Risk, vaccine hesitancy and information literacy during the COVID-19 pandemic

Introduction

Vaccination has been positioned as playing a key role in ending the COVID-19 pandemic (CDC, 2019). However, initial uptake has slowed in the United Kingdom and is currently (at the time of writing) hovering at just under the 70% that is typically suggested as necessary for herd immunity (Gov.uk, 2021). In addition, there appears to be a gradual hardening of resistance to vaccination; in May 2021, 9% of unvaccinated people in the UK indicated that they would be unlikely to have the vaccine (Kings College, 2021). Information is important in vaccine decision-making (Dubé et al., 2021, p.184); research has indicated, for example, that a lack of information about influenza inoculations results in lower vaccination intentions (Kim and Real, 2016). Vaccine refusal or delay has also been linked to misinformation campaigns (e.g., Savolainen, 2021; Sharon et al., 2020). However, this research also runs the risk of positioning vaccine hesitancy as resolvable through simply sharing better quality information - and vaccine hesitant people as open to manipulation. It also neglects to examine the important role that information literacy, which is defined in this study as a social practice that references situated ways of knowing (Lloyd, 2010), plays in helping people to become informed about the COVID-19 vaccination. The study reported here addresses these issues through the following research question:

• How do vaccine hesitant people become informed about the COVID-19 vaccine?

In asking the question, this study defines vaccine hesitancy as ‘occurring on a spectrum that can include full or partial engagement with vaccination or vaccination refusal’ (Calnan and Douglas, 2020, p.293). This definition recognises that the term is complex, that there are many reasons why people may refuse vaccines, that people may hesitate over certain vaccines but not others, or that they may accept vaccines unwillingly (Dubé et al., 2013, p.1764).

Literature Review

Information sources form a common theme within vaccine hesitancy literature although the typical public health focus means information rarely forms the focus of study. More specifically, research tends to examine the internet and the media, with numerous studies linking the presentation of emotional anecdotes and inaccurate science on social media to increasingly entrenched perspectives on the value of vaccination (Dubé et al., 2013; Dubé and Gagnon, 2018). These ideas are also seen in the small number of studies examining COVID-19 vaccine hesitancy where celebrity influencers, amongst others, are seen to discourage vaccine take-up (Chadwick et al., 2021). At the same time, studies can also be critiqued for ignoring the complexity of decision-making, including the idea that people lack knowledge, agency, and the capacity to think critically (Goldenburg, 2016). Another commonly examined information source is the social network, which has been valued for the emotional support that it provides during vaccine decision-making (Reich, 2020). However, social networks have also been critiqued for reinforcing vaccine-hesitant attitudes, including through building social capital to help manage stigma (Attwell et al., 2018; Reich, 2020). An information source that has been almost completely sidelined from this literature is the body. Referenced through links to salutogenic parenting (Ward et al., 2018) as well as parental instinct (Johnson and Capdevila, 2014), the body is typically dismissed as peripheral to vaccine hesitancy.

The concept of trust plays an equally prominent role within vaccine hesitancy literature. Forming one of the three main determinants of vaccine confidence (Macdonald, 2015), trust is seen to be particularly important during times of uncertainty (Casiday, 2006, p.355). However, while trust in health professionals is typically quite high, especially when personalised vaccination health advice is offered (Casiday, 2007), trust in governmental information is often found to be extremely low. Often blamed on the government’s mishandling of previous health crises (Casiday, 2007), a lack of trust consequently leads to increased cross-checking of official information sources (Perretti et al., 2019), including governmental and health advice. Relatedly, and somewhat surprisingly, given the emphasis literature places on a manipulable public, studies also report increased cross-checking of media stories due to scepticism of the press’ vaccine agenda (Gardner et al., 2010; Perretti et al., 2019). The few studies that have explored COVID- 19 vaccine hesitancy to date confirm this emphasis on trust, with general surveys and qualitative research indicating that it is a lack of trust in the government rather than misinformation that fuels vaccine uncertainty (Royal Society for Public Health, 2020; Walker et al., 2021).

Vaccine hesitancy has not been widely examined within Library and Information Studies literature. The literature that exists commonly focuses on early childhood experiences and centres medical messaging as well as the role that trusted maternity care providers play in vaccine decision-making (Greyson and Bettinger, 2017; Koltai, 2020; Narayan and Preljevic, 2017; Rubincam et al., 2021). Questions of trust are also raised by Bossaller (2014), who notes the role that librarians can play in supporting vaccination decision-making in her examination of comments on vaccination news articles. Research examining COVID vaccination has been limited, being mostly focused on misinformation and vaccine hesitancy to date (e.g., Hagen et al., 2021; Savolainen, 2021). Scientific information and authorial expertise are noted by Savolainen (2021) as important criteria for the assessment of COVID-19 information credibility in his examination of a Reddit discussion forum, but much research remains to be done.

Conceptual Framework

The study is interpreted through the conceptual framework of risk. Risk has been theorised as either a techno-scientific objective danger to which people are exposed or as a sociocultural concept that is product of historical, social, and cultural ways of perceiving danger (Lupton, 2013, p.50). This study adopts a sociocultural lens, which draws upon the work of Douglas (1992) to position risk as ‘understood, lived, embodied and negotiated’ through sociocultural processes (Lupton, 2013, p.36). Focusing attention on the ways in which risk is shaped, this perspective emphasises how risk is brought into being through social, embodied, and epistemic sources of knowledge, including prior experience. Risk forms a key theme with vaccine hesitancy literature, where risk perception and risk communication are often positioned as central to precautionary action (e.g., Hackett, 2008; Volkman et al., 2020). While these studies often adopt a techno-scientific perspective, where risk is defined by experts and perceived by lay people (Ward et al., 2018, p.1118), research is increasingly starting to examine how people construct or weigh up risk related to vaccination (Casiday, 2007; Hobson-West, 2003; Ward et al., 2018), including in relation to social concerns, such as being a bad parent (Casiday, 2007). In contrast, most COVID-19 research to date has focused on high and low risk populations (e.g., Royal Society for Public Health, 2020), an epidemiological perspective that obscures broader considerations of meaning-making.

Methods

This study forms the third piece of work in a research programme examining how people become informed within the COVID pandemic (Lloyd and Hicks, 2021a; 2021b). The purpose of the third stage of this programme is to examine how people inform themselves about the COVID-19 vaccine. The project carried out 14 semi-structured interviews with people in the UK who were still making up their minds whether to have the COVID-19 vaccine. Interviews took place online through an end-to-end encrypted video conferencing tool in May- July 2021, after every adult in the UK had been offered the opportunity to be vaccinated. Interviews were audio-recorded and professionally transcribed, and questions centred on sources of vaccine information, misinformation, and information overload, amongst other topics.

Participants were recruited through adverts placed on social and community websites. Inclusion criteria included being over 18 years old and based in the UK. Participants were offered £20 gift cards for their time. Participants included six males and eight females and represented a wide range of ages and locations in the UK. Data were coded using constant comparative techniques used in constructivist grounded theory methods (Charmaz, 2014). Each researcher reviewed and coded each recording and transcript separately before discussing coding together over several sessions. Limitations of this study include the use of online recruitment methods, which may have favoured technologically proficient participants.

Findings and Analysis

Analysis is ongoing but early findings indicate that vaccine hesitant people inform themselves about the COVID-19 vaccination through Accessing experiential information, Reading the body, Confirming, Pooling and Hedging.

Accessing experiential information

One of the major ways in which vaccine hesitant people inform themselves about the vaccine is through accessing experiential information from previously immunised friends and family. Providing a way for people to access nuanced information about the vaccine, accessing experiential information, which they do through listening to people’s stories, allows people to assuage concerns that they may have about the impact of the vaccine (Participants B, T, W and X). It may also alert them to potential side effects and issues:

‘There were new experiences also about the vaccine, the, some of them were, some of them shared photos of how they feel, how they were desperate, they were not able to work’ (Participant U).

A powerful resource for action, accessing experiential information also illustrates how corporeal information affords a sense of reflexivity. At the same time, participants employ a range of checks and balances, including triangulating experiential information with online accounts (Participant G) and checking details of individual stories (Participant U), to assess the credibility of narrators. The emphasis on the storyteller's experience illustrates how the allocation of trust must be seen as similarly embodied and experiential.

Reading the body

People increasingly read their own body to become informed about the COVID-19 vaccination. Frequent mentions of distressing past experiences with vaccination (participants B, H, W) demonstrates how the body takes centre stage within participant hesitancy about the COVID-19 vaccination:

‘I have a bit of a bad history of not developing antibody responses to vaccines’ (Participant H)

The importance of the body in managing chronic illness has long been recognised (e.g., Birkelund and Larsen, 2013). Participants further centre their bodies as they read or monitor their own health and wellbeing, including taking precautionary measures such as wearing personal protective equipment (PPE) and eating more healthily (Participants J, L, M, N and Q). The body further brings additional understandings of risk into view (Lloyd and Hicks, 2021a; 2021b) as participants’ non-vaccinated status means that they become more aware of their bodies in relation to others’:

‘I always have my mask, I keep my social distance, and especially like around vulnerable people I adhere to keeping my distance’ (Participant L).

Demonstrating how bodies become the centre of safeguarding practice (Lloyd and Hicks, 2021a), comments that reflect the importance of embodied information echo arguments that complementary and alternative medicine advocates make about the primacy of the corporeal (Frawley et al., 2021).

Pooling

Analysis also demonstrates that pooling facilitates access to other useful forms of information. Referring to the combining ‘of fragments of knowledge’ (Lloyd, 2014, p.55), pooling helps people to tackle confusion over complex scientific or technical ideas (Participant B) or to cope with limited digital skills, including looking up information for parents, family, and community elders (Participants B, J, W). Connecting people to nuanced forms of knowledge, pooling alludes to future-oriented agentic activity through the emphasis on collaborative problem- solving. At the same time, participants also pool information to purposefully influence conversations in which they are involved, particularly if friends and family have marginalised their fears about vaccination. Pooling consequently forms the means through which people may spread unverified information: participant L, for example, used WhatsApp to distribute information about vaccine side effects when her family showed no interest in her point of view. Providing a further example of how information sharing is entangled with social support (e.g., Birkelund and Larsen, 2013), the emphasis on social inclusion also links pooling with broader questions of stigma.

Confirming

Another important strategy that participants employ in the process of becoming informed is confirming the veracity of the information that they come across. Often perceived to be side-lined within vaccine hesitancy, confirming typically centres on using sources of medical information to confirm or deny information, including the NHS website (Participants M, R, T and W) and family doctors, who assess the risk of vaccination in relation to participants’ medical history (Participants R, T and X). At the same time, participants’ trust in medical experts is not absolute, and they continue to critically assess medical expertise rather than accepting it unquestioningly:

‘And if that’s [vaccination development] going to take years, how can you get something with – I don’t care what university they went to’ (Participant N).

Demonstrating how participants subject even people that they typically trust to a range of additional checks, these findings also suggest that a person’s ‘sphere of authority’ (Wilson, 1983, p.19) may not remain constant in times of high uncertainty.

Hedging

Hedging was identified as a final strategy employed by participants to become informed about the COVID-19 vaccination. Participants indicated that they hedged when they suspected information sources may be misleading. Manifest in terms of careful distancing from specific sources or authors rather than individual pieces of information, hedging centres on the gradual lessening of contact with information rather than total avoidance. Government advice forms one of the most prominent forms of information that participants hedge against due to the perception that it lacks detail (Participant G), contradicts medical advice (Participant H, K, W, X) or forms a deliberate attempt to deceive (Participant G, Q). The press is similarly reviled, being variously labelled as ‘draining’ (Participant L), ‘negative’ Participant (W) or as ‘fear mongering’ (Participant K). Hedging consequently forms an attempt by participants to shield themselves from what they perceive to form poor quality information as well as additional emotional distress. At the same time, hedging does not indicate a complete withdrawal from society as indicated by the range of technological affordances that participants use to selectively monitor information (Participants L, K, R and W). Forming a pull approach to dealing with information, hedging also reinforces the affective dynamics of becoming informed within an uncertain information environment.

Discussion and Conclusion

Participants become informed about the COVID-19 vaccine through employing information strategies that bring vaccination risk into view. Helping to situate vaccine hesitant people in relation to epidemiological understandings of risk, including risk to the community and national COVID-19 efforts, these information strategies also position people in relation to social and physical health risks connected to the vaccine, which are accessed through experiential and embodied sources of information. These findings demonstrate distinct differences in epistemological approaches to risk, for example, how seeing striking side effects amongst friends and family (see Peretti et al., 2019) mean that vaccine hesitant people demand a different type of evidence for vaccine safety. They also underscore that unlike may be assumed (e.g., Dubé and Gagnon, 2018), vaccine hesitant people do not downplay medical risks related to COVID-19, as evidenced by the way in which they read their bodies in relation to others. Instead, information literacy practice brings multiple forms of risk into being, including social and other health risks related to COVID-19 as well as helping to mediate between conflicting responsibilities and priorities. These ideas also pick up on research related to the later UK lockdowns, when the government’s economic understandings of risk were not accessible to people who judged mental or physical health to be more of a concern (Lloyd and Hicks, 2021b).

Findings from this study have implications for our understanding of information literacy, not least because participants in this study reference information skills that would be recognisable by teaching librarians, including activities designed to find, locate, and evaluate information. At the same time, participants also reference information activities that are rarely recognised in mainstream information literacy discourse, including the idea that becoming informed in the COVID-19 context emphasises protection and withdrawal. Findings from this study consequently challenge whether ‘informed learning’ (Bruce, 2008) and other mainstream information literacy narratives uniquely centre on affirmative and preparatory information activities, as is typically assumed (cf. Lloyd and Hicks, 2021b).

Future research should examine vaccine hesitancy in relation to the booster shot campaigns currently being rolled out in many countries as well as the experience of young people, as the vaccine is approved for children aged five years and older. Research should also continue to explore the vaccine hesitancy spectrum, including engaging with vaccine refusers.

Acknowledgements

This project was generously funded by a Leverhulme/British Academy Small Research Grant (SRG2021/211338).

About the author

Alison Hicks is programme director and lecturer (assistant professor) in the Department of Information Studies at University College London. Alison’s research focuses on sociocultural approaches to information literacy within academic, everyday and health contexts with a focus on transition and risk. Contact: a.hicks@ucl.ac.uk
Annemaree Lloyd is a social science researcher in the Department of Information Studies, University College London. She conducts research into information literacies and contemporary information practices in formal and informal learning connected to workplaces, community settings and in education. Professor Lloyd pursues this research agenda working with a range of groups including refugees, emergency services personal, nurses and with patients suffering chronic illness. Contact: annemaree.lloyd@ucl.ac.uk

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