VACCINE hesitancy is a pressing issue of global concern, with the World Health Organization identifying vaccine hesitancy as one of the top 10 threats to global health in 2019.

Vaccines are one of the most successful and cost-effective public health interventions of all time, and yet, we are in a time when parents, in particular, seem to be questioning their safety and effectiveness more than ever. Vaccine preventable disease (VPD) outbreak reporting is presently dominating the global media, with grave concerns that many diseases thought to be close to eradication are returning in full force.

There has been a 31% increase in measles cases globally between 2016 and 2017. In 2018, measles cases in Europe soared to a 20-year high, with 72 deaths and over 80 000 people contracting the disease in 47 of 53 European countries.

As the WHO warns, pockets of low vaccine coverage in different countries and regions can readily erupt into disease outbreaks. For optimal disease prevention, rigorous monitoring and evaluation is urgently required to understand why populations are undervaccinated, design and implement effective interventions and identify trends in vaccine attitudes in different regions.

We know that vaccine refusal plays a clear role in VPD outbreaks, such as has been shown for measles and pertussis. However, it is important to recognise that vaccine hesitancy and refusal alone do not account for all these cases. Practical and programmatic issues also play a substantial role in low vaccine coverage. The nuance and complexity associated with this issue is often not portrayed by the media. Instead, the frequency of these outbreaks is often blamed on antivaccine information, spread online through social media, which causes parents to become fearful and refuse vaccines.

In fact, there are two main contributors to undervaccination: acceptance and access factors. The contribution of each varies between high, middle and low income countries and between different populations or cultural groups. Incomplete vaccination has been shown to be associated with many logistical factors, including family size, low parental education and missed opportunities or unnecessary delays in vaccine delivery.

For example, GPs or immunisation nurses may recommend a parent delay their child’s vaccines due to intercurrent illness, such as an upper respiratory infection with no fever, when this is not required. Other barriers include incomplete Australian Immunisation Register records, parents being unable to get time off work to attend immunisation sessions, or the financial and practical pressures facing families with many children. It has been estimated that only 3.3% of Australian parents are registered or unregistered vaccine refusers, leaving the bulk of the undervaccinated proportion of children due to these more logistical issues.

We urgently need to be able to accurately identify the relative contribution of each factor in areas affected by low coverage in order to tailor effective, evidenced-based solutions and use our limited resources and health dollars more wisely.

Despite relatively high vaccine coverage rates at present in Australia, with between 90.75% to 94.67% of 1-, 2- and 5-year-olds fully vaccinated, low coverage pockets still exist in every state in Australia and at both ends of the socio-economic spectrum. Furthermore, 2016 saw the removal of non-medical vaccine objection, which had served as a surrogate to monitor vaccine objection in the population. As a result, we now know less than ever before about the reasons for under- and non-vaccinated children in Australia. Most countries rely on vaccine coverage rates to monitor vaccination programs, but these are a very blunt instrument. Vaccination rates cannot tell us why specific people are undervaccinated or which provider communication approach might influence their decisions and behaviour. We cannot unpack how a multifaceted vaccine promotion intervention may operate or identify when confidence in vaccines is wavering and people may be susceptible to vaccine misinformation or scare campaigns. Importantly, vaccine coverage rates are also unable to provide information on timeliness and cannot distinguish between the key determinants of behaviour.

The WHO has recommended that every country develop strategies to “increase acceptance and demand for vaccination,” and has highlighted a pressing need for new tools that measure vaccine acceptance.

While vaccine acceptance measures have been developed for adolescents and for specific vaccines, only two measures of child vaccine acceptance have undergone validation. However, neither these nor any other available tool measures barriers to accessing vaccines, either alone or in combination with items measuring vaccine acceptance. As such, we currently lack the appropriate tools to “diagnose” all the causes of undervaccination in different settings where low vaccine coverage is a serious issue. In Australia, there is also no tool to enable regular national assessment of vaccine concerns or guide development of strategies to promote vaccine acceptance and uptake. For the most part, the measurement of the drivers of vaccine uptake is inconsistent and incomplete, resulting in limited evidence on effective strategies for different populations.

Supported by the National Health and Medical Research Council in 2018, our research team from the Murdoch Children’s Research Institute and the University of Melbourne, with key collaborators from the University of Sydney and the University of Newcastle and internationally, is developing the first comprehensive and interlinked model of parental acceptance and access barriers to childhood vaccination. The tool, named the Vaccine Barriers Assessment Tool or VBAT, will consist of a short and a long form.

The short form, likely featuring five questions, will be based on the most predictive and representative survey items and will be relevant for use in annual state-based or national health surveys to track vaccine attitudes over time. The long form (most likely 15 questions) will be relevant for evaluation of immunisation programs and interventions. It may also be used by local program delivery teams to improve uptake, or by clinicians to screen and diagnose barriers for individual parents and to guide more effective conversations to address their concerns.

The VBAT will be a validated tool that will draw on all known determinants of health behaviour to predict vaccine uptake. The tool will be developed in Australia using the COM-B framework to ensure all behavioural determinants of vaccine uptake are covered. The COM-B model has been used to explain and categorise barriers to vaccine uptake, according to (i) capability (knowledge about when and where to get a vaccine), (ii) opportunity (access to and social norms about vaccines) and (iii) motivation (attitudes and beliefs about vaccines). For the first time, the VBAT will allow identification of the key drivers of undervaccination in specific populations to guide the selection and implementation of cost-effective interventions to increase vaccine uptake. In the future, we anticipate that it will be adapted for use in low resource settings.

Once barriers have been accurately identified, the next step is to develop multicomponent interventions to target key time points and high-risk groups to improve vaccine uptake, including pregnant women, parents of young children and children who are medically at risk or have a disability, to name a few. The evidence is clear that such interventions should incorporate:

  1. structural levers at the systems level, with
  2. provider training in communication skills to further equip those at the front line to tackle the complexity of a conversation with a vaccine hesitant or refusing parent, and
  3. clear, easily accessible information that parents can trust to address their key vaccine safety concerns.

Parents don’t want motherhood statements that “all vaccines are safe and work,” they want the facts about vaccine safety, effectiveness and disease severity to be able to interpret the risks and benefits within their frame of reference and moral belief system. They need to be reminded of the severity of the diseases, without intimidation. Parents who have questions about vaccines and are “sitting on the fence” care deeply for their children and want to do the right thing but often remain conflicted and scared.

This is why the role of the trusted health care provider – the GP, midwife, paediatrician, obstetrician or adult physician – plays such a crucial role in building vaccine confidence and addressing vaccine safety concerns. Positive communication with a trusted health care provider and a recommendation to vaccinate is the most powerful predictor of vaccine acceptance, which explains why simply providing parents with more information on vaccines alone is not enough. Trust – in the government, health care providers and the health care system – is crucial to building vaccine-resilient communities that can weather the storm of vaccine safety scares and celebrity-driven antivaccine messages.

Billions of dollars fund the research and development of vaccines to ensure their efficacy and safety – now a serious investment in high quality vaccine communication science needs to be made to ensure sustained vaccine confidence. If we are to continue the global assault on VPDs and achieve the United Nations General Assembly Third Sustainable Development Goal to ensure healthy lives and promote wellbeing for all, it is essential that vaccine programs and research studies measure more than just uptake; we need valid and reliable instruments to measure and monitor people’s awareness, acceptance and access to vaccines to inform effective interventions.

Dr Margie Danchin is a clinician researcher and Team leader, Vaccine acceptance, Uptake and Policy, within the Department of Paediatrics, University of Melbourne and Murdoch Children’s Research Institute. Her research is focused on developing new interventions to improve vaccine confidence and uptake among different populations and in different settings and she is the lead investigator on the Vaccine Barriers Assessment tool funded by the National Health and Medical Research Council.

Jessica Kaufman is a post-doctoral researcher at the Murdoch Children’s Research Institute and the Centre for Health Communication and Participation (La Trobe University), and an Honorary Fellow of the University of Melbourne. Her current research projects include designing and testing new interventions to improve uptake and acceptance of maternal and childhood vaccines, vaccine program evaluation, and developing a database of instruments to measure vaccine-related attitudes, knowledge and decision making.



The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.

5 thoughts on “Building vaccine confidence: more information is not enough

  1. Anonymous says:

    Invest as much money as you want trying to ‘convince’ parents who are ‘on the fence’. Parents who have witnessed their child have an adverse reaction straight after routine vaccinations will never believe the safe and effective BS.

    Ex-vaxers (those who once vaccinated) are some of the most educated people that I have ever met. There are plenty of GPs, physicians, neurologists, biologists etc who warn of the risks associated with vaccines.

    Physicians for informed consent are a good starting point for independent research. Christopher Exley PhD FRSB
    Professor in Bioinorganic Chemistry
    Aluminium and Silicon Research Group is also doing groundbreaking research related to adjuvants in vaccines.

    Most of the doctors in Australia don’t even know about this research when I have asked them. Parents need to get educated and stop believing all the fear mongering. Our children are relying on us to demand better safety and efficacy than the joke that is vaccine (tabacco) science.

  2. Anonymous says:

    Wow. Just … wow. Anti-vaxxers, you’re a breed apart. You and the climate-deniers, UniMed blowhards, the Flat-Earthers and the “we-never-landed-on-the-Moon” crew are as impervious to science and evidence as your average block of granite. Go live in a commune somewhere, fenced off from the rest of us, where you can not vaccinate to your heart’s content and do the rest of the population no harm at all. Bye bye.

  3. Elijah Varga says:

    If these pro vaxxers think that they are on the top of the vaccine debate, there is more to come.These so called antivaxxers are well versed in the issue and under no circumstances will they change their minds. They do know very well what are they talking about and intelligently seen thru the lies, propaganda and deceptions. If you are a pro vaxxer, this is your personal issue and please stay out of our business and let us be in peace and stop attacking us.You will never convince us nor by any force or ridicule humiliate us. If vaxx is for you, keep it to yourselves. OK?

  4. Robin says:

    All you have to do is ask a vaccine-hesitant parent what they are hesitant about, and address that. Have you?

    For example, they might say there are no pre-licensing safety studies on any vaccine that compares the vaccine to a true placebo – so you can show them a double-blind RCT with a true placebo. Or they might say the studies that supposedly show vaccines don’t cause autism have together only looked at one vaccine and one ingredient – than you can show them true vax-unvax studies (where unvax means had no vaccines) that looked at all health outcomes. You could especially show them a SIDS study that compares vax vs unvax.

    You can sit with parents and watch a video of a parent describing how their child developed a severe condition, or died, immediately after vaccination and try to look genuine while you say it was a coincidence.

    They might say they are worried about the aluminium in vaccines because it is stored in the body, can move to the brain and cause inflammation there – and you can lie through your teeth and say there’s more aluminium in food and water than in vaccines, when you know perfectly well that the Al in food and water is dissolved and in ionic form, and it is easily flushed from the body, while injected Al is in insoluble Al compounds and its very purpose is to cause inflammation (and it is swallowed up by macrophages which carry it around the body).

    Maybe you could address the latest science from very pro-vaccine scientists such as Cherry and Benn saying the whooping cough vaccine is making children sick from unrelated infections (you know, linked-epitope suppression). Or explain to parents the whooping cough vaccine does actually stop infection and transmission.

    And when these ignorant parents show you disease mortality figures that clearly show vaccines have not been responsible for the decline in infectious deaths, and that the decline was so steep in the 1950s that it is obvious the rates would have continued to go down without vaccines, you can tell them the figures are wrong, or something.

    And please do explain to Dr BURGESS that today’s AFM patients (you know, re-named polio) use ventilators, not iron lungs.

    But I know you’ll keep saying you don’t know why some well-educated parents are vaccine hesitant, and never ask them why – you wouldn’t have any answers, the parents are way ahead of you.

  5. Dr Roger BURGESS, radiologist says:

    Has anyone else noted that there is a growing trend for the children of anti-vaxers to sneak under their parents guard and, when they are able to, get themselves vaccinated and, down the track, vaccinate their children?
    Could this be a rewarding line of approach? I mean, as an example, conduct a series of lectures to high school students…even run competitions with fair dinkum prizes out of these lectures. The lectures must be graphic eg showing a child with the painful tetanic spasms of tetanus, patients who have spent virtually all their lives in an “iron lung” machine, diphtheritic membrane choking a child, images such that poor little child with post-meningococcal amputations etc. What a wonderful, wonderful brave little girl.

    Kids are not stupid.

    Most, if not all, will get the message. I reckon that a good start to the lecture would be to hand out a simple quiz sheet on all of the vaccine-preventable diseases. Have them swap their answer sheets with the person sitting beside them and then mark them at the end of the lecture. Have substantial prizes for the first four winners of the quiz say $250, 150, 100 and $50 or whatever PLUS certificates. I bet they will even swot for the test!!!!!!!!!!! Just a thought.

    Again…anti-vaxers…there are none so blind who will not see.

    Keep up the good work Margie and Jessica!

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