The political polarization of the country has framed “anti-vaxxers” as a left versus right, rural versus urban, educated versus uneducated debate. The truth is far more complicated and has larger implications for human health.

As the mRNA vaccines rolled out to the public in the US in 2021, portions of the US population resisted receiving them. While the polarized climate led to a blanker term for this group, “anti-vaxxer,” the condensing of so many people into one category naturally wall-papered over many, many cracks and differences in their reasoning.

How stakeholders effectively communicate information to and about “anti-vaxxers” rests upon a more complex understanding of the underlying subsegments of those populations. And this task has taken on more urgency. Looking at the biopharma pipeline, we’ll soon have mRNA-based immunotherapies that can provide prophylaxis against several cancers, including pancreatic cancer.

In established suite of infant vaccines – including MMR, DTaP, Hib, HepB, IPV, or RV – the US has an increasing number of parents opting to seek alternatives to public schooling due to vaccine requirements. Others send unvaccinated children to daycares where outbreaks of preventable illness occur. Some children, especially those with immunocompromised children, have become seriously ill as a result.

Although there are approximately 24 segments organizations that I have worked with have identified, here are a major five that broadly encompass the themes that breakdown within them vertically:

Complacency: Some people consider the risk of disease so low that vaccination seems unnecessary. This mindset becomes more common in areas where the incidence of vaccine-preventable diseases is low, often due to previous successful vaccination efforts. For example, Western Europe and the United States have more issues with MMR vaccination than sub-Saharan Africa. In areas with vaccine-preventable outbreaks, vaccination tends to go up as a result. Reading this backward, the urgency to vaccinate against disease wanes leading to minor outbreaks that can have longer-term health implications for the

Convenience: Accessibility significantly influences vaccine uptake. This transects the urban/rural divide, race, language, and gender. In areas where healthcare facilities are scarce or distant, or where vaccination incurs a high cost or significant time commitment, people are more likely to skip vaccinations. In rural or impoverished areas, lengthy travel to a clinic or the inability to take time off work can be major barriers to receiving a vaccine. And perhaps against normal thinking, white collar workers with long hours and inner-city communities with a lack of access have eerily similar uptake rates. Communication here must emphasize benefits while also preceding action to improve access to maximize uptake.

Calculation: For some, deciding whether to vaccinate involves a complex assessment of risks and benefits. Those who hesitate often do so after heavily weighing the potential risks over the proven benefits. This might include parents who fear potential side effects more than the risk of the actual disease. We see a slower uptake in HPV vaccines among teen boys than teen girls, largely related to side effect and personal cancer risk, and in some European countries, those under 30 without underlying conditions did not vaccinate against COVID 19 over the relatively higher risk of myocarditis. This decision was later reinforced by some governments, especially among several Scandinavian national health services.

Compliance: Skepticism towards medical guidelines and governmental mandates can also foster vaccine hesitancy. This form of hesitancy is particularly prevalent among individuals who prioritize personal autonomy and may view vaccine mandates as an infringement on their personal freedoms. This point of view became prominent during the COVID pandemic, but it’s been attached to political battles over the last 150 years. In the 1910s and 1940s, Americans fought torrid battles over the extent to which the draft could control/mandate the health of drafted soldiers. Anti-vaccination leagues became attached to municipal elections in New York, Chicago, and San Francisco in the 1870s and 1880s and echoes a much longer discussion on the once-common belief that the right to make decisions about one’s health was an inherent right. Communicating with this group must emphasize their decision to vaccinate and their right to protect themselves. Additional pressure breeds more resistance and resentment.

Confidence: Trust, or the lack thereof, plays a crucial role in vaccine hesitancy. Some individuals might question the safety and effectiveness of vaccines due to skepticism about the healthcare system or the motives of pharmaceutical companies. This lack of trust can be broken down into two contexts: historical and misinformation. In one vein, black and Spanish-speaking communities have been on the receiving end of medical experimentation, coercion, and, more often lacking health insurance,

 The other form of distrust is often fueled by misinformation, such as false claims spread on social media that vaccines cause unrelated health conditions. Some misinformation manifests as a political priority, such as the myth that COVID mRNA vaccines contained poisons, fetal cells, or government tracking devices.

On the other side, scientists like Andrew Wakefield have created a highly clinical vocabulary around myths that vaccines cause autism. Zip codes with a popular chain of organic grocery stores, for instance, have the same childhood uptake rates as many rural areas where access and resistance to mandates also proliferates. These individuals are often misinformed but otherwise highly educated and actively seek out clinical-sounding articles and information online. This also makes it very difficult to refute all their claims, because one must be familiar with a complex corpus of pseudoscientific literature.

Communicating to those with low or no confidence takes specific and intentional strategies and coordination between public health officials, non-profits, pharmaceutical manufacturers, and the PR/Comms agencies that serve them.

In Sum

Different groups have different specific concerns, such as fears about side effects, doubts about vaccine efficacy, or beliefs influenced by misinformation. Others have doubts about the intentions of pharmaceutical/biopharmaceutical companies, or the healthcare system in general. (Unexpected medical bills and dismissive HCPs rank high as causal agents of the erosion of trust). Communication strategies need to be designed to address these varied concerns specifically and clearly. For example, parents worried about vaccine ingredients require different information and reassurance than those concerned about the speed of vaccine development. This often requires proactive engagement through several channels, especially to those who are routinely exposed to misinformation. Additionally, point of care must be trained and knowledgeable in these different forms of hesitancy to interact effectively with patients.