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The vaccine confidence gap The recent Decade of Vaccines Global Vaccine Action Plan(GVAP) [1] includes the strategic objective that:

“Individuals and companies should understand the value of vaccines, and demand immunization as both their right and responsibility”.

This was express recognition by the GVAP of the importance of addressing at a global level the so-called “vaccine confidence gap”. Acceptance of vaccination is an important but often forgotten element of vaccination uptake. Yet lack of confidence in and acceptance of vaccination remains a significant public health challenge; it has led to recent measles outbreaks across Europe, and polio resurgence in Nigeria. The second of five goals of the Decade of Vaccines is to “meet vaccination coverage targets in every region, country and community” [1]. To measure success, the GVAP tentatively proposes two indicators:

1. Percentage of countries that have assessed (or measured) confidence in vaccination at subnational level

2. Percentage of un- and under-vaccinated in whom lack of confidence was a factor that influenced their decision

  Measuring the problem. You cannot understand and change what you cannot measure (we say that a lot). We need standardised indices that allow us to measure & track key determinants of uptake & actual uptake. These must enable monitoring over time, as relative changes are likely to give more actionable information than absolute scores. Actual vaccination uptake can be hard to measure, and it may be necessary to record self-reported behaviours where possible to complement official data. The best proxy of behaviour is probably stated intention. A robust, psychometrically validated instrument could enable measurement and tracking of attitudes, intentions and self-reported behaviours (uptake). Importantly, such a tool could also identify social, psychological and demographic predictors of behaviour change which could be used to inform and tailor social and behavioural change interventions at a country or even community level. We are currently developing such an attitudinal barometer for adult vaccination in collaboration with Imperial College (who have already tested an instrument for parental attitudes to MMR) and will discuss this further soon.

However, this approach highlights a cardinal challenge to vaccination uptake – the definition of the problem must be measurable. People are variously looking at whether it is about refusal, hesitancy, confidence, trust or acceptance, and this seems often to lead to rather circular discussions. We propose that acceptance may be the best definition because it gives both a positive slant to the challenge and is potentially measurable. Acceptance could be defined as:

‘The intention to get vaccinated where there is access to, and awareness of, an affordable vaccine.’

While this will certainly not capture all the dimensions that may affect vaccination acceptance, it is a potentially measurable definition that may at least be an indicator.

Listen, understand, engage. It is also now possible to track and measure the conversation around vaccination in the mainstream and social media. This approach is increasing being used by companies to monitor the conversation around their products, services and brand. For example, Nestle has a (rather unfortunately named) ‘War Room’in which a team sits in front of 12 big screens and tracks mentions and discussions of their products in social media 24/7, responding to the public, and informing their marketing strategies in near real-time. We are currently testing a monitoring system (social barometer) that is fed by both passive monitoring of media and active (event-based) reporting from the HealthMap system. We envisage a simple dashboard that may be used by vaccination program managers to listen to discussions of their vaccines and programs at a local level, and perhaps to help them engage actively in the public discussion to build and sustain trust in their programs. Conceivably it may be possible to develop a composite index of vaccination uptake (official & self-reported), acceptance, intention to vaccinate, and pressure and temperature (volume and sentiment) of online discussions. Which again would only be an indicator, but may facilitate better tracking (in real time) of the mood around vaccination within a country or region, which is the first step in the Listen-Understand-Engage cycle of good vaccination advocacy.


Refs 1. WHO. Global vaccine action plan 2011-2020. Available at: 2. WHO. Weekly Epidemiological Record, No. 20. 2013, 88, 201-216.

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In a series of blog posts, Mike Watson ( and I will propose a structured, evidence-based, globally applicable approach for building and sustaining acceptance of vaccination. An approach that will give national vaccination programs a triple-A rating for uptake: Access, affordability, awareness, acceptance, activation (yes, thats 5 in fact). And then provide a matrix of solutions for the development of a strategy that will help close any vaccination uptake gap.

The topic of vaccination acceptance has finally hit the global agenda, yet now that the problem has been widely acknowledged, we seem to be struggling to figure out what to do. You cannot understand what you cannot measure. Recent discussions overheard at many levels suggest that the natural scientists who populate the vaccination ecosystem are struggling to measure vaccination acceptance with natural science methodologies. This is not surprising, given that vaccination acceptance is about people, not microbes. Biology can tell us a lot about a virus, from its genome to its epidemiology, but these methodological approaches fail miserably to explain those weird irrational human behaviours that control our decisions.

If we cannot apply a natural sciences approach to a human problem, then what are we to do? Well, there is good news. Very good news. The social and behavioural sciences have, for quite some time, been doing a great job of measuring and understanding what influences human behaviour. It is time for vaccinologists to agree that the sciences we use have hit their limit with this new/old problem of trust in vaccination. And instead of trying to put a screw in with a hammer, we need to get a screwdriver (no offence meant to social scientists).

We claim no expertise in the social or behavioural sciences, which is exactly the point. Everything we are learning about the social and cognitive determinants of vaccination behaviour is coming from behavioural and social science experts and literature. We have happily acknowledged the limitations of clinical medicine, molecular biology, epidemiology and so on. We have accepted that we are odd irrational beings who can apply our years of training in empirical sciences to better justify post-hoc the decisions we have made through a trail of cognitive short-cuts that passed through the prism of our worldview.

And we now want to do things better, to actually have an impact, with the help of the social and behavioural sciences.

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Talking vaccination in Tartu

By: Angus Thomson | 0 Comments

On: September 23rd, 2012 in Adults,Vaccination | Tags:

I was in Tartu last weekend to speak at the Baltic Vaccination Day. In this small Estonian university town that has endured invasions by Germans, Poles, Swedes, Russians, Germans again and then Soviets, we discussed other smaller invaders of the respiratory and nervous systems of adults across the world: the pneumococcus, influenza virus, tuberculosis and the TBE virus which rides in on ticks in search of our brains.   There was a mild sense of exasperation at the fact that we are able to make childhood vaccination programs work well – including here in the Baltic – but programs for adults continue to stumble along with coverage rates that are only a fraction of the recommended targets.   In the US about 300 children die from vaccine-preventable diseases each year. As opposed to 50,000 adults. Prof Arvydas Ambrozaitis from Vilnius University noted that if this were the other way around – 50,000 deaths of children – it would be a national emergency.   Yet adult immunisation seems to be caught in a fog of apathy, indecision and inaction. Prof. Stephan Gravenstein noted that in the US, the target seasonal influenza vaccination rate for high-risk adults is 90%, but the actual rates are about 30%. In Lithuania, Prof. Ambrozaitis said that the actual rates for this group hovers around 6% – a long, long way from the more modest EU target of 75%.   I was however quite impressed to see that in Latvia actual coverage rates for tetanus and diphtheria (Td) vaccination of adults are between 50 – 60%. This may be below their target of 80%, but I am not sure many other countries manage to get coverage this high.   Everyone seemed to agree that a major reason for this adult vaccination gap is simply that most people, including HCWs, don’t often put the words ‘adult’ and ‘immunisation’ in the same sentence. Vaccines are for kids, not grown-ups in many people’s minds.   Crises of confidence in childhood vaccination in the Baltic seem to regularly come from the mass media. One headline that was recounted to me: “Vaccination is like Russian Roulette”. However, Prof. Ludmila Viksna noted that the continued widespread use of certain vaccines which have higher incidence of local complications, such as BCG which can induce pain, scarring and sometimes abscesses at the injection site, also impact the public’s perception of vaccines.   When it came to solutions for this challenge of low vaccination coverage in adults, the words ‘education’, ‘information’, ‘factual’, and ‘misunderstanding’ popped up rather a lot. Read my previous blog post to see that information and education are not major drivers of behaviour.   Or as Stefan rather nicely put it: We keep trying to eat soup with a fork.   But there was also discussion of the access barriers that must be overcome, and the fact that opportunities to immunize adults are often missed.   And interestingly, civil society organizations (CSOs) have played very positive roles in supporting vaccination in the Baltic region. Active supporters of vaccination in Latvia include religious organizations, the Latvian Red Cross, a Hepatitis Society, and a ‘Mommie’s Club’. A few years ago Vanina Laurent-Ledru and I discussed the emergence of CSOs as a key stakeholder in immunization in this paper.   Most encouragingly though was Stefan’s account of the outcomes of a mindstorm (brainstorming by mind map if I understood right) by the National Adult Vaccination Program (NVAP) which aimed to build an action-plan to increase adult immunization rates in the US. They identified policy actions such as expanding policies and mandates (those may not work so well in Europe…) to require large employers to have a vaccination policy, and structural options such as centralized registries and broadening the definition of immunizers.   But, of course, the stuff I liked was a call for more public engagement, and for collaboration with the social sciences (make sure you don’t miss the cognitive scientists Stefan) to help us better understand people’s concerns around vaccination.   I thank all the participants because I really had a stimulating and challenging day in a beautiful part of the world. I have, however, been wondering since how it could be conducted to give more practical, concrete outcomes.   Does anyone know of other vaccination days in other parts of the world, and if so, what do they do to have a lasting impact on policy or the public?

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Measles notification rates in Europe in 2011, ECDC

Measles notification rates in Europe in 2011, ECDC

A quick glance at HealthMap today showed resurgence of whooping cough in the US, Canada and Scotland. Rubella is bouncing back, and measles is hanging on in Europe. These diseases are all preventable by vaccines. And in all these countries the vaccines are available, accessible and affordable to all. That leaves awareness and/or acceptance of vaccination as the gap. On May 25 in Geneva at the World Health Assembly ministers of health from 94 countries endorsed the Global Vaccine Action Plan. One of the 6 strategic objectives of this roadmap for global vaccination in the next decade is:   “Individuals and communities understand the value of vaccines and demand immunization as both their right and responsibility”   This objective clearly aims to fill the awareness/acceptance gap. Importantly, the public is also clearly identified as a stakeholder in vaccination. However, with preventable disease outbreaks cropping up everywhere, clearly there is a need for all stakeholders in vaccination – public included – to do a better job securing public acceptance of this life-preserving act. Mike Watson and I recently published an editorial in Science Translational Medicine in which we propose a broad, integrated framework for vaccination advocacy that moves way beyond the standard ‘broadcast the facts and wonder why they don’t get it’ communications approach employed by most authorities and advocates at present (see my last post).1 This approach is based on 4 insights we had:

  • the deficit model of science communication doesn’t work
  • because people tend to prefer to trust their sense of ‘truthiness’ (see below)
  • the cognitive and social sciences can tell us how and why that happens
  • then we can use those insights to communicate the evidence in an evidence-based way (hint: stop broadcasting, start engaging)

I will be expanding upon the many themes we touch upon in this paper in later blog posts. Meanwhile, here is the renowned social scientist Stephen Colbert explaining his concept of truthiness2:   “The truth that you feel in your gut, regardless of what the facts support”   1. A. Thomson, M. Watson. (2012) Listen, understand, engage. Sci. Transl. Med. 4, 138ed6 (Download PDF from link on this page to avoid log-in) 2. Newman EJ et al. (2012) Nonprobative photographs (or words) inflate truthiness. Psychon Bull Rev. DOI: 10.3758/s13423-012-0292-0 [abstract here]

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Knowledge ≠ truth; perception = truth

If the social contract heralded in the modern world, we are now in a postmodern era1. The scientific truths that emerge from empirical studies are no longer necessarily accepted by the public as truth. Indeed people increasingly accept that there is no absolute truth, and that we each have our own subjective truths in life.

Patients are becoming consumers, evidence is balanced with values, risks loom larger than benefits, and trust in scientific authorities has been shaken by their handling of crises such as mad cow and swine flu. As patients demand a greater say in their health care, they increasingly expect their values & beliefs be considered along with the medical evidence. They want to make informed choices. The vast online conversation ongoing through social media is fertile soil for post-modernism. And what are we, the scientific establishment doing? We are up in the clouds, broadcasting dry fact-based public health messages to an indifferent public who are busy, well, talking to each other. This has been called the ‘empty vessel’ or ‘deficit’ model of science communication2. The undereducated, barely numerate public are considered empty vessels which we simply need to fill with facts and information to a sufficient level and …voila, they will accept vaccination. Problem is, it doesn’t work.

This little animation illustrates what scientific and health authorities need to do. You can see the authorities up in the clouds, absent from the conversation yet bravely broadcasting anyway in their foreign (scientific) language. They need to get down and join the conversation, starting by listening to what is being said. This should be proper active listening, to help us understand the real concerns and questions that people have regarding immunisation. Then the experts need to start conversing in the same language. They must ditch the jargon, and translate their treasured numbers into something that is meaningful to a normal person (does a risk of 1/1000 versus 1/100000 really mean anything to anyone?). They must listen, actively, and then answer the actual questions people have, not the questions they think people have. And then we will have engagement, not broadcast. And I suspect, as scary as it sounds, that may foster public understanding and perhaps even trust.

Getting the public back into public health

Back to the social contract. A contract is always between two parties, and so if the authorities must change, so should the public. They must somehow understand that even if these diseases are no longer wreaking havoc around us, they are lurking in wait. They must realize that public health belongs to the public and relies upon the public. How might that happen in the absence of fear of diseases? One approach could be to try to rekindle fear. But, as we saw with H1N1 in France3, this comes with an attendant risk. We do not carry fear comfortably; indeed we will usually do whatever it takes to unload that fear as soon as possible. As fear of the disease faded people had to put it somewhere. Somewhere like the vaccines for example. How then might we keep diseases in the public consciousness without resorting to the double-edged sword of fear? I like the idea of crowd-sourced epidemiology. Epidemiology is basically the detection and tracking and measurement of disease in a population. Vaccine-preventable diseases are traditionally tracked by ‘sentinels’ in a community such as general practitioners and laboratories. There is usually a delay before the data is available. Now there is no reason why the general public could not participate in this process. The FluNearYou app allows people to report flu symptoms through their smartphone, and to see the number of reported cases in their area. Other approaches are being tested for other diseases and other interfaces such as regular mobile phones (check out some of the great presentations at the Digital Disease Detection meeting hosted earlier this year by HealthMap). We know already that google search trends track the dengue season and twitter mentions can track flu (but not election outcomes).

My question is this: would a mother who has just reported on her smartphone that her child was diagnosed with chickenpox have some level of increased ‘ownership’ of that disease? Would that in turn augment her awareness of other diseases, even if she only sees them on a real-time map, and lead her to take steps to protect her kids from those diseases? I don’t yet have the answer to these questions, but would like to hear any thoughts others might have.


1. Gray JA. Postmodern medicine. Lancet 354:1550-1553 (1999).

2. Sturgis P and Allum N. Science in Society: Re-Evaluating the Deficit Model of Public Attitudes. Public Understanding of Science 2004 13, 55-74 (2004)

3. Report from the French Assemblee Nationale Commission of Enquiry into the planning, explanation and management of the Influenza A (H1N1) vaccination campaign.

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Thomas HobbesCitizens assert to honour the rights of others in return for assurances that their own rights will be protected.” Thomas Hobbes

The social contract

Along with his rather fine facial hair, Thomas Hobbes sported some pretty fine thinking. With some other great thinkers like John Locke and Jean-Jacques Rousseau, he helped lay the ground for modern democracies through his discourses on the social contract. A path out of our nasty, brutish and short lives, the social contract described an implicit agreement between people to cooperate to protect themselves and one another. Importantly, this contract necessitated the sacrifice of certain personal freedoms in return for state protection of the rights, security and health of its citizens.

Dark passengers, lurking

At a TEDxBrussels event on April 5th 2012 I spoke about the need for us all to revisit the more specific social contract of vaccination. This need is well illustrated in the progress and setbacks of the Global Polio Eradication Campaign. Polio was driven back by the biggest volunteer army (which includes child soldiers) ever assembled in human history, until by 2006 it was hanging on in only 4 countries. The rest of the world was free of polio.

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