It's not just vaccine refusers who might not get the COVID-19 vaccination

22 February 2021
The surprising reasons why people don’t get vaccinated
As the COVID-19 vaccine rolls out, Coronavirus joins many other disease super-villains tackled by vaccination, including smallpox, whooping cough and polio. While some people still won't be vaccinated, the reasons might not be what you think.

Know your enemy and know yourself. This piece of advice, written 2500 years ago by military strategist and philosopher, Sun Tzu, now applies to the global battle being waged against COVID-19.

On the ‘know your enemy’ side of the equation, is one of the most concentrated and goal-driven medical endeavours ever undertaken, with thousands of researchers working to understand a virus that before January 2020, was unknown to science.

As a range of vaccines is produced and rolled out, the ‘know yourself’ element comes into play. That’s where Professor Julie Leask works. She is a social scientist and world authority on why people are and are not willing to be vaccinated. Currently she is applying her expertise to the emerging data on COVID-19 to find new and useful insights.

“It’s an area of huge complexity,” says Leask. “It incorporates sociology, psychology, cultural studies, implementation science, public health ethics, and other disciplines.”

Global collaboration

Leask doesn’t do this thinking just for Australians. As chair of a World Health Organisation (WHO) Working Group on the behavioural and social drivers of vaccination, she influences global strategies. She also co-wrote the WHO’s COVID vaccine safety communication plan. As COVID vaccines roll out, the plan is shaping how countries maximise uptake.

The groundwork for this has been happening since well before the vaccine, and well before COVID. It is in the nature of public health professionals that they aim for a constant state of knowledge and preparedness. When COVID-19 appeared, the focus just sharpened.

Professor Julie Leask

Professor Julie Leask

“For some time my team has been interviewing people about COVID-19,” she says. “People from culturally and linguistically diverse groups; people living in less wealthy areas of Sydney; people in other parts of New South Wales and in Melbourne’s hot spots. We’ve asked how COVID has affected their lives.”

“We’ve also looked at why some people who get symptoms don’t get tested and why some might not accept the vaccine.”

Because my grandmother refused vaccination, I went into the topic seeing it as just an issue of personal belief.
Professor Julie Leask

Once the information is assessed, the findings are fed through to state health departments to assist them with planning and producing information in a way that’s most likely to be effective.

It’s important work and Leask’s 23-year contribution hasn’t gone unnoticed. In 2019 at the Australian Financial Review 100 Women of Influence, she won the Global category then went on to become the overall winner.

And the work continues. Leask has a small team at the University and also works closely with former PhD students now at the National Centre for Immunisation Research and Surveillance. Together, they recently came up with possible negative scenarios around the COVID vaccine rollout and how to deal with them. Scenarios like: What if a stress-related fainting spell among a group of people in a clinic is blamed on the vaccine? What if people feel unwell after the jab and start putting their friends off having it? And what if reports emerge linking the vaccine to a medical syndrome?

This final scenario came close to playing out when it was recently reported that around 30 Norwegian aged care residents died after being vaccinated. Suddenly Leask found herself on television explaining the situation, “I never imagined myself in the rough and tumble of live media interviews,” she says.

Ultimately, no connection to the vaccine was found and, as Leask explained in her interviews, many of the residents were people with pre-existing conditions and some were in palliative care.

The barriers to vaccination uptake

A great advantage for Leask in understanding those who refuse vaccination is that her own grandmother was against it, believing instead that healthy living would prevent and cure diseases. “She said it was the worst day of her life when her grandchildren were vaccinated,” remembers Leask. “I know those perspectives. They’re not shocking to me.”

In a world where so-called anti-vaxxers get a disproportionate amount of media attention considering their small influence (vaccination rates in Australia have held between 91% and 93% since 2003), Leask admits that early in her studies, she also started down the wrong path.

“Because my grandmother refused vaccination, I went into the topic seeing it as just an issue of personal belief,” she says, “So when I started my PhD, I made the assumptions most people make about why immunisation rates are low.

“Problem was, the research didn’t support my preconceived ideas. It just didn’t. There were other forces at play. This was a slightly inconvenient fact for me and I had to reframe my PhD.””

Leask now calls this moment an epiphany where she started seeing people who weren’t vaccinating as a much broader group.

In reality, most are people faced with day-to-day logistical barriers. They might be single parents or families with multiple children where vaccination drops down their crowded to-do list, or people with questions about vaccination who don’t have easy access to health professionals they can talk to.

For Leask, the answer is in developing systems that address these obstacles. “Where this is done, there is success,” She says. “With busy parents, a simple reminder or a home visit can do the trick. And for people with questions, well trained health professionals can encourage them to be vaccinated with empathic questions and a recommendation.”

“Public health is a really constructive world to be in.”
Professor Julie Leask

So, the question can be asked: how will Australians respond to the vaccine rollout?

Based on Leask’s research, she anticipates the majority of Australians will welcome the COVID vaccines, as long as there aren’t any major safety or other hurdles. Some people will be unsure because they don’t believe such a new vaccine can be safe. A smaller number will refuse it outright for any number of reasons. An even smaller group will grab their keyboards to loudly campaign against its use.

With the limited resources she has, Leask doesn’t waste too many of them trying to convert the refusing groups. Instead, she focusses on what are called ‘the hesitant’. Still a relatively small number of people, they are the largest group of people not vaccinating, though it would be unfair, and even counterproductive, to label them antivaxxers.

Learning from measles to understand our future

For an insight into the post-vaccination future of Australia, there may be useful clues in Australia’s history with measles.

It’s not that widely known, but Australia was declared measles free in 2014, which we should all be happy about.

There was a time, pre-measles vaccination, when every Australian could expect to be infected with the virus at some time in their lives, with the danger of long term effects, like middle ear infections that could cause deafness, and brain swelling possibly leading to brain damage or death.

Despite the success of the measles vaccination program, the term ‘measles free’ is a slight misnomer. Rates of measles have plummeted since the vaccine was introduced from the early 1970s, but Australians still get measles, with the Department of Health citing 285 cases in 2019.

These measles infections mostly happen when travellers bring the virus back from overseas. These spot fires are easily put out because of herd immunity; meaning so many people here are immune or vaccinated against measles, that the virus quickly hits a wall.

That said, it can do serious damage when it does take hold because unvaccinated people often cluster in communities. If a travelling friend brings back measles, it can burn through an unprotected community like a bush fire.

So, will occasional COVID spot fires be the future of the virus in Australia? There is no predicting how a virus will behave or how a vaccination program will play out; Leask certainly won’t commit to an outcome, instead emphasising the need for more knowledge and education, which is another element of her work.

Improving communities through public health

Originally studying to be a nurse (“I found it too chaotic and I’m not a very practical kind of person in that way”), Leask is glad that her road away from nursing eventually led her back to it.

She now shares her knowledge about vaccination and evidence-based practice with nursing students at the University’s Susan Wakil School of Nursing and Midwifery. She is also a member of the Marie Bashir Institute for Infectious Diseases and Biosecurity and she has a connection to the School of Public Health through an affiliate appointment.

“There’s a shared value of working for the benefit of communities and society,” she says. “Public health is a really constructive world to be in.”

Written by George Dodd for the Sydney Alumni Magazine.
Photography by Stephanie Zingsheim.
Illustrations by Sam Bailey.

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