Evidence-based strategies to promote vaccine acceptance

Despite a substantial majority of the UK population holding positive views about the COVID-19 vaccine (Freeman et al, 2021), the success of the UK mass vaccination programme will depend on a high uptake across the whole population. Anderson et al (2020) have set out how the extent of vaccination coverage is calculated to yield herd immunity, with the efficacy of the vaccine and duration of the immune response complicating the calculation. Another complicating factor is the mutation (antigenic drift) of the virus, which may undermine existing vaccine efficacy. The percentage of the population that must be vaccinated initially is larger than in subsequent years once population immunity is stabilised. More recently, Grant and Hunter (2021) have questioned whether it will be possible to achieve an adequate level of population COVID-19 immunity using vaccination alone, because not all the vaccines prevent asymptomatic infections. Although less infectious, these asymptomatic infections will still enable population transmission. In summary, the ability of the vaccination programme for COVID-19 to manage the disease, like other vaccination programmes for seasonal influenza, measles, polio. etc., will depend on the extent of uptake by the population, and, in the case of the COVID-19 vaccination, an uptake of at least 80%, if not higher, will be required during the first year of the vaccination roll-out (Anderson et al, 2020).

Vaccine hesitancy

The range of psychological, physical and contextual barriers to vaccination uptake are set out in a previous paper (While, 2021). Importantly, there appear to be significant levels of vaccine hesitancy across some ethnic and socio-economic groups in the UK (Royal Society for Public Health (RSPH), 2020; Freeman et al, 2021; Paul et al, 2021) that are most at risk from SARS-CoV-2 (Public Health England (PHE), 2020), which needs to be addressed if whole-population COVID-19 vaccination is to be successful in protecting those most vulnerable to severe disease and death from COVID-19. Loiacono et al (2020) also found significant differences in the seasonal influenza vaccination uptake by ethnicity, sex, age, socioeconomic deprivation and comorbidities, including obesity, which, if repeated for COVID-19 vaccination, would undermine vaccination coverage. With lower COVID-19 infection rates, the intention to be vaccinated may come under threat in line with personal risk perceptions of the pandemic (Caserotti et al, 2021). Even among relatively well-educated university students (n=1122), disease knowledge can be variable, including the presence of some misconceptions (Ryan et al, 2019).

Vaccine hesitancy is not restricted to the general population, and vaccination uptake can vary among NHS healthcare staff. For example, Clover (2021) reported different COVID-19 vaccination uptake among NHS staff of different ethnicities. Dubé (2017) highlighted the importance of health professional vaccine hesitancy, because this hesitancy can cascade into their practice, with a lack of confidence about vaccination (safety, effectiveness and importance of vaccination) and increased inability to address the fears of hesitant patients.

The simplistic notion that the availability of vaccines will result in uptake is debunked by the large number of possible causes of vaccine hesitancy. Thomson et al (2016) developed a practical taxonomy from a narrative analysis of 38 articles (2003–2013) that included 17 studies conducted in the UK. They identified five root causes (5As) that may underpin the extent of vaccine coverage, namely: access (ability of individuals to reach or be reached by a vaccination programme); affordability (ability of individuals to afford vaccinations, both non-financial costs such as time and, outside the UK, financial costs often apply, although loss of earnings and transport costs may apply in the UK); awareness (extent of knowledge of the need for and availability of recommended vaccines alongside their benefits and risks); acceptance (likely acceptance, questioning or refusal); and activation (degree to which individuals are ‘nudged’ towards taking a vaccination).

While most people in the UK are expressing positive attitudes towards COVID-19 vaccines and are likely to accept a vaccination, Sonawane et al (2021) noted that a significant proportion of the population is undecided and, if this diffidence converts to vaccination refusal, it may result in an insufficient vaccination coverage to achieve herd immunity. Responding to this critical concern, the ethnicity sub-group of the Scientific Advisory Group for Emergencies (SAGE) prepared a paper to inform Government decision-making (UK Government, 2020), outlining the factors influencing the uptake of COVID-19 vaccinations by ethnic minority groups and the potential strategies to address vaccine hesitancy. The evidence relating to these strategies is described in the next section.

Effective strategies to promote vaccination uptake

Alongside the systematic review to understand influenza vaccine hesitancy (World Health Organization (WHO), 2016), another systematic review (WHO, 2014) addressed strategies to manage vaccine hesitancy. The review included 116 empirical papers published between 2007 and 2013, with most interventions focused on ‘individual/social group influences’ with the use of knowledge- and awareness-raising strategies. There were also many ‘vaccine and vaccine-specific’ interventions related to the role of health professionals and the mode of delivery. ‘Contextual influences’ interventions highlighted the engagement of community leaders, including faith leaders, in communication campaigns. The most effective interventions directly targeted the unvaccinated and under-vaccinated populations, aimed at increasing knowledge and awareness related to vaccination, improved convenience and access to vaccination, targeted specific populations such as a local community, employed a reminder and follow-up and engaged local community leaders to promote vaccination. Mandating or imposing a sanction for non-vaccination was also effective, although this is counter-culture in the UK. The most effective interventions were multi-component-that is, they focused on increasing knowledge and awareness alongside direct targeting of a population and improving access to vaccination. The least effective interventions were those involving service improvements, such as extended clinic hours, and more generalised interventions, such as posters and media announcements, although these may have raised general health awareness.

WHO (2014) noted that the quality of the evidence was often weak (i.e. the quality of the trials had weak controls for bias), but, nonetheless, the nature of the interventions was analysed in terms of other dimensions, namely, dialogued-based interventions, non-financial incentives and reminder-recall interventions. Within dialogue-based interventions, the WHO (2014) recommended the involvement of community leaders to counter misconceptions and community distrust through dialogue to inform and influence by means of natural community processes and bring about social mobilisation. Mass media were effective is raising awareness of both vaccinations and health services, and, while social media were also effective, these need to be well managed to avoid exploitation. This review also noted the value of communication-based and knowledge-based training of health workers, so that they can address vaccination concerns of individuals and groups (WHO, 2014). Non-financial incentives have been effective in low-income settings, especially when it is linked with basic survival, so it is difficult to know whether food-based incentives would have the same positive impact in the UK. Reminder-recall interventions were effective, but, on their own, they cannot address the psychological and other issues underlying vaccine hesitancy.

Two reviews have been published after the WHO (2014) review. Jarrett et al's (2015) systematic review of evidence from 2007 to 2013 included 116 peer-reviewed and 15 grey literature papers of evaluation studies. Remarkably few of the evaluations reported on vaccination uptake/coverage (n=9) or changes in vaccination knowledge/awareness/attitudes (n=3), with three evaluations reporting on both vaccination uptake and changes in vaccination knowledge/awareness/attitudes. This review reported similar findings to those of the WHO (2014) review, namely, the most effective strategies had multiple components and directly targeted the unvaccinated and under-vaccinated populations, aimed to increase knowledge and awareness related to vaccination, improved convenience and access to vaccination, targeted specific populations such as healthcare staff or specific communities and engaged local community leaders to promote vaccination. The greatest increases (>20%) in knowledge/awareness/attitudes occurred when new knowledge education was embedded within existing practice, such as a healthcare procedure, while tailored interventions that targeted specific populations and their specific concerns were most effective in increasing vaccine uptake, as well changing vaccination knowledge/awareness/attitudes. As found in the WHO (2014) review, the least effective interventions involved service improvements, such as extended clinic hours and passive interventions like websites and posters. The evidence was mixed regarding reminder-recall interventions.

Like the WHO (2014) review, Jarett et al's (2015) analysis found that dialogue-based interventions were most effective when they involved community leaders, included social mobilisation, used mass media to raise awareness, used social media but in a controlled fashion to avoid misinformation and involved communication-based training of health staff. Information-based training of health staff had mixed results in one study included in this review. The reminder-recall interventions were also effective, but, again, the authors cautioned that this intervention on its own cannot address the complex issues underlying vaccine hesitancy.

The European Centre for Disease Prevention and Control (EDCU) (2015) published a rapid literature review of 29 papers reporting studies conducted in the EU and EEA countries in 2004–2014. This review made recommendations regarding the design, format and content of communication interventions. It recommended that hesitant populations should be involved in the design and that such interventions should be built on a health needs assessment and use existing social networks. If it is online, it should maximise its visibility through search engine optimisation. The format should be clear and easy to read, specific to the target audience, provide continuous information with monitoring and regular updates, and if online, it should be transparent and monitor the needs of the hesitant population. The content should set out the risk and consequences of the disease, the risk of not being vaccinated, the effects of vaccines on the immune system and other forms of prevention and how these compare with vaccination. The EDCU recommended that online campaigns should include easy-to-understand facts about vaccination, including the ability and responsibility to protect others, avoiding criticising hesitant populations and empowering people to ask their doctors the right questions. As with the previous reviews, the EDCU found mixed evidence regarding the effectiveness of interventions, in part because the evaluations were poorly designed (the interventions lacked specificity and outcome measurement was poor), which should be remedied if research is to provide strong evidence to inform future strategies to address vaccine hesitancy.

Finney Rutten et al (2021) assessed evidence-based strategies to address COVID-19 vaccine hesitancy in the US, where there is a convergence of uncertainties, including pandemic fatigue and social trends, such as high social media use, widespread propagation of misinformation and everyone becoming an ‘expert’ in SARS-CoV-2, all of which are increasing vaccine uncertainty specific to the COVID-19 vaccination campaign. The authors made recommendations drawing on the evidence from other vaccination campaigns and the social sciences, including implementation science. They recommended that access barriers to vaccination should be minimised so that everyone is enabled to receive a vaccination. Their review provided evidence of the potential impact of interactions between health professionals and their patients. They asserted that health staff recommendations are consistently trusted sources of information and, particularly for COVID-19, are effective promoters of vaccination (Table 1) (Finney Rutten et al, 2021). This echoes Dubé's (2017) assertion of the importance of health professionals, including nurses, as vaccination promoters and the RSPH's (2020) online survey, which revealed that 76% of their UK sample would accept a COVID-19 vaccination if advised to do so by their GP or other health professional. Importantly, 35% of those from ethnic minority backgrounds reported that they would likely change their minds and take a vaccine if they were given more information by their GP about its effectiveness (RSPH, 2020). A necessary first step is for all health professionals, including nurses, to be role models by being vaccinated themselves, especially as there is evidence that there is a significant relationship between the vaccination status of nurses and vaccination promotion to their patients. In other words, some nurses may be less fit for their public health role (While, 2014) (Table 1).

Finney Rutten et al (2021) cautioned that individual-level interventions for health professionals and patients are largely ineffective unless combined with other interventions. They noted that health professionals required education, which includes information about vaccine efficacy, safety and reactogenicity, to ensure that they can offer strong recommendations and answer queries as they arise, but they also acknowledged that the use of several vaccines increases the communication challenges regarding COVID-19 vaccination. Importantly, health professionals need to be able to offer honest, consistent and culturally appropriate advice that can be supported by other members of the health team, including administrative staff (Finney Rutten et al, 2021).

Finney Rutten et al (2021) cited evidence that patients should be offered education materials to support positive messages emphasising the benefits of vaccination, together with the potential negative consequences of remaining unvaccinated, as well as an appeal to altruism and societal benefit. They recommended tailored reminders addressing common concerns in addition to the inclusion of new information about the disease and/or vaccination benefits. They advised that reminders were not the place to counter common misconceptions, with the correcting of misconceptions best addressed through a targeted approach that affirms personal values to increase likely receptivity, explains motivation behind the misinformation, while providing alternative facts about the vaccine with repetition to strengthen their efficacy. Unlike the previous reviews, Finney Rutten et al (2021) reported that reminders/recalls were effective, especially where they involve direct contact with the individual and include point-of-care prompts where a reminder is offered during a clinical contact. The use of point-of-care prompts is similar to ‘making every contact count’ (MECC) (PHE, 2016), which involves the opportunistic delivery of consistent and concise health information while encouraging conversations related to health so that people make informed and positive health decisions. As with interventions to address vaccine hesitancy, MECC uses behaviour change evidence within existing health contacts to have brief conversations to promote desired health behaviours (Table 2).

Strategies to promote vaccine uptake among health professionals

Vaccine confidence among some health professionals can be fragile, and belief in vaccination is not always matched by confidence in vaccine safety (Dubé, 2017). Zhang et al (2012) found that nurses' seasonal influenza vaccination behaviour was complex, and they recommended differentiated vaccination promotion strategies reflecting the different knowledge levels, beliefs and risk perceptions of the unvaccinated nurses, with the highlighting of health benefits and professional responsibilities. The WHO (2020) has published an extensive COVID-19 vaccine safety manual drawing on the lessons learnt from the lack of initial confidence in the H1N1 vaccination, so that there is a global system of vaccine safety surveillance, including adverse event monitoring with data sharing. In the UK, healthcare staff and the public can be reassured that the new COVID-19 vaccines have been subject to rigorous testing and scrutiny by the regulator-the Medicines and Healthcare products Regulatory Agency-prior to distribution as part of the vaccination programme. Nonetheless, some healthcare staff have various concerns, and, in response, the NHSE (2021) has issued guidance to NHS trusts about how they may reassure these staff members through individual conversations. Peers may also promote vaccine uptake, both by example and by engaging in discussions that address concerns and identify ‘key informants' whom their colleagues may trust for detailed conversations about vaccines and vaccination.

Conclusion

Vaccination is a powerful public health intervention, but its success in achieving herd immunity depends on the coverage of the vaccination programme, which may be undermined by vaccine hesitancy. Evidence suggests that some strategies are more effective in promoting vaccination uptake. Community nurses can contribute to the promotion of vaccination uptake by helping design and deliver effective vaccination campaigns and incorporating evidence-based interventions into their practice, including point-of-care prompts, so that every contact counts.

KEY POINTS

• Herd immunity through vaccination depends upon high levels of vaccine uptake
• Vaccination promotion should focus upon the unvaccinated and under-vaccinated populations
• Understanding the information need is an important first step
• Information should be clear, concise and targeted at the audience individual
• Barriers to vaccine uptake should be minimised

CPD REFLECTIVE QUESTIONS

• What do you need to consider when promoting a vaccination to a client?
• What changes will you make to your practice to promote the uptake of the annual seasonal influenza vaccination?
• How can you contribute to the promotion of the COVID-19 vaccination programme?