Vaccination as a Social Practice: Towards a Definition of Personal, Community, Population, and Organizational Vaccine Literacy

"A comprehensive and agreed-upon definition of vaccine literacy (VL) could support the understanding of vaccination and help policy-makers and individuals make informed decisions about vaccines."

Health literacy (HL) and vaccine literacy (VL) can help people make decisions about vaccination. The concept of HL has been widely explored in the literature and can be defined as the knowledge, motivation, and competencies to access, understand, appraise, and apply information to form judgments and make decisions regarding health care, disease prevention, and health promotion. HL has been explained not only at the personal level but at community and organisational levels. For example, a health-literate community is able to gather information on social determinants of health, to mobilise the collective resources to act upon these determinants, and to advocate efficiently for structural changes in order to improve the daily living conditions of its members. From this perspective, the HL of the community is fundamental for its own empowerment, which implies community ownership and actions that explicitly aim for social and political change. However, though closely tied to HL, the meaning of VL is still a matter of debate. To provide clarity, researchers conducted a scoping review to collect, summarise, and analyse available definitions of VL. Based on the findings and on consultation with a panel of experts, they propose a new definition of VL.

The researchers searched PubMed/MEDLINE, Embase, Web of Science, and Google Scholar from inception to December 1 2022 for original articles or abstracts (in case of conference proceedings) that presented a specific definition of "vaccine literacy". Fifty-three articles were included in the review; two of them appeared to be the milestones around which the other definitions were grouped. The core research team (University of Florence) discussed the analysis internally and then shared the results and a first draft of the definition with a panel of experts that comprised four representatives from the core research team, two members of European research groups working on HL, a public health expert with HL experience, and an expert in vaccinology and in developing measurement tools for assessing VL.

The new definition proposed by the panel of experts, based on the scoping review and their analysis, is as follows:

"Vaccine literacy is linked to health literacy. It entails people's and communities' knowledge, motivation, and competencies to access, understand, and critically appraise and apply information about immunization, vaccines, vaccination programmes, and organizational processes to access vaccination and to navigate the health system, in order to make informed decisions about vaccines for themselves, the members of their family, and the community, and to appreciate the larger global impact of vaccines with respect to population health. A vaccine literate community is able to mobilize collective resources, and to advocate for structural changes to make it easier to access vaccination."

Thus, VL includes not only the personal perspective, but also the community, population, and organisational perspectives. Furthermore, it is a relational concept: it is the balance between personal, community, and population skills, as well as the complexity/demand of the context. Within this perspective, the concept of organisational vaccine literacy (OVL) must be introduced, as follows:

"Organizational vaccine literacy is defined as an organizational effort (for example, definition of policies, resource allocations, consultations) to build an environment that supports individuals to navigate, understand, and use vaccine information and services to form judgements and make decisions for themselves, the members of their family, and their community."

When OVL is taken into account, the different organisations that can influence the provision of vaccine information to individuals and communities adopt strategies that can promote equitable access and engagement,  meet different levels of VL skills, and support individuals and communities in participating in the decision-making process regarding their choice to receive vaccination. In this sense, a vaccine-literate environment (that is, the way information and services regarding vaccines and vaccinations are provided) can compensate for low individual, community, and population VL, and it constitutes an opportunity to improve VL. A vaccine-literate environment requires the development of effective partnerships between the involved actors and coordinated communication plans.

Several stakeholders have the potential to play a crucial role in establishing an environment that promotes VL. This can be achieved through developing easily accessible and straightforward information campaigns, fostering active community participation, and encouraging other entities to enhance their communication efforts. For example, organisations such as the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) have been instrumental in spreading accurate information about vaccination.

In particular, a vaccine-literate community plays a pivotal role in fostering a vaccine-literate environment. By actively addressing barriers and advocating for improved access to accurate and reliable information, a vaccine-literate community contributes positively to enhancing overall VL levels. This, in turn, helps empower individuals to make informed decisions about vaccinations and ultimately improves public health outcomes. These aspects are particularly relevant when considering preventive measures that can affect individual as well as the community and the society at large, as in the case of vaccine-preventable diseases.

In this context, similar to a health-literate healthcare organisation, a vaccine-literate healthcare organisation (VLHO) should:

1. Inform people by sharing clear, trustworthy, up-to-date evidence about vaccines and vaccination.
2. Encourage questions and dialogue between people and healthcare workers about vaccines and vaccination.
3. Communicate clearly the comparative risks and benefits of vaccination for each single person and the whole society.
4. Develop a supportive environment that provides navigation assistance and that facilitate access to vaccination services to reduce structural or psychological barriers that make vaccination difficult (e.g. availability, affordability, accessibility, comprehensibility of information, effort, costs).
5. Communicate clearly which individuals will have free access and which ones will have to pay to receive vaccines.
6. Prepare its workforce to be vaccine literate, and enhance communication skills.
7. Include the served populations while designing, implementing, and evaluating vaccine information materials and vaccination services.
8. Meet the needs of populations with a range of VL skills while avoiding stigmatisation.
9. Design and distribute print, audiovisual, and social media content that is easy to understand and act on.
10. Have a leadership that provides (organisational) capacities, infrastructures, and resources to ensure that the organisation can be vaccine literate.

Reflecting on the conceptualisations put forth here, the research team notes that HL and VL should be considered only partially overlapping, because competencies and knowledge on vaccine, vaccination, and vaccination programmmes are very specific, and even people with a wide range of HL skills may be lacking in specific abilities that encompass vaccination, especially from the community point of view.

According to the proposed definitions of vaccine hesitancy, personal, community, and organisational VL share many aspects with the psychological determinants of vaccine hesitancy described in the "3C" model and in its evolutions ("4C", "5C", and the most recent "7C" model), although they remain distinct concepts. Thus, VL can be considered as a set of competencies related to, but different from, the psychological determinants of vaccine hesitancy/acceptance.

Per the research team, the new definition of VL proposed here can contribute to the overall paradigm of HL and its distinct component of VL, possibly improving the implementation of public health strategies to allow vaccination to be understood as a social practice by the entire community.

In conclusion, this study has described the conceptual foundations, skills, and civic orientation to be taken into account when developing measurement tools devoted to assessing VL at different levels and in different contexts. Future studies that aim to deepen the relationship between VL, HL, and the components of the models for vaccine hesitancy or acceptance are encouraged to shed further light on this complex link.