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PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES MODULE 22 Disclaimer: The resource modules were authored by the individuals under the guidance of the UNICEF Regional Office for Europe and Central Asia. The text is presented in draft format and it is expected that it will be adapted and contextualized for use by interested countries. The material has not been edited to official publication standards. UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. Coordination and Editing: Aleksandra Jovic, UNICEF, Early Childhood Development Specialist Lead Author: Bettina Schwethelm, Young Child Health and Development Specialist, Director, MCH-ECD Co-authors: Svetlana Stefanet, UNICEF, Immunization Specialist Sergiu Tomsa, UNICEF, Communication for Development Specialist Contributors: Silvia Sanchez R., UNICEF, Knowledge Management Consultant Viviane Bianco, UNICEF, Communication for Development Consultant UNICEF/ Krepkih Andrey TABLE OF CONTENTS Key Messages Why is this Topic Important to you? ..................................................................................6 Learning Outcomes ....................................................................................................................................6 Pre-Test for this Module ...............................................................................................................................7 Glossary and Definitions ............................................................................................................................10 I. Introduction ..................................................................................................................................111. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing ................................112. Vaccination Trends Globally and in Europe ...........................................................................................................143. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary ..........................................................................................................................15 II. Immunization and Vaccine Preventable Diseases A Major Public Health Achievement ...................161. Childhood Immunization .......................................................................................................................................162. How Vaccines Work .............................................................................................................................................173. The Benefits of Vaccination to the Individual Child and Society ...........................................................................204. Vaccine Safety and Side Effects ...........................................................................................................................225. Family-Held Vaccination Records ..........................................................................................................................23 III. Understanding Barriers to Vaccination ...............................................................................................241. Caregivers Along the Continuum of Vaccine Acceptance, Hesitancy, and Rejection ...........................................242. Understanding how Individuals Make Behavioural Choices .................................................................................26 a. The Behaviour Change Journey ........................................................................................................................26b. Factors Influencing Caregiver Decisions ...........................................................................................................27c. Perception Biases, Beliefs, and Myths About Vaccines The Internet and Social Media ................................31d. The Role of Health Workers ..............................................................................................................................34 IV. Communication Skills and Tools to Support Vaccine Acceptance by Caregiver .................................371. Active Listening Skills ...........................................................................................................................................37 a. Verbal Communication ......................................................................................................................................37b. Non-Verbal Communication ..............................................................................................................................38c. Empathy ............................................................................................................................................................39 2. Working with Caregivers Along the Continuum of Vaccine Hesitancy .................................................................39a. Vaccine-Accepting Families ...............................................................................................................................40b. Vaccine-Hesitant Caregivers .............................................................................................................................41c. Vaccine Refusers and Anti-Vaccine Advocates .................................................................................................44 3. Helping Caregivers Overcome Barriers to Vaccination .........................................................................................46a. Preparing Caregivers for Vaccination and Helping Them Manage Mild Side-Effects ........................................46b. Helping Caregivers Problem-Solve ....................................................................................................................46c. Addressing Rumours in the Community ...........................................................................................................47 V. Summary of Key Points and Post-Test .................................................................................................481. Summary of Key Points ......................................................................................................................................482. Post-Test with Answers ......................................................................................................................................49 VI. Websites And Video Clips .....................................................................................................................531. Websites .............................................................................................................................................................532. Relevant Video Clips ...........................................................................................................................................53 Annexes: Information Cards ........................................................................................................................55Information Card 1 - Common Vaccine-Preventable Diseases ...........................................................................................55Information Card 2 - Frequently Asked Questions (FAQS) About Childhood Vaccinations .................................................58Information Card 3 - Simple Ways to Show Empathy ........................................................................................................62Information Card 4 - Responses that Encourage Communication ......................................................................................63Information Card 5 - Roadblocks to Communication ..........................................................................................................64Information Card 6 - Practical Communication Skills Case Study ....................................................................................65Information Card 7 - The CASE Approach ...........................................................................................................................66Information Card 8 - Steps to Address Negative Rumours in the Community ...................................................................67Information Card 9 - Reducing Pain ....................................................................................................................................68Information Card 10 - What is Community or Herd Immunity and Why is it Important? ....................................................70 Worksheets................ ..................................................................................................................................71 References................. ..................................................................................................................................73 6 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES KEY MESSAGES Why is this topic important to you? Vaccination is one of the worlds safest and most cost-effective public health interventions. Yet growing distrust in science, coupled with misinformation, means that vaccination coverage rates are declining in some countries and communities, resulting in an upsurge of vaccine-preventable diseases. The routine vaccination schedule brings families into frequent contact with the healthcare system, providing opportunities to reach children with life-saving vaccines and other crucial services for children and their families. Research shows that those caring for children tend to trust the advice of their health workers when it comes to vaccination, despite conflicting and often misleading information from other sources. That is why your role is so important: poor or disrespectful responses to caregivers and their concerns, coupled with a lack of uptake of vaccines (whether at a clinic or during a home visit), can have a strong and negative impact not only on their future demand for vaccination, but also for a whole range of other health services. As a professional who is trusted by the families you serve, you have a unique opportunity to identify vaccine-hesitant caregivers; understand their fears, dilemmas and choices; provide them with relevant information; help them overcome their vaccination hesitancy; strengthen their confidence in vaccines and immunization, and, in some instances, vaccinate their children. Using your communication skills and your knowledge about how individuals make behavioural choices, you can influence and guide parents to make decisions in the best interests of their children by listening to and understanding their concerns, providing answers to their questions, and helping them make the best choice for their child and their community. LEARNING OUTCOMES Once you have completed this module you will: Have a good understanding of vaccine-preventable diseases and the importance of immunization. Understand the role of health workers particularly home visitors in guiding families in their decisions to have their children protected against vaccine-preventable illnesses. Understand the importance of checking the immunization status of the child during each relevant visit and reminding caregivers about upcoming vaccination appointments. Understand that the views of caregivers range across a continuum from vaccine acceptance, to hesitancy and rejection, and that tailored approaches and actions are required from you to ensure that as many infants and children are protected against vaccine-preventable diseases as possible. Be able to apply evidence-based techniques and approaches to address hesitancy and influence caregivers decisions and behaviours. When checking a childs records, know how to give their caregivers the space to voice concerns and ask questions so that you can provide facts about vaccination benefits and address rumours and misinformation. Know how to identify caregivers who are hesitant about vaccines and respond to their questions and concerns with facts and empathy to help them make informed decisions and move towards vaccination. Communicate with caregivers who are rejecting vaccines in a respectful and empathetic way, reminding them that vaccines are safe, advising them of the dangers and symptoms of vaccine-preventable diseases, and reinforcing their responsibilities, as caregivers, to inform health workers if their child has not been vaccinated. Show your appreciation and validation of families that have accepted vaccination and that might be willing to become vaccine advocates in your community. Be able to advise parents on how to deal with the possible common side effects of vaccination. 7 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES PRE-TEST FOR THIS MODULE Some of these questions may refer to topics that are unfamiliar to you at this early stage, but do not worry. The module will cover all of these issues and features a post-test (with answers) at the end so that you can assess your own progress. 1. Costing studies have shown that childhood vaccinations constitute one of the most cost-effective public health interventions. True False 2. The number of parents refusing vaccinations for their infants and young children is increasing. This group should, therefore, be the main target for education by home visitors. True False 3. Increasing herd/community immunity is not a good argument for increased support for immunization programmes. True False 4. Several countries in Europe have had a high number of measles cases. Some of the reasons for this include (please mark all answers that apply): a. Shortages of measles vaccine in these countriesb. Caregivers who are complacent, because they do not know that measles is a dangerous and very infectious diseasec. Researchers who have been unable to dis-prove the myth that measles vaccine causes autismd. Measles brought in by travellers from poor, under-developed countriese. Falling immunization coverage. 5. The reason for vaccine hesitancy is simple: caregivers just lack the evidence about the benefits of vaccines. True False 6. Some of the strategies to overcome vaccine hesitancy among parents include (please mark all answers you consider correct):a. Improving the interpersonal and communication skills of health workersb. Listening to the concerns of caregivers and showing empathyc. Understanding how behaviour change takes place and using a solid behaviour-change approachd. Ensuring that health workers welcome caregivers who may feel socially excluded and stigmatizede. Telling caregivers that health professionals know best and that they should not question immunization, as they are not expertsf. Improving the quality of health services. 7. Some of the challenges to the achievement of high immunization coverage rates for measles and rubella coverage (please circle the answers you consider correct)a. The rejection of vaccines by some families in small communities and urban areas creates pools of unprotected children, increasing the risks of the rapid spread of epidemicsb. Measles vaccine is routinely provided to children when they are one year of age: a time when some caregivers may feel that their young children have already received enough vaccines to be protected MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 8 c. Lack of trust in vaccine safetyd. Shortage of vaccines in some countries as a result of recent epidemics. 8. Home visitors should be prepared to respond flexibly to the concerns of parents about vaccinations, with brief, tailored and fact-based elevator speeches (short enough to be presented during an elevator ride of just a few floors). True False 9. Polio has been eradicated and will soon be removed from all immunization schedules. True False 10. Arrange the following stages into the correct sequence for an expanded behaviour-change model: 11. List some non-verbal communication features you can use to make caregivers feel more comfortable: 12. Giving young infants multiple vaccines at the same time can overwhelm their immune system. True False 13. Naturally acquired immunity works better and is safer than vaccine-acquired immunity. True False 14. The following approaches need to be avoided when addressing the concerns of caregivers about vaccines (mark all that apply): a. Reflective listeningb. Solving any problems the caregiver has in getting to the clinicc. Empathy for their concerns about whether they are making the best decision for their childd. Praising them by telling them that they are your best parents and that you are so proud of theme. Rebuking caregivers for missing vaccination appointmentsf. Reminding caregivers that they are not experts and should not question immunization. Stages Step Decision Advocacy Pre-contemplation Maintenance Preparation Contemplation Trigger Fine-tuning Trial 9 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 9 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 15. Caregivers who refuse vaccines are likely to include individuals with some of the following characteristics (mark all that apply)a. They are from marginalized populationsb. They question science and are often highly educated c. They come from poor and uneducated families in urban areasd. They dont trust their health care system or health workers. 16. The three Cs are (mark all that apply) Complacency Concern Convenience Confidence. 17. Vaccination programmes are expensive because of the costs of vaccines, cold-chains and the salaries needed to deliver so many vaccines to so many children. It is an important public health intervention, but not very cost-effective. True False 18. 18. Measles is so dangerous because (mark all that apply)a. The disease kills most unvaccinated children because the vaccine only starts working when a child is around two years oldb. It is so infectious that herd community cannot be achievedc. It can wipe out much of the immune memory that a young child had acquired before contracting measlesd. Survivors of measles have an increased likelihood of death in the 2-3 years after contracting the diseasee. The infection spreads rapidly when a group of unvaccinated individuals is exposed to a case of measles. 19. There are no good sources of credible information about vaccines and vaccine safety. True False 20. Vaccine rejectors have a responsibility to inform health workers that their child has not been protected against vaccine-preventable diseases and should know about the signs and symptoms of these diseases. True False 21. While vaccination contributes primarily to Sustainable Development Goal 3 (SDG 3) on good health and wellbeing by reducing the number of vaccine-preventable deaths, it also contributes indirectly to many other SDGs. True False 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES GLOSSARY AND DEFINITIONS Caregiver. The parent or primary guardian of the child. This module uses the terms parent and caregiver interchangeably, recognizing that while most children are cared for by their parents, this is not always the case. For the purposes of this module, the terms parent or caregiver refer to the adults responsible for children and who make critical decisions on their behalf around immunization. Closed questions. Questions that are generally answered with a simple yes or no, in contrast to open-ended questions that encourage the other person to elaborate on their answer and encourage a genuine, two-way dialogue. Empathy. The capacity to understand or feel what another person is experiencing from their point of view, i.e. putting yourself in their shoes. This contrasts with sympathy, which often conveys pity for someone else, but not necessarily an understanding of their situation. European Centre for Disease Prevention and Control (ECDC). EU agency aimed at strengthening Europes defenses against infectious diseases. The core functions cover a wide spectrum of activities: surveillance, epidemic intelligence, response, scientific advice, microbiology, preparedness, public health training, international relations, health communication, and the scientific journal Eurosurveillance.1 Herd/community immunity. It is achieved when the vast majority of a population (at least 95% of children for childhood vaccination) is vaccinated, ensuring the protection of the whole community, including individuals who have not been vaccinated. Immunization. The process by which a person develops resistance to an infectious illness, usually through the application of a vaccine. Interpersonal communication. The exchange of information, thoughts, and feelings both verbal and non-verbal between two or more people that leads to dialogue, mutual understanding, respect for different perspectives and positions and immediate feedback. It can take place in a face-to-face setting or via video or audio settings by phone or Internet. MMR. Measles-mumps-rubella vaccine. Vaccination. Act of introducing a vaccine into the body to produce immunity to a disease. Vaccine hesitancy (WHO, 2019). The reluctance or refusal to vaccinate despite the availability of vaccines. Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines, and is influenced by multiple factors, such as complacency, convenience and confidence. 1 European Centre for Disease Prevention and Control. https://www.ecdc.europa.eu/en/about-ecdc https://www.ecdc.europa.eu/en/about-ecdc 11 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IINTRODUCTION 1. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing Recent decades have seen a surge of research on neuroscience and child development that has identified what newborns and young children need to survive, thrive, and lead healthy and productive lives. In May 2018, this critical body of scientific knowledge was brought together and used to create the Nurturing Care Framework by the World Health Organization (WHO), UNICEF, the World Bank and other partners. Compelling and robust scientific evidence was translated into five easily understandable and mutually supporting components that are essential for children to thrive (also shown in Figure 1): Good health Adequate nutrition Opportunities for early learning Responsive caregiving, and Security and safety. G OOD HEAL TH ADEQUATE NUTRITION G O PP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y R ESPO NSIV E C AR EG IVIN G Components of nurturing care Figure 1. The Nurturing Care: five interconnected components UNICEF/Kudravtsev 12 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES To survive, thrive and reach their full developmental potential, infants and young children need all five components of the Nurturing Care wheel. The components are not stand-alone, nor do they work as additions to each other: they are indivisible and synergistic. Responsive caregiving, for example, creates an enabling environment that can safeguard the other components: that is, a caregiver who is responsive to a child will be able to detect early signs that the child is feeling ill, tired, overwhelmed, anxious or threatened and will be able to respond in a way that protects the childs wellbeing. Similarly, a responsive caregiver is sensitive to the signs that a child is feeling well, alert, and ready to play and explore, and will be able to respond with appropriate activities. While parenting is perhaps the most challenging task for any adult, measures and support to prepare people for parenthood and education in parenting are more often available in high-and middle-income countries. Where such support is available in low-income countries, it tends to be accessed most frequently by high- and middle-income families. Families in many countries in the Europe and Central Asia region are fortunate to benefit from universal health care and home-visiting services provided by the public sector during the critical times of pregnancy and the first few years of a childs life. While the number of visits provided to all families is often limited, home visiting can be an effective entry point and opportunity to provide reliable and valid information and advice on child development, child rearing and parenting. Universal home-visiting services can also be used to identify families that are vulnerable or that need additional and targeted services. Providing all families with trusted and evidence-based information and advice and identifying the families with additional needs require knowledge and special skills in working with families from all walks of life to build a genuine and supportive partnership. About the resource package for home visitors and its modules The resource package for home visitors Supporting Families for Nurturing Care is a growing set of training modules (see Figure 2). It aims to strengthen the knowledge of home visitors on the key components of Nurturing Care, and enhance their skills in working with families to enable and empower them to provide the best start to their children. While targeting home visitors, many of these modules are also suitable for other health and non-health professionals who interact with pregnant women and the families of young children. Each of the modules responds to one or more components of Nurturing Care and builds capacity and skills needed by the home visitor to provide supportive home visits. In addition, each module aims to help home visitors reflect on professional attitudes and strengthen practices to engage inclusively and respectfully families that are diverse and face different needs and challenges. The modules have been developed by well-known experts and can be translated and adapted to different country contexts. In some countries, the modules have already become a mainstay of lifelong learning and continuing professional development for health workers and social-service providers engaged in promoting the comprehensive wellbeing of young children and their families. You can find hard copies of all modules on the International Step by Step Association (ISSA) website at https://www.issa.nl/modules_home_visitors and on UNICEF Agora. UNICEF/Voronin https://www.issa.nl/modules_home_visitors 13 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Knowledge Module 1: The Early Childhood Years - A Time of Endless Opportunities Module 7: Parental Wellbeing Module 11: Working against Stigma and Discrimination - Promoting Equity, Inclusion and Respect for Diversity Module 12: Children Who Develop Differently - Children with Disabilities or Developmental Difficulties Module 18: Gender Socialisation and Gender Dynamics in Families - The New Role of the Home Visitor Skills Module 2: The New Role of the Home Visitor Module 10: Caring and Empowering - Enhancing Communication Skills for Home Visitors Module 13: Developmental Monitoring and Screening Module 15: Working with Other Services Module 17: Supervision - Supporting Professionals and Enhancing Service Quality Module 22: Protecting Young Children from Vaccine-Preventable Diseases Figure 2. The Supporting Families for Nurturing Care resource package and its modules (asterisks indicate complementary pre-existing training packages) Components of nurturing care Thinking Healthy*Care for Child Development*Module 4: Falling in Love - Promoting Parent-Child AttachmentModule 5: Engaging Fathers Module 8: Common Parenting Concerns Integrated Management of Childhood Illnesses (IMCI)*Module 20: Healthy Weight, Physical Activity, Sleep and Sedentary TimeModule 21: The Care of Small and Sick NewbornsModule 22: Protecting Young Children from Vaccine-Preventable Diseases Module 6: The Art of Parenting - Love, Talk, Play, ReadModule 19: Early Childhood Education Programmmes Module 9: Home Environment and SafetyModule 14: Keeping Young Children Free from Violence, Abuse and Neglect Infant and Young Child Feeding (IYCF)*Baby-friendly Hospital Initiative (BFHI)Module 16: Responsive Feeding G OOD HEALT H ADEQUATE NUTRITIO NG OPP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y RE SPO NS IVE C AR EG IVIN G 14 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. Vaccination Trends Globally and in EuropeSince the development of the first vaccination against smallpox more than a century ago, vaccine programmes for children have become an integral component of preventive primary health care in every country on earth. Vaccination programmes prevent between 2 and 3 million deaths globally each year (WHO, 6.12.2019). In 2019, about 86 per cent of infants worldwide (116.3 million infants) received 3 doses of diphtheria- tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness, disability or death. Individuals and governments benefit from vast cost-savings as a result of the prevention of illness (EU and WHO, 2019). Based on the costs of illnesses, including treatment costs and productivity losses, that have been averted, every dollar invested in vaccines during the Decade of Vaccines (2011-2020) is estimated to have yielded a net return of about $16 (Ozawa et al., 2020). Two of the three strains of wild polio virus strains have been eradicated. A growing number of countries have achieved disease-free certifications (i.e. the European region has sustained its polio free status since 2002). The growing number of combination vaccines (i.e. the child is vaccinated against several diseases with one injection) is reducing the number of injections needed. In recent years, however, vaccination programmes have become victims of their own hard-earned success: few caregivers remember epidemics of polio, measles, pertussis or chickenpox that took the lives of many children, left many more with disabilities, and undermined their health and development. They may be unaware that measles is one of the worlds most contagious diseases, and that its transmission can only be halted if at least 95 per cent of the population is protected by immunization. In addition, misinformation that links vaccines to autism is easy to find and continues to circulate through social media and on websites, despite being discredited repeatedly, including by large-scale population studies (Hviid et al., 2019). Misinformation is sometimes disseminated deliberately to contradict (and appear alongside) evidence-based information about the benefits of vaccination. As a result of such challenges, countries around the world, and particularly in the Europe and Central Asia Region, have seen a resurgence of measles as the number of unprotected children and adults has grown. Measles cases have reached their highest level in Europe in 20 years (The Guardian, 21.12.2018). In total, 49 of the 53 countries in WHO European Region reported more than 192,943 measles cases and more than 100 measles-related deaths between 1 January 2018 and 31 December 2019, with a regional coverage with 2 doses of measles vaccination of only 91 per cent for the two doses of measles vaccination, which is too low to ensure herd immunity. Large disparities at the local level persist: some communities report over 95% coverage, and others below 70%. Several countries in the region Albania, the Czech Republic, Greece and the UK have recently lost their measles free certification. In the absence of disease, fear of disease has been replaced by fear of vaccines for some people (WHO, 2017). UNICEF/Bershadskyy Yuriy Immunization is one of the most cost-effective ways to save lives and promote good health and well-being. Every year, vaccines save 2-3 million lives, and millions more are protected from disease and disability. It routinely reaches more households than any other health service and brings communities into regular contact with the health system. This provides an effective platform to deliver other primary health care services and upon which to build universal health coverage. (Gavi The Vaccine Alliance, 2019) 15 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary UNICEF/ Krepkih Andrey Because of the frequency of the contact required with families, especially during the early months of a childs life, the quality of immunization services can either enhance or endanger the trust families place in health care services and professionals. As a health visitor for families with young children, you are in a unique position to educate the families you meet on the importance of vaccines and the vaccination schedule and identify caregivers who have some concerns or who may even reject vaccines. In their own home, and when talking to someone the family trusts their home visitor caregivers may feel more comfortable asking questions and voicing fears that have not been addressed during crowded vaccination sessions or in a busy doctors office. Your knowledge of the benefits and safety of vaccines, your communication skills and empathy for families, and your understanding of their concerns are your major tools for the promotion of this crucial health intervention. Once you have completed this module, you will be able to answer questions and provide practical tips to caregivers on how to support their child while they are being vaccinated and help them deal with common side effects. You will also be able to provide evidence-based information to counter any misinformation that might be spreading through the caregivers network or social media. Because you have the information about the childs vaccination status, you can tailor your response and refer families to other experts and specialists where necessary. The quality of your support is vital. It may influence whether caregivers complete the vaccination schedule for their children, and the way in which they engage with health services in the future. You may never know for sure, but you may have saved a childs life, while protecting other young children who cannot be vaccinated because of counter-indications, as well as infants who have not yet received their first vaccines! MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 16 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IIIMMUNIZATION AND VACCINE PREVENTABLE DISEASES A MAJOR PUBLIC HEALTH ACHIEVEMENT 1. Childhood Immunization In its listing of 100 objects that have shaped public health, Global Health NOW of the Johns Hopkins Bloomberg School of Public Health called immunization one of the most important public health achievements in human history.2 The development of vaccines has accelerated since the first use of a smallpox vaccine in 1798, and particularly since the middle of the 20th century. Today more than 30 infectious diseases can be prevented with vaccines (see Information Card 1 in annexes for information about common vaccine-preventable childhood diseases). Even though the worlds population has grown by almost 70 per cent, Gavi The Vaccine Alliance reports that cases of common vaccine preventable diseases have fallen by around 90 per cent (Gavi, 29.01.2019). Smallpox has been eradicated, as well as two of the three wild polio strains (WHO, 24.10.2019), and a number of countries have achieved measles-free status. Today, WHO recommends 10 vaccines during infancy and the early childhood years, plus one (for HPV) during adolescence recommendations that apply to every country (WHO, April 2019). Bacillus Calmette Guerin (BCG) (1 dose protects against tuberculosis) DTP-containing vaccine (3 doses protects against Diphtheria, Tetanus, and Pertussis Td (Tetanus and Diphtheria) booster at 9-15 yrs Hepatitis B (34 doses - protects against hepatitis type B) Hib (3 doses - prevents Haemophilus influenzae type b) Pneumococcal (3 doses - protects against pneumococcal disease) Polio (OPV and/or IPV, 34 doses - protects against poliomyelites) Rotavirus (23 doses - protects against rotavirus disease) Measles (2 doses - protects against measles) Rubella (1 dose - protects against rubella) HPV (2 doses - protects against human papilloma virus that can cause cervical and other types of cancer) (adolescent girls) Most of the countries in the ECA region use the MMR vaccine, a combined vaccine against measles, mumps and rubella. WHO recommends vaccination against mumps in high performing immunization programmes with the capacity to maintain coverage over 80% and where mumps reduction is a public health priority. Unfortunately, there has been a 30 per cent increase in cases of measles globally, and many countries in Europe and Central Asia have reported falling immunization coverage: half of the countries in the Region have DTP3 and MCV1 coverage below the 95 per cent minimum needed to ensure herd immunity. In 2019 WHO declared vaccine hesitancy as one out of 10 threats to global health. As we will discuss in more detail below, the WHO Vaccines Advisory Group has attributed this to the three Cs: Complacency, in-Convenience, and lack of Confidence, which contribute to vaccine hesitancy among parents and caregivers. Health workers, especially home visitors who work closely with their communities, have a critical role to play, as their advice is trusted by parents and can influence decisions around vaccination. To fulfil this role, however, home visitors need clear, factual information on vaccines, as well as communication tools to tackle the global threat to health posed by vaccine hesitancy (WHO, 2019). 2 Global Health NOW. One hundred objects that shaped public health. Retrieved from https://www.globalhealthnow.org/object/vaccines https://www.globalhealthnow.org/object/vaccines 17 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 17 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. How Vaccines WorkAs a home visitor, you often have very little time to cover a large range of relevant topics with the families you visit. That is why you need to be able to explain, in concise and understandable terms, how vaccines work and why it is important to vaccinate all children. To be efficient, apply the Elevator speech approach (Karam et al., 2019a, b) to make your most important points in the time that it would take for a ride in an elevator. It is important to tailor your messages to each family, taking into account their existing level of knowledge, as well as their concerns and attitudes around vaccination. Visuals can often be very powerful, helping you to make a point quickly and convincingly. Reflection and discussion There are many reasons why children are not vaccinated or vaccinated incompletely, but the following four steps can help you prepare short, clear responses to families that have concerns. First write down some of the questions and concerns you and your colleagues have heard from the caregivers you visit. Then choose several questions related to how vaccines work and develop brief elevator speeches with your colleagues or on your own. For your responses, use simple language, avoid jargon and technical terms; use analogies or simple examples and comparisons. Then try out your elevator speeches on others (family, caregivers, etc.) Finally, compare your responses to those provided by experts from WHO and the European Centre for Disease Prevention and Control (ECDC) and modify your elevator speeches as needed. Here are your practice questions: the kind of questions you may well be asked by the families you visit. Look through them and prepare some answers. When you have finished, compare your answers to the information provided in Box 1 below: How do vaccines work? Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Can vaccines cause the infection they are supposed to prevent? What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? I have heard that vaccinating my child also protects other children. What is community/ herd immunity and why is it important? UNICEF/Krepkih Andrey MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 18 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES How do vaccines work? Vaccines contain either a much-weakened form of the virus or bacterium that causes a disease, or a small part of it. When the body detects the contents of the vaccine, its immune system will produce the antibodies required to fight off infection and eliminate the disease-causing virus or bacterium. When a person later comes into contact with the virus or bacterium, the immune system will recognize it and protect the person by producing the right antibodies before any disease can be caused. (ECDC, Questions and answers about childhood vaccinations) Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Infants and young children are vaccinated in controlled settings (doctors offices or clinics), and parents are informed about possible side effects, how to manage these, and when to seek additional advice. With vaccines, the immune system is stimulated to develop protection without infection, hence it is more effective (WHO, 2017). The only way a child can acquire natural immunity is to become sick with the disease itself. Even when the impact on the child is mild, it may mean additional caregiving and expenses for some families. But the disease could also result in complications, long-term illness, disability and even death, and many other children may become exposed in the process. For measles, the Center for Disease Control and Prevention (CDC) has reported complications with 30 per cent of measles cases, most commonly diarrhoea, ear infections and pneumonia. For every 1,000 cases of measles, one child may also be affected by encephalitis and two may die. Whats more, the measles infection can destroy much of the wider immunity a child has built up, increasing their risk of contracting other diseases. Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Newborns commonly manage many challenges to their immune systems at the same time. The mothers womb is free from bacteria and viruses, so newborns immediately face a host of different challenges to their immune systems. From the moment of birth, thousands of different bacteria start to live on the surface of the intestines. By quickly making immune responses to these bacteria, babies keep them from invading the bloodstream and causing serious diseases. In fact, babies are capable of responding to millions of different viruses and bacteria because they have billions of immunological cells circulating in their bodies. Therefore, vaccines given in the first two years of life are a drop in the ocean of what an infants immune system successfully encounters and manages every day. (ECDC. Questions and answers about childhood vaccinations) Can vaccines cause the infection they are supposed to prevent? Inactivated vaccines do not have live germs and cannot cause infections. Live vaccines have weakened germs that are unable to cause disease in healthy people. Rarely a mild form of infection may occur. (WHO, 2017) What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? The defences of children who have survived a vaccine preventable-disease are not necessarily stronger. On the contrary, the disease tends to make the child weaker and more vulnerable. Recent research on measles has shown that having suffered and survived this deadly disease may make it harder for a child to fight other infections for years to come. It has been known for some time that children who had measles were 2-3 times more likely to die from pneumonia, diarrhoea or other conditions in subsequent years. Now, we have learned that the measles virus infects and destroys memory B-cells. These are the cells where the immune system stores information about past Box 1. How vaccines work https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html https://www.ecdc.europa.eu/en/immunisation-vaccines/childhood-vaccination/faq?pdf=yes&preview=yes 19 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 19 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES infections that can help it in fighting new infections. In addition, the measles virus also reduces the ability of the immune system to respond to new and dangerous pathogens. It now seems possible that there could be actually five times more indirect deaths from immune amnesia (caused by the measles virus) than the initial infection caused. (Gallagher, 2019) I have heard that vaccinating my child also protects other children. What is community/herd immunity and why is it important? Vaccination protects you and your family, and it also helps protect others. It contributes to community immunity. This is achieved when enough people in a population are immune to an infectious disease (through vaccination and/or prior illness) so that it is unlikely to spread from person to person. Even those who cannot be vaccinated because they are too young, are allergic to vaccine components, or vaccination is contraindicated for them, are offered some protection because the disease cannot spread in the community and infect them. This is also known as herd or community immunity. When more than 95% of population is (blue dots) in a community they can protect those who are not yet vaccinated (yellow dots) from those who are infectious (red dots) When groups of unvaccinated people build up and are in close proximity, community immunity doesnt work and the disease spreads. For additional brief answers to common questions and concerns (developed by WHO and ECDC communication experts), check Information Card 2 Frequently Asked Questions (FAQs) about Childhood Vaccinations (in annexes), which also includes links to additional information. However, keep in mind that you will have to tailor your answers to the needs of individual families, their attitudes towards vaccination, and level of knowledge, so just learning some standardized answers by heart is not enough. 20 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 20 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. The Benefits of Vaccination to the Individual Child and Society NOPOVERTY AFFORDABLE ANDCLEAN ENERGY CLIMATEACTION LIFE BELOWWATER LIFE ON LAND PARTNERSHIPSFOR THE GOALS DECENT WORK ANDECONOMIC GROWTH SUSTAINABLE CITIESAND COMMUNITIES ZEROHUNGER EDUCATIONQUALITY EQUALITYGENDER AND SANITATIONCLEAN WATER PEACE, JUSTICEAnd STRONG INSTITUTIONS RESPONSIBLECONSUMPTIONAND PRODUCTION GOOD HEALTHAND WELL-BEING INDUSTRY, INNOVATIONAND INFRASTRUCTURE REDUCED INEQUALITIES GLO BA L S TRA TEGY FOR WOME NS, CHILDRENS AND ADO LESCEN TS HEA LTH SU RVIV E TH RIV E TRANSFORM Figure 3. Sustainable Development Goals (SDGs) Reflection and discussion Immunization for vaccine-preventable diseases provides one of the strongest financial returns of any public health intervention, but its benefits go far beyond the health sector alone. Take a look at Figure 3, which sets out all of the Sustainable Development Goals. Can you list ways in which the benefits of immunization can be felt across all of these goals? To help you, the potential links between immunization and the SDGs are set out in Table 1: perhaps you can think of others! When you see how vaccination supports the achievement of the SDGs, you can feel confident and proud in promoting such a cost-effective and safe service to your community and to the families you serve. Immunizing children is one of public healths best buys. Vaccines are relatively easy to deliver and, in most cases, provide lifelong protection. They boost development both through direct medical savings and indirect economic benefits such as cognitive development, educational attainment, labour productivity, income, savings and investment (Gavi The Vaccine Alliance, 2019) https://www.gavi.org/vaccineswork/value-vaccination https://www.gavi.org/vaccineswork/value-vaccination 21 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Sustainable Development Goal Vaccination programmes 1. No povertyPrevent expensive illnesses and associated health-care costs, reducing the number of people forced into poverty. 2. Zero hungerProtect childrens nutritional status, because illness impairs absorption of essential nutrients. Malnourished children are also at a higher risk of death from vaccine-preventable diseases. 3. Good health and wellbeing Reduce mortality and morbidity and provide the platform for the delivery of other health services. 4. Quality educationVaccinated children have better nutrition and health status, and have, therefore, better chances to learn and achieve. 5. Gender equalityGlobally, this is a gender-equal intervention, with similar rates of vaccination for girls and boys 6. Clean water and sanitation (WASH) Prevent diarrhoeal diseases, alongside WASH programming. 8. Decent work and economic growth Contribute to the growth of healthy children who attain education and become a productive workforce. Caregivers are more likely to be able to work when children are not affected by vaccine-preventable diseases. 10. Reduce inequalityProtect all communities and children, including the most marginalized, those living in rural areas and in conflict zones, which can be further devastated by epidemics of infectious disease. 11. Healthy citiesProtect children from increased risk of exposure to vaccine-preventable diseases in cities where infections are more able to spread quickly. 16. Peace, justice and strong institution Contribute to equity and strong health services. Table 1. Vaccination and the achievement of the Sustainable Development Goals (SDGs) Source: Gavi, 2019 UNICEF/ Krepkih Andrey 4. Vaccine Safety and Side Effects Before you respond to concerns about the safety of vaccines in general

Page 1 Page 2 A lie can travel halfway around the world while the truth is putting on its shoes. Mark Twains quote is more relevant than ever in times of online communication, where information or misinformation, bundled in bits and bytes, streams around the earth within seconds. SUMMARY DISCLAIMERUNICEF working papers aim to facilitate greater exchange of knowledge and stimulate analytical discussion on an issue. This text has not been edited to official publications standards. Extracts from this paper may be freely reproduced with due acknowledgement. For the purposes of this research, no personal data has been extracted and stored for data collection and analysis. This UNICEF working paper aims to track and analyse online anti-vaccination sentiment in social media networks by examining conversations across social media in English, Russian, Romanian and Polish. The findings support the assumption that parents actively use social networks and blogs to inform their decisions on vaccinating their children. The paper proposes a research model that detects and clusters commonly-used keywords and intensity of user interaction. The end goal is the development of targeted and efficient engagement strategies for health and communication experts in the field as well as for partner organisations. Page 3 CONTENT1. Rationale 2. Introduction 2.1 Social Media: the conversation shift 2.2 Social Media: Fertile ground for anti- vaccination sentiment 2.3 Social Media Monitoring 2.4 Influencers 3. Research Objectives 4. Methodology 4.1 Descriptive and Explorative Research Design 4.2 Data Collection 4.3 Limitations 4.4 Ethical Considerations 5. Empirical Findings 5.1 Networks: Volume and Engagement 5.2 Common Arguments 5.2.1 Religious and Ethical Beliefs 5.2.2 Side Effects 5.2.3 Development Disabilities 5.2.4 Chemicals, Toxins and Unnecessary 5.2.5 Conspiracy Theory, Western Plot and Conflict of Interest 5.3 Influencers 6. Discussion and Recommendations 6.1 Discussion 6.2 Recommendation Acknowledgements Literature Appendix 4 555 78 9 1111121313 1414191920212222 23 252527 313134 Page 4 Over the past few years, the region of Central and Eastern Europe and the Commonwealth of Independent States has been troubled by the rise of a strong anti-vaccine sentiment, particularly via the internet. Wide ranging in origin, motive, source, and specific objectives, this online sentiment has succeeded in influencing the vaccination decisions of young parents, in many instances negatively. A number of factors are at play in this online anti-vaccine sentiment. First, vaccination coverage in this region is generally high. As a result, vaccine-preventable childhood diseases like polio and measles have been absent in most countries for the past few decades. This has led to complacency toward the diseases and has unfortunately made vaccines, rather than the diseases, the focus of debate and discussion. Meanwhile, poorly-managed immunization campaigns in some countries have caused widespread mistrust of vaccines and government vaccination programs. Most countries have run sluggish, high-handed public communication campaigns while avoiding transparent dialogue with the public on possible side effects, coincidental adverse events and other safety issues. Moreover, when new vaccines have been introduced, they have often just exacerbated the publics existing doubts, hesitations or outright resistance. Into this mix, rapid penetration of the internet in the region has provided a powerful, pervasive platform for anti-vaccine messages to be disseminated. Rooted in scientific and pseudo-scientific online sources of information, messages are often manipulated and misinterpreted, undermining the confidence of parents and causing them to question the need for, and efficiency of, vaccines. The result is hesitation towards vaccination, which in large numbers poses a serious threat to the health and rights of children.This paper aims to examine this rapidly growing phenomenon and its global lessons. Depending on the nature of the problem, special strategies need to be developed to tactically address and counter, diffuse or mitigate its impact on ordinary parents. The prevailing approach of most governments in largely ignoring these forces is unlikely to address this growing phenomenon. Governments, international agencies and other partners - in particular the medical community - need to combine forces to identify the source and arguments of these online influences, map the extent to which they control negative decisions, develop more effective communication strategies and ultimately reverse this counterproductive trend. RATIONALE Page 5 The first part of this paper describes how anti-vaccination groups communicate and how social networks connect concerned parents in new ways. The second part emphasizes the role of social media monitoring in strategic communication, based on understanding audience needs. 2.1 Social media: The conversation shifts The rise of social networks has changed both the way we communicate and the way we consume information. Even within the relatively recent internet era, a major evolution has occurred: In the initial phase known as Web 1.0, users by-and-large consumed online information passively. Now, in the age of social media and Web 2.0, the internet is increasingly used for participation, interaction, conversation and community building1. At the same time, conversations or social interactions that used to occur in community centres, streets, markets and households have partly shifted to social media2. Parents, for instance, suddenly have an array of collaborative social media tools with which to create, edit, upload and share opinions with their friends, peers and the wider community. These conversations are recorded, archived and publicly available. 2.2 Social media: Fertile ground for anti-vaccination sentiment In todays information age, anyone with access to the internet can publish their thoughts and opinions. On health matters in particular, the public increasingly searches online for information to support or counter specialised, expert knowledge in medicine3. Due to the open nature of user participation, health messages, concerns and misinformation can spread across the globe in a rapid, efficient manner4. In this way, social media may influence vaccination decisions by delivering both scientific and pseudo-scientific information that alters the perceived personal risk of both vaccine-preventable diseases and vaccination side effects. INTRODUCTION 1 Constantinides et al, 2007 2 Phillips et al, 2009; Brown, 2009 3 Kata, 2012 4 Betsch et al, 2012 Page 6 In addition to this accelerated flow of information (whether accurate or not), social media messages tend to resonate particularly well among users who read or post personal stories that contain high emotional appeal. This holds true for anti-vaccination messages too. In other words, both logistically and qualitatively, social media is intensifying the reach and power of anti-vaccination messages. Negative reactions to vaccines are increasingly being shared across online platforms. All of this leads to a frustrating predicament and critical challenge: Immunizations protect people from deadly, contagious diseases such as measles, whooping cough and polio. But parents influenced by anti-vaccination sentiment often believe vaccines cause autism, brain damage, HIV and other conditions, and have begun refusing them for their children. As a consequence, health workers face misinformed, angry parents, and countries face outbreaks of out-dated diseases and preventable childhood deaths5. Why do anti-vaccination messages resonate with so many parents in the first place? Parental hesitation regarding vaccinations is thought to stem from two key emotions: fear and distrust: Vaccination is a scary act for many children and parents. A biological agent is injected into the child. The way the biological agent works in the childs body is for most people unclear, which appeals to parents fears. The high level of distrust stems from the intersection of government, medicine and pharmaceutical industry. The nature of its act and the fact that vaccinations are mostly compulsory leads to worries among citizens. (Seth Mnookin, 2011) This distrust, along with the interactive nature of social media, suggests an urgent need for health workers to become attuned to arguments and concerns of parents in different locations and of various cultural backgrounds. To achieve more synergistic relationships with an audience, organisations need to shift their communications strategy from getting attention to giving attention6. Compounding this challenge is the fact that some anti-vaccination groups are not merely sceptics or devils advocates, but operate in an organized, deliberate and even ideological manner. These anti-vaccination groups often employ heavy-handed 5 Melnick, 20116 Chaffrey et al, 2008 Page 7 communication tactics when dealing with opponents: they delete critical comments on controlled media channels, such as blogs7 ; they mobilize to complain about scientists and writers critical of their cause; sometimes they go going as far as to take legal action to prohibit the publishing of pro-vaccine material. Governments and organisations aim to keep parents accurately informed about vaccinating their children. As more of the public conversation indeed battle takes place across social media, there is an urgent need to understand this online landscape. This, in turn, requires the use of effective monitoring tools. 2.3 Social media monitoring Social media analysis plays an important strategic role in understanding new forms of user-generated content8 . Indeed, this type of monitoring has become a leading trend in Marketing, PR, political campaigns, financial markets and other sectors. As demand for this kind of data increases, more monitoring tools are becoming available. These tools search social networks for relevant content, and archive the publicly available conversation in a database. Researchers conduct their internet analysis primarily by formulating combinations of keywords that can be placed in relation and weighted for importance. There are four different types of social media monitoring: Monitoring by volume looks at the amount of mentions, views and posts a topic, organization or user receives. Monitoring by channels maps and examines the various networks that users use to exchange content. Monitoring by engagement seeks deeper insight into how many users actually respond, like, share and participate with the content. Monitoring by sentiment analysis is a qualitative approach that uses word libraries to detect positive or negative attitudes by users towards an issue9. The first phase in social media monitoring is listening to what users say, because in order, for instance, to engage effectively with parents on social networks, it is important to know what they are talking about10. 7 Kata, 2012 8 Cooke et al, 2008 9 The approach must employ qualitative analysis as machines are not able to track sarcasm or slang. 10 Kotler et al, 2007 Page 8 Social media monitoring is a young discipline that began just a few years ago, and in its initial phase the practice faced a number of challenges. Data was very complex, so first generation monitoring tools produced results that were unstructured and generally overwhelming11. Even when that data was sorted and structured, organizations struggled to generate actionable management recommendations from it12. Since that time, however, social media professionals and research communities have made steady progress in overcoming the early challenges. 2.4 Influencers Recent studies on social media networks emphasize the central role played by influential individuals in shaping attitudes and disseminating information13. Indeed, it is argued that a group of such influencers is responsible for driving trends, influencing public opinion and recommending products14. One study found that 78% of consumers trusted social peer recommendations, while just 14% trusted advertisements15. Intensive interaction and content sharing through social media means that an audience instinctively determines its own opinion leaders. What makes opinion leaders particularly interesting and important from our perspective is that they add their personal interpretation to the media content and pass it on to their audience. Depending on whether these influencers speak responsibly or not, this can have positive or negative impact on the goal of disseminating accurate information. In his book The Panic Virus, journalist Seth Mnookin offers some examples of controversial influencers: A British gastroenterologist, Andrew Wakefield, entered into the vaccine discourse and alleged that the measles-mumps-rubella vaccine might cause autism. The medical community eventually dispelled his arguments and he lost his medical license. For a decade Wakefield - though not a public health specialist - very successfully disseminated misleading information and garnered a significant social media following. Meanwhile, actress and model Jenny McCarthy has become another self-proclaimed expert on vaccine safety. Through frequent public appearances she has positioned herself as an 11 Wiesenfeld et al, 201012 Owyang et al, 201013 Tsang et al, 2005; Kiss et al, 2008; Bodendorf et al, 201014 Keller and Berry, 200315 Qualman, 2010 Page 9 educated, internet-savvy mother set on challenging the medical establishments information about vaccinations. This, too, has helped fuel the recent growth in anti-vaccination sentiments. The public following and authority gained by Wakefield and McCarthy demonstrate how with the proliferation of online channels and the user as the centre of attention, it becomes difficult for information seekers to differentiate between professional and amateur content16. By the time the record is set straight, trust in immunization is been partly destroyed. Fostering the positive opinion of influencers in communities can have a disproportionately large impact in terms of online reputation17. Though they may not know each other in the real world, and despite ever-expanding advertisement platforms and sources, consumers around the world still place their greatest trust in other consumers18. Audiences listen to opinion leaders because they are known to be independent, credible and loyal to their peers19. Identifying and influencing the influencers of the social media conversation in the region should therefore be part of any effective strategy to reinforce positive messages in the vaccination debate. Though the internet is increasingly used to search for health information, a number of questions about social media and vaccination decisions are still unanswered: Which channels are used by anti-vaccination groups? What are the key arguments and conversation themes? What makes anti-vaccination messages appealing to parents? Who are the opinion leaders in online discussions? What are the best strategies to respond to anti-vaccination arguments? This paper seeks to understand the internal dynamics of anti-vaccination sentiment in social media networks in Eastern RESEARCHOBJECTIVES 16 Cooke et al, 200817 Ryan et al, 200918 Nielsen, 200919 Weiman, 1994 Page 10 Europe20. These insights are expected to help health workers, partners and national governments to develop appropriate response strategies in order to convince the public of the value, effectiveness and safety of vaccinations. The objectives of this research are: 1. To monitor social media networks, consolidate existing data and information from partners. 2. To categorize and analyse conversation themes, based on volume of discussion, influence, engagement and audience demographic as appropriate. 3. To identify influencers in the different language groups and platforms. 4. To contribute to a set of recommended strategies to address specific anti-vaccine sentiment around the various conversation themes. This content analysis is expected to help us understand the motivations and mind sets behind the sentiment, and offer clues that can inform the development of a strategy to effectively address the phenomenon. The research is also expected to help drawing comparisons between the anti-vaccination sentiment phenomenon and similar sentiments expressed against interventions in nutrition, child protection and other areas of UNICEF practice. This paper is supported by UNICEF Department of Communication in New York and UNICEF Regional Office for Central and Eastern Europe and the Commonwealth of Independent States. The region covers 22 countries and territories: Albania, Armenia, Azer-baijan, Belarus, Bosnia & Herzegovina, Bulgaria, Croatia, Georgia, Kazakhstan, Kosovo (UN Administered region), Kyrgyzstan, TFYR Macedonia, Moldova, Montenegro, Roma-nia, The Russian Federation, Serbia, Tajikistan, Turkey, Turkmenistan, Ukraine, Uzbekistan. UNICEF does not have a country programme in the Russia Federation but is in discussions to develop a new mode of engagement. Page 11 In order to assess the dynamics of the anti-vaccination sentiments in the four languages, a systematic mapping and content analysis via social media monitoring is proposed. For the purpose of stakeholder monitoring in social media, a combination of descriptive and exploratory methods in form of quantitative and qualitative observation is proposed. According Wiesenfeld, Bush and Skidar (2010) it is reasonable to combine both methods because social media monitoring offers the richness of qualitative research, with the sample sizes of quantitative research. It may also give the opportunity to overcome problems associated with each research method in order to understand stakeholders dynamics in social media. 4.1 Descriptive and Explorative Research Design The descriptive methodology involves recording the activities of users and events in a systematic manner. Information is recorded as events occur and archived. Descriptive research in this case involves: Figure 1: Research Process for data gathering and analysis. METHODOLOGY 12 Aggregating text from public accessible social networks in in English, Russian, Polish and Romanian language. Cleaning and categorizing the data over time. The data is categorized and analysed into reoccurring conversation themes, based on volume of posts, engagement and audience demographic as appropriate. The exploratory methodology follows the descriptive research to allow for the interpretation of patterns and to provide background understanding of sentiment and attitudes of users. The results of the structured observation will be put into context by the human judgement of the researcher through the participant observation. In this research, the researcher will be a complete observer and will not interact with the users during the participant observation (Saunders et al, 2009). 4.2 Data Collection Traditional sampling techniques such as random, convenience or judgemental sampling are difficult to apply to a fluid social media environment. On top of the social media measurement process, the selected social media channels feed into the sample set. The posts are further categorized into different issue arenas that will be associated with relevant stakeholders. Figure 1 presents the data collection process for monitoring stakeholders in social media.The process contains the following six steps: 1. Channels: The first step of the data collection process involved the selection of relevant social media channels. Social media monitoring is instead generally considered to provide a complete set of all contributors, because tools like Radian6 or Sysomos are designed to capture a wide range of social media channels, such as blogs, forums, Twitter, Tumblr, Youtube and Facebook. 2. Demographics: The software gathered relevant posts that were posted in English, Russian, Polish and Romanian language3 during the period of 1 May and 30 July 2012. Posts could be submitted from all regions worldwide. 3. Context: The quality of data collection is determined by how well the collected data is gathered with regards to formulated searches. Keyword logic and search profiles were employed to filter the data. The full list of keyword combination can be found in Appendix A. 3The approach must employ qualitative analysis as machines are not able to track sarcasm or slang. Page 13 4. Data Collection: Relevant social media mentions that contained an issue-related keyword in relation to a stakeholder-related keyword was archived in the database. The list of relevant mentions was stored chronologically and assigned an ID. The full list of exported information about each mention was stored in a separate EXCEL file. 5. Data Analysis: The empirical application and content analysis of the relevant posts can be found in Chapter 6. 4.3 Limitations There are limitations in terms of reliability and validity of the recorded data. The data collection covers a three-months period. There is a need for caution when generalizing the data because events and evolution of discussions may alter the findings in other time periods. Therefore, limitations in reliability refer to reproducibility of research results. Reliability in the extent to which measures are free from error and therefore provide consistent results, such as the consistency of data availability in social media monitoring, is the second limitations. Quantitative observation has relatively high reliability because it reduces the potential for observer bias and enhances the reliability of data (Malhorta et al, 2007). However, social media monitoring might carry the risk of monitoring bias, as the relevant posts are extracted through keyword logic that is developed by the researcher. The collected data cannot be regarded as complete. For example, the share of Russian-speaking discussions seems to be fairly low compared to the amount of users accessing social media. Governmental control and censorship might also be contributing for lower volumes.The external validity, which is defined as the extent to which the research results are applicable to other research settings (Malhotra et al, 2007), is relatively low. Because of the richness of data, the sampling needs to be based on the experience of the researcher. As a disadvantage, the lack of established sampling technique in social media limits the ability to generalize the findings to other relevant issue arenas or stakeholders in the population. However, the ability to generalize the results was enhanced by careful use of the theoretical terms and relationships in the stakeholder literature (especially Freeman, 1984; Mitchell et al, 1997; Luoma-aho et al, 2010; Owyang et al, 2010). 4.4 Ethical Considerations Monitoring social media conversations raises two important questions about a) the protection of privacy, and b) ethical concerns. The growth of interest in social media monitoring has Page 14 triggered a new debate about ethics, which centers on what is in the public domain and what is not (Poynter, 2010). Privacy is a big issue, and social networking sites are under public criticism for lax attitudes regarding the security and respect of users privacy (Wakefield, 2011). It is the responsibility of the market researcher to protect a respondents identity and not disclose it to external audiences (Malhotra et al, 2007). Social media monitoring offers a rich volume of data, however the Internet is largely unregulated. The data of users around the world is stored on servers in the US and completely available to the US authorities. What might seem legal to the researcher may not necessarily be deemed morally right by society. Public interactions in social media are available for anyone and can be assigned to a personal IP address, geographic location, language, date and even specific computer. For the purposes of this research, no personal data has been extracted. The IP addresses and geographic locations have not been stored in the excel exports as it is not necessary for the purpose of the research. A unique post ID identifies each post. The following findings start with an overview of the networks used by the anti-vaccination community. Trends in volume and engagement are outlined in 5.1. In 5.2, clusters of common belief of the anti-vaccination sentiment are categorized and explained. The importance of influence in the anti-vaccination discussion is illustrated 5.3 because it is critical to understand that communication needs require adjustment to each country or region, which itself can present a challenge. 5.1 Networks: Volume and Engagement During May to July 2012, the researchers recorded messages with anti-vaccination sentiment from 22,349 participants. The majority of participants spoke English, followed by Polish, Russian and Romanian. EMPIRICALFINDINGS Page 15 Figure 2: Participants of anti-vaccination discussions per language. Across all four researched languages, blogs are the most frequently used channel for posting anti-vaccination content in social media. Blog is short for weblog, which is a website normally maintained by an individual (or group of individuals) and updated with regular entries. Entries are typically displayed in chronological order and tagged with relevant keywords and phrases. Blog visitors usually have the opportunity comment and share the content on blogs. Blogs are by far the most important channel in terms of volume of posts in Romanian (86% of all posts) and Polish (85% of all posts). In Russian discussions, 65% of all posts are submitted on blogs and in English nearly half of the anti-vaccination content (47%) is posted on blogs. Facebook is the second largest channel in terms of volume of posts. The social network has a share of 25% in English speaking networks, 13% in Polish, 8% in Romanian, and 5% in Russian channels. Facebook allows users to build personal profiles accessible to other users for exchange of personal content and communication via the Facebook. Twitter, which allows users to send brief (<140 character-long) updates, is the second largest channel in Russian-speaking (24% of the total volume) and fourth with 5% in English-speaking anti-vaccination communities. Other channels to consider are News websites and Forums in which users post comments to engage in discussions about specific topics. Since 68% of all participants in the anti-vaccination discussions during the observed time-period speak English, the dataset is able to reveal more accurate insights into demographics compared to the other languages. Insights in all languages can be found in Appendix 4, while the following analysis focuses on the English Page 16 data set. The English dataset also reveals that blogs have generally the highest rates of mentions (61%), conversations (67%), posts (67%) and interactions (43%). Based on the volume of posts, it is a logical consequence that most engagement takes place on blogs. Engagement is defined as followed: Post: An initial message submitted to a social networking site, i.e. a blog post, Facebook status, tweet, video, etc. Interaction: Any activity created as a direct response to an initial post, i.e. comments, likes, retweets, @replies, etc. Conversation: The sum of a post and all its related interactions. Note: a post with at least one interaction is considered as conversation. Mention: An appearance of search terms in a public social media space. Figure 3: Distribution by channel for Romanian, Russian, English and Polish networks Page 17 Blogs, forums, and Facebook are the leading networks for anti-vaccination discussions in English during the observed time-period. In other words, the anti-vaccination sentiments are expressed on those platforms through posting user-generated content. However, while conversations on forums only makeup 2% of total conversations, they account for 25% of all interactions among users. This indicates a heavily engaged audience. It can Figure 4: Mentions, Conversations, Posts and Interactions per channel. Page 18 be argued that opinions are formed during interactions among users and therefore, it is vital to add pro-vaccination content to the discussions on forums. Similarly, Facebook only contains 9% of conversations, but 21% of interactions. Both channels are important to consider for interactions with the anti-vaccination sentiment even if more posts occur on blogs. Similar findings occur in Forums. Forums are designed to be interactive conversation, where topics are discussed in greater depth. The English dataset is a reflection of this distinguish feature 16% of all posts and 25% of all interaction occur on Forums. The figures show that while the volume of content on Forums is relatively low, the engagement is an important strength that shaped the opinion in the anti-vaccination community. Figure 5 indicates that the data skews towards female audiences when issues such as developmental disabilities (59%), chemicals and toxins (56%) and side effects (54%) are discussed within the anti-vaccination sentiment, whereas men focus on arguments around conspiracy theory (63%) and religious/ethical beliefs (58%). Anti-vaccination social media participants are approximately 56% female and 44% male. Figure 5: Gender comparison in English per argument. Page 19 5.2 Common Arguments The amount of argument-mentions in anti-vaccination sentiment changes significantly by language during the observed time-period. Figure 6 illustrates that conspiracy theory and religious/ethical beliefs are the main topic trends in English, while religious/ethical beliefs drive the majority of discussions in Russian speaking anti-vaccination discussions. Polish anti-vaccination discussions are driven by arguments about side effects and chemicals and toxins in vaccines. The issue of chemicals and toxins is the major driver in Romanian discussions during the observed time-period. The arguments are described in detail in the following sections. The categories are based on keyword strings that were narrowed down over time. Issues should not be regarded in a static way, they might overlap and are interconnected. 5.2.1 Religious and Ethical Beliefs Religious and ethical discussions are especially active in discussion in Russian, with 96% of all anti-vaccination discussions focused on that issue. In English discussions, 32% of all anti-vaccination discussion use religious and ethical arguments. The arguments are less relevant in Polish (5%) and Romanian (0%) speaking anti-vaccination discussions. The main train of thought derives from Figure 6: Allocation of arguments by language for the anti-vaccination sentiment. Page 20 the belief that humans are created just as they should be and external interference is not required. My body was designed by God to be self healing and self regulating and no man will be able to do better than God is a quote by a female blog commentator from the US. Another user states, anything that involves substances that should never belong in a humans body, should not be injected or consumed without that individuals consent. Anti-vaccination advocates believe in homeopathy and alternative medicine. My BodyMy Decision writes a community member from Australia. A broad sentiment that mandatory vaccination is a violation of human rights can also be detected. From an ethical standpoint, the anti-vaccination community claims that it is a basic human right to be free from unwanted medical interventions, like vaccine injections. The same kind of argumentation can be recorded in all four languages. On June 15th 2012, the Polish Parliament voted to change the existing laws on vaccinations. The Act on Preventing and Fighting Infections and Infectious Diseases in Humans and in The Act on National Sanitary Inspection has created controversy among social media users because of it makes vaccination mandatory. The anti-vaccination advocates were sending petitions to the Polish President demanding him to stop the act. The petition received support from some representatives of the Catholic Church, but not an official support from the church as whole. Radio Maryja, the most powerful independent catholic media in the country, also critiqued the act based upon: The argument that vaccines are made based on cell lines derived from the bodies of babies killed by abortion. The notion of unethical activities by campaigning teenagers and women to be vaccinated against HPV infection and it is promoting immoral, and disorderly behaviour in the area of sexuality. 5.2.2 Safety and efficacy Side effects are the most common anti-vaccination theme in Polish networks (28%), but they also play a role in English networks (9%) and Romanian (5%). The argument is mentioned in less than 1% of all anti-vaccination discussions in Russian language. Typically, parents who reach out to online communities because they are unsure about vaccines trigger the discussions about side effects. Individual stories from parents are powerful because they humanize the discussion. One user writes, My baby is 5 months old, not vaccinated and he is going through pertussis right now! Its very scary! I HATE it! I have 3 children, the other 2 were vaccinated but Im scared to vaccinate my baby! Any other mommys new at Page 21 this? This quote reflects a level of fear and uncertainty about the right thing to do, even though the mother has experienced both the effect of vaccines and vaccine-preventable diseases. Another parent writes: My brother, sister in law, and all three kids under the age 5 were vaccinated for whooping cough and they all got it! An argument in a Russian network claims that live vaccines can mutate in the organism and create deadly strains. The fear of side effects leads to discussion about vaccines causing diseases and death. A user from the UK argues, The only way you can get this virus is if it is injected into you. Besides individual stories, argumentation backed by figures without context or sources are equally powerful in fostering fear of vaccines. For example, a member in one English network posts: Vaccinated children have up to 500% more diseases than unvaccinated children. Community members in Russia postulate that vaccinated children get sick 2-5 times more often than non-vaccinated children. For example in Romania, school nurses perform the mandatory vaccination during class, which is seen as a human rights violation and a safety issue. Parents are sceptical about the skills of the school nurses and feel surpassed by authorities in its decision to have children vaccinated. A user in a Polish anti-vaccination community states: I am a mother of two disabled children. When my daughter was five months old, she had a negative reaction to the vaccine, now she has been diagnosed with autism and mental retardation. For 10 years, I did not vaccinate my children and I would not want the right to decide on this matter taken away from me. I am an educated person, and have researched the subject and do not believe in the efficacy or safety of vaccinations. 5.2.3 Developmental Disabilities Another reoccurring argument in the anti-vaccination sentiment claims that vaccines contain toxins and harmful ingredients. Injecting vaccines into the body of a child leads to brain injury and developmental disabilities. This theme is discussed in 15% of all English and Polish speaking anti-vaccination discussions. Development Disabilities was in less than 1% of anti-vaccination discussions mentioned in Russian or Romanian networks. The arguments evolve from sentiment surrounding vaccines posing challenges to the immune system and producing antibodies that may cause autoimmune diseases. Another notable argument is that vaccines are not able to fight off the mutant viruses that develop over time. Across communities, anti-vaccination advocates link vaccines to Page 22 epilepsy, autism and neurodegenerative diseases (Parkinson and Alzheimer). A member of the Polish community writes: Mercury causes developmental disorders in children (including epilepsy and autism), in adults, neurodegenerative diseases (Parkinsons and Alzheimers), and degenerative changes in the reproductive systems of men and women, impairing their ability to reproduce offspring. It is notable that figures are used based on estimates by the author without links to sources. A Russian speaking user notes that vaccinations against pandemic influenza H1N1, also known as swine, can lead to the development of Guillain-Barr syndrome, acute poliradikulita in adults, according to Canadian researchers, published in the journal JAMA. 5.2.4 Chemicals, Toxins and Unnecessary(administration of vaccines) Our doctor has advised us to avoid vaccines in absence of a direct disease risk, since the long-term side effects have not been studied writes a member of an English-speaking community. One common argument recorded in the anti-vaccination sentiment is that studies about risks and impact of vaccinations are insufficient. Vaccines have not been tested enough and have concerns regarding the lack of long-term side effects studies. Another user states that I would really want to know whether and how well vaccine manufacturers test their final vaccine products () and how much contamination they discover. A common belief is that children having a vaccine-preventable illness just need food, water, and sanitation. In Polish communities, members use the example of Scandinavian countries lobbying for a ban of questionable and potentially harmful ingredients in vaccines. The notion that Scandinavian countries banned Thimerosal a long time ago and they have a much lower percentage of children with autism was classified was an important argument for users. Drawing on that example, the most common belief in Polish communities is that mercury may cause autism. A Russian-speaking user concludes, a recent large study confirms the results of other independent observations, which compared vaccinated and unvaccinated children. They all show that vaccinated children suffer 2 to 5 times more often than non-vaccinated children. Sources or links to the recited studies are not provided. 5.2.5 Conspiracy Theory, Western Plot and Conflict of Interest In English-speaking anti-vaccination communities (24%), a strong distrust against governments and pharmaceutical industry is Page 23 recorded. The same applies for Polish (5%), Russian (1%) and Romanian (3%) at a smaller scale. However, the U.S. and western governments are viewed critically when discussing about governments and conflict of interest. In Polish networks excessive vaccinations are seen as promoted by pharmaceutical companies in order to gain profits. The role of the pharmaceutical industry is discussed mostly negatively. The sector is regarded as corrupt marketing machine. An English-speaking user states that: In the vaccine industry, scientific fraud and conflicts of interests are causing a similar cycle of deaths and injuries that is being concealed and denied by regulators and vaccine manufacturers. The industry is viewed as profit-driven and has moved from its original purpose to save lives and protect humans. Romanian discussions directly blame the U.S. for purposefully infecting people with HIV using polio vaccines. Users create a direct link between vaccines and widespread HIV in Romanian orphanages. In the same sense, users claim that vaccines are being used against the Romanian populations. According to members of the anti-vaccination sentiment, vaccines against polio and chickenpox are used in Romania, which are not used in the U.S. anymore. Polish anti-vaccination communities state the examples of swine flu and bird flu two years ago. According to the users, both cases are plots by giant pharmaceutical companies. Some countries desperately bought a huge quantity of vaccines, while Poland acted rationally and did not buy the vaccines, which saved the state budget a couple of billion. The activists are suspicious because the epidemic ended after the new vaccines were purchased by several governments. The distrust against governments is also reflected in conspiracy theories. Patterns in English-speaking communities suggest that immunization is used to control and reduce the world population. One strain of argumentation is that vaccines that are not allowed in developed countries are imported to developing countries in order to reduce population growth. 5.3 Influencers Opinion leaders in anti-vaccination sentiment show varying characteristics across countries. However, they often appear to be well educated in alternative medicine. Some have no college education; others are in the medical field (such as nurses). A high level of volume and interaction can be recorded for influencers. They often subscribe to social channels of homeopaths and Page 24 alternative medicine advocates but they can be found across platforms. The following section lists a range of influencers that are active in different channels or languages: Name Position Facebook Fans Twitter Followers Blog Language Dr. Tennpen-ny The Voice of Reason about Vaccines 36,282 1,475 Yes English The Truth About Vac-cines Answering questions from concerned parents 21,246 N/A Yes English International Medical Council on Vaccination Purpose is to counter the messages asserted by pharmaceutical com-panies, the government and medical agencies that vaccines are safe, effective and harmless 7,983 N/A Yes English The Refusers "Vaccination choice is a fundamental human right." 9,069 12,457 Yes English Mothering Magazine Mothering is the pre-mier community for naturally minded par-ents. 66,504 102,173 Yes English Oglnopo-lskie Sto-warzyszenie Wiedzy o Szczepieniach STOP NOP Protest against new laws for mandatory vaccinations in Poland and against disinforma-tion campaigns about the effectiveness and safety of vaccines. 3,203 N/A Yes Polish STOP Pr-zymusowi Szczepie Petition campaign against new new laws for mandatory vaccina-tions in Poland. 2,866 58 Yes Polish Table 1: Examples of influencers in the anti-vaccination sentiment in social media. Page 25 With respect to the above-mentioned arguments, opinion leaders in the anti-vaccination movement put an emphasis on highlighting negative stories that focus on individual cases. In some cases, they blame outbreaks on shedding vaccinated children who get unvaccinated children sick. The argumentation is based on the conviction that vaccines are unsafe and dont work. A list of common arguments by arguments by influencers per language can be obtained in Appendix B. In this section the research question will be discussed in light of the theoretical and empirical findings. It needs to be noted that the discussion only focuses on engagement with anti-vaccination advocates in the four researched languages. This does not include pro-vaccination movements, medical professionals, partners or others. The discussion will propose a model that illustrates the different drivers of anti-vaccination sentiment based on three elements. The recommendations section builds on the three elements of the model and provides practical advice for communication strategies. 6.1 Discussion In order to develop engagement and messaging strategies for anti-vaccination sentiment, it is vital to have an abstract understanding of what drives users to become suspicious about vaccinations. Based on the findings, the paper proposes a model of anti-vaccination sentiment identification and salience. We classify three main spheres that attribute to a negative sentiment towards vaccine, which help us in the identification of trends within the anti-vaccination sentiment. The classification is illustrated in the following figure: DISCUSSION &RECOMMENDATIONS Page 26 The first attribute is the individual sphere. The main motivations for users to get involved are highly personal matters driven by concern and fear. When it comes to vaccinations, some parents are not sure what the right decision is. Am I a good mother if I do not get my child vaccinated or is it my responsibility as a caring parent to ensure the best protection for my child? Personal testimonies of other parents, especially negative stories, have a huge impact on the parent and fuel the concern. The second element that characterizes the anti-vaccination sentiment is the contextual sphere. The main driver behind the contextual sphere is a distrust of governments, pharmaceutical industry, scientific bodies and international organizations. It seems to be overwhelming for parents to understand the role of the big players. An interesting observation is that users in the contextual sphere do not seem to have a general resentment against vaccines per se but most arguments focus on lack of transparency in the decision processes as well as the potential conflict of interests trigger distrust. The third attribute is labeled as transcendental sphere. Negative attitudes towards vaccinations are derived from idealistic, religious and ethical beliefs. Arguments are rooted in strong beliefs and appear dogmatic, such as God creates us in the most ideal way or a body has its natural balance. Figure 7: Model of anti-vaccination sentiment identification and salience. Page 27 Individual, contextual and transcendental sphere are the key attributes of a member of the anti-vaccination movement. We argue that the various combinations of these attributes are indicators of the salience of members. We can identify four groups that derive from Figure 3. In order to understand salience within anti-vaccination community members, we propose the following classification Core Members are users that apply to all three spheres. They are concerned about side effects, distrust the government and live according to strong religious or ethical beliefs. Intense Members are members that apply to two of the three spheres. For example, a user might have concerns about vaccinations based on an individual sphere and also carry distrust against the pharmaceutical industry. But they are not driven by any idealistic beliefs. Alert Members are users that apply only to one of the three spheres. The doubt about vaccines derives only from one sphere and has human characteristics. They seem to be less convinced of the harm of vaccinations than the other two member groups. There is a fourth group of users, the Non-Members. They simply do not apply to any of the classification. We argue that Alert Members are easier to convince of the necessity of vaccines than Intense Members. Core Members are the hardest to convince, because the arguments against vaccines are based on various foundations. The findings also show that the intensity of argumentation, the interaction and the volume varies between the spheres. Therefore, the next section outlines practical recommendation on how to draft engagement strategies for each sphere. 6.2 Recommendations The following graphic summarizes the framework for the engagement and messaging plan that enables communication officers and health workers to react to the anti-vaccination sentiments. The framework is designed to be customizable for local realities. However, it does provide an overarching guidance for communication and campaigning initiatives. Members of the individual sphere should be approached with an emotional appeal. Users in this sphere go online and search for information in order to make an informed decision. Content that encourages parents to get their children vaccinated needs to be easy to find. Hence, search engine optimization plays an important role in the outreach strategy. Search marketing is used to gain visibility on search engines when users search for terms that relate to immunization. In order to appear on top if the search Page 28 results two general approaches should be considers: Organic search (SEO): When you immunization or vaccines into a search engine like Google or Yahoo!, vthe organic results are displayed in the main space of the results-page. For example, when parents search for information about vaccinations, pro-vaccine information should rank on top of the search engine results. By optimizing websites and posts, organizations and governments can improve the ranking for important search terms and phrases (keywords). Engaging actively in discussion and providing links to pro-vaccination content also helps to increase the visibility in the ranking. Paid search (SEM) enables to buy space in the sponsored area of a search engine. There are a variety of paid search programs, but the most common is called pay-per-click (PPC), meaning the information provider only pays for a listing when a user clicks the ad. The emphasis of the content strategy is to empower parents to ask doctors the right question in order to build confidence for the decision making process. Rather than criticising parents choices not to vaccinate, the messaging should promote an individuals ability to make the world a safer place for children. The communication strategy should also highlight the individual right and responsibility to choose to vaccinate. Through emotional Figure 8: Engagement Matrix for core spheres of the anti-vaccination movement. Page 29 messaging, hesitating parents should receive key information and explain how their choices affect their own children and the ones of others. The communities in the contextual sphere source their scepticism from general distrust against the large players involved in the vaccination industry. The engagement strategy should be based on a rational appeal that focuses on the hard facts of vaccines. It is important to avoid obvious communication tactics. Transparency about vaccines, testing, ingredients, potential side effects, funding and preventable diseases is crucial to reduce distrust. The messaging should also take into account past errors in vaccine campaigns by governments and suppliers in the regions and most importantly focus on the lessons learnt and how processes have been improving since then. Transparency can be built through a multi-channel approach that features the development of vaccines with expert testimonies. Successful cases, such as the near eradication of polio as a global effort, help to reduce distrust as well. This can be backed by official statistics on how infant mortality rates have been reduced over the past 20 years. Countries that generally have a favourable public perception, such as Scandinavian countries,

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