Vaccine Hesitancy: Guidance and Interventions

Despite availability of vaccines, the number of countries reporting hesitancy has steadily increased since 2014. In response to the need to understand what can be done to tackle this problem, this Knowledge, Evidence and Learning for Development (K4D) Helpdesk report summarises research, evidence, and lessons learned related to vaccine hesitancy. Commissioned by the United Kingdom (UK) Department for International Development (DFID), it outlines various definitions of vaccine hesitancy, reviews existing guidance/recommendations for development of vaccine policies, examines approaches used to tackle vaccine hesitancy, and highlights lessons learned from responses to hesitancy "outbreaks".

The evidence for this rapid review comes from grey literature and peer-reviewed academic papers from vaccine-related projects (e.g., the Vaccine Confidence Project - VCP). The review does not: examine gender issues, focus on anti-vaccination (anti-vaxx/anti-vac) sentiments or movements, or explore drivers of vaccine hesitancy.

Key points related to definitions: Proposed in 2011 by the World Health Organization (WHO), the "3Cs" (complacency, convenience, and confidence) definition of vaccine hesitancy is used widely by governments as a standard term. A related, more positive term, "vaccine confidence", is also used.

Examples of types of guidance to address vaccine hesitancy include:

• Guidance for policymakers:
  • Evidence shows that integrated stakeholder approaches, such as National Immunization Technical Advisory Groups (NITAGs), can provide guidance for policy developments and strengthen national vaccine decision-making, by acting as referees or technical resources in response to rumours or hesitancy. However, gaps remain; for example, in 2016, only 43% of 47 African countries had an established NITAG, of which only two-thirds were assessed as functional.
  • An evaluation of the WHO's The Guide to Tailoring Immunization Programmes (TIP) tool conducted in 2016 indicates that TIP has been applied successfully in a few countries (Bulgaria, Lithuania, Montenegro, Sweden, and the UK) to improve the understanding of concerns in vaccine-hesitant populations and to develop targeted strategies. Other countries have initiated application of TIP, and the process is ongoing.
• Guidance for public health professionals/institutions - Resources discussed include: recommendations by the WHO Strategic Advisory Group of Experts (on Immunisation) Vaccine Hesitancy Working Group (WHO SAGE), the WHO Western Pacific Regional Guidance on Addressing Vaccine Hesitancy to Help Foster Vaccine Demand, European Centre for Disease Prevention and Control (ECDC) guides/toolkits, and Learning Network for Countries in Transition (LNCT)/VCP resources.
• Guidance for healthcare workers (HCWs): ECDC notes that HCWs can also be hesitant, whether considering vaccination for themselves, their children, or their patients. Among the tools for HCWs to empower them to become more effective advocates of vaccination are those from the ECDC and the United States Centers for Disease Control and Prevention (CDC) - some of which have been adapted for use in other countries. Researchers have also developed recommendations for health professionals and regulatory agencies to address parents' hesitancy about vaccinations (e.g., US Policy Lab, and the Vaccine Education Center).
• Guidance for measuring vaccine hesitancy - An example is the Parent Attitudes About Childhood Vaccines survey (PACV), which has been widely used in the Americas (Canada), Asia (India, Malaysia, the Philippines, Singapore), and Europe (England, Croatia). Other examples include the Vaccine Hesitancy Scale (VHS), the Accelerated Development of Vaccine Benefit-Risk Collaboration in Europe (ADVANCE) Toolkit, and Immunisation Information Systems (IIS). The latter could help to fight vaccine hesitancy through recording additional information regarding reasons for delay, interruption, or refusal of vaccinations. However, a review revealed gaps in knowledge due to the paucity of studies in low- and middle-income country (LMIC) settings.

Key points related to potential methods to tackle vaccine hesitancy include:

• In light of rising vaccination hesitancy, some European countries have turned to mandatory vaccination programmes, including rigid penalties for non-compliance. However, experimental evidence shows that making one vaccine mandatory might reduce people's uptake of others.
• Interventions with religious or traditional leaders align themselves with natural community processes (e.g., Nigerian Community Engagement Framework). Research shows that success could be attributed to the efforts made to understand the intended audience via open dialogue and integrate activities with familiar processes and systems.
• Mass media channels (e.g., television, radio, public transport advertising) have been used to communicate public policy about vaccines to all segments of a community. Group sessions with journalists and mass media campaigns have also been used to positive effect to support message consistency.
• There is a plethora of misinformation about vaccines on social media, reducing public trust and confidence in their safety and efficacy. Denmark's Stop HPV - Stop Cervical Cancer information campaign has been found to be successful due to collaborations between health agencies and social media. In the aftermath of the April 2019 polio eradication panic, the Pakistani government is considering a lower-profile approach during the government-led immunisation campaign in order to avoid renewed suspicions started on social media.
• Evidence on training for HCWs indicates, for example, that interventions focusing on improving knowledge of HCWs have mostly been found to have a positive impact on vaccine uptake; however, unless the intervention is appropriately targeted, it may be unsuccessful due to low confidence of HCWs.
• Adapted storytelling strategies can be used by individuals to tell personal stories about vaccines.
• Other approaches reviewed include non-financial incentives to build confidence and reminder-recall notifications.

Recommendations related to hesitancy "outbreaks":

• Conduct quality hesitancy assessments/trend information.
• Encourage government investment in immunisation - e.g., the United Nations Children's Fund (UNICEF) is urging governments in Europe and Central Asia to invest in health systems that prioritise reaching the most vulnerable children with life-saving immunisations, alongside national campaigns to address the concerning trend of growing vaccine hesitancy.
• Integrate activities with health programmes - e.g., UNICEF Country Offices in Pakistan and Afghanistan are working to integrate polio activities around health, nutrition, education, and water, sanitation, and hygiene (WASH) in these communities.
• Target strategies for specific populations - e.g., adolescents.
• Understand/rebuild trust through, for example, government collaborations: "The government must bring in people with genuine fears for their children's health, open the conversation, and rebuild trust around vaccines again."

Other findings:

• Vaccine hesitancy and political populism are driven by similar dynamics: a profound distrust in elites and experts.
• A unidirectional (top down) approach to communication is successful among some individuals and groups, but not all; success is dependent on the nature and degree of hesitancy.
• Familiarity and trust with the messenger is a key feature in tackling hesitancy.

The document concludes with a list of hyperlinked vaccine hesitancy resources.