Vaccination Programmes and Health Systems in the European Union

"...introduce a rationale for effective public health, health literacy and communication strategies which are perceived as personally relevant, credible and trustworthy."

The European Union (EU) is facing increasing outbreaks of vaccine-preventable diseases (VPDs). This report identifies the main factors (enablers and obstacles) influencing vaccination uptake and assesses measures that can be explored to improve vaccination coverage. Adopted after a public hearing, it is an official "opinion" of the Expert Panel on effective ways of investing in Health (EXPH), a group of independent scientists set up by the European Commission (EC).

After providing historical timelines of vaccine development and outlining a systems approach to national vaccination programmes (including, among other elements, a function for monitoring public attitudes to vaccination and, where necessary, correcting emerging misconceptions), the report offers an overview of factors influencing vaccination coverage. Low perceived benefits and/or high costs are the source of what is known as vaccine hesitancy leading to refusal. The report defines 3 key drivers of vaccine hesitancy, the so-called 3 Cs (Complacency, low Confidence, and lack of Convenience), and discusses a a model of determinants of vaccine hesitancy developed by a World Health Organization (WHO) working group that identifies 3 domains of influences that affect the decision to vaccinate: contextual influences, individual and group influences, and vaccine- and vaccination-specific issues.

One section of the report focuses on the situation where there is misinformation, where those spreading it do so with the intention to mislead. To combat this contributor to vaccine hesitancy, risk communication involves providing "sufficient, meaningful, and relevant information about risks to empower stakeholders to make well informed choices and to give them a sense of control over their own health and safety....It has been acknowledged that risk communication should be a participatory dialogue with the public to build a shared understanding of risk rather than a one-way communication process from experts to the public....In developing communication strategies, information will need to be adapted to the needs of specific groups..."

As the EXPH notes, the effectiveness of risk communication depends on the trust the public has in the communication organisation. Trust is also discussed in relation to: the recommended vaccines, the provider that administers the vaccine, and those who make decisions about vaccine provision (policymakers). The literature highlights the importance of a participatory approach to communication that includes two-way engagement with stakeholders and building stakeholder relationships. Transparency and openness have also been identified as critical factors in building and maintaining trust, requiring open acknowledgment and communication of uncertainty around risk. Effective communication strategies and accessible websites, together with information from trusted healthcare workers, can play a critical role. EXPH finds that primary care providers are particularly well suited to engage in dialogue with potentially hesitant individuals, who receive a number of other health services that are distinct from vaccines. This provides an opportunity to initiate a dialogue with a trusted source of health information.

The EXPH explains that acceptability of vaccination depends not only on the essential ingredients of information but also on the framing of the information. Techniques from behavioural economics are increasingly being used; arguments against "nudging" include lack of transparency and paternalism.

The report examines vaccine hesitancy and confidence in the EU, drawing on data from The State of Vaccine Confidence (2016) project. Overall, the results show that although at least 85% of the respondents in each of the 20 European countries studied think that vaccines are important, a sizeable minority of people in some countries have concerns about their effectiveness. These concerns are found to be "clustered" so that in countries where there are concerns about vaccine importance, there are also concerns about their effectiveness and safety and, to a certain degree, compatibility with religious beliefs.

Noting that insight into the knowledge, beliefs, attitudes, and current behaviours of different population groups or intended audiences, and the environmental context in which they occur, is an important consideration in understanding risk appraisal and behaviour change in relation to vaccination uptake, the EXPH reviews various social cognition models that are used in the design of communication interventions in this area. The report details the Health Belief Model and the Theory of Planned Behaviour. However, these psychological theoretical models have been criticised for placing too much emphasis on rationality and deliberative decision-making processes, ignoring factors such as emotional reactions, cognitive bias, unrealistic optimism, and the role of wider social, economic, and environmental factors. This is where frameworks such as the socio-ecological model come into play.

Next, the report looks at psychological, social, and contextual factors that affect the decision by a parent not to vaccinate their child. It draws on resources such as a systematic review by Smith et al (2017), which included 68 published papers reporting 64 different studies. In short, some of the obstacles to vaccination coverage that have been identified include: individuals' and parents' concerns or fears about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths undermining confidence in vaccines, failure by some healthcare providers to counter these myths and provide evidence-informed advice, access barriers (e.g., poor availability, copayments), and failure to understand the underlying mechanisms that decrease vaccination confidence. Enablers include: sources of reliable information about vaccination, exposure to positive media messages, trust in institutions and providers, confidence in vaccination, easy access and availability to healthcare services, ease of administration, active involvement and engagement by healthcare providers, and outreach to high-risk groups.

The report looks at some unintended consequences of messaging on childhood vaccination, such as when approaches seeking to address information deficit "backfire", reducing uptake rather than promoting it. Several examples of this are provided. Another risk of public health campaigns is portraying a problematic behaviour as being frequent, and therefore a source of concern. This plays to the tendency of many people to act in accordance with what they perceive as social norms. Relatedly, messages promoting vaccination may be seen as threatening the identity of the group in question, causing them to become more cohesive and adhere to their beliefs more strongly than ever. Public health campaigns that appeal to fear can also have adverse effects. "Overall, there seems to be a strong case for a much more nuanced approach to the messages used to promote vaccination uptake. As highlighted earlier, this includes the use of theory-based communication strategies that can be adapted to the needs of population groups that encounter substantial barriers in routine vaccination programmes such as Roma, Travellers and other ethnic minorities."

The EXPH identifies a range of policy options that countries can implement to increase vaccination coverage. Communication strategies about the benefits of vaccination are important but need to be combined with opportunities for dialogue with vaccine-hesitant groups and participatory approaches. These strategies need to be geared not only toward the uninformed (those who lack of information) but also toward the misinformed (when the information is incorrect) or disinformed (when information is spread with the intention to deceive).

Some countries have responded to the need to increase uptake by mandating vaccination, while others recommend it. When mandatory, it can be unpopular with some individuals or groups, which reinforces the case for good communication strategies to improve acceptability. One policy option is to allow individuals to opt out of vaccination subject to certain conditions (e.g., an exception process that includes a mandatory consultation and dialogue with a healthcare worker who can make individuals and parents aware of the risk of not being covered), but only if vaccination coverage levels are sufficiently high to ensure herd immunity. More broadly, family physicians can use interactions with parents and children with other illnesses or attending check-ups as opportunities to raise awareness. Furthermore, family physicians and nurses do not have to be the exclusive providers of vaccines; access could be improved by increasing availability of vaccines from pharmacists and/or providers of community services, subject to appropriate training. Healthcare and other workers engaging in communication and dialogue related to vaccination should be supported with specific training to address vaccine concerns from hesitant individuals, in particular in relation to safety and side effects.

The EXPH suggests that there is scope for strengthening the monitoring and the surveillance systems at international, national, and sub-national levels to ensure up-to-date data to guide regional- and country-level policy and planning designed to optimise coverage and impact, and identifying areas where low coverage is concentrated.

A concluding thought: "At the EU and national level, there is scope for improving advocacy and communication strategies to promote the value and safety of vaccines and effective intervention strategies, incorporating participatory methods, for addressing vaccine hesitancy."