Addressing Parents' Vaccine Concerns: A Randomized Trial of a Social Media Intervention

"In an RCT conducted in a large integrated healthcare organization, an Internet-based intervention delivered during pregnancy and early childhood led to significant improvements in vaccine-related attitudes among vaccine-hesitant parents."

The objective of this randomised controlled trial (RCT) was to assess whether an internet-based platform with vaccine information and interactive social media components improved parents' vaccine-related attitudes. The rationale for the investigation included the fact that parents often seek vaccine information on the internet, even before the 2-month well-child visit, and providers report insufficient time during well-child visits to adequately address parents' vaccine concerns.

The study was conducted at Kaiser Permanente Colorado (KPCO) in the United States (US). Parents were enrolled during September 2013 through October 2015 and followed through November 2016; data were analysed in 2017. Parents, recruited during the third trimester of pregnancy, were randomised to the following: a study website with vaccine information and social media components (VSM arm); a website with vaccine information only (VI); or usual care. A multidirectional communication model served as the theoretic basis for the internet-based social media intervention and consisted of 3 components. Component 1 was a top-down process in which the study team developed and presented content to users on the study website. Component 2 was a bottom-up process that allowed website users to create content and interact with the study team. Component 3 was a side-to-side process in which website users could interact with each other and share information. This model is designed to empower users by allowing them to become active, engaged participants in the communication process, a process thought to promote positive changes in health behaviours. While the VSM study group received all 3 components, the VI group received only component 1.

The vaccine content presented on the study website was developed in collaboration with a health communications expert and used an "adapted mental models approach". The vaccine content and website design were pilot-tested and revised using focus groups and individual interviews with pregnant women and parents of young children. The factual vaccine content was guided by the Health Belief Model and the Theory of Planned Behavior, and it focused on encouraging parents to receive recommended vaccines on time while trying to adopt a collaborative and non-judgmental tone (by acknowledging that parental vaccine concerns were understandable given the ubiquity of vaccine misinformation). Seeking to accurately represent vaccination risks and benefits, the study website included content on the immune system, vaccine development, vaccine ingredients, vaccine safety, and vaccine-preventable diseases. It also featured relevant local information - e.g., about community disease outbreaks or changes to Colorado's school immunisation requirements. Content was clearly labeled and presented in short, easy-to-read sections, and the information sources were explicitly referenced and accompanied by hyperlinks. The vaccine content on the study website was identical for the VSM and VI groups.

Via the study website, the VSM group also had access to several social media formats including a blog, an "ask a question" portal, a discussion forum, and chat room. Parents could ask detailed questions of the vaccine subject matter experts and receive tailored responses within a few days. They were also emailed monthly newsletters encouraging website use, highlighting website updates, and providing additional vaccine content. Study website users were required to have a login and password, which may have created a more civil discourse by preventing staunchly anti-vaccination individuals from outside the KPCO community from posting highly negative comments.

The survey was administered to study participants at 3 timepoints: at study enrollment (i.e., at baseline), when their child was aged 3-5 months (Timepoint 1), and when their child was aged 12-15 months (Timepoint 2). Among 1,093 study participants, 945 (86.5%) completed all 3 surveys. Comparing baseline with Timepoint 1 among vaccine-hesitant parents, the VSM and VI arms were associated with significant improvements in attitudes regarding vaccination benefits compared to usual care (VSM mean change 0.23 on a 5-point scale, 95% confidence interval (CI)=0.05, 0.40, VI mean change 0.22, 95% CI=0.04, 0.40). Comparing baseline with Timepoint 2 among hesitant parents, the VSM and VI arms were also associated with significant reductions in parental concerns about vaccination risks compared to usual care (VSM mean change -0.37, 95% CI= -0.60, -0.14, VI mean change -0.31, 95% CI= -0.55, -0.07). Self-efficacy around vaccine decision making also improved among vaccine-hesitant parents. No intervention effect was observed among parents not vaccine-hesitant at baseline.

In discussing the results, the researchers observe that the intervention was effective among hesitant parents, whether interactive social media components were included or not. However, through discussing the topic online, and in-person with family and friends, parents contribute to the broader public discourse and help define social norms regarding the importance of vaccination for disease prevention. Furthermore, the finding that the intervention improved vaccine-related attitudes as well as vaccination behaviour may be viewed as strengthening the likelihood of causality of the observed effects.

They do acknowledge that potential challenges to dissemination exist. Ongoing resources will be needed to update the study website to the newest operating systems and portable device platforms. Creating new content, moderating the chat room and discussion forum, and directly responding to participants' questions was time intensive and required substantial vaccine subject matter expertise. One suggestion would be for communities to collaborate with regional immunisation coalitions to identify individuals with the knowledge and willingness to address challenging vaccine-related questions.