Improving vaccination demand and addressing hesitancy
Increasing and maintaining vaccination uptake is vital for vaccines to achieve their success. Addressing low vaccination requires an adequate understanding of the determinants of the problem, tailored evidence-based strategies to improve uptake, and monitoring and evaluation to determine the impact and sustainability of the interventions.
1. Understanding the drivers of immunization uptake
A range of factors influence whether a person is vaccinated or not. The Increasing Vaccination Model (see below chart) states that what people think and feel and social influences will affect motivation to vaccinate. Practical factors affect the ability to act on the motivation and get vaccinated.
To support the systematic assessment of these factors affecting uptake, WHO is developing a set of tools to support programmes and partners to measure and address these reasons for under-vaccination, and to track consistent and comparable data over time. The tools include quantitative surveys, qualitative interview guides, and related user guidance.
In November 2018, a global expert group called ‘Measuring Behavioural and Social Drivers of Vaccination’ (BeSD) was established by WHO, in collaboration with core partners, to oversee development of these tools. They are expected to be finalized in late 2020. For more information about the work of this group, please consult their meeting report from May 2019.
2. Improving and sustaining uptake
Since a range of determinants affect vaccination rates, the most effective interventions are multi-component. In most cases, interventions should be dialogue based and directly targeted to a specific under-vaccinated population group.
By engaging collaboratively with health workers, caregivers/parents, and their families and communities, national authorities can generate the insights to develop better quality health services, systems, policies, and communication strategies that support and enable recommended vaccination behaviours.
Tailoring Immunization Programmes
To equip Member States to better diagnose the factors influencing vaccination intentions, decisions and behaviours, WHO/Europe developed the Guide to Tailoring Immunization Programmes (TIP). It consists of methods and tools to:
- Identify populations susceptible to vaccine-preventable diseases
- Diagnose supply- and demand-side barriers and enablers to vaccination
- Recommend evidence-informed responses to enhance and sustain vaccination uptake.
- Global guidance on TIP
- Evaluation of the TIP tool and approach in the European Region from 2013 to 2016
- Further information on TIP from the WHO Regional Office for Europe
Addressing missed opportunities for vaccination
Many children and adults are not vaccinated because the opportunity to vaccinate them has been missed. WHO has produced materials to support countries in assessing, implementing and monitoring solutions to missed opportunities for vaccination here.
Hesitancy in relation to vaccination may affect motivation, causing people to reject it for themselves or their children. Hesitancy can be caused by individual, group, and contextual influences, as well as any vaccine-specific issues.
Given the potential for hesitancy to rapidly undermine vaccination coverage in specific settings, it is important that all countries take steps to understand both the extent and nature of hesitancy at a local level, on a continuing basis. Accordingly, each country should develop a strategy to increase acceptance and demand for vaccination, which should include ongoing community engagement and trust-building, active hesitancy prevention, regular national assessments of concerns, and crisis response planning. (SAGE 2017 assessment report of the Global Vaccine Action Plan)
The WHO SAGE Vaccine Hesitancy Working Group in 2013-2014 undertook to define hesitancy and its determinants. Below are the group’s main outputs.
Report of the SAGE working group on vaccine hesitancy (November 2014)
Appendices to the report of the SAGE working group on vaccine hesitancy (October 2014)
Strategies for addressing vaccine hesitancy - A systematic review (October 2014)
Conclusions and recommendations from the October 2014 SAGE meeting, published in the Weekly epidemiological record, 12 December 2014
- Journal of Vaccine: special issue on vaccine hesitancy (August 2015)
Summary of WHO SAGE conclusions and recommendations on Vaccine Hesitancy:
Hesitancy survey questions
A compendium of survey questions to assess the underlying determinants of vaccine hesitancy was developed by the SAGE Working Group, though further validation of these questions is still required. If doing so, methods and findings should be shared with WHO to help inform future development and refinement of such tools.
Supporting health workers
Health workers remain the most trusted advisor and influencer of vaccination decisions. The capacity and confidence of health workers are often stretched, though, as they are faced with time constraints, limited resources, and inadequate information and/or training to respond to questions and discuss the rare risks and benefits of vaccination. For health workers to be prepared for the different types of interactions they might face, a number of actions are required.
To explore existing knowledge, attitudes and practices, as a basis for the design and evaluation of trainings and tools, the following guide is available:
A guide for exploring health worker/caregiver interactions on immunization
To build capacity in managing pain during vaccination and in engaging in difficult conversations with hesitant caregivers, two specific and adaptable trainings are available:
Health worker training module: managing pain during vaccine administration
Health worker training module: conversations with hesitant caregivers
Engaging with communities
Communities also need to be at the centre of drives to improve the quality of immunization and health services, access and equity. The linkages between health systems and communities are inter-dependent and thus systems should engage directly with communities in face-to-face interactions. This participatory process can play a role in improving the quality of services in such a way that builds trust and demonstrates respect, with broader benefits for immunization coverage.
For more information on community engagement for quality, integrated, people-centred and resilient health services, please refer to the WHO web page on this topic.
3. Monitoring and evaluating interventions to improve uptake
Any interventions that are implemented to enhance acceptance and demand should be systematically monitored and evaluated, to guide adjustments and any potential wider scale-up of successful strategies. More information on this activity will be made available shortly.