Addressing Vaccine Hesitancy: The Potential Value of Commercial and Social Marketing Principles and Practices

"While the use of commercial and social marketing practices and principles does not guarantee success, the evidence, lessons learned, and applications to date indicate that they have considerable value in fostering vaccine acceptance."

This review examines how social and commercial marketing principles and practices can be used to help address vaccine hesitancy. It provides an introduction to key marketing and social marketing concepts, identifies some of the major challenges to applying commercial and social marketing approaches to immunisation programmes, illustrates how immunisation advocates and programmes can use marketing and social marketing approaches to address vaccine hesitancy, and identifies some of the lessons that commercial and non-immunisation sectors have learned that may have relevance for immunisation.

The authors explain that social marketing takes commercial marketing principles (e.g., the notion that products and services are most likely to be successful - i.e., purchased or taken up - if they are focused on identifying, addressing, and satisfying the needs of current and potential customers) and applies them to influence behaviours that are intended to benefit the individual and society. The four "P's" - Product, Price, Place, and Promotion - are used to create, communicate, and deliver value to intended populations, with each category including elements that can be changed or varied in order to make an offering, service, idea, recommendation, or the adoption of a behaviour more attractive and appealing.

In the context of vaccination: (i) The specific vaccines, the recommended immunisation schedule, or the act of getting vaccinated are characterised as the "Product". (ii) The financial costs, the convenience and ease of access to the vaccine or immunisation services, and perceptions of safety and efficacy and value to individuals and the community are in the "Price" category. (iii) Where the vaccine is obtained or administered (e.g. doctors’ offices, clinics, retail outlets) in the "Place" category. (iv) Messages, communication materials (e.g., posters, brochures, websites, public service advertisements), news media outreach and stories, spokespersons, and interpersonal communication (e.g., provider-parent communication) fall in the "Promotion" category.

As applied to vaccine hesitancy, social marketing prompts immunisation programme planners to ask questions like: What is the "brand", and how is it perceived? What are the immunisation programme product's attributes and benefits as seen through the eyes of the individuals for whom vaccination is recommended or of the parents for whose children vaccination is recommended? Social marketing also "seeks/encourages an enhanced understanding of how different subgroups in the targeted population are likely to be persuaded given that hesitancy varies and is not uniform across the population, and the factors influencing hesitation are not the same across the subgroups....Applying social marketing to immunization makes a very clear distinction between hesitancy toward new vaccine introduction and hesitancy regarding older vaccines such as the measles–mumps–rubella (MMR) vaccine." Finally, the authors note that social marketing not only helps immunisation programmes identify and understand the physical, social, and economic environmental factors that play a major role in determining vaccine acceptance but also calls attention to the need to examine immunisation convenience - e.g., by encouraging consideration of alternative methods and outlets to reach intended populations, according to their profiles.

That said, the authors explain that there are challenges in application of marketing and social marketing to immunisation, as documented by the Working Group on Vaccine Hesitancy - cited in this paper. "In addition, because public health vaccination programs are about health rather than profit, there are ethical issues such as beneficence and justice that need to be considered. Further, while commercial sector firms face competition from other product or service offerings, vaccination programs struggle with anti-vaccine movements, political groups that oppose or ban vaccination, and social/cultural norms within certain communities. If lack of trust underlies vaccine hesitancy, the source or issue may or may not be vaccine-related - often, distrust in vaccines may reflect or emanate from a broader distrust of health providers, the health system or the government and/or politics."

The paper then provides field examples. For instance, "Immunize Australia" was a public health social marketing campaign undertaken in 1997 by the Australian government that involved: conducting formative (communication) research with parents; using the research to identify different parent groups or segments (i.e., as the basis for a segmentation strategy); grounding the communication strategy in both the research and a theoretical framework (in this case, the Health Belief Model); and designing activities for immunisation service providers (e.g., over 60,000 providers received an "Australian Immunization Handbook", and new communication channels were opened to keep providers updated) to increase and reinforce their knowledge levels of, and support for, immunisation. Organisers also launched a community/parent education campaign that included: television and magazine advertisements; posters in clinics, hospitals, and doctors' offices; and a series of Immunization Awareness Days.

Several vaccine-specific social marketing examples are also provided. For instance, as part of the Global Polio Eradication Initiative (GPEI), the United Nations Children's Fund (UNICEF) and other organisations worked in partnership with the Government of Pakistan, using social marketing principles to develop programmes that specifically address the needs and concerns of those living in the Federally Administered Tribal Areas where polio transmission has been persistent. "Similarly, Hajjeh in 2011, in describing factors that facilitated the introduction of Haemophilus influenzae type b (Hib) vaccine as part of the Gavi Hib Initiative, noted that a number of marketing and communication principles were associated with higher and better acceptance....These included communication strategies that ensured decision-makers and other stakeholders had timely access to Hib disease information that was relevant and understandable; extensive communication and advocacy efforts that increased health-care provider and public awareness about the public health importance of Hib disease and Hib vaccine; extensive engagement with health-care providers to inform the development of Hib messaging; and framing of the Hib vaccine as an important tool for overall pneumonia prevention."

The next section of the report shares insights gleaned from commercial and non-immunisation communication efforts. Research is shared on marketing and social marketing frameworks and principles that have been used to guide public health campaigns and efforts on a variety of health issues, including tobacco cessation and prevention, reproductive health, physical activity, HIV/AIDS prevention, nutrition, and family planning. For example, in looking at trends in the practice of health communication campaigns, Noar and Heard (researchers cited in the report) noted that "the most effective campaigns are those where behavioral determinants are well understood, where social media and interpersonal communication are part of the strategy, and where members of targeted subpopulations are highly exposed to the messages and materials, including because of factors such as visibility, repetition, and long-term exposure."

In terms of reaching children directly, the authors suggest, amongst other things, that: "Ensuring education and knowledge dissemination about vaccines among children, adolescents and young adults - including through school-based programs - may be a good opportunity to foster parental acceptance as well as shape the future vaccine acceptance behavior of parents and other adults....The high levels of social media use among children means it is also possible to reach and influence children outside of schools. Peer-group provision or sharing of information is both common and influential, and finding ways to use those channels to educate young people about vaccine preventable diseases and the importance of vaccines, may provide additional opportunities to shape future vaccine beliefs and behaviors."

An excerpt from the concluding section of the report follows: "The following considerations need to be taken into account:

1. ...Efforts must be made to learn how members of targeted populations perceive vaccines and vaccination recommendations, and what factors could potentially facilitate acceptance. As the examples described here illustrate, it is also likely the case that efforts will need to encompass developing, disseminating, and providing training to health-care workers.
2. In using marketing and social marketing practices and principles, immunization programs and advocates need to be aware that the word 'marketing' can be problematic as a label...
3. It is probable that some groups or individuals, such as those adamantly opposed to vaccines and vaccinations, are unlikely to be persuaded or to change their beliefs even if marketing and social marketing practices are used as a foundation...
4. It is likely that one of the potential sources or causes of hesitancy - the 'product' (i.e. a specific vaccine or the immunization schedule) - represents a relatively inflexible category when it comes to developing a marketing strategy..."