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Vaccination is one of the most effective public health interventions, and one that prevents 2-3 million deaths worldwide every year. [1] In 2018, 86% of all eligible infants in the world received at least one dose of measles vaccine and 69% received the second dose, leaving around 20 million children who did not receive any dose. Also about 86% of infants worldwide (116.3 million infants) received their third dose of diphtheria-tetanus-pertussis (DTP), with 129 countries achieving at least 90% coverage [2] These are tremendous achievements. However the health gains achieved by the success of vaccination programmes are under threat. The rise in the incidence of measles, especially observed in Europe and North America, the 2015-16 outbreak of yellow fever in Angola, and two new cases of polio in the Philippines can be directly linked to a decrease in vaccine coverage in these countries. They illustrate the challenges we face in protecting citizens against the threat of vaccine-preventable diseases. There is a tendency for people to delay in accepting or even refusing vaccination altogether, despite the widespread availability of vaccination services. This is referred to as vaccine hesitancy. The most important determinants are individual choices and group influences, combined with specific features of certain vaccines and vaccination-related issues and often aggravated by contextual factors. [3]
Maintaining high vaccination coverage levels to protect the population requires a permanent commitment by those delivering, monitoring, and funding vaccination programmes. Poor vaccination uptake may reflect changing societies with shifting values and preferences, greater mobility of people, and changing vulnerabilities. But there are also issues of communication and deliberate attempts to undermine the success of vaccination by so-called ´anti-vaxxers’. They spread and take advantage of public fears about the safety of vaccination. How to deal with these challenges?
Better understanding of determinants of vaccination acceptance
People feel the need to make an informed and deliberate decision pro or contra vaccination for themselves or their children, but they often feel unable to do so based on the available information. Information provided by health authorities is perceived as too limited or biased. Information available on the internet is often unbalanced and does not give the full picture. Parents of young children do not always consider the information provided by health professionals as satisfactory, with some arguing that it is not designed to inform but to induce conformity. Other factors that play a role for people to accept or refuse vaccination include personal convictions, for instance after some bad experience with vaccination or a disease, psychosocial determinants (e.g. risk perception, feelings of loss of control, or decisional uncertainty), and pragmatic reasons (e.g. time constraints, inconvenient location, or limited provider choice). So the question is: ‘How do people make their decisions on whether or not to accept specific vaccinations?’ While there is an abundance of literature on how people make personal choices in their lives, little research has been conducted on decision making regarding vaccination.
A more systematic approach to comprehensive vaccination programme development
Until recently, most vaccination programmes had an information and education component, using various channels (individual letters, posters, group meetings, etc.), and they offered various service options (e.g. vaccination on appointment). With the advent of the internet, this appears to be no longer sufficient. A modern successful vaccination programme needs to be based on a good understanding of the enablers and the barriers to vaccination acceptance and include an effective translation of behavioural change methods into practice. Careful planning with relevant stakeholders in various stages of a vaccination programme is a must. It starts with answering questions such as ‘What is the problem?’ and ‘For whom is this a problem?’, followed by the question ‘Which determinants could influence vaccination acceptance?’ Subsequently, it is important to discuss how to achieve the programme goal by answering a question like ‘Who has to do what in order to promote vaccination under the target group?’ Next, the most relevant and amenable determinants have to be selected. In the third step, a strategy can be designed by arranging all change objectives by determinant and identifying theoretical methods which are potentially applicable for that determinant in order to achieve the change objective. Feasibility and possible fit of the practical applications of these methods with the needs and intervention context of the target group are essential. Integration of the various elements that were chosen in the previous step will lead to a concrete approach containing, for instance, a personal invitation letter, an information folder or website, and a deliberation tool. [3]
Once a vaccination programme has been developed, implementation must guarantee improved access to vaccination and provide different sectors of the healthcare workforce with adequate resources. They must be able to deliver a high-quality vaccination programme that develops data solutions to enable individuals to demonstrate their vaccination status regardless of where they are and that provides clear messages on the evidence for vaccination. Vaccination programme monitoring must also help to identify groups and communities that are most underserved in order to vaccinate them.
Dialogue
Community engagement is key to successfully controlling infectious disease outbreaks. That is not only and once again the lesson learned in the recent Ebola virus disease outbreak in DRC; it also applies to vaccination campaigns in general. The best chances for overcoming low coverage rates are through a respectful and extensive dialogue with target groups, in particular when misconceptions, religious arguments, or mistrust of authorities dominate. [4] A similar approach is needed towards the debate on voluntary versus mandatory vaccination policies, whereby sufficient attention should be paid to what people in concrete societal contexts think and feel about these themes. A strained relationship between health authorities, service providers and the general public could be detrimental to the success of vaccination programmes, as its success depends on people’s continued trust and acceptance.
References
- https://www.who.int/immunization/newsroom/new-measles-data-august-2019/en/
- https://www.who.int/news-room/fact-sheets/detail/immunization-coverage
- Visser O. Preventing pertussis in early infancy Developing of a strategy for implementing pertussis vaccination of new parents and health care workers. PhD dissertation, Nijmegen, Radboud Institute of Health Sciences, 2018.
- Ruijs H. Acceptance of vaccination among orthodox Protestants in the Netherlands. PhD dissertation. Nijmegen, Radboud Institute of Health Sciences, 2012.
