Attitudes to Vaccination: A Critical Review

"[O]ur consolidated evidence base suggests that understanding vaccination attitudes requires incorporating institutional trust into models of information, communication and cognition more explicitly."

This is one finding from a paper that provides an overview of public and healthcare professionals' attitudes towards vaccination in Europe with a focus on self-reported determinants of vaccination attitudes. The researchers define hesitancy as an expression of concern or doubt about the value or safety of vaccination. This means that hesitant attitudes are not confined only to those who refuse vaccination or those who encourage others to refuse vaccination. For many people, vaccination attitudes are shaped not just by healthcare professionals but also by an array of other information sources, including online and social media sources.

Bringing together evidence across various vaccines, countries, and populations, the paper is based on a review of 38 articles (15 countries represented - all of which are developed countries, not economically poor contexts) published in English from 2009 until August 2012, as well as an analysis of unpublished market research data from member companies of Vaccines Europe.

The synthesis suggests that hesitant attitudes to vaccination are prevalent and may be increasing since the influenza pandemic of 2009. The researchers find that healthcare professionals report increasing challenges to building a trustful relationship with patients, through which they might otherwise allay concerns and reassure hesitant patients. They also find a range of reasons for vaccination attitudes, only some of which can be characterised as being related to lack of awareness or misinformation. Reasons that relate to issues of mistrust are cited more commonly in the literature than reasons that relate to information deficit.

An excerpt from the Discussion section follows:
"As part of the effort to restore trust and credibility in institutions involved with vaccination, the EU [European Union] and national authorities need to consider not only their own relationship with the public, but also the support they offer healthcare professionals. Physicians are the main and most influential source of vaccination information, but in our review they reported facing increasing difficulties in building trustful relationships with patients. Physicians now contend with an increasing number of sceptical patients, whilst also being faced with a lack of time for building relationships with patients. If this continues unabated, the scope for opportunistic 'alternative' sources of information to be seen as trustworthy is likely to grow. Our paper found that many physicians felt there was not enough support from governments and health authorities, and wanted better vaccination campaigns.

A more pro-active stance from public institutions involved with vaccination would be welcomed by most stakeholders, but responding with more information campaigns is likely to be insufficient for building trust; for trust-building, more engagement and interaction is needed. Institutions involved with vaccination may take note of the influence of online social networks and try to build further 'online social presence' or try to highlight the costs of mistrust and suspicion (i.e. more illness); but the impact of such efforts are likely to remain dependent on how trusted they are to begin with. Such efforts need to be allied with other online and offline platforms that draw in healthcare professionals and medical societies to support sustained dialogue with hesitant patients. Through engagement and dialogue, perhaps institutions will one day make the notion of herd immunity as ubiquitous in everyday health conversations as the notion of patient-choice has recently become.

The paper showed that concern about safety underpinned most hesitant attitudes. The way in which safety concerns develop into overall hesitancy and rejection is likely to be affected by systems for monitoring what happens after vaccination, for reporting any adverse reactions and for engaging with post-vaccination anxieties....Where such systems are not available, frustrations are more likely to be expressed among friends or through the internet and other media, where the scope for shifting attitudes is perhaps narrower. Further investigation into vaccine safety surveillance systems (including active surveillance studies) will help improve our understanding about what institutional features sustain confidence in vaccine safety over the long term. This may also help avoid raising expectations that vaccines should be 100% effective and safe.

Our paper also suggested that the some assumptions regarding the design of teaching curricula and training programmes of healthcare professionals may need examining. Curricula and training programmes may assume that healthcare professionals will (a) readily understand and support vaccination with minimal introduction and will not need to subsequently revisit the topic in their continual professional development, and (b) have the skills to improve attitudes to vaccination among the general population effectively. For example, unassertive physicians might benefit from acquiring skills from assertive physicians before attempting to persuade and garner trust in hesitant patients. Where healthcare professionals feel inhibited due to personal reservations, they may need to be alerted to the mechanisms that exist for debating uncertainties about vaccines and vaccination policy, offering them support in accessing wider bodies of professional knowledge and expertise.

Restoring trust in institutions is a multi-stakeholder problem. Policy-makers must not shy away from the scale of engagement needed with healthcare professionals and other stakeholders whilst navigating notions such as patient-choice and the common good."