Steffens et al.

BMC Public Health (2019) 19:1348

https://doi.org/10.1186/s12889-019-7659-3

RESEARCH ARTICLE Open Access

How organisations promoting vaccination

respond to misinformation on social media:
a qualitative investigation
Maryke S. Steffens1* , Adam G. Dunn1,2, Kerrie E. Wiley3 and Julie Leask3,4

Abstract
Background: Vaccination misinformation is associated with serious public health consequences, such as a decrease
in vaccination rates and a risk of disease outbreaks. Although social media offers organisations promoting
vaccination unparalleled opportunities to promote evidence and counterbalance misinformation, we know relatively
little about their internal workings. The aim of this paper is to explore the strategies, perspectives and experiences
of communicators working within such organisations as they promote vaccination and respond to misinformation
on social media.
Methods: Using qualitative methods, we purposively sampled 21 participants responsible for routine social media
activity and strategy from Australian organisations actively promoting vaccination on social media, including
government health departments, local health services, advocacy groups, professional associations and technical/
scientific organisations. We conducted semi-structured, in-depth interviews to explore their perspectives and
practices. Applying Risk Communication principles as a lens, we used Framework Analysis to explore the data both
inductively and deductively.
Results: Organisations promoting vaccination face multiple challenges on social media, including misinformation,
anti-science sentiment, a complex vaccination narrative and anti-vaccine activists. They developed a range of
sophisticated strategies in response, including communicating with openness in an evidence-informed way;
creating safe spaces to encourage audience dialogue; fostering community partnerships; and countering
misinformation with care.
Conclusions: We recommend that communicators consider directly countering misinformation because of the
potential influence on their silent audience, i.e. those observing but not openly commenting, liking or sharing
posts. Refutations should be straightforward, succinct and avoid emphasizing misinformation. Communicators
should consider pairing scientific evidence with stories that speak to audience beliefs and values. Finally,
organisations could enhance vaccine promotion and their own credibility on social media by forming strong links
with organisations sharing similar values and goals.
Keywords: Misinformation, Immunisation, Vaccination, Anti-vaccination movement, Social media, Health
communication, Health promotion, Public health, Qualitative methods

* Correspondence: maryke.steffens@hdr.mq.edu.au
1
Centre for Health Informatics, Australian Institute of Health Innovation,
Macquarie University, 75 Talavera Rd, North Ryde, NSW 2113, Australia
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Steffens et al. BMC Public Health (2019) 19:1348 Page 2 of 12

Background Methods
Organisations promoting vaccination to the public on This study was approved by the Macquarie University
social media are in a unique position to address and Human Research Ethics Committee. In an approach
counterbalance misinformation. Understanding how similar to Mergel et al. [30], the purpose of this study
such organisations use social media—and the challenges was to uncover the experiences and decisions driving so-
they face therein—is therefore an important step to- cial media practices. Qualitative inquiry is useful to
wards neutralising misinformation. Yet little is known understand these internal processes.
about what guides such organisations’ practices.
The term misinformation refers to false information Sampling
shared without intention of harm [1]. Vaccination We compiled a list of Australian organisations promot-
misinformation is any claim that has been investigated ing vaccination via a web search in October 2017 using
and rejected with reasonable confidence in the peer- the keywords immunisation, immunise, vaccination, and
reviewed literature. The public are increasingly using vaccine. We searched Facebook and Twitter using the
social media to access health information [2], espe- same keywords, and explored their ‘Following’, ‘Fol-
cially parents with low confidence in vaccination [3]. lowers’, and ‘Friends’ lists. When creating this list, we
While these online spaces are useful for promoting identified seven broad categories of organisations. We
health [4, 5], there are few safeguards preventing the purposively sampled from the following five unequivo-
promotion of misinformation [6, 7]. Misinformation cally engaged in health promotion: advocacy groups,
can be popular [8], persuasive [9], and spread with government health departments, local health services,
relative ease [10]. Moreover, conventional health in- professional associations, and technical/scientific organi-
formation gatekeepers like specialist journalists have sations. We excluded media and health information
limited oversight on social media, creating an envir- pages, and companies selling products or services related
onment where the public may struggle to assess infor- to vaccination, because they were providing information
mation quality and credibility [11]. only, or selling a product. Short-listed organisations
As vocal critics of vaccination, anti-vaccine activists were active on either Facebook or Twitter (posted in the
disseminate misinformation via social media [12, 13]; last month) and were posting regularly (at least monthly)
one survey found half of parents with young children about vaccines and/or had run a vaccination-related
were exposed to negative messages about vaccination in campaign in the last 12 months. We chose to focus on
this environment [14]. Trolls and bots have also been activity on Twitter and Facebook as a marker of social
shown to post more frequently about vaccination than media engagement because of their popularity in
other users [15], although their potential reach and im- Australia [31]. Our final list consisted of organisations
pact has not been investigated. Misinformation is associ- with a primary or major focus on vaccination in their so-
ated with serious public health consequences, such as cial media communications. We subsequently identified
increased public fear and loss in vaccine confidence [16, other relevant organisations using snowball sampling.
17]. Misinformation may lower vaccine acceptability and Eligible participants were consenting, English-speaking
vaccination rates [18], and clusters of refusal are associ- adults responsible for the day-to-day running of their or-
ated with disease outbreaks [19]. ganisation’s social media page (individually or as part of
Social media offers communicators promoting vaccin- a team) or for developing the organisation’s social media
ation—including those from government, professional, strategy. We contacted potential participants via email
and community groups—opportunities to foster trust in and phone, inviting them to participate in a 30 to 60-
vaccination by promoting evidence and counterbalancing min anonymous interview, either in person or by phone.
misinformation [20–23]. Previous research describes the Written consent was obtained via an information and
social media practices of health promoting organisations consent sheet detailing the purpose of the study.
[24–29], but focuses largely on publicly observable charac-
teristics, such as the content and reach of their posts. Our Data collection
understanding of their internal decision-making and strat- Both our research questions and Risk Communication
egies to promote vaccination on social media is incom- principles informed semi-structured, in-depth interview
plete. To inform efforts to promote vaccination and questions (Additional file 1). Risk Communication prin-
combat misinformation, there is a need to document and ciples offer evidence-based best practices for engage-
analyse such organisations’ social media practices and ment with the public about risks such as vaccination
perspectives. This study aims to describe the strategies, [32], and are applicable to social media communication
viewpoints and experiences of Australian health commu- [33]. Risk Communication principles include communi-
nicators as they promote vaccination and respond to mis- cating clearly, openly, and with compassion; collaborat-
information on social media. ing with credible sources; listening to and involving
Steffens et al. BMC Public Health (2019) 19:1348 Page 3 of 12

stakeholders as partners; and planning thoroughly and Results

carefully [34]. Previous literature provided context for We approached 21 organisations in total. Four de-
the interview schedule; due to the limited availability of clined: 3 cited lack of time and 1 individual was new
similar research, it did not inform specific questions. to the role. We analysed 18 interviews, representing a
Interview topics included purpose of social media activ- total of 21 participants from 17 organisations. Eight
ity; perceived role promoting vaccination; and strategies organisations had an exclusive focus on vaccination;
for engaging. We audio-recorded interviews between the remainder posted about vaccination as well as
November 2017 and July 2018, and transcribed them other health topics. Most interviews involved a single
using a confidential service. We collected additional data participant; we interviewed two participants from or-
on participants’ professional experience and training. ganisations with separate roles for strategic direction
We initially recruited 12 participants, identified emer- and day-to-day social media activities. Each interview
ging themes through analysis, then continued to sample, lasted approximately 1 h; 16 took place over the
following identified leads until we reached thematic phone. Participants represented organisations from
saturation. each of the 5 categories. Most were media and com-
munications professionals (communications or social
Analysis media officers); some had a background in science
We used Framework Analysis [35] as it allows the use of and health (public health professionals, nurses, doc-
pre-defined and emergent themes to guide analysis [36]. tors). A small number were involved in social media
Using NVivo 11 for Windows (NVivo qualitative data for personal or other reasons. Participants held both
analysis software; QSR International Pty Ltd. Version 11, paid and volunteer positions, and all contributed daily
2015), analysis followed the five stages outlined by to their organisation’s social media activity. Table 1
Ritchie and Spencer [37]: 1. Familiarisation, 2. Identify- shows the number of participating organisations, par-
ing a thematic framework, 3. Indexing, 4. Charting, and ticipants and participant background by organisation
5. Mapping and interpretation. We moved back and category.
forth between stages throughout our analysis. After a Participants mostly discussed experiences of vaccine
small number of interviews, we familiarised ourselves promotion on Facebook. Most used Twitter primarily
with the data (stage 1). We then developed an initial for purposes other than vaccination promotion, and only
framework (stage 2) from themes derived from the inter- a handful reported using Instagram.
view schedule and social media Risk Communication We identified multiple themes and sub-themes in
principles [33]. Five a priori themes, derived from our analysis. In this paper, we present five overarch-
Veil et al.’s [33] recommendations on incorporating ing themes relating expressly to vaccination promo-
social media tools in risk and crisis communication, tion and misinformation. The first three themes
included: 1. Plan for using social media to communi- pertain to participants’ perceptions of the social
cate about risk; 2. Listen to and track audience con- media landscape and the actors in it: perceived
cerns and issues; 3. Create a presence and interact to threats to trust in vaccination on social media; how
build credibility and trust; 4. Build partnerships; and participants constructed their audience; and how par-
5. Be honest, forthcoming, and human. As we indexed ticipants saw themselves and their role. Figure 1 illus-
the initial interviews (stage 3), we expanded and re- trates these themes and their associated sub-themes.
fined the framework into a useful structure with The final two themes concern participants’ strategies
which to organise our data. Each index item within to promote vaccination and neutralise misinformation.
the framework was assigned a meaningful description. Figure 2 illustrates these themes and associated sub-
As we continued to interview, we indexed and sum- themes.
marised (stages 3 and 4) transcripts into a manage-
able data set, adapting the framework as necessary. In Perceived threats to trust in vaccination in the social
the final stage of data analysis (stage 5), we explored media landscape
the data for patterns both inductively and deductively Communicators identified several key threats to pub-
using Risk Communication principles. We were atten- lic trust in vaccination on social media, including
tive to similarities and differences between participant misinformation, an anti-science sentiment, complexity
categories. A critical realist perspective [38] informed of the vaccination narrative, and hostile anti-vaccine
our analysis. We used investigator triangulation when activists.
developing themes to ensure analytic rigour [39], and
were reflexive about our perspectives, arising from Misinformation
personal and professional stakes in vaccination pro- Misinformation was encountered routinely, on Face-
motion, through memo-writing and group discussions. book in particular, both on participants’ own pages
Steffens et al. BMC Public Health (2019) 19:1348 Page 4 of 12

Table 1 Number of organisations, participants and participant background by organisation type

Participant background
Type of organisation # of organisations # of participants Media Science /health Other
Advocacy group 8 8 2 4 2
Government health department 2 3 3 – –
Local health service 3 4 4 – –
Professional association 2 2 2 – –
Technical/scientific organisation 2 4 3 1 –
TOTAL 17 21 14 5 2

and further afield. Vaccine-related news stories on troubled by misinformation appearing credible in
Facebook, for example, were described as frequently what they depicted as a lawless environment, void of
inundated with comments containing distortions. Par- rules delineating fact from fiction, where “anyone can
ticipants noted recurring anti-vaccine claims, such as say anything and because it’s on social media, they’re
an alleged link between the measles, mumps, rubella allowed to be right, even if they’re wrong” (Advocacy
(MMR) vaccine and autism, as well as the misuse of group participant AG5).
research findings to support anti-vaccine tropes like
vaccine shedding associated with the MMR and per- “Social media is a place where you don’t need to
tussis vaccines. Anti-vaccine activists were mostly support your claims. You can make a pretty meme
held responsible for spreading misinformation, al- that says something like, ‘My child had their MMR
though social media users were acknowledged as also and the next day they were autistic and I regret that
unwittingly sharing poor quality information. Con- decision’… It’s a place where you don’t need evidence
cerns about misinformation threatening public trust for anything. It’s kind of like the Wild West in terms of
in vaccination centred on its pervasiveness lending making claims about immunisation.” (Advocacy group
weight to anti-vaccine claims. Participants were also participant AG8)

Fig. 1 Themes representing participant perceptions of the social media landscape and the actors in it
Steffens et al. BMC Public Health (2019) 19:1348 Page 5 of 12

Fig. 2 Themes relating to strategies used by participants to promote vaccination and neutralise misinformation

Anti-science sentiment perceived as wanting “simple answers, simple truths and

The authority of scientific knowledge was perceived as simple patterns”, whereas vaccination science was “a com-
diminished in the social media landscape; a phenomenon plex business” (Advocacy group participant AG1). Explain-
noted by advocacy group participants in particular. Anti- ing vaccine safety and adverse events—without alarming
science sentiment was characterised by resistance to audiences or appearing to gloss over the risks—exempli-
mainstream expertise, and scepticism of scientific evi- fied this difficulty.
dence. Doubts about vaccine science’s integrity, sus-
tained by compelling narratives circulated on social “The truth is that people can get sick from taking a
media, helped participants make sense of this attitude. vaccine … so you can never say something is 100%
Disregard of scientific knowledge was also attributed to safe. So when someone just asks you straight up, ‘Is it
a broader social trend of elevating beliefs over evidence. 100% safe?’, in some cases we can say yes, because
there’s a lot of research, but in others we can’t … and
“There’s the anti-professionals attitude with a lot of then instantly you look like you’re trying to hide
people; ‘Just because they’re a scientist, or just because something from someone. It’s quite difficult.”
they wear a white coat, that doesn’t mean they know. (Government participant G1)
I’m a mother, I know my child’, that attitude. I think
there’s a lot of people at the moment who just have no
respect for science and will dismiss it and replace it Anti-vaccine activists as a further hazard
with what they think, and they do that freely and do it Most participants reported frequent encounters with
all the time. I think that’s the world we’re living in at anti-vaccine activists on their own pages and posts,
the moment. Then those attitudes end up on social although a small group had a divergent experience,
media and that’s where the spread of it happens.” (Ad- expressing surprise at the rarity of direct exchanges.
vocacy group participant AG8) Distinct from hesitant parents with questions, activists
were depicted as people who “feed people lies and try
and convince people that not vaccinating is really,
A complex narrative really safe and a good thing to do” (Advocacy group
The disparity between ideal health messages—straightfor- participant AG4). Participants judged activists as so-
ward, clear and simple—and the reality of communicating phisticated and crafty operators, employing various
a vaccination narrative characterised by complexity and strategies to exert influence, such as masquerading as
uncertainty was depicted as problematic. Audiences were hesitant parents.
Steffens et al. BMC Public Health (2019) 19:1348 Page 6 of 12

“They’ll have somebody that will come and go, ‘Oh, anger and exhaustion. Emotional distress—at being char-
I’m not really sure about vaccines. Can you tell me a acterised as ‘an idiot’, ‘in it for the money’ and ‘wanting
bit about this?’ And once they’ve engaged you, their babies to die’ for example—was a hallmark of advocacy
friends on Facebook will see the conversations start, group participants’ accounts.
then suddenly you have all of these other people
jumping on board.” (Health services participant HS2) Constructions of their audience
Parents, and their family and friends, were the priority
Prolific posting of misinformation—putting up “link audience for advocacy groups, government health de-
after link after link after link after link after link so that partments and local health services. While professional
you had to shut the conversation down because it was association and scientific/technical organisation partici-
absolutely overwhelming everybody” (Health services par- pants primarily engaged with an expert audience, they
ticipant HS2)—was another strategy, as was operating as acknowledged also reaching parents.
a group, coordinating with American counterparts for
example, to amplify their efforts and project themselves Audience as information seekers
as a sizeable force. Audiences were characterised as information seekers,
people who “might see someone posting that there’s all
“There might only be 20 people actually actively this mercury and bad stuff in the vaccine and just want
commenting, but they’re just making lots and lots of to know” (Government participant G1). While most of
comments. But for someone who’s not familiar with it, their audience were understood to accept vaccination,
if they just come in and see comment, after comment, participants identified a hesitant group with doubts. As
after comment of ‘Vaccination killed my baby’, ‘I was opposed to anti-vaccine activists and their disingenuous
paralysed after this vaccine’, ‘There’s all sorts of toxins advances, this group was characterised as being ‘genuine’
in these vaccines’, that sort of thing … it’s quite and open to accepting vaccination. Participants also por-
disheartening.” (Advocacy group participant AG7) trayed this group as swayable: amenable to the ‘right’ in-
formation, but susceptible to messages from anti-vaccine
Anti-vaccine activists represented a significant threat: activists. Their perceived suggestibility gives clarity to
they were perceived as persuasive, constructing eloquent participants’ disquiet about the threat posed by misinfor-
arguments, skilfully commandeering scientific research mation and the rejection of science.
and endorsing misinformation to support their claims.
The silent audience
“They say, ‘Read this article’ and then you go and read The audience was seen as extending beyond those
the article. And you know, I work in a [technical/ openly commenting, liking and sharing on social media,
scientific organisation], I value science, I value especially by participants representing advocacy groups.
vaccinations. But you read it and it does sow a seed of Some of these ‘silent’ observers were perceived as cau-
doubt. And then you quickly push it from your mind, tious about making themselves publicly visible, prefer-
but some of them are very convincing … I know they’re ring to just observe or make contact privately. One
not true but for someone else, they might read that advocacy group participant made sense of this by sug-
and think, ‘Oh God, this is a big cover-up’.” (Tech- gesting they feared attack from anti-vaccine activists:
nical/scientific organisation participant TS2) “People message us all the time saying, ‘I wasn’t brave
enough to comment on that thread but thank you, the in-
Activists were often labelled pejoratively as ‘anti-vax- formation you provided made sense’“ (Advocacy group
xers’. Participants created a dichotomy between them- participant AG3).
selves and activists, which served to justify their
unflattering portrayals: activists were unreliable, unbal- Constructions of themselves and their role on social
anced, and ‘hysterical’. media
Through their language, participants evoked a notion The role of information provider
of being at war with anti-vaccine actors: activists aggres- Having cast their audience as information seekers—and
sively ‘bombarded’, interactions were ‘battles’ and social hesitant parents as vulnerable to misinformation—par-
media was a conflict zone with ‘sides’. Participants ticipants’ principal role was a provider of high quality in-
recounted activists’ crude language and name-calling, as formation; an advocacy group participant (AG5)
well as vitriol and personal attacks. The potential for ac- characterised their role as finding and sharing the “high-
tivists’ explosive reactions made the landscape a volatile est standard of information”. More than a role, it was a
‘minefield’, where participants had to be wary and on ‘responsibility’. Casting themselves as benevolent guides,
guard. Participants’ reactions ranged from resignation to they directed their audience to credible information in a
Steffens et al. BMC Public Health (2019) 19:1348 Page 7 of 12

misinformation-littered landscape and reassured them of to what they’re saying’.” (Advocacy group participant
the value of vaccination with easy to understand infor- AG7)
mation. Audience questions focused on vaccine safety,
eligibility, and cost; some were more technical, like re- Some responded by highlighting shared experiences
quests for individualised schedules. Some participants and concerns, such as being fellow parents. One advo-
saw themselves as compensating for a shortfall in sup- cacy participant (AG3), for example, pitched themselves
port from general practitioners (GPs), supporting a flood to audiences as “just mums and dads” with “our own
of parents on social media requesting personalised stories about how we came to be doing this” (Advocacy
information. participant AG3).

“There is a huge demand for it … I often don’t have

Strategies to promote vaccination
time to answer them. I do my best and I recruit other
Using facts and evidence
helpers, but at the same time I’m always like, ‘Make
Despite reservations about the diminished status of sci-
sure you see your GP’. But I feel like they’re not always
entific knowledge, scientific evidence and facts were im-
getting the answer they need in the short little GP
portant tools for addressing audience concerns.
sessions.” (Advocacy group participant AG4)
Communicating information and promoting ‘the truth’
to audiences was a paramount strategy; cutting through
with facts was crucial to winning the battle against mis-
Rational, reasonable, open and authentic
information and anti-vaccine messages. Facts could cre-
Participants positioned themselves as rational, objective,
ate a safe and sanitised information environment, an
and evidence-based—a trusted voice on vaccination in
antidote to the “contaminated, lazy advice on the inter-
the social media landscape. They situated themselves as
net” about vaccination (Advocacy group participant
strongly connected with science, thus differentiating
AG5). Facts were able to ‘satisfy’ audiences; they could
themselves from unreliable and unreasonable anti-
soothe and comfort. Aware of the potential for misinter-
vaccine activists. Appearing level-headed—especially in
pretation, however, complex facts were distilled with
interactions with activists—was important for building
great care, using straightforward language.
trust with audiences, who might be observing in silence:
“We need to come across as the responsible, reasonable,
calm ones because of all the people that are reading and Humanising the threat of disease
not commenting.” (Advocacy group participant AG3). Having observed some emotional posts achieving a
Wariness about appearing dishonest in the face of com- broader reach, some participants conceded the difficulty
plex information—“like we’re trying to hoodwink people” of engaging audiences using only impersonal facts. Some
(Technical/scientific organisation participant TS2)— expressed fear that audiences might migrate to ‘unsafe’
underscored efforts to be open and forthcoming with in- places on social media in search of more emotionally
formation, especially about thorny topics like adverse satisfying experiences.
events.
“If all the information they’re getting is
“[We’ve had] a lot of people applauding us for intellectual—it’s on a government website, it’s someone
highlighting that vaccines aren’t perfect. I think it saying, ‘Of course this is safe’—that doesn’t fill that
helps with being transparent and authentic and emotional gap. And so where do people go? They go to
honest. You know these things do happen and if I just their parenting groups. The online Facebook parenting
post ‘vaccines are wonderful’ all the time that’s not groups are the worst for this type of thing, where you
being 100% honest. I think it helps with credibility.” have a question and guess who’s going to reply? …
(Advocacy group participant AG4) Non-vaxxers are going to jump on board and try to
bring that person over to the dark side.” (Advocacy
Broadcasting their authenticity was a significant con- group participant AG5)
cern for advocacy group participants, who were mindful
of reassuring their potentially wary audience of their In response, scientific evidence was supplemented with
trustworthiness and independence. strategies that humanised the threat of disease. Personal
stories, for example, generated emotional associations
“I want [them] to go, ‘Okay, so these guys are just quiet with vaccination by making the threat ‘real’: “If you say,
and rational, they provide information, they answer ‘There’s this 40-year-old mum of three on the Gold Coast
questions. They’re not funded by the government, who has died from [a vaccine preventable disease]’, a lot
they’re not funded by pharma. Maybe I should listen of people go ‘Oh, she’s my age, that could have been me’.
Steffens et al. BMC Public Health (2019) 19:1348 Page 8 of 12

So that changes their perspective and makes it less theor- views by responding. As expressed by one advocacy
etical” (Advocacy group participant AG1). participant (AG3): “We don’t want to frame the whole
vaccination thing as a debate”. Others lacked the re-
Creating safe spaces sources to respond more frequently. Some felt they
A sense of responsibility for creating safe spaces—enab- should respond to misinformation only when a post
ling audiences to ask questions without fear of harass- had the potential to reach large numbers of people,
ment—was evident. An awareness of watchful, cautious, such as when celebrities or other high profile people
and silent audience members rendered this approach were spreading misinformation.
imperative for some advocacy group participants, who
created safe spaces through private messaging and “If it’s a typical conversation about some anti-vax
closed Facebook groups. Almost all participants reported myth then I ask, ‘Is this something the average per-
hiding or removing aggressive comments and reporting son will be hearing? Or is this just sort of withering
users to Facebook if necessary. Through these strategies, away in these anti-vaccine groups?’ If it’s a massive
participants further revealed their impression of social public issue then I will make a comment on it …
media as a hostile environment, and audiences as in otherwise I’ll just ignore it.” (Advocacy group par-
need of protection—mostly from belligerent anti-vaccine ticipant AG4)
activists, but sometimes from unruly vaccine supporters
as well. Others chose not to respond because they viewed anti-
vaccine activists as ‘immovable zealots’ and “a lost cause”
“Swearing at others in the community is a definite ‘no’ (Technical/scientific organisation TS2), and attempts to
and that gets deleted immediately. We don’t want to convince them akin to “banging your head against the
engage in that stuff. We want to make sure it’s a safe wall” (Government participant G2).
place for our parents to go and chat about different
issues.” (Advocacy group participant AG6) “I would never directly answer every single anti-vaxxer
and refute their claim, because they’re just going to
come straight back and be like, ‘Well, look at this, blah
Strategies to neutralise misinformation blah blah’. They want an argument, and we don’t
The information space on participants’ social media want to give them an argument.” (Technical/scientific
pages was controlled primarily by monitoring for misin- organisation TS2)
formation. Responses took various forms.
These participants reported scrutinising profiles to
Partnering with the pro-vaccine community identify activists and blocking repeat posters. This ap-
In the first instance, vaccine-accepting members of the proach was not without risks, however: one advocacy
audience were relied on to respond to misinformation group participant described the possibility of rebuffing
while participants watched and moderated responses. genuine requests for information. This was due to the
These individuals were variously described as ‘legitim- difficulty of differentiating between activists and ques-
ate’, ‘passionate’, and helping to ‘defend science’, and tioning parents: “Deciding that is a time consuming ac-
were styled as critical allies in a deeply combative tivity … and sometimes I get that wrong. I guess I have
landscape. not responded or banned too many people who probably
just had genuine questions.” (Advocacy group participant
A circumspect approach to responding AG4)
Careful consideration about responding was the pre-
vailing approach to misinformation. When responding Tracking conversations
directly, attempts were made to be concise and re- Tracking and monitoring conversations on social media,
spectful, mindful of their silent audience, watching including in anti-vaccine groups, was used to understand
and listening. Only a handful of participants always “the latest anti-vax myth” (Advocacy group participant
responded to misinformation immediately, however. AG4). Participants were thus able to anticipate hesitant
Instead, many were selective, using a range of ap- parents’ concerns and avoid being caught unaware, un-
proaches in lieu of direct responses: ignoring, delet- prepared to adequately address new rumours. Several
ing, or hiding offending posts, for example, or did so covertly to mitigate organised efforts to spread
addressing recurring themes in separate posts. Partici- misinformation by anti-vaccine activists. These strategies
pants offered a range of reasons for this circumspect reveal communicators as engaged in an arms race of
approach. Some wanted to avoid amplifying misinfor- sorts, competing against activists to exploit the function-
mation or lending false legitimacy to anti-vaccine ality of social media to their advantage.
Steffens et al. BMC Public Health (2019) 19:1348 Page 9 of 12

Strengthening the pro-vaccine voice time of interviews may be less important as the land-
Strengthening the pro-vaccine voice to match that of scape develops.
anti-vaccine activists was viewed as critical to counter- Here we explore several questions raised by the find-
acting misinformation and promoting trust in vaccin- ings about countering misinformation, the role of facts
ation. Publicly supporting vaccination on social media and evidence, responding to anti-vaccine activists, and
was seen as vital support for hesitant individuals consid- the possibilities raised by collective action.
ering vaccination.
Questions around responding to misinformation
“Just having that voice and that presence … we’re just While participants sometimes directly responded to mis-
reminding people we exist. ‘Look, there’s someone out information, they often utilised other strategies. There is
here who thinks vaccination is a good idea. We’re not mixed evidence on the effectiveness of refuting misinfor-
commercially invested. We’re not the government. mation on social media. Correcting misinformation, par-
We’re just like you and you’re doing the right thing’. ticularly in an adversarial manner, can be distressing for
It’s encouraging those hesitant parents and just communicators, bring attention to anti-vaccine ideas
reminding them they’re doing the right thing and and reduce intention to vaccinate among those with
they’re not alone.” (Advocacy group participant AG5) concerns about vaccine safety [9, 40–42]. Avoiding or
deferring a response, however, may miss opportunities
To this end, partnerships with other organisations to refute the misinformation, a strategy recently shown
played an important role. Informal relationships— to mitigate the negative effects of exposure to anti-
through which they shared and amplified each other’s vaccination arguments [43]. This may be important for
posts—increased their combined reach and strengthened those audiences who are silent, i.e. those observing but
their collective voice. The belief that vaccine-promoting not openly and publicly engaging by commenting, liking
organisations as a group were failing to adequately en- or sharing posts. Silent observers are likely to make up a
gage in the social media landscape was a source of frus- significant portion of the audience [44], and their beliefs
tration for some advocacy group participants, however: may be modified when they witness others being cor-
“There are so many anti-vaccine voices. They’re just pre- rected by a reputable source [45].
dominant and there’s very little from official and profes- We recommend communicators consider directly
sional organisations to make sure there’s just as much countering misinformation because of the potential to
out there that’s in support of immunisation” (Advocacy influence their silent audience. Not all situations will
group participant AG8). These participants especially warrant direct refutation; like health journalists, commu-
expressed a desire to create a strong and united front in nicators could address misinformation only when it
the face of anti-vaccine sentiment. meets certain criteria, such as spreading beyond the
source community [46]. When crafting a response, com-
Discussion municators could avoid strengthening misinformation in
This study provides novel insights into how health their audience’s memory by emphasizing the corrective
communicators promote vaccination in a social media information, and warning of any upcoming misinforma-
environment they perceive as adversarial and littered tion [47]. Furthermore, explaining why misinformation
with misinformation. Participants used a set of so- is incorrect (and if possible, providing an alternative ex-
phisticated strategies—frequently aligned with Risk planation) is more effective than simply labelling misin-
Communication principles [33]—to address these formation as false [48].
challenges, including: building a presence on social In situations that don’t warrant direct refutation, com-
media and engaging with audiences to build trust; lis- municators could focus on empowering audiences to in-
tening and responding to audience concerns; commu- dependently recognise and resist misinformation, for
nicating with openness in an evidence-informed way; example by exposing flawed anti-vaccine arguments [13,
countering misinformation with care; and harnessing 49]. Such as approach should unmask the technique
the reach of like-minded organisations. (such as selective use of evidence) and address each
Our study may be limited by the fact that we did not point with evidence-based information [50]. Like our
reach all organisations promoting vaccination, possibly participants, communicators could also partner with
rendering the picture of how such organisations engage vaccine-accepting members of the public; such relation-
on social media somewhat incomplete. Participants rep- ships are especially valuable in times of crisis [34, 51].
resented Australian organisations, which may limit gen- Communicators should avoid relinquishing all oppor-
eralisability to other countries and contexts. Finally, our tunities to respond to misinformation, however; reput-
understanding of social media is constantly evolving; able organisations are more effective than individuals at
strategies and circumstances that were relevant at the correcting misperceptions [45].
Steffens et al. BMC Public Health (2019) 19:1348 Page 10 of 12

Questions around the role of facts and evidence vaccine voice [33], our findings point to limited formal
Consistent with strategies used by other pro-vaccine or- collaboration. We recommend communicators seek out
ganisations [52], participants’ use of facts and evidence reputable organisations with shared values and goals.
corresponds with the knowledge deficit model, where Improved coordination amplifies pro-vaccine messages;
lack of support is considered to be driven by lack of strengthening formal links may enhance collective cred-
knowledge [53]. On its own, however, scientific informa- ibility, a salient benefit given lack of public trust in ex-
tion is not always sufficient [54, 55]; experimental stud- perts and science-related content online [60, 66, 67].
ies suggest narrative forms may be more convincing Combining resources may also enable collaborating
[56], a point not lost on anti-vaccine activists [57–59]. organisations to more effectively and efficiently address
Thus, we recommend pairing scientific evidence with misinformation and audience questions—by building a
story-telling. Positive first-person accounts, or the pos- credible and personalised information and support ser-
ition shift of someone previously holding anti-vaccine vice, for example. This could take the form of question
views, can reinforce vaccination as a social norm [22, and answer sessions hosted by a well-connected organ-
57]. Anecdotes from people personally affected by isation, or a dedicated Facebook page staffed by a panel
vaccine-preventable diseases are perceived as particularly of vaccination experts, medical staff, and the public. Fi-
credible [60], although require care in their use given nally, structured collaboration may help map the com-
the variable effects of appeals to fear on different audi- plementary roles vaccine promoting organisations play
ences [40, 41, 61]. Communicators should bear in mind in the social media landscape, thus overcoming ineffi-
the narrative structure of their stories, developing spe- ciencies and perceived lack of participation. Advocacy
cific components such as setting, characters, plot and groups, for example, may be suited to providing personal
moral to speak to audience beliefs and values [55]. support, while government health departments and local
Factual information will always be necessary to com- health services may best fulfil audience needs by acting
municate about vaccination [62, 63]. Overloading audi- as a transparent and evidence-based information source.
ences with complexity, however, may reinforce
misperceptions—especially if the misinformation offers a Conclusion
simple and compelling account [47, 62, 64]. Hence cor- Communicators face a variety of challenges promoting
rective explanations should be straightforward and suc- vaccination on social media, including competing against
cinct. Communicators should also be transparent and misinformation spread by anti-vaccine activists, promot-
forthcoming with information, which can decrease audi- ing science in the face of anti-science sentiment, and the
ence perceptions of risk [63] and discourage audiences difficulty of conveying a complex vaccination narrative.
from turning to less credible sources [33]. We found that some communicators chose not to respond
to misinformation directly, while others were aware of the
Responding to anti-vaccine activists impact that direct refutation may have on silent audience
Avoiding hostile interactions with anti-vaccine activists members who were observing but not engaging. Many
is an approach supported by evidence: argumentative en- participants perceived of the social media landscape as a
gagement suggests the value of vaccination is in dispute conflict zone and described efforts to remain civil and
[60]. In keeping with our participants’ approach, we rec- avoid hostile interactions with anti-vaccine activists. Most
ommend interactions with anti-vaccine activists be brief, prioritized facts and evidence in their communication;
factual and polite. Avoid inflammatory labels such as many recognised the value of a strong collective pro-
‘anti-vaxxers’; easily interpreted as an attack, this lan- vaccine voice.
guage risks entrenching an adversarial paradigm [64]. In response to these challenges, we recommend that
Vocal anti-vaccine activists create a disproportionately communicators weigh up the value of directly countering
large social media footprint by using ‘guerrilla’ tactics to misinformation because of the potential influence on their
amplify their influence. In reality, however, they are silent audience. Any refutation should be straightforward,
small in number and loosely organised [12, 65]. Thus succinct and should avoid emphasizing the misinforma-
communicators should avoid implying the anti-vaccine tion; any interactions with anti-vaccine activists should be
movement is larger, more powerful, and more organised brief and polite. Communicators should avoid lending the
than it really is by overstating its size. When necessary, anti-vaccine movement undue influence by overstating its
refer to activists in specific numbers or as individuals ra- size. When developing communications, we recommend
ther than a collective [46]. approaches that pair scientific evidence with stories that
speak to audience beliefs and values. Finally, we suggest
Collective action to strengthen the pro-vaccine voice that the efforts of organisations promoting vaccines on so-
While Risk Communication principles emphasize par- cial media would be enhanced by strong links with organi-
ticipation in social media spaces to strengthen the pro- sations sharing similar values and goals.
Steffens et al. BMC Public Health (2019) 19:1348 Page 11 of 12

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