Vaccine criticism on the Internet: Propositions for future research

ABSTRACT

Research on vaccine criticism on the Internet is now at a crossroads, with an already important body of knowledge published on the subject but also a continuous and even growing interest in the scientific community. In this commentary, we reflect on the published literature from the standpoint of sociologists interested in social movements and their activists and the influence they can have on vaccination behaviors. We suggest several avenues of research for future studies of vaccine criticism on the Internet: 1) paying more attention to the actors who publish vaccine critical contents and to their use of the Internet in relationship to the other means through which they try to mobilize the population - the production of vaccine critical information on the Internet, and not only its nature and its reception, should therefore become one of the main objects of this strand of research -; 2) paying closer attention to what distinguishes the different strands of vaccine criticism regarding both what they dislike about vaccines (or about a given vaccine) and how this fight is integrated in a more general political or cultural struggle; 3) investigating further how the new forms of social interactions allowed by the Internet affect the transmission of vaccine related information and the capacity of vaccine critical actors to enroll members of the public in their political or cultural struggle.

KEYWORDS:

• antivaccine
• controversies
• internet
• social movement
• vaccine criticism

Introduction

The Internet is a multifaceted tool which has revolutionized information-seeking behaviors and communication strategies. This specific network, which connects individuals to producers of information via their public websites but also to other internet users through social media, has become one of the main sources individuals from developed countries turn to when looking for health-related information.¹ In countries where the majority of the population has easy access to the Internet, this platform represents a great opportunity for public health authorities to promote positive health related behaviors.

But, conversely, the ease with which information is published and accessed on this platform also represents an opportunity for those who question and criticize recommendations by public health authorities. The various formats of participation and diffusion of information on the Internet (websites, chatrooms, petitions, social media, wikis, etc.) are tools which facilitate organized action against public health recommendations and extend its reach. As many sociologists interested in social movements and health-related media controversies have underlined, the Internet constitutes a crucial asset for activists in their cultural or political struggle against state and scientific authorities.² Vaccinologists and public health experts interested in vaccination have been among the first in the medical community to identify and underline the medically subversive potential of the Internet. As soon as the year 2000,³ doctors and public health experts have underlined the existence of vaccine criticism on the Internet and, for almost ten years now, this specific platform has been at the core of contemporary concerns regarding the development of vaccine hesitancy and vaccine-related controversies (see for instance refs.^4-6).

Many studies have been devoted to the existence of vaccine critical discourse on the Internet and research on this subject has been particularly dynamic for the past five years (as testified by the multiplication of empirical studies on the subject published recently). This field of inquiry is at a crossroads, with an already important body of knowledge constituted on the subject but also a continuous (and even growing) interest in the scientific community. Therefore, we feel it is necessary to look back on past achievements and underline what has been learned on this subject and what the blind spots and unanswered questions are in the literature.

This commentary will reflect our specific approach to this subject: that of sociologists interested in social movements and their activists and the influence they can have on vaccination behaviors. Because we wish to focus on the broad issues facing this field of inquiry, we will not propose a systematic review of the results and methodology of all past studies. We will focus on the main results of this work and on ways to build upon what has been learnt.

We will first present how past researchers have defined the objective of the study of vaccine criticism on the Internet and how this has shaped the scope of this domain of research (section 1). We will then highlight the important empirical results from this academic literature. Researchers have mainly focused on two empirical questions: what kind of vaccine critical discourse can be found on the Internet and what influence does it have on Internet users? Sections 2 and 3 will respectively present the ways in which each of these questions have been investigated and new ways to approach and understand these questions.

Why study vaccine criticism on the internet?

Before we can evoke the empirical study of vaccine criticism on the Internet, it is necessary to understand why researchers have taken an interest in this phenomenon. An answer to this question can be found in the interpretations proposed by academics in dedicated articles under the “perspective” or “commentary” format or included in the “introduction” or “discussion” sections of research articles dedicated to this subject or to vaccination behavior in general. These commentaries constitute an important part of the academic literature on vaccine criticism on the Internet. Often based on the first-hand experience of doctors, public health experts or representatives of public health organizations, they make explicit the issues and assumptions underlying all research on this subject. The main reason why academics have studied vaccine criticism online is to understand the origins of low vaccination coverage and skeptical attitudes toward vaccination in the general public. The beginning of the 2000s has seen a multiplication of references to the Internet as a major source of misinformation on vaccination for the public and therefore as a possible cause for this noncompliance with public health recommendations. In these early works and comments, the Internet was already presented as a platform on which individuals went looking for information on vaccination in general or on some vaccines in particular.^3,7,11 From the inception, analysts have insisted on the necessity for public health experts to debunk this misinformation which appeared pervasive on the Internet and devise specific communication actions for this new media. Of course, the content of such commentaries and recommendations has evolved at the same time as the Internet itself. Since the beginning of the 2010s, commentaries tend to focus more on issues pertaining to social media while previous commentaries were mainly about websites, blogs and chatrooms.^4-6,12-21 In addition to original concerns about the ease with which information is published and accessed online, these more recent commentaries have highlighted how the growingly participative nature of the Internet exacerbates transmission of rumors via diffusion processes based on personal trust and comparable to word-to-mouth.

Beyond these minute changes, the underlying impetus for most research and commentaries is still centered, 15 years later, on the vaccine critical contents that can be found on the Internet on the one hand, and, on the other, on the effect they have on Internet users (see for instance refs.^22-24). This focus in the literature (commentaries and empirical research) on the interface between the public and the contents published on the Internet has enabled to better understand many aspects of vaccine-related belief formation, as we will see further in the next sections.

But the Internet can also be used to better understand the producers of vaccine criticism, their motivations, their potential audience and the type of resources they have and devote to their activism. The public can be influenced by these arguments only because some people, actors, organization, etc. strive to build these arguments and make them public on the Internet and therefore engage in some form of activism.² While this aspect has often been evoked, it has also been much less commented and researched (for exceptions, see refs.^6,7). Vaccine critical actors give a tremendous amount of information on themselves online (personal trajectory, professional activity, location, gender, proximity with other political or cultural groups, other types of vaccine-related activities in the real world such as organization of marches, protests, petitions, lobbying, etc.). Therefore, the Internet constitutes a goldmine for anyone interested in vaccine related social mobilizations and vaccine critical actors. Studying vaccine criticism on the Internet should therefore also be about understanding the social processes that guide production of this criticism which is the perspective of social movement analysis.^2,25 Using core concepts of social movement analysis such as that of “arenas” or “forums” which refer to the different institutional settings where political struggle can take place,²⁶ “boundary framing” which refers to how actors try to distinguish themselves from each other,²⁷ and to the actors' resources and strategies²⁸ would greatly help understand why vaccine critical information is so easily available on the Internet and the forms that it takes. Such an approach has already helped shed light on the various ways vaccines can be politicized and reach specific subcommunities.^5,29 Conversely, this would help make the study of vaccine criticism on the Internet an integral part of the understanding of vaccine criticism and vaccine related controversies in general.

Proposition 1: Future research on vaccine criticism on the Internet should focus more on the actors who publish vaccine critical contents and to their use of the Internet in relationship to the other means through which they try to mobilize the population. The process of production of vaccine critical information on the Internet, and not only its nature and its reception, should therefore become one of the main objects of this strand of research.

This broadening of the perspective has several methodological implications. Firstly, it entails a switch from a purely Internet-centered perspective to the investigation of the relationships between online and offline activities of vaccine critical actors. New research questions would then emerge: Are these actors mostly on the Internet or do they participate in political rallies, ecological fairs, professional gatherings, etc.? What other activities do they engage in and how do they relate to their presence on the Internet? This approach would help apprehend vaccine criticism in a comprehensive manner and analyze precisely and in an empirically grounded way what the Internet has changed about vaccine critical mobilizations. Secondly, this means that many more methodological tools, mostly developed by social scientists interested in social movements and their online activities (for a review, see ref.³⁰), can be applied to research on vaccine criticism on the Internet beyond the ones currently used (see in the next sections). For instance, many softwares and algorithms have been developed to make sense of activism and controversies using information gathered on the Internet. “Crawling” softwares are one particularly heuristic and easy to use example of such tools (for a review, see ref.³¹). By exploring how different vaccine critical websites cite each other, they would help identify the different communities involved in these controversies and their relationships to each other. This would raise another set of essential questions such as: are vaccine critics united in their fight or are there separate or even opposing communities? Are these “landscapes of actors” the same for each vaccine?

Studying vaccine critical discourse

Most empirical work on vaccine criticism on the Internet has focused on evaluating the tone of vaccine-related information present on the various platforms which constitute the Internet and on describing the arguments against vaccination that can be found there. Academics have mostly been focused on the English speaking part of the Internet (for notable exceptions, see refs.^32-40). These analyses have been applied to websites and blogs found via Google and other search engines,^{3,7,8,32,35,36,38,39,41-48} to contents posted on media websites, participative websites, chatrooms and social media such as Twitter, Facebook and Myspace ^{33,34,37,40,49-57} and, more rarely, to videos published on Youtube.^58-62 Their topic has mostly been vaccination in general, but some studies have studied specific vaccines such as the HPV vaccine^{32,36,37,39,44,47,51,55,59,61} or the pandemic and flu vaccines.^{34,35,45,50,56,57,60,62}

These studies are all grounded in some form of thematic or argumentative qualitative coding scheme, ranging from a simple evaluation of the tone of the content - positive, negative, neutral or ambiguous – (see for example refs.^45,59) to more elaborate schemes inspired by the Health Belief Model and/or a typology of cultures and arguments commonly associated with vaccine criticism (for the richest coding schemes see refs.^{42,44,51,54,61}). These coding schemes have enabled to document the variety of arguments mobilized to criticize vaccines, ranging from association of specific diseases with specific vaccines, general defiance toward “unnatural” products, alternative medicines, political arguments about freedom of choice, denunciation of the ties between the pharmaceutical industry and public health authorities, all the way to intriguing conspiracy theories involving the Illuminati and other hidden agents of the “New World Order.” Also, one general result is the importance of arguments pertaining to the safety of vaccines and to the untrustworthy nature of the medical community and public health authorities.

Results from these qualitative coding schemes are important additions to the qualitative literature on vaccine criticism in general. Coding results are then often correlated to objective attributes of these websites such as the number of views, the page ranking of these websites, etc. using elementary tools of statistical analysis (see for instance refs.^43,59). This quantitative approach has helped further demonstrate the pervasiveness of the theme of vaccine safety on all of these platforms and has generated interesting but more contextual results. Beyond this, it has not generated generalizable results or long term research perspectives. This limit can be partly attributed to the type of quantitative approach used by these authors: multivariate analysis based on the qualitative coding schemes evoked above. Such research would probably benefit from the application of quantitative tools specifically designed for the analysis of discourse, such as lexicometric algorithms for instance (for an introduction, see refs.^30,63). These more adequate quantitative tools would probably help analysts find more precise correlations by working on bigger samples of Internet discourse and sources.

But the main barrier to progress in the understanding of vaccine criticism on the Internet, which can be found both in quantitative and qualitative approaches, comes from the fact that most academics lump all forms of vaccine critical activism in a single category: the “antivaccine movement,” and therefore pay little attention to what separates vaccine critics from one another. Vaccine critical activists disagree with each other on a number of subjects, including on what political cause vaccine criticism should serve and on what makes any given vaccine dangerous. As we have argued elsewhere,³⁹ paying closer attention to the different ways in which activists give meaning to similar arguments, mobilize different arguments and even refuse to endorse arguments from other factions of vaccine criticism would help us understand more about why these actors' mobilize on the Internet. It would also shed light on why some vaccines are more controversial than others, why some vaccines are controversial in some countries and not others, how these controversies evolve on the Internet and why these controversies revolve around different or similar political or cultural issues. This approach would help better understand the emergence of vaccine hesitancy, since this phenomenon has been found to be very context-dependent.²³ These differences in positioning of vaccine critical activists also affect the likelihood that individuals will be convinced by the arguments they find on the Internet and the social and cultural profiles of people who will be convinced by each type of argument. It would therefore help better understand the origins of the various forms of vaccine hesitancy beyond the most radical forms of vaccine refusal.^64,65

Proposition 2: Future research on vaccine criticism on the Internet should pay closer attention to what distinguishes the different strands of vaccine criticism regarding both what they dislike about vaccines (or about a given vaccine) and how this issue is integrated in a more general political or cultural cause.

How vaccine critical actors influence the public through the internet

The Internet has worried public health experts and academics because it makes criticism of vaccines easily available and therefore makes vaccine critics potentially more influential. Many academics have tried to evaluate the degree of availability of this type of information and the effect it has on Internet users. Some researchers have corroborated the hypothesis that critical information found on the Internet does tend to induce more skeptical attitudes toward vaccines in the general population,^56,66,67 but these studies have been rather rare and small in scope. Attention has rather been focused on search engines and their critical role in making these contents easily accessible to the general public. Many studies have shown that vaccine critical websites appear in the first pages of results when typing keywords relative to vaccination in general,^{3,8,35,39,42,43,46} or some vaccines in particular,^{32,36,39,44,46,47} in the main search engines. A high proportion of vaccine-critical information has also been found on other web platforms such as Youtube^58,59,61 and Pinterest.⁵⁴ Most researchers have combined this evaluation of the accessibility of vaccine critical contents with explanations of what makes these contents so influential. This has mostly been done by investigating the rhetorical strategies used by vaccine critics to convince their audience, such as reliance on anecdotes rather than statistics, emotive appeals, use of pictures, self-presentations as “martyrs” or “underdogs” or representatives of “real Science,” etc.^{3,7,8,40,43,47,48,54,68} Most of these studies have focused on the discourse published by vaccine critics (tone, arguments, themes, style) with a focus on one specific form of internet use: active research of information by the individual in order to make a decision on the subject of vaccination. One way to move forward, building on the results obtained through this perspective, would be to shift the gaze toward the many ways in which vaccine criticism can circulate on the Internet in more complex and interactive ways than by just being available via the common tools of web research. Indeed, many Internet users can come across vaccine critical information without looking for it, through the mailing lists they sign up for, recommendations by friends on Twitter or Facebook, suggestions by news platforms, etc., which has been shown to be a decisive element when it comes to decision-making regarding vaccination.^69,70 The variety of formats through which interest is raised and information diffused on the Internet and (petitions, links, alerts, posts, likes, pins, retweets, RSS feeds, etc.) constitutes another open avenue of research on vaccine criticism on the Internet. While many studies have suggested that vaccine critics rely in some way on interactive ways to mobilize on the Internet,^{3,5,7,38,39,42,43,48,50} for instance via the administration of private forums or the setting up of petitions, few researchers have investigated this phenomenon further (for exceptions, see refs. ^{34,40,51,52,54,56}) and none have done so in a systematic way. The increasingly interactive and personalized nature of Internet use makes this issue of the ways through which individuals are confronted to vaccine criticism even more pressing. The fact that Internet users give a lot of information about themselves on social media constitutes a great opportunity for academics who can go beyond the content of vaccine criticism and study the circulation of information in the different social communities that exist both on the Internet and outside. This suggests important avenues of research such as: Do social media favor the dissemination of vaccine criticism beyond its habitual social groups or on the contrary participate in closing people on more homogenous subcommunities? Does the integration to a social group based on a common subculture (alternative medicine, spirituality, ecological movement, far right activism, libertarian, etc.) favor such an exposition and in which specific subcommunities does vaccine criticism hold the most grounds? Through which channels are people confronted to unexpected vaccine criticism: through online news media? Is it via recommendations by close friends and families or by more distant acquaintances? In order to start answering these questions, researchers could draw inspiration from the social sciences which have developed tools to investigate the different cultural communities on social media^31,71 and theoretical frameworks allowing to model social interactions, such as conversation analysis.^72,73

Proposition 3: Future research on vaccine criticism on the Internet should investigate further how the new forms of social interactions allowed by the Internet affect the transmission of vaccine related information and the capacity of vaccine critical actors to enroll members of the public in their political or cultural struggle.

Conclusion

Research on vaccine criticism on the Internet has been particularly dynamic in the past years. Using results and commentaries from previous publications, we suggested ways for research on vaccine criticism to advance in the future. More generally, we suggested that research on vaccine criticism on the internet would gain from drawing inspiration from general social science research and more specifically from one of its most dynamic strands: social movement analysis. This would help academics and public health experts better understand the dynamics of vaccine criticism, how these discourses are produced, by whom and how they resonate with wider political debates.

Results from this type of research would help public health authorities better identify the social groups which are the most confronted to vaccine critical information, better tailor their discourse to the specific concerns these individuals have both online and offline, but also design more effective and interactive ways to make their message heard.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Funding

We would like to thank the ANSM (Agence Nationale de Securité du Médicament et des produits de santé, convention n°2013S064) and the ANR (Agence Nationale de la Recherche, convention ANR-15-CE36-0008-01) for their support to the research which enabled us to write this commentary.