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What influences decisions about vaccination?

Understanding the range of factors at play

Vaccines can improve health and prevent deaths only if they are used.1 While most people accept vaccinations in the majority of populations globally, a range of different factors can act as barriers that delay or prevent people from taking up available vaccines.2,3

In 2019, the World Health Organization (WHO) declared vaccine hesitancy as one of the ‘ten threats to global health’.3 Understanding vaccine hesitancy and the factors that can contribute to it can help when discussing vaccination with patients.

What is vaccine hesitancy?

The WHO defines vaccine hesitancy as below:

‘Vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence.’2,4

Here you can explore vaccine hesitancy in a little more detail.

  • Acceptance, refusal and the vaccine hesitancy continuum

    People who are hesitant about accepting vaccines fit along a continuum between two extremes: the large number of people who accept all vaccines with no doubts, and the small number of people who refuse all vaccines with no doubts.2

    The group of vaccine-hesitant individuals in the middle ground is heterogeneous, including people who agree to some vaccines but refuse others and people who accept or delay vaccination but have doubts about their decision to do so.2

    Illustration of the vaccine hesitancy continuum, from those who accept all vaccines to those who refuse all vaccines

    Figure adapted from MacDonald NE et al. 2015 under the Creative Commons Attribution 3.0 International Public License

  • Factors influencing decisions about vaccination

    A wide range of factors can influence the sometimes complex decision-making process that can lead to someone accepting, delaying or refusing vaccination.2

    The WHO’s original ‘3Cs’ model, which categorised determinants of vaccine hesitancy into three groups (complacency, convenience and confidence), has more recently been updated to the ‘5Cs’ model shown here:2,3,5

    Illustration of the five ‘Cs’ which influence decisions about vaccination. Complacency, confidence, collective responsibility, convenience, and calculation

    Figure adapted from Nuwarda RF et al. 2022 under the Creative Commons Attribution 4.0 International Public License

  • Impact of vaccine hesitancy

    Icon of a virus

    The WHO has warned that vaccine hesitancy ‘threatens to reverse progress made in tackling vaccine-preventable diseases’.3 It risks:

    • Low vaccine demand2
    • Failure to establish or maintain herd immunity5
    • A resurgence of vaccine-preventable diseases5
    • Disruptions to vaccine development, delivery, availability and research5

    Data from the UK on childhood vaccination, for example, show declining vaccination coverage in recent years.6

  • Spotlight on convenience

    As the 5Cs model indicates, practical issues that affect the convenience of accepting vaccination from the patient perspective influence uptake.5 Such factors include the following:2,5

    • Physical availability
    • Affordability
    • Ease of access
    • Ability to understand information about vaccines (language and health literacy)
    • Appeal of vaccination services
    • Service quality
    • Respect from providers
    Icon of five Cs linked together

    A survey by the Royal Society for Public Health on the barriers to vaccination across the life course, for example, revealed common barriers for parents to getting children vaccinated were timing of appointments (49% of parents surveyed), availability of appointments (46%) and childcare duties (29%).7,8
    Suggested interventions to help overcome these barriers include sending invites and reminders, making every contact count by checking patients are up to date with vaccinations whenever they visit the clinic, discussing vaccination confidently with patients and offering flexible appointments.7,9

  • A team effort

    Healthcare workers are the most trusted source of information on vaccines, but they cannot address vaccine hesitancy alone.10 A collaborative effort is called for from wide-ranging groups:1,10

    Icon of a team of doctors
    • Healthcare workers
    • Parents/guardians/carers
    • Public health officials/health policy makers
    • Experts in specific diseases
    • Sociologists, behavioural psychologists, anthropologists, and experts in social marketing and communication
    • Governments
    • The technology sector
    • Civil society
    • Media platforms, including social media

Key points: What influences decisions about vaccines?

  • While most people accept vaccinations, some are hesitant to do so and a small number refuse vaccines altogether2,3
  • The 5Cs model identifies complacency, convenience, confidence, calculation and collective responsibility as factors that influence decisions about accepting vaccination5
  • Common practical barriers for parents, for example, that affect the convenience of accepting vaccinations for their children include timing of appointments, availability of appointments and childcare duties7,8
  • Understanding vaccine hesitancy helps identify possible strategies to support patients who are uncertain about vaccination

Find out more

Discussing vaccines with patients

Health workers are trusted sources of vaccine information

References

  1. Eskola J et al. How to deal with vaccine hesitancy? Vaccine 2015;33:4215–4217.
  2. MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine 2015;33:4161–4164.
  3. World Health Organization. Ten threats to global health in 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019 (accessed February 2024).
  4. World Health Organization. Vaccine hesitancy: A growing challenge for immunization programmes. https://www.who.int/news/item/18-08-2015-vaccine-hesitancy-a-growing-challenge-for-immunization-programmes (accessed March 2024).
  5. Nuwarda RF et al. Vaccine hesitancy: Contemporary issues and historical background. Vaccines (Basel) 2022;10:1595.
  6. NHS England. Childhood vaccination coverage statistics. https://app.powerbi.com/view?r=eyJrIjoiZTI3NWZhNzItMTIyZS00OWM2LTg0MzMtOGY5YTJjMGY0MjI1IiwidCI6IjUwZjYwNzFmLWJiZmUtNDAxYS04ODAzLTY3Mzc0OGU2MjllMiIsImMiOjh9 (accessed March 2024).
  7. UK Health Security Agency. Increasing vaccine uptake: Strategies for addressing barriers in primary care. https://ukhsa.blog.gov.uk/2019/05/16/increasing-vaccine-uptake-strategies-for-addressing-barriers-in-primary-care/ (accessed March 2024).
  8. Royal Society for Public Health. Moving the needle: Promoting vaccination uptake across the life course. https://www.rsph.org.uk/static/uploaded/3b82db00-a7ef-494c-85451e78ce18a779.pdf (accessed March 2024).
  9. Royal College of Paediatricians and Child Health. Immunisations. https://stateofchildhealth.rcpch.ac.uk/evidence/prevention-of-ill-health/immunisations/ (accessed March 2024).
  10. The Lancet Child & Adolescent Health. Vaccine hesitancy: A generation at risk. Lancet Child Adolesc Health 2019;3:281.

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July 2024 | NP-GB-ABX-WCNT-240006 (V1.0)