What is vaccine hesitancy and what factors influence it?

Vaccine hesitancy is the delay in acceptance, or refusal, of vaccines despite the availability of vaccine services. It is complex, context-specific, and varies across time, location, disease burden and vaccines available. Attitudes towards vaccines fall on a continuum - as shown in the diagram below. It is therefore critical to acknowledge and respond with communities to challenge misperceptions and misinformation, and promote vaccine confidence and uptake.

Source: Johns Hopkins University of Medicine - Coronavirus Resource Center

The Vaccine Confidence Project has developed a Vaccine Confidence Index (VCI), which defines four domains influencing vaccine confidence including importance, safety, effectiveness, and compatibility with beliefs. Globally, this tool has been used in India, Pakistan, Nigeria, Georgie, and the UK to map vaccine confidence for routine, new and underutilised vaccines.

The Vaccine Hesitancy working group within the WHO Strategic Advisory Group of Experts (SAGE) outline reasons for vaccine hesitancy across three domains.

  1. Individual and group influences – This includes people who are against vaccines in general, feel that vaccines are at odds with alternative or traditional medicines, perceive the risk of getting COVID-19 to be low, deem personal vaccination unnecessary if everyone else in their vicinity is vaccinated, and that certain social groups have different levels of immunity.

  2. Contextual influences – This includes people who are vaccine hesitant due to issues of health equity, distrust in national institutions, fears of ethnic persecution, experiences with past vaccinations (HPV, MMR), and those who feel vaccines are incompatible with their religious, political, cultural, social, economic and or philosophical views. Past negative experiences related to vaccines or other aspects of health service delivery may colour people’s decision making about COVID-19 vaccines, even if those experiences related to events many decades before.

  3. Vaccine and vaccination – This includes people who may resist vaccines due to concerns about safety, the side effects, the pace of the vaccine development, perceived lack of efficacy, vaccine roll-out schedules and accessibility, and the emerging mutations and variants.

Misinformation, rumours and misunderstanding about COVID-19 vaccines contribute to vaccine hesitancy within each of these three domains. The working Group also highlights that it is critical to use local insight, knowledge and data in every context. This is because the willingness to accept vaccines is not static - it is highly dependent on real-time information, the status of the pandemic, the perceived risk of contracting the infection and subsequent disease, and previous experience with vaccination campaigns and roll-out, vaccines and rumours about vaccines. This necessitates a dynamic, compelling and productive two-way conversation to challenge vaccine misinformation and misunderstandings, and enable vaccine uptake.

What can response actors do to promote vaccine confidence and uptake?

Below are some general principles to consider in order to build vaccine confidence:

  • Meaningful community engagement is key - Response actors should seek to strengthen community engagement components of their programmes and develop their skills in active listening, tolerance and empathy in order to build vaccine confidence. This may involve setting up structured and informal mechanisms to gather and document questions, concerns and opinions on vaccines. Where possible, data should be collected on a rolling basis to capture changes in perceptions. Response organizations should also facilitate regular opportunities for staff to come together to discuss community perceptions and decide on potential courses of action to address these within programming.

  • Identify diverse ways of promoting vaccine confidence - For each individual there will be a different combination of factors that will influence their attitudes towards vaccines. For example, it is important to recognise that your programmes are not the only source of vaccine information that people are exposed to. Each individual will have their own combination of people within their social circles that influence their behaviour and beliefs, and they will be exposed to a range of information (including mis-information) and stories about vaccines. Therefore there also needs to be a range of programmatic responses to promote vaccine uptake.

  • Facts alone may not shift opinions - The sharing of correct information about vaccines is critical in promoting vaccine confidence, but may not always be sufficient to overcome vaccine hesitancy. This is because vaccine hesitancy is often related to deeper underlying values that an individual may hold. Facts and figures will only be accepted after people feel they have been listened to and that their concerns and values have been acknowledged. For others, they may be more persuaded by seeing and hearing the vaccination experiences of people who are similar to them or by hearing ‘thought leaders’ within their communities endorse the use of vaccines.

  • Utilise behaviour change thinking - Behavioural science plays a leading role in understanding and addressing a range of opportunities and constraints to vaccine uptake. The Little Jab Book presents common barriers, such as structural (cost, access, infrastructure), behavioural (inertia, prevailing social norms, misperception, social motives etc), and informational barriers (misinformation, lack of and complexity of information). Additionally, the following existing Hygiene Hub briefs might be useful when trying to understand and define effective behaviour change interventions:

  1. Lessons from previous outbreaks that can inform the COVID-19 response

  2. Common behavioural responses to outbreaks

  3. A summary of what works to change handwashing & hygiene behaviours

  4. Process for designing effective behaviour change projects for COVID-19 prevention

  • Build trust - Mistrust is often the most common reason for vaccine hesitancy. Trust can be broken down into three levels - trust in the vaccine (the product), trust in the vaccinator (the provider), and trust in those who make the decisions about vaccine provision (the policymaker/institution responsible for development and delivery). It is important to realise that mistrust normally exists for a reason, such as inadequate health care services or decision making that lacks transparency or is not always in the best interests of populations. Building trust may require response actors to look at strengthening broader aspects of health care systems and re-evaluating the conduct of health care staff and policy makers.

  • Be honest about what is not known - Response actions must be transparent and honest about both their own expertise and the state of evidence around COVID-19 vaccines. It’s perfectly ok to respond to community questions by saying “I don’t know but I will find out”, and then follow up with this individual when you have more information. The amount of new evidence about COVID-19 is so overwhelming that no one has all the answers, and pretending that you have all the answers is setting organisations up for failure. Build realistic expectations from the community and enable community-led solutions.

Below we list a range of response interventions and tools, which could be replicated and or adapted across a range of settings:

Practical approaches for understanding and learning from communities:

  1. Conduct formative research (and or make use of existing findings) about the factors that influence vaccine perceptions in your context. This should aim to explore patterns of social influence and sharing patterns, historical, cultural and religious beliefs related to vaccines, common vaccines concerns, local disease coping strategies and community level innovations or mechanisms that could support the vaccine roll-out and continuation of preventive behaviours. Think carefully about how you ask about vaccines. Rather than just asking “Would you accept the vaccine?”, frame and convey the right questions so that they are more action-oriented questions, i.e., “What information would you like, what do you need, from who and how?”.

  2. Map and understand where conversations about vaccines are happening within the community as different countries and social groups will use different platforms.

  3. Make use of existing ways that vaccine perceptions are being tracked and try to align your work to these. Some examples include, but are not limited to COVID-19 Misinfo.org, Oxfam’s Community Perception Tracker, Rumour has it by CDAC Network, UNICEF’s Talkwalker National Country Dashboards, Rooted in Trust - Global Rumour Bulletin, Internews Rumour Tracking Methodology, First Draft and WHO’s infodemic management toolkit. Utilisation of these resources may help you preempt the emergence of similar perceptions in your local community and can allow you to connect with people in other regions of the world to understand what is working to encourage vaccine acceptance.

    Useful resources to guide the development of your strategy for promoting vaccine confidence

  4. Develop a strategy to engage and communicate with a range of audiences via a range of delivery channels. The following resources incorporate useful guidance and tips to inform this process. The Vaccine Misinformation Management Field Guide provides a phased approach (preparation, listen, understand and engage), with tips to make your content resonate more than misinformation, examples of inoculating messages, and interventions to build immunity to misinformation. Other tools related to effective Risk Communication and Community Engagement (RCCE) include 10 steps, RCCE tools, behavioural indicators and the Global COVID-19 RCCE strategy.

    Possible activities and approaches for promoting vaccine uptake

  5. Develop a list of frequently asked questions that are emerging from communities and recommend ways that staff can address these if they arise in the course of their work. Keep this list updated and ensure information is in line with current evidence and national vaccine roll out plans. Having this document to refer to will boost the confidence of staff when discussing vaccines, given that this topic is unfamiliar to many frontline workers.

  6. Share personal experiences of getting vaccinated as this can be a powerful motivator for others. Ethan Lindenberger, who initiated a wave of pro-vaccine advocacy in 2018 conveyed that “people resonate with people, not data” and emphasised, “it’s important to start with empathy as a way of opening up the conversation”. Sharing experiences can be as simple as encouraging people to take vaccine selfies and share their vaccine status on social media or it could involve developing short videos of well known individuals getting their vaccine and talking about the factors that influenced their decision making.

  7. Engage religious leaders, social groups, health workers, teachers and other influential individuals and encourage them to discuss vaccine uptake with people in their community.

  8. Use presumptive communication by framing vaccination as the default or normative behaviour.

  9. Help communities to understand vaccine concepts like herd immunity and focus on the fact that vaccination is something that you can do to protect everyone in society, not just yourself.

  10. Build public resilience to misinformation, including by building digital and media literacy. This helps individuals understand what to look out for in fake news or false information and when they should or shouldn’t share content with their network of friends and family. For example, GoViral is a 5-minute game that helps protect you against COVID-19 misinformation. Studies have also shown that encouraging critical reflection can make people less likely to share misinformation. The use of different audio-visual communication formats can help people to stop and think before they share information or content on social media without fact-checking it first.

  11. Focus on making vaccine-related communication clear, simple and actionable. This could include developing clear ‘calls to action’ to drive behaviours and ensuring information is contextualised and tailored to specific sub-groups of the communities and certain types of beliefs. Using terms like ‘you’ and ’we’ is more likely to drive motivation and action and prioritising and grouping key messages can prevent people being overwhelmed with information. For example the ‘rule of three’ can be a helpful approach to enable people to remember key behaviours (eg. hand hygiene, mask use, physical distancing).

  12. Mass media such as television and radio are a trusted source of information for many. Response actors can work with the media as a partner to create opportunities for two-way communications which address factors contributing to vaccine hesitancy. Some examples include:

  • COVID and Me which are short film-based dramas which share conversations about vaccine research and the importance of being vaccinated. Each story is based on real patient experiences and conversations are conveyed in multiple languages.

  • BBC Media Action’s updated handbook on communication about COVID-19 includes ideas and tips for effective communication to support prevention behaviours, vaccine confidence, and counter misinformation. It is designed for media but is useful for anyone communicating about the pandemic and response.

  • Team Halo, an active global network which uses a network of scientists and health professionals who communicate Q&A videos of COVID-19 vaccine research and immunisation programmes to demystify their work and address the issues around vaccine fears. Their bite-sized videos are posted to TikTok, Twitter, and Instagram.

Key takeaways:

  • Willingness to accept a vaccine is not static, therefore it is critical to understand historical, contextual and social factors that may affect attitudes towards vaccines.

  • Learn about COVID-19 vaccine concerns and create opportunities for ongoing dialogue.

  • Identify community skills, strengths, advocates and trusted individuals that could facilitate uptake.

Want to learn more about integrating vaccine promotion into COVID-19 prevention work:

Editor Notes:

Written by: Jenny Lamb

Reviewed by: Lizzie McKee, Tom Heath, Victoria Maskell, Genevieve Hutchinson, Sarah Malycha, Rupali J. Limaye, Sian White, Daniel Korbel

Last update: 30.06.2021

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