Mapping vaccine hesitancy—Country-specific characteristics of a global phenomenon

The term vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite the availability of vaccination services. Different factors influence vaccine hesitancy and these are context-specific, varying across time and place and with different vaccines. Factors such as complacency, convenience and confidence are involved. Acceptance of vaccines may be decreasing and several explanations for this trend have been proposed. The WHO Strategic Advisory Group of Experts (SAGE) on Immunization has recognized the global importance of vaccine hesitancy and recommended an interview study with immunization managers (IMs) to better understand the range of vaccine hesitancy determinants that are encountered in different settings. Interviews with IMs in 13 selected countries were conducted between September and December 2013 and various factors that discourage vaccine acceptance were identified. Vaccine hesitancy was not defined consistently by the IMs and most interpreted the term as meaning vaccine refusal. Although vaccine hesitancy existed in all 13 countries, some IMs considered its impact on immunization programmes to be a minor problem. The causes of vaccine hesitancy varied in the different countries and were context-specific, indicating a need to strengthen the capacity of national programmes to identify the locally relevant causal factors and to develop adapted strategies to address them.     

Measuring vaccine hesitancy: The development of a survey tool

In March 2012, the SAGE Working Group on Vaccine Hesitancy was convened to define the term “vaccine hesitancy”, as well as to map the determinants of vaccine hesitancy and develop tools to measure and address the nature and scale of hesitancy in settings where it is becoming more evident.The definition of vaccine hesitancy and a matrix of determinants guided the development of a survey tool to assess the nature and scale of hesitancy issues. Additionally, vaccine hesitancy questions were piloted in the annual WHO-UNICEF joint reporting form, completed by National Immunization Managers globally. The objective of characterizing the nature and scale of vaccine hesitancy issues is to better inform the development of appropriate strategies and policies to address the concerns expressed, and to sustain confidence in vaccination.The Working Group developed a matrix of the determinants of vaccine hesitancy informed by a systematic review of peer reviewed and grey literature, and by the expertise of the working group. The matrix mapped the key factors influencing the decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine-specific. These categories framed the menu of survey questions presented in this paper to help diagnose and address vaccine hesitancy.     

The effect of health literacy on COVID-19 vaccine hesitancy among community population in China: The moderating role of stress

BackgroundThe public’s hesitant attitude is a major subjective barrier in promoting vaccination against COVID-19 to build herd immunity. The current study aimed to address how individual factors such as health literacy and perceived stress affect people’s vaccine hesitancy of COVID-19 vaccine, and to provide insights for tailoring vaccine-promotion strategies.MethodsWith structured questionnaires, an online survey was conducted to address the relationship between the health literacy, perceived stress, and COVID-19 vaccine hesitancy among community population in mainland, China. Moderated analysis was conducted to test the effect of health literacy on vaccine hesitancy among people with different levels of perceived stress.Results560 responses were collected in total. 39.8% of the participants reported vaccine hesitancy, and this rate was higher among younger people and female. Moreover, people with higher level of health literacy showed reduced vaccine hesitancy, while this effect was only significant among those with low or moderate level of stress. For people with high level of stress, no significant effect of health literacy was found.ConclusionsThe findings suggest that increasing people’s health literacy could lead to reduced vaccine hesitancy in community sample. However, this effect disappeared when the stress level was high, suggesting other promotion services may need to be developed to increase the acceptance of COVID-19 vaccine. In conclusion, vaccine promotion strategies should be tailored for different populations, with taking account of individual’s health literacy and perceived stress.     

Addressing vaccine hesitancy: The potential value of commercial and social marketing principles and practices

Many countries and communities are dealing with groups and growing numbers of individuals who are delaying or refusing recommended vaccinations for themselves or their children. This has created a need for immunization programs to find approaches and strategies to address vaccine hesitancy. An important source of useful approaches and strategies is found in the frameworks, practices, and principles used by commercial and social marketers, many of which have been used by immunization programs. This review examines how social and commercial marketing principles and practices can be used to help address vaccine hesitancy. It provides an introduction to key marketing and social marketing concepts, identifies some of the major challenges to applying commercial and social marketing approaches to immunization programs, illustrates how immunization advocates and programs can use marketing and social marketing approaches to address vaccine hesitancy, and identifies some of the lessons that commercial and non-immunization sectors have learned that may have relevance for immunization. While the use of commercial and social marketing practices and principles does not guarantee success, the evidence, lessons learned, and applications to date indicate that they have considerable value in fostering vaccine acceptance.     

Vaccine hesitancy in pregnant Women: A narrative review

Pregnant women are often at higher risk for morbidity and mortality due to contracting vaccine-preventable diseases that result in adverse pregnancy outcomes such as spontaneous abortion, preterm births, and congenital fetal defects. For example, health care provider recommendation is correlated with maternal acceptance of influenza vaccination, however, up to 33 % of pregnant women remain unvaccinated irrespective of provider recommendation. Vaccine hesitancy is a multifactorial problem that both the medical and public health systems need to address synergistically. Vaccine education should incorporate balanced perspectives to deliver vaccine education. This narrative review addresses four questions: 1) what are the primary concerns of pregnant women that lead them to be hesitant about receiving vaccinations; 2) to what extent does the source (e.g. provider, friend, family) of vaccine advice and information influence a pregnant person’s decision to accept a vaccine; 3) how does the delivery method of vaccine education influence their decision; 4) how can categorizing patients into four distinct groups based on their opinions and behavior regarding vaccines be used to improve provider-patient communication and increase vaccine acceptance. Results from the literature show that the three most common reasons for vaccine hesitancy include: i.) fear of side effects or adverse events; ii.) lack of confidence in vaccine safety; iii.) low perception of being at high risk of infection during pregnancy and/or not having previously received the vaccination when not pregnant. We conclude that vaccine hesitancy is dynamic therefore people do not always hold a static level of vaccine hesitancy. People may move between a continuum of vaccine hesitancy for a multifactorial reasons. A framework, characterized by levels of vaccine hesitancy before and during pregnancy, was constructed to help providers find balance between promoting individual health and public health while providing vaccine education.     

Overcoming COVID-19 vaccine hesitancy among ethnic minorities: A systematic review of UK studies

Ethnic minority communities in the UK have been disproportionately affected by the pandemic, with increased risks of infection, severe disease, and death. Hesitancy around the COVID-19 vaccine may be contributing to disparities in vaccine delivery to ethnic minority communities. This systematic review aims to strengthen understanding of COVID-19 vaccine concerns among ethnic minorities in the UK. Five databases were searched in February 2022, yielding 24 peer-reviewed studies reporting on vaccine hesitancy or acceptance in ethnic minority groups. Data were extracted using a standardised form, and quality assessment was carried out using the Standard Quality Criteria. There were three key themes: (1). Prevalence of vaccine hesitancy; (2). Reasons for vaccine hesitancy and acceptance; and (3). Recommendations to address vaccine concerns. Vaccine hesitancy, which was more common among some ethnic minority groups, is a complex phenomenon, driven by misinformation, mistrust, concerns about safety and efficacy, and structural and systemic inequities. Community engagement and tailored communication may help to address vaccine concerns. Robust data disaggregated by ethnicities are needed to better understand barriers and facilitators for COVID-19 vaccine delivery in ethnic minority communities. Strategies to address structural disadvantage need to be inclusive, comprehensive, and behaviorally informed and foster confidence in healthcare systems and governments. Community leaders and health care practitioners may prove to be the most important agents in creating an environment of trust within ethnic minority groups.     

Counselling of non-communicable diseases’ patients for COVID-19 vaccine uptake in Jordan: Evaluating the intervention

BackgroundPeople with noncommunicable diseases (NCDs) are at a significantly higher risk of worst outcomes if infected with COVID-19 and thus amongst the main target population for vaccination. Despite prioritizing them for vaccination, the number of vaccinated patients with comorbidities stalled post vaccine introduction. Despite that the government along with partners ran a national awareness campaign to ramp up vaccination coverage, the coverage remained suboptimal. Thus, a one-to-one health counselling initiative was implemented to explore the acceptance of COVID-19 vaccines by the NCDs patients and address the main issues surrounding vaccine hesitancy. This study evaluates the impact of this intervention by analyzing the change in COVID-19 vaccine acceptance.MethodsIn this analytical observational study, a random sample of 57,794 people living with NCDs were approached. Out of them, 12,144 received one-to-one counselling by a group of trained health professionals. The counselled group’s vaccine acceptance was assessed on a Likert scale from 1 to 5 pre- and post- counselling. Moreover, a random sample was followed up 2 months after initial counselling to measure their vaccine acceptance and update their vaccination status.Results44.5% of total respondents were already registered in the vaccination platform. On a scale from 1 to 5, the overall mean confidence significantly increased by 1.63 from 2.48 pre-counselling to 4.11 post-counselling. Two-months post counselling, a random sample was contacted again and had a mean vaccine confidence of 3.71, which is significantly higher than pre-counselling confidence level despite a significant decrease to post-counselling results.DiscussionImplementing an intervention that targets all key factors impacting health decisions, such as health literacy, risk appraisal and response efficacy, helps reach an adaptive response and increase vaccine confidence. Scholars should be cautious when implementing an intervention since it could lead to maladaptive defensive responses. One-to-one interventions are more effective in population when addressing new interventions and vaccines.     

Vaccine hesitancy and healthcare providers

While most people vaccinate according to the recommended schedule, this success is challenged by individuals and groups who delay or refuse vaccines. The aim of this article is to review studies on vaccine hesitancy among healthcare providers (HCPs), and the influences of their own vaccine confidence and vaccination behaviour on their vaccination recommendations to others.The search strategy was developed in Medline and then adapted across several multidisciplinary mainstream databases including Embase Classic & Embase, and PschInfo. All foreign language articles were included if the abstract was available in English.A total of 185 articles were included in the literature review. 66% studied the vaccine hesitancy among HCPs, 17% analysed concerns, attitudes and/or behaviour of HCPs towards vaccinating others, and 9% were about evaluating intervention(s). Overall, knowledge about particular vaccines, their efficacy and safety, helped to build HCPs own confidence in vaccines and their willingness to recommend vaccines to others. The importance of societal endorsement and support from colleagues was also reported.In the face of emerging vaccine hesitancy, HCPs still remain the most trusted advisor and influencer of vaccination decisions. The capacity and confidence of HCPs, though, are stretched as they are faced with time constraints, increased workload and limited resources, and often have inadequate information or training support to address parents’ questions. Overall, HCPs need more support to manage the quickly evolving vaccine environment as well as changing public, especially those who are reluctant or refuse vaccination. Some recommended strategies included strengthening trust between HCPs, health authorities and policymakers, through more shared involvement in the establishment of vaccine recommendations.     

Measuring vaccine acceptance and knowledge within health professions education

BackgroundRecent rises in the incidence of vaccine-preventable illnesses and suboptimal vaccine acceptance are considered a consequence of accumulating misinformation. Evidence-based approaches to patient-provider communication are key to addressing vaccine hesitancy.ObjectivesThe aim of this study was to assess vaccination attitudes and foundational knowledge among healthcare professions students.MethodsA 72-item survey was developed to assess vaccine attitudes and knowledge about vaccination among health professions students. The survey incorporated 14 demographics questions, 41 attitude questions, and 17 knowledge questions. 16 of the attitude questions, derived from a set of core questions used to diagnose vaccine hesitancy from the WHO Strategic Advisory Group of Experts on Immunization (SAGE) Vaccine Hesitancy Matrix, were analyzed together to derive a vaccine acceptance score.Results295 anonymous survey responses were collected between July 2019 and November 2020. Respondents represented students enrolled in medical, dental, pharmacy, optometry, and biomedical science health professions programs. Respondents scored 82.0% ± 0.8% (mean ± standard error of the mean) on questions that gauged vaccine acceptance. The mean vaccine acceptance score was 85.4% ± 1.0% for medical students and 88.0% ± 1.6% for biomedical science students. The mean knowledge score across all programs was 67.7% ± 1.1%. The greatest proficiency in knowledge scores was seen amongst medical students (79.0% ± 1.3%).ConclusionsAmongst the different health professions, students in the fields of medicine and biomedical sciences had the highest levels of vaccine acceptance attitudes and knowledge. The vaccine acceptance score can be utilized by health professions educators to guide vaccine education for future health professionals to better prepare them to address vaccine hesitancy and educate patients on vaccination.     

How to deal with vaccine hesitancy?

Based on the concerns about vaccine hesitancy and its impact on vaccine uptake rates and the performance of national immunization programmes, the Strategic Advisory Group of Experts (SAGE) on Immunization Working Group on Vaccine Hesitancy [1], carried out a review, and proposed a set of recommendations directed to the public health community, to WHO and its partners, and to the World Health Organization (WHO) member states. The final recommendations issued by SAGE in October 2014 fall into three categories: (1) those focused on the need to increase the understanding of vaccine hesitancy, its determinants and the rapidly changing challenges it entails; (2) those focused on dealing with the structures and organizational capacity to decrease hesitancy and increase acceptance of vaccines at the global, national and local levels; (3) and those focused on the sharing of lessons learnt and effective practices from various countries and settings as well as the development, validation and implementation of new tools to address hesitancy.     

Addressing personal parental values in decisions about childhood vaccination: Measure development

ObjectiveEvidence-based strategies to address vaccine hesitancy are lacking. Personal values are a measurable psychological construct that could be used to deliver personalized messages to influence vaccine hesitancy and behavior. Our objectives were to develop a valid, reliable self-report survey instrument to measure vaccine values based on the Schwartz theory of basic human values, and to test the hypothesis that vaccine values are distinct from vaccine attitudes and are related to vaccine hesitancy and behavior.MethodsParental Vaccine Values (PVV) scale items were generated using formative qualitative research and expert input, yielding 24 items for testing. 295 parents of children aged 14–30 months completed a self-report survey with measures of Schwartz’s global values, the PVV, vaccine attitudes, and vaccine hesitancy. Factor analysis was used to determine vaccine values factor structure. Associations between vaccine values, vaccine attitudes, vaccine hesitancy, and vaccination behavior were assessed using linear and logistic regression models. Late vaccination was assessed from electronic medical records.ResultsA six-factor structure for vaccine values was determined with good fit (RMSEA = 0.07, Bentler’s CFI = 0.91) with subscales for Conformity, Universalism, Tradition, Self-Direction, Security- Disease Prevention, and Security- Vaccine Risk. Vaccine values were moderately associated with Schwartz global values and vaccine attitudes, indicating discriminant validity from these constructs. Multivariable linear regression showed vaccine hesitancy was associated with vaccine values Conformity (partial R² = 0.10) and Universalism (0.04) and vaccine attitudes Vaccine Safety (0.52) and Vaccine Benefit (0.16). Multivariable logistic regression showed that late vaccination was associated with vaccine value Self-direction (OR = 1.80, 95% CI: 1.26–2.65) and vaccine attitude of Vaccine Benefit (OR = 0.44, 95% CI: 0.32–0.60).ConclusionsThe PVV scale had good psychometric properties and appears related to but distinct from Schwartz global values and vaccine attitudes. Vaccine values are associated with vaccine hesitancy and late vaccination and may be useful in tailoring future interventions.     

Immunity debt or vaccination crisis? A multi-method evidence on vaccine acceptance and media framing for emerging COVID-19 variants

Renewed COVID-19 outbreaks, stemming from the highly infectious Delta and Omicron variants, prompted rising fears of a ‘pandemic among the unvaccinated’. To address this prevalent vaccination crisis, media framing communication strategies can amplify the scientific evidence on COVID-19 vaccines to reach diverse geographic and socio-economic communities. The critical role of media framing strategies to engage and encourage large populations regarding vaccine acceptance has been rarely studied, despite growing evidence on vaccine hesitancy. The present study used a multi-method approach (i.e., content analysis and quasi-experiments) that unpacked the framing practices employed by the mainstream media in Pakistan. The findings of the content analysis revealed that the media extensively used uncertainty, conflict, consequences, and action rather than new evidence and reassurance frames in its COVID-19 related campaigns. In a series of quasi-experiments involving 720 participants, we manipulated these six frames of COVID-19 related news coverage (i.e., uncertainty, conflict, consequences, action, new evidence, and reassurance) to investigate the underlying mechanism that influences vaccine acceptance. The findings established that the message-consistent effects of media frames manifesting fear (e.g., consequence and uncertainty) and action cues made receivers more supportive of vaccination. The present study findings theoretically address the calls for a more inclusive “community-health reporting model”, besides offering new evidence on the media framing strategies to deliver more targeted, meaningful, and effective campaigns to raise public acceptance for COVID-19 vaccines.     

Vaccine hesitancy: Definition,scope and determinants

The SAGE Working Group on Vaccine Hesitancy concluded that vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence. The Working Group retained the term ‘vaccine’ rather than ‘vaccination’ hesitancy, although the latter more correctly implies the broader range of immunization concerns, as vaccine hesitancy is the more commonly used term. While high levels of hesitancy lead to low vaccine demand, low levels of hesitancy do not necessarily mean high vaccine demand. The Vaccine Hesitancy Determinants Matrix displays the factors influencing the behavioral decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine/vaccination-specific influences.     

Review of vaccine hesitancy: Rationale,remit and methods

Despite a wide array of safe and effective vaccines in use globally, with major impacts on health worldwide, the WHO Strategic Advisory Group of Experts (SAGE) on Immunization has been repeatedly confronted with reports of hesitancy towards accepting specific vaccines or vaccination programmes. This paper summarizes the rationale for a SAGE review of the issue of vaccine hesitancy, its impact and ways to address it, and the convening of a Vaccine Hesitancy Working Group in March 2012 to prepare for the SAGE review. It describes the methods used and mode of operations, and advances in the relatively new field of research on vaccine hesitancy. It further elaborates and references the work conducted, including a series of products, conclusions and recommendations that emerged from the SAGE review in October 2014.     

Comparative analysis of the Parent Attitudes about Childhood Vaccines (PACV) short scale and the five categories of vaccine acceptance identified by Gust et al.

BackgroundThere is a need to develop a standardized tool to aid in identifying, measuring and classifying the unique needs of vaccine-hesitant parents (VHPs). This will also assist in designing tailored interventions to address these needs. The Parental Attitude about Childhood Vaccines (PACV) short scale developed by Opel et al., and the Gust et al. vaccine acceptance categories have been acknowledged as potentially useful tools to measure parental vaccine hesitancy. The PACV short scale requires further validation. In our study, we evaluated how the Gust et al. vaccine acceptance categories correspond with the PACV short scale.MethodsAs part of a larger study on vaccine attitudes, using the PACV short scale and Gust et al. vaccine acceptance categories, we assessed the correlation between the two measures using Spearman correlation coefficient, and the association between the two measures using the Cochran-Mantel-Haentszel test of association. We used logistic regression modelling to compare the association between a child’s up-to-date immunization status and (a) PACV short scale and (b) Gust et al. vaccine acceptance categories.ResultsThe PACV short scale and Gust et al. vaccine acceptance categories were positively correlated (r = 0.6, df = 198, p < 0.05), and the Cochran-Mantel-Haentszel test of association yielded a statistically significant association (p < 0.05). The two scales similarly predicted children’s up-to-date immunization status for all recommended childhood vaccines.ConclusionThe ability of the PACV short scale to identify and classify parental vaccine hesitancy is similar to classification using Gust et al. vaccine acceptance categories, and both measure linear entities. The PACV short scale is recommended for screening parents at their first pediatric visit because it is easier to administer. A clearer understanding of how to classify parental vaccine hesitancy can be used to design tailored interventions based on these classifications, to address their specific needs.     

Factors influencing vaccine acceptance and hesitancy in three informal settlements in Lusaka,Zambia

IntroductionHeterogeneous coverage threatens to compromise the effectiveness of immunization programs in Zambia. Demand-creation initiatives are needed to address this; however, there is incomplete understanding of why vaccine coverage is suboptimal. We investigated overarching perceptions on vaccine acceptability, hesitancy, and accessibility at three informal settlements in Lusaka, Zambia.MethodsNested within a cholera vaccination uptake study, we sought to understand overarching perceptions on vaccines’ hesitancy in three informal settlements in Lusaka, Zambia. We conducted 48 focus group discussions with a convenience sample of laypersons, lay healthcare workers, neighbourhood health committee members and vaccinators.ResultsBoth laypersons and community-based health actors reported high vaccine acceptance though several sources of hesitancy were reported. Traditional remedies, alcohol use and religious beliefs emerged as drivers of vaccine hesitancy, likely reinforced by a background of distrust towards western medicine. Also mentioned were previous adverse events, fear of injections and low perceived need for immunization. Limited understanding of how vaccines work and overlapping local terms for vaccine and other medical concepts created confusion and inaccurate views and expectations. Some reported refusing injections to avoid pain and perceived risk of infection. Discussants emphasised the importance of education and preferred mobile immunization campaigns, with weekend to reach those with poor access and delivered by a combination of professional and volunteer workers.ConclusionsVaccine hesitancy in Zambia is underpinned by many factors including personal experiences with vaccinations, alternative belief models, limited knowledge, deep misunderstanding about how vaccines work, and barriers to access. To overcome these, community-driven models that incorporate factual communication by professionals and operate outside of traditional hours, may help. Better research to understand community preferences for vaccine uptake could inform interventions to improve immunization coverage in Zambia.     

Multi-domain narrative review of vaccine hesitancy in childhood

Vaccine hesitancy, where individuals delay or refuse some or all vaccines, is a perennial problem. It undermines the success of the immunisation programmes and places the society, especially vulnerable populations such as children, at risk of contracting infectious diseases. The phenomenon has been extensively analysed based on four aspects - confidence, complacency, convenience and costs. We suggest the alternative use of a multi-dimensional framework adapted from the “Generalist Wheel of Knowledge, Understanding and Inquiry” that was developed by Prof Larry Green and Kurt Stange, to assess the multiple facilitators and barriers towards vaccine hesitancy in childhood vaccination. The framework identifies domains in the healthcare system namely the child and parent/family, the clinician, the healthcare system and policy, and the infectious disease and corresponding vaccine that influence vaccine hesitancy. This narrative review includes literature beyond those covered by the World health Organisation Global Vaccine Action Plan (WHO GVAP). It identifies emotional distress, past negative experience and misconceptions that contribute to vaccine hesitancy in children and family, while attitude and motivation underpin vaccine hesitancy in clinicians. The healthcare system contributes to vaccine hesitancy when enforcements, diligent monitoring and transparency are absent or lacking. Inefficient dissemination of information about the disease and its associated vaccine as well as inadequate surveillance of misinformation add to vaccine hesitancy. The inter-domain factors highlight the roles of relationship between the clinician, child and parent, information mastery of the clinician, prioritisation of resources and equity in combating vaccine hesitancy. Using this framework, we present evidence-based strategies which have been effective in mitigating vaccine hesitancy for each domain and their corresponding inter-domains. By providing new perspectives of a complex problem and its potential solutions, this narrative review aims to complement and support the WHO GVAP by developing a coordinated multi-domain strategy to mitigate vaccine hesitancy in childhood.     

Hesitancy towards COVID-19 vaccines on social media in Canada

To effectively end the pandemic, the acceptance of effective vaccines against COVID-19 is critical. Comments posted in online platforms act as a barometer for understanding public concerns regarding vaccination and can be used to inform communication strategies for the ‘moveable middle’. The aim of this exploratory study was to identify online dialogue regarding the nature of vaccine hesitancy related to COVID-19 vaccine(s). We analyzed user comment threads in response to news reports regarding COVID-19 vaccines on the Canadian Broadcasting Corporation national news website (with as many as 9.4 million unique visitors per day). User comments (n = 1145) were extracted from 19 articles between March 2020 and June 15th, 2020. Comments were then coded inductively for content to establish a coding framework that was subsequently applied to the dataset. Our data provide empirical support for misrepresentation as a form of misinformation and further demonstrate the utility of social media content as data for social research that informs public health communication materials. The data point to the need for, and value of, rapid communication interventions to foster vaccine acceptance. False information will continue to create challenges for delivering COVID-19 vaccines. Communication strategies to get ahead of the pace of misinformation are critical, particularly in light of boosters and the possibility of COVID-19 vaccination on an annual basis.