As vaccines for coronavirus roll out across the globe, people can start to see a path out of the pandemic. Yet despite the development and distribution of safe and efficacious vaccines, a number of challenges lie ahead. Achieving high vaccination coverage will be crucial to the goal of suppressing community transmission of the disease. This will require effective strategies to overcome barriers to vaccine uptake, including lack of access and low vaccine confidence. BMJ Open has been a home to both qualitative and quantitative research on vaccine attitudes and uptake, including interventions to promote vaccine uptake, national trends in vaccine uptake, determinants of vaccine hesitancy and evaluations of vaccination campaigns. In this post, Dr Samantha Vanderslott from the Oxford Vaccine Group speaks to us about vaccine uptake and public attitudes towards vaccination, and offers advice to doctors for improving patients’ vaccine confidence.
Hi Samantha, thanks for taking the time to talk to us. Can you tell us a bit about your research?
In my research I am interested in people’s attitudes and behaviours towards vaccination. As a medical intervention deployed on a mass scale to healthy populations, it provides an interesting lens to view the relationship between society and health. Closely implicated are public policies and media representation; also, important insights can be gained from historical and country comparisons.
How is the UK and its neighbours progressing in relation to vaccine uptake and what are the main barriers?
The UK has been performing relatively well since the measles, mumps and rubella (MMR) scare in the early 2000s. However, it is a fragile state of affairs because small drops, dependent on which vaccines and whether lower uptake is clustered, can have disproportionate effects on public health. For example, vaccination rates have slowly dipped in England over the last few years for key childhood vaccines offered routinely and the UK lost its ‘measles-free’ status with the World Health Organisation (WHO). Measles outbreaks returned to Europe in 2018-19. The barriers are mixed, as trust in governments and health systems are closely connected to uptake. Investment needs to continue in immunisation services and public health engagement, especially as misinformation online continues to be a growing problem.
What factors might be driving differences in vaccine uptake between the UK and its neighbours?
Some European neighbours have been introducing mandatory vaccination (e.g. France and Italy). However, those countries already had long standing mandatory vaccination for one or more vaccines, so strengthening the law to all routine childhood vaccines was part of clarifying the policy. In the UK, there has been a history of opposition against mandatory vaccination and the opinion of many health researchers is that non-coercive methods are preferable in the long-term to ensure there is not a backlash against such policies.
What is vaccine hesitancy and how common is it?
Vaccine hesitancy tends to refer to a position on vaccination that is not completely pro or anti. It refers to a scale where a person may have questions and concerns about vaccination, and this might materialise into simply being unsure or anxious, or taking steps such as delaying or picking and choosing vaccines. Using this definition, vaccine hesitancy is common and does not necessarily translate into being a problem for public health but requires a constellation of trust, information, communication, and support to vaccinate.
Does research suggest vaccine hesitancy is more prevalent in particular socio-demographic groups?
Research is mixed over whether particular socio-demographic groups are more vaccine hesitant and prevalence changes over time and place. If there has been an issue of certain groups mistrusting or being suspicious of outside interventions and when there is political instability already then vaccine hesitancy is higher.
Do we know what the main reasons are for vaccine hesitancy, and do they relate to the vaccine itself or the institutions that manufacture and promote them?
The main reasons for vaccine hesitancy are related to the vaccine itself and the institutions behind it – both feed into each other. Safety of vaccines is the key reason why people are hesitant, in thinking that vaccines have side effects that will harm them. They may not view vaccines to be effective, as is a common view of flu vaccines. For some, it may even be that vaccines are just not important compared to other views, such as what constitutes a healthy lifestyle.
A concept that has come up a lot in this pandemic is “herd” (or “population”) immunity. What are the public’s conceptions of herd immunity and do these generally align with the accepted definition of the term?
Herd immunity, when disease transmission is interrupted by immunity in the population, is an important concept for vaccination. For many vaccines the rationale for vaccinating is not just to protect individuals but to also provide protection for vulnerable groups who cannot always be vaccinated. For example, these groups include newborn babies, those with compromised immune systems, and others that for reasons unknown are not protected by vaccination. Therefore, herd immunity can be a motivating factor to vaccinate in order to protect others. Although it can also provide a false security in believing that others vaccinating removes the need to do so – obviously if too many people think this way then herd immunity is lost. More recently, during the COVID-19 pandemic, the idea of herd immunity developed through natural infection rather than acquired immunity by vaccination was popularised. This idea could be harmful because of the risk of illness and complications and death caused by the disease. Instead, vaccines are a safer way to develop immunity, without the higher risks associated with contracting the disease itself.
Are there any lessons from previous mass vaccination campaigns that policymakers should be taking on board for this pandemic, in relation to promoting pro-vaccination behaviours and acceptance?
The important historical lesson of mass vaccination campaigns is that the availability of a safe and efficacious vaccine does not automatically mean that a pandemic can be ended. A number of other factors need to be aligned. Of course, we are now well aware of how vaccine supply, production, regulation, and distribution places limitations on the success of a vaccine campaign. If lower income countries do not have access to vaccines, the past also has shown that not only is this situation inequitable, but it will likely prolong the pandemic. Vaccine demand plays a factor too and effort is required to effectively communicate and engage groups to be vaccinated. Lastly, it is clear that other health measures and innovations will continue to be needed alongside vaccines and these may include low-tech interventions such as social-distancing, mask-wearing, and quarantine, along with test-and-trace, surveillance, treatments, and vaccines targeting new variants.
Last but not least, do you have any advice for doctors and healthcare professionals for improving patients’ confidence about taking one of the coronavirus vaccines?
The constraints doctors and healthcare professionals are under make it difficult to have the time and resources to engage effectively with patients hesitant about coronavirus vaccines. I have also heard some truly inspirational accounts of health professionals going out of their way to speak with people and answer their questions – this has included organising impromptu information sessions making efforts to ring up patients individually to discuss their concerns. Research has shown that being impartial, balanced, and transparent in discussions is key. Patients will want to know that you are acting in their best interest to present neutral information and also be ready to respond to media stories, rumours, and negative publicity about vaccines. Resources to draw on include fact-checking websites like Full Fact (www.fullfact.org) or those with detailed information about vaccines like the Vaccine Knowledge Project (www.vk.ovg.ox.ac.uk) at the Oxford Vaccine Group where I am based.