Report of the SAGE Working Group on Vaccine Hesitancy

"[R]egardless of the setting and causes of vaccine hesitancy, poor communication needs to be addressed generally, in addition to developing targeted communication to address hesitancy and improve vaccine uptake."

This is one of the lessons that emerged from a November 2011 meeting of the Strategic Advisory Group of Experts (SAGE) on Immunization, where SAGE noted with concern the impact of reluctance to accept immunisation on the uptake of vaccines reported from both developed and developing countries.

The context: "High vaccine uptake rates, specific to each vaccine preventable disease, are needed for community-level immunity to be achieved and sustained in order that disease risk can lowered beyond what would be predicted by vaccine coverage alone. Even in countries with overall high national vaccine uptake rates, there may be clustered pockets or subgroups where the rates of uptake are lower than required for protection of the community. In the past decade, such pockets have been associated with outbreaks or resurgence of measles, mumps, Haemophilus influenzae b, pertussis and polio in countries where these diseases had previously been controlled."

In response to this challenge, SAGE established a working group on vaccine hesitancy. This group: undertook a systematic review of literature on vaccine hesitancy and an immunisation managers' survey, discussed examples of hesitancy in populations where measureable improvements had occurred following targeted intervention, and reviewed presentations and materials from other World Health Organization (WHO) groups, researchers, and partners (such as WHO vaccine safety, the United Nations Children's Fund (UNICEF), and others).

Each section of the report begins with the deliverables established in the SAGE Terms of Reference for the Working Group, followed by the conclusions of the Working Group and then the detailed discussion of the work done to address the deliverables. In the final section, the working groups' recommendations to SAGE are presented. For example, it is noted that a multitude of factors can potentially influence parents'/guardians' decision(s) to seek out/accept immunisation for themselves or their child. These factors vary with the population subgroup, context, setting, time, and specific vaccine. So, to address vaccine hesitancy effectively, interventions must target the specific factors in the subgroup of the population that are leading to vaccine hesitancy at that time and in that context.

To help countries address this complex problem, WHO European Region (EUR) developed an evidence- and theory- based behavioural insight framework, the Guide to Tailoring Immunization Programmes (TIP) in 2013. TIP is "a diagnostic guide to define and diagnose behaviourally related concerns such as vaccine hesitancy and then outline appropriate interventions, implement them, and then test and evaluate the outcomes. In WHO EUR, TIP has now been successfully applied in Bulgaria, Sweden, and the United Kingdom to diagnose and develop targeted interventions for subgroups with lower than expected vaccine uptake. In Bulgaria, TIP diagnostics revealed that for the Roma population, continuing the default intervention to increase vaccine program information and awareness messages was not likely to improve uptake in this subgroup. Neither lack of knowledge and awareness about vaccines nor lack of confidence in the vaccines was the cause of the hesitancy. The major barrier was access to an immunization program that was welcoming to Roma, as the quality of the health worker-caregiver encounter was found to be the most significant determinant of vaccine uptake. These diagnostic findings were used to tailor and target programs designed to address the main cause of Roma vaccine hesitancy."

A lesson learned from TIP: "[T]he integrated knowledge and skills of sociologists, behavioural psychologists, anthropologists, experts in social marketing and communication as well as specific disease experts need to come together to be integrated into core behaviour insights groups at WHO headquarters and at the regional level. Insights can be initially applied to tackling vaccine hesitancy and driving equitable demand for vaccine(s) and then applied to other communicable and non- communicable disease areas where behavioural decisions markedly influence outcomes."

The working group explored evaluation tools such as Grading of Recommendations Assessment, Development and Evaluation (GRADE), which revealed, amongst other findings, that the limited evidence available showed that effective vaccine uptake strategies included social mobilisation, mass media, communication tool-based training for health care workers, non-financial incentives, and reminder-recall activities. Using GRADE, it was noted that "dialogue-based interventions, particularly those incorporating a focus on community engagement/social mobilisation and the improvement of health care worker communication, were most effective in improving uptake. Similarly, single-component interventions did not work as well as those that were multi-component. Also, passive interventions (e.g., posters, radio announcements, websites, and media releases) that did not have an additional engagement component(s) were less effective. However, as was found in the vaccine hesitancy strategy systematic review, the specific factors underlying poor reproductive health intervention uptake were not well defined in the study populations, making interpretation of effectiveness with different determinants difficult."

An excerpt from the report focused on general vaccine hesitancy and communication follows: (footnote numbers have been removed)

"...While communication is not a specific factor, like confidence, complacency and convenience, when it is poor or inadequate it can negatively influence vaccine uptake and contribute to vaccine hesitancy. Poor quality services of any type, including poor communication, can undermine acceptance.

Poor, inadequate or misguided communication can be a problem in any setting. In HIC [a high-income country] with well-resourced vaccine programs, inadequate or poor vaccine communications can increase vaccine hesitancy and outright refusal. For example, in 1999, the reason underlying the decision to minimize thimerosal as a preservative in some vaccines in the USA [United States of American] was poorly communicated. As a consequence, this impacted on public confidence in vaccines and the vaccine system, leading to increased vaccine hesitancy and refusal. In LMIC [low- and middle-income countries], scarce communication resources limit the capacity to counter negative information about vaccines and achieve community support for vaccination programs. For instance, the Independent Monitoring Board on Polio Eradication noted deep concern about 'the Global Programme's weak grip on the communications and social mobilization that could not just neutralize communities’ negativity, but generate more genuine demand. Within the Programme, communications is the poor cousin of vaccine delivery, undeservedly receiving far less focus. Communications expertise is sparse throughout and needs to be strengthened.' The WHO African Task Force on Immunization is collaborating with UNICEF on the development of a tool to improve vaccine program communications in the region because these deficiencies, especially during crises with poor quality communication, may result in significant vaccine hesitancy."