Fear, lack of information, and adherence to social and cultural beliefs are just some of the causes of vaccine hesitancy - so how can governments and policymakers overcome these factors?
Areas of expertiseHealth , Research and Evidence (R&E)
CountriesArmenia , Georgia , Kyrgyzstan , Moldova, Republic of , Republic of
KeywordsHealth systems governance (HSG) , India Health Hub , Community health workers (CHWs) , Covid-19 , Maternal Newborn, and Child Health (MNCH) , Primary Health Care , Monitoring, Evaluation, and Learning (MEL)
Vaccines are one of the most successful and cost-effective health innovations to prevent diseases, thereby improving health outcomes. Today, there are more than 20 life-threatening diseases (like diphtheria, tetanus, measles) for which preventive vaccinations exist, helping people live healthier, longer lives everywhere. Add to this, the recent phenomenal feat of the global scientific community in coming up with, in record time, Covid-19 vaccines that help prevent severe complications and death.
The question of trust
Many parts of the world, however, are still dealing with inadequate access to vaccines, while there are others coping with low acceptance by their populations, despite provision. While the benefits of vaccines have been known for decades, scepticism around their use persists. In 2019, the World Health Organisation declared vaccine hesitancy (lack of confidence in the benefits of vaccination thereby causing delay in acceptance or refusal of vaccines despite availability), to be one of the key threats to public health. This was before the global pandemic knocked at our doors!
With the outbreak of the Covid-19 pandemic the importance of increasing vaccine uptake was highlighted. Although initial scarcity led to a massive demand for vaccines, with increased production and better access we witnessed anti-vaccination sentiment in several parts of the world. For governments of many countries this offers a ‘policy window’ for them to think strategically about developing immunisation systems, not just to facilitate discovery, production, procurement and distribution of vaccines but also to ensure that people are willing to accept them. While most countries ensure supply and distribution of vaccines through their National Immunisation Programmes, few countries also have a well thought-out strategy in place to systematically address anti-vaccination sentiment through social and behaviour change interventions.
How can we increase popular support for vaccines?
Vaccine hesitancy remains a complex problem which is determined by various factors such as individual motivation, insufficient knowledge, lack of confidence in the benefits of vaccination, overconfidence in one’s ability to avoid the disease, anxiety about vaccines, and fear of side effects to name a few. Gavi, the Vaccine Alliance, has developed guidelines to help countries in their endeavour to increase vaccine uptake (in circumstances where vaccine hesitancy reduces uptake despite availability). These relate to the following broad areas:
i) Engaging communities and shaping social norms involves programme strategies so that vaccines are viewed not as optional but rather the norm. Several countries are implementing efforts to change negative views on vaccination. In Zimbabwe, Ethiopia, Ghana, Madagascar, and Honduras ‘community motivators’ assist in inspiring resistant sections to accept vaccines. The European Immunisation Week observed in multiple European countries helps communicate the benefits of immunisation at mass level by drawing attention to the importance of every child’s need and right to be protected from vaccine preventable diseases.
ii) Dealing with unexpected events and emergencies is imperative to ensure continued uptake. Even in places where vaccination is viewed positively, public sentiment can alter drastically if any vaccine-associated serious side effects or deaths are reported. Adverse events following immunisation require systems and strategies to promptly detect and effectively manage negative publicity and reassure populations when needed.
iii) Improving the quality of the vaccination experience: Often people may put off vaccination if they have to wait in long queues, in poor facilities and deal with rude and unhelpful health staff. Ensuring that the vaccination experience is not painful and providing staff with training so that they are supportive and can address doubts and queries can go a long way to increase uptake. In Kyrgyzstan and Moldova for example, the Government has imbedded inter-personal communication training in the curricula for nurses and doctors. Interestingly, in Japan, primary care physicians are made aware of linkages between public subsidies and vaccines, which helps in increasing their likelihood to recommend vaccination for Hib, PCV and HPV, resulting in increasing coverage.
iv) Using social data to help governments learn and take right decisions requires looking at the human stories behind the numbers. Information about people’s experiences and their response to and acceptance of these services and what determines their behaviors related to them can be useful in developing suitable programmes to increase vaccine acceptance. Several countries have incorporated Knowledge Attitude Practices and Behavior Insights studies to learn more about vaccine user perspectives and perceptions.
v) Targeting the people that matter: This includes targeting civil society as well as people within government in positions of power. Thus advocacy is needed so as to raise the profile of the importance of vaccination and influence those holding the purse strings to increase levels of funding towards not just purchasing vaccines but having in place appropriate social and behaviour change communication strategies towards increasing uptake.
Do countries implement the suggested strategies to increase uptake of vaccines?
The answer is Yes and No. While in most countries some of the Gavi suggested strategies are implemented, activities are often not systematically integrated in the National Immunisation Programs. In a recently concluded study with support from UNICEF, we assessed the demand generation strategies for vaccines in four countries - Armenia, Georgia, Moldova, and the Kyrgyz Republic. While all four countries implement some of the Gavi suggestions, in most cases these efforts are ad hoc and not mainstreamed or sustained over time. They are implemented by a health system lacking staff with the requisite specialist skills, paucity of budgets directed to addressing vaccine uptake, and dependence on external funding.
How can strategies to increase vaccine uptake be mainstreamed in government policies?
Several countries have already made headway into addressing this complex problem. Moldova has developed a communication strategy to address hesitancy and encourage vaccination. Georgia has established a system for monitoring social media with devoted government funding towards addressing vaccine demand. Armenia and the Kyrgyz Republic have included modules in the curricula of doctors and other health workers to improve patient experience with regard to routine vaccinations.
Mainstreaming such strategies would require action on multiple levels. Our study identified improved planning and coordination among key government departments at national and sub-national levels; allocation of funds specifically towards increasing uptake; identifying the need for adequately trained specialist health staff; and building strategies to identify and address concerns of under-immunised communities to allow for course corrections, as some of the emergent priorities.
Learning from our shared experience
The Covid-19 pandemic provides the required impetus for governments to put in place a sustainable approach to increase vaccine uptake, as embedded in their systems as strategies related to vaccine supply. This is important to ensure that people view vaccination as valuable and necessary and realise that increasing uptake helps them protect themselves as well as others. The time to strike is now - we cannot wait for another pandemic to spur action.
Agrima Sahore is a Research Assistant at Oxford Policy Management
Dr. Akaki Zoidze is Associate Professor at Ilia State University
Dr. Ruhi Saith is a Senior Consultant at Oxford Policy Management
Dr. Kavita Chauhan is a Behavioural Science Professional
Sergiu Tomsa is Regional Communication for Development Specialist at UNICEF
This article contains examples from an assessment conducted by Oxford Policy Management for a project supported by UNICEF ECARO. All opinions presented in the article are of the authors and may not represent the views and position of UNICEF.