinformative, more politically polarized, and more likely to be seen in users' newsfeeds. We explain these findings as a consequence of Facebook's system architecture, which provides substantial flexibility to motivated users who wish to disseminate misinformation through multiple channels. Facebook's architecture may therefore afford antivaccine content producers several means to circumvent the intent of misinformation removal policies.

Fighting the infodemic: the 4 i Framework for Advancing Communication and Trust.

BACKGROUND: The proliferation of false and misleading health claims poses a major threat to public health. This ongoing "infodemic" has prompted numerous organizations to develop tools and approaches to manage the spread of falsehoods and communicate more effectively in an environment of mistrust and misleading information. However, these tools and approaches have not been systematically characterized, limiting their utility. This analysis provides a characterization of the current ecosystem of infodemic management strategies, allowing public health practitioners, communicators, researchers, and policy makers to gain an understanding of the tools at their disposal. METHODS: A multi-pronged search strategy was used to identify tools and approaches for combatting health-related misinformation and disinformation. The search strategy included a scoping review of academic literature; a review of gray literature from organizations involved in public health communications and misinformation/disinformation management; and a review of policies and infodemic management approaches from all U.S. state health departments and select local health departments. A team of annotators labelled the main feature(s) of each tool or approach using an iteratively developed list of tags. RESULTS: We identified over 350 infodemic management tools and approaches. We introduce the 4 i Framework for Advancing Communication and Trust (4 i FACT), a modified social-ecological model, to characterize different levels of infodemic intervention: informational, individual, interpersonal, and institutional. Information-level strategies included those designed to amplify factual information, fill information voids, debunk false information, track circulating information, and verify, detect, or rate the credibility of information. Individual-level strategies included those designed to enhance information literacy and prebunking/inoculation tools. Strategies at the interpersonal/community level included resources for public health communicators and community engagement approaches. Institutional and structural approaches included resources for journalists and fact checkers, tools for managing academic/scientific literature, resources for infodemic researchers/research, resources for infodemic managers, social media regulation, and policy/legislation. CONCLUSIONS: The 4 i FACT provides a useful way to characterize the current ecosystem of infodemic management strategies. Recognizing the complex and multifaceted nature of the ongoing infodemic, efforts should be taken to utilize and integrate strategies across all four levels of the modified social-ecological model.

Social network analysis of COVID-19 vaccine YouTube videos in Odisha, India: mapping the channel network and analyzing comment sentiment.

India has reported more than 35 million confirmed cases of COVID-19 and nearly half a million cumulative deaths. Although vaccination rates for the first vaccine dose are quite high, one-third of the population has not received a second shot. Due to its widespread use and popularity, social media can play a vital role in enhancing vaccine acceptance. This study in a real-world setting utilizes YouTube videos in Odisha, India where the platform has deep penetration among the 18-35 target population, and secondarily their family and peers. Two contrasting videos were launched on the YouTube platform to examine how those videos operate within the broader recommender and subscription systems that determine the audience reach. Video analytics, algorithms for recommended videos, visual representation of connections created, centrality between the networks, and comment analysis was conducted. The results indicate that the video with a non-humorous tone and collectivistic appeal delivered by a female protagonist performed best with regard to views and time spent watching the videos. The results are of significance to health communicators who seek to better understand the platform mechanisms that determine the spread of videos and measures of viewer reactions based on viewer sentiment.

LetsTalkShots: personalized vaccine risk communication.

Introduction: Vaccine hesitancy is a global health threat undermining control of many vaccine-preventable diseases. Patient-level education has largely been ineffective in reducing vaccine concerns and increasing vaccine uptake. We built and evaluated a personalized vaccine risk communication website called LetsTalkShots in English, Spanish and French (Canadian) for vaccines across the lifespan. LetsTalkShots tailors lived experiences, credible sources and informational animations to disseminate the right message from the right messenger to the right person, applying a broad range of behavioral theories. Methods: We used mixed-methods research to test our animation and some aspects of credible sources and personal narratives. We conducted 67 discussion groups (n = 325 persons), stratified by race/ethnicity (African American, Hispanic, and White people) and population (e.g., parents, pregnant women, adolescents, younger adults, and older adults). Using a large Ipsos survey among English-speaking respondents (n = 2,272), we tested animations aligned with vaccine concerns and specific to population (e.g., parents of children, parents of adolescents, younger adults, older adults). Results: Discussion groups provided robust feedback specific to each animation as well as areas for improvements across animations. Most respondents indicated that the information presented was interesting (85.5%), clear (96.0%), helpful (87.0%), and trustworthy (82.2%). Discussion: Tailored vaccine risk communication can assist decision makers as they consider vaccination for themselves, their families, and their communities. LetsTalkShots presents a model for personalized communication in other areas of medicine and public health.

Production of vaccination videos in India: learnings from a science-art partnership.

BACKGROUND: Cross-cultural communication, often conceptualized along culture and language dimensions, is an important issue for collaborative teams that include both scientists and artists. Such teams must balance the standardization needs of rigorous scientific methods, on the one hand, with openness for artistic creativity, on the other. The scientific literature does not provide clear guidance on how to structure such collaborations. DISCUSSION: We created eight videos manipulating the type of appeal, message tone, and gender of the vaccine promoter in a 2 × 2 × 2 between-subjects experiment. The four stages of the filmmaking process were 1) conceptualizing filmmaking and script writing through a scientific lens, 2) pilot testing and finalizing the script, 3) video production and editing, and 4) dissemination. We describe the process and learnings from a collaboration that included filmmakers, researchers, and vaccine experts from India and the United States in producing, disseminating, and evaluating videos that promoted vaccine uptake in Odisha, India. CONCLUSIONS: When projects require close collaborations between scientists and artists, committing to a unified vision is essential for facilitating open, bidirectional communication and building trust between the partners. Clearly denoting research boundaries ensures that the scientific needs of the project are met while simultaneously welcoming space for the filmmakers' creativity, fostering a sense of ownership, and enhancing the final product.

Trusted information sources in the early months of the COVID-19 pandemic predict vaccination uptake over one year later.

INTRODUCTION: COVID-19 vaccine uptake has been a major barrier to stopping the pandemic in many countries with vaccine access. This longitudinal study examined the capability to predict vaccine uptake from data collected early in the pandemic before vaccines were available. METHODS: 493 US respondents completed online surveys both at baseline (March 2020) and wave 6 (June 2021), while 390 respondents completed baseline and wave 7 (November 2021) surveys. The baseline survey assessed trust in sources of COVID-19 information, social norms, perceived risk of COVID-19, skepticism about the pandemic, prevention behaviors, and conspiracy beliefs. Multivariable logistic models examined factors associated with the receipt of at least one COVID-19 vaccine dose at the two follow-ups. RESULTS: In the adjusted model of vaccination uptake at wave 6, older age (aOR = 1.02, 95 %CI = 1.00-1.04) and greater income (aOR = 1.69, 95 %CI = 1.04-2.73) was associated with positive vaccination status. High trust in state health departments and mainstream news outlets at baseline were positively associated with vaccination at wave 6, while high trust in the Whitehouse (aOR = 0.42, 95 %CI = 0.24-0.74) and belief that China purposely spread the virus (aOR = 0.66, 95 %CI = 0.46-0.96) at baseline reduced the odds of vaccination. In the adjusted model of vaccination uptake at wave 7, increased age was associated with positive vaccination status, and Black race (compared to white) was associated with negative vaccination status. High trust in the CDC and mainstream news outlets at baseline were both associated with being vaccinated at wave 7, while high trust in the Whitehouse (aOR = 0.24, 95 %CI = 0.11-0.51) and belief that the virus was spread purposefully by China (aOR = 0.60, 95 %CI = 0.39-0.93) were negatively associated with vaccination. CONCLUSIONS: These findings indicated that vaccine uptake could be predicted over a year earlier. Trust in specific sources of COVID-19 information were strong predictors, suggesting that future pandemic preparedness plans should include forums for news media, public health officials, and diverse political leaders to meet and develop coherent plans to communicate to the public early in a pandemic so that antivaccine attitudes do not flourish and become reinforced.

Creation, dissemination, and evaluation of videos to promote COVID-19 vaccination in India: A research protocol.

Background: Vaccine hesitancy is one of the greatest challenges to the success of coronavirus disease 2019 (COVID-19) vaccination campaigns. Videos promoting vaccines have a narrow scope focusing solely on facts, and less on the emotional and narrative elements of communication that can be equally persuasive. The role of humor, for example, has remained largely unexplored.   Objective: This study investigates whether theory-based videos can change people's attitudes, beliefs, and intentions to receive the second COVID-19 vaccine. Our primary research question is: How do collectivistic and individualistic appeals, humor, and protagonist gender individually and jointly affect vaccination attitudes, beliefs, and intentions?   Methods: This project tapped into the underutilized Indian film industry-the world's largest film producer-to promote vaccination messaging through short videos. Feedback from a community advisory board was utilized to inform the video scripts that were then shot by a production team. Eight videos were filmed and shared by adopting a 2 (appeal: individualistic or collectivistic) x 2 (tone: humor or non-humor) x 2 (protagonist gender: male or female) between-subjects design approach. Our sample includes Odia-speaking participants aged between 18 - 35 years old randomly assigned to watch one of the eight study videos. An online survey questionnaire, social media network analysis, and small group qualitative interviews will be utilized to explore how the entertainment-education videos can be used to reduce vaccine hesitancy.  Discussion: Vaccine messages do not fall into a cultural or cognitive vacuum. People process and make sense of information based on their prior experience, properties of the message, and their social environment. Yet, these considerations have taken secondary importance in vaccine communications. This research shows that it is possible to deliver high-caliber videos created in accordance with the audience's cultural and cognitive background.   Conclusions: This study will inform future health promotion messaging through brief videos on the internet.

Promoting Vaccination in India through Videos: The Role of Humor, Collectivistic Appeal and Gender.

Vaccination hesitancy is a barrier to India's efforts to control the COVID-19 pandemic. Considerable resources have been spent to promote COVID-19 vaccination, but evaluations of such efforts are sparse. Our objective was to determine how vaccine videos that manipulate message appeal (collectivistic versus individualistic), tone (humorous versus serious), and source (male versus female protagonist) toward vaccines and vaccination. We developed eight videos that manipulated the type of appeal (collectivistic or individualistic), tone of the message (humor or serious), and gender of the vaccine promoter (male or female) in a 2 × 2 × 2 between-subjects experiment. Participants (N = 2349) were randomly assigned to watch one of eight videos in an online experiment. Beliefs about vaccines and those about vaccination were obtained before and after viewing the video. Manipulation checks demonstrated that each of the three independent variables was manipulated successfully. After exposure to the video, beliefs about vaccines became more negative, while beliefs about vaccination became more positive. Humor reduced negative beliefs about vaccines. Collectivism and protagonist gender did not affect beliefs about vaccines or vaccination. Those able to remember the protagonist's gender (a measure of attention) were likely to develop favorable beliefs if they had also seen the humorous videos. These findings suggest that people distinguish beliefs about vaccines, which deteriorated after exposure to the videos, from beliefs about vaccination, which improved. We recommend using humor when appropriate and focusing on the outcomes of vaccination, rather than on the vaccines themselves.

Twitter and Facebook posts about COVID-19 are less likely to spread misinformation compared to other health topics.

The COVID-19 pandemic brought widespread attention to an "infodemic" of potential health misinformation. This claim has not been assessed based on evidence. We evaluated if health misinformation became more common during the pandemic. We gathered about 325 million posts sharing URLs from Twitter and Facebook during the beginning of the pandemic (March 8-May 1, 2020) compared to the same period in 2019. We relied on source credibility as an accepted proxy for misinformation across this database. Human annotators also coded a subsample of 3000 posts with URLs for misinformation. Posts about COVID-19 were 0.37 times as likely to link to "not credible" sources and 1.13 times more likely to link to "more credible" sources than prior to the pandemic. Posts linking to "not credible" sources were 3.67 times more likely to include misinformation compared to posts from "more credible" sources. Thus, during the earliest stages of the pandemic, when claims of an infodemic emerged, social media contained proportionally less misinformation than expected based on the prior year. Our results suggest that widespread health misinformation is not unique to COVID-19. Rather, it is a systemic feature of online health communication that can adversely impact public health behaviors and must therefore be addressed.

Use of a Qualitative Story Deck to Create Scenarios and Uncover Factors Associated with African American Participation in Genomics Research.

To gain a complex understanding of willingness to participate in genomics research among African Americans, we developed a technique specifically suited to studying decision making in a relaxed social setting. The "Qualitative Story Deck," (QSD) is a gamified, structured elicitation technique that allows for the spontaneous creation of scenarios with variable attributes. We used the QSD to create research scenarios that varied on four details (race/ethnicity of the researcher; research goal; biospecimen requested; and institutional affiliation). Participants created scenarios by randomly choosing cards from these categories and provided: (1) a judgement about their willingness to participate in the research project represented; and (2) their thought process in reaching a decision. The QSD has applicability to topics involving decision making or in cases where it would be beneficial to provide vignettes with alternate attributes. Additional benefits include: rapid establishment of rapport and engagement and the facilitation of discussion of little known or sensitive topics.

Willingness of Black and White Adults to Accept Vaccines in Development: An Exploratory Study Using National Survey Data.

PURPOSE: Explore acceptability of vaccines in development: cancer, Type II diabetes, Alzheimer's disease, Lyme disease, Ebola, and obesity. Research questions: To what extent does acceptability vary by vaccine type? To what extent does acceptability of vaccines in development vary by race and other key demographics? To what extent are general vaccine hesitancy and key demographics associated with acceptability of vaccines in development? DESIGN: Cross-sectional online survey administered through GfK's KnowledgePanel in 2015. Analysis completed in 2020. SUBJECTS: Nationally representative sample of Black and White American adults (n = 1,643). MEASURES: Willingness to accept a novel vaccine was measured on a 4-point Likert scale. Independent variables included demographics (e.g. age, race, gender) and measures of vaccine hesitancy, trust, and the "Three C's" of vaccine confidence, complacency, and convenience. ANALYSIS: Exploratory analysis including descriptive statistics and regression modeling. RESULTS: Acceptability varied from 77% for a cancer vaccine to 55% for an obesity vaccine. White race, male gender, older age, having a chronic health condition, and higher socioeconomic status were associated with higher acceptability. Higher vaccine confidence and lower vaccine hesitancy were predictors for acceptability. CONCLUSION: The success of a vaccine depends on widespread public acceptance. Vaccine hesitancy may hinder acceptance of future vaccines, with significant differences by demographics. Future social science research is necessary to better understand and address vaccine hesitancy.

Facebook Pages, the "Disneyland" Measles Outbreak, and Promotion of Vaccine Refusal as a Civil Right, 2009-2019.

Objectives. To understand changes in how Facebook pages frame vaccine opposition.Methods. We categorized 204 Facebook pages expressing vaccine opposition, extracting public posts through November 20, 2019. We analyzed posts from October 2009 through October 2019 to examine if pages' content was coalescing.Results. Activity in pages promoting vaccine choice as a civil liberty increased in January 2015, April 2016, and January 2019 (t[76] = 11.33 [P < .001]; t[46] = 7.88 [P < .001]; and t[41] = 17.27 [P < .001], respectively). The 2019 increase was strongest in pages mentioning US states (t[41] = 19.06; P < .001). Discussion about vaccine safety decreased (rs[119] = -0.61; P < .001) while discussion about civil liberties increased (rs[119] = 0.33; Py < .001]). Page categories increasingly resembled one another (civil liberties: rs[119] = -0.50 [P < .001]; alternative medicine: rs[84] = -0.77 [P < .001]; conspiracy theories: rs[119] = -0.46 [P < .001]; morality: rs[106] = -0.65 [P < .001]; safety and efficacy: rs[119] = -0.46 [P < .001]).Conclusions. The "Disneyland" measles outbreak drew vaccine opposition into the political mainstream, followed by promotional campaigns conducted in pages framing vaccine refusal as a civil right. Political mobilization in state-focused pages followed in 2019.Public Health Implications. Policymakers should expect increasing attempts to alter state legislation associated with vaccine exemptions, potentially accompanied by fiercer lobbying from specific celebrities.