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Immunization in Focus: Building confidence in vaccines to increase acceptance and’s complicated


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Immunization in Focus

MOMENTUM Routine Immunization Transformation and


Photo of a health worker filling a needle for an immunization.

imageNOVEMBER 2021

Building confidence in vaccines to increase acceptance and uptake: It’s complicated

The COVID-19 pandemic has thrown immunization into the spotlight, popularizing such technical concepts as cold chain, herd immunity, and particularly vaccine hesitancy. The rapid development and introduction of COVID-19 vaccines has changed the global landscape for immunization, bringing a mix of hope, doubt, and controversy about vaccines and vaccination.

Since the inception of the World Health Organization’s Expanded Program on Immunization almost 50 years ago, all countries have established national immunization programs that at a minimum provide a basic package of vaccines for children and women of childbearing age. The experience from routine childhood immunization, new vaccine introductions, and accelerated disease control initiatives such as polio eradication and measles elimination has generated rich learning about factors that promote and impede community acceptance and uptake of vaccines. While concern about the impact of vaccine hesitancy on uptake increased in the decade preceding the pandemic, hesitancy among families has not been systematically monitored. During this same time, global immunization coverage remained basically unchanged at approximately 85 percent.

This issue of Immunization in Focus provides an overview of what is known about increasing uptake and confidence in vaccines, in lower and middle income countries, including managing vaccine hesitancy and misinformation. It provides links to practical tools that USAID Missions and projects can use to promote vaccination acceptance and use.

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Traditional Chief receiving COVID-19 vaccine in his palace in Prestea Ghana. Source: JSI/Ghana.


What is known about building vaccine confidence, acceptance, and uptake? 

Evidence over the past decades indicates that vaccine uptake is a function of several factors related to demand, supply of services, prior experience with those services, and other broader determinants. Demand tends to be strong when the perceived risk and severity of vaccine-preventable diseases is high, there is confidence in vaccines and vaccination, and alternative measures to mitigate the risks of those diseases are inadequate or difficult to implement.

As shown in the Behavioural and Social Drivers (BeSD) of immunization framework (Figure 1), vaccine uptake is determined not just by these factors but also by social processes: the social norms for immunization, recommendations from health care providers, and gender-related issues. These factors, along with individuals’ views of benefits, safety, and trust, build motivation and the intent to seek vaccination. Of critical importance as well are practical issues that affect the ability to act on that intention. These are largely a function of health system performance and include access, affordability, availability, and reliability of services and experience in using them.



The BeSD framework above highlights the need to identify the reasons for low vaccine uptake rather than assume that it is due to a single factor such as low demand or vaccine hesitancy.

If clients or caregivers find it difficult and expensive to go for vaccination or encounter poor treatment or vaccine stockouts, then they tend not to seek services despite their intentions. While clients need to have confidence in vaccines, they also need confidence in the vaccination services, and have the agency to use them easily.

The pandemic and COVID-19 vaccine rollout have introduced new challenges. COVID-19 as a disease is still unfamiliar and poorly understood by a substantial part of the world’s population. Seen by many as just one of several diseases or health risks that they face, COVID-19 may not be viewed as particularly life-threatening. Further, people recognize that they can take other actions such as social distancing and wearing masks to protect themselves. The rapid development of COVID-19 vaccine and the speed of its introduction have led to uncertainty and confusion, with social and mass media as key channels for rapidly spreading misinformation. The uncertainty about the vaccine is compounded by the evolving scientific knowledge of the virus and its variants, the disease, and the vaccine safety and effectiveness. Adverse events that follow an immunization, regardless of whether caused by a COVID-19 vaccine, can further fuel unease about vaccination and must be managed with transparent communication to build trust over the long term.

Many impediments to COVID-19 vaccine acceptance and uptake lie within the health system. In some places, health workers’ doubts about the vaccine persists so that they neither vaccinate themselves nor serve as credible information sources to others. The limited quantities of COVID-19 vaccine available to lower-income countries and the confusion about multiple vaccine products and preferences for some over others have limited uptake in some places. It has proven difficult to get the vaccine to priority groups (older populations, those with co-morbidities) not traditionally reached with vaccination at sites that they can easily access. The need to use COVID-19 vaccines very quickly due to their short shelf lives and special handling requirements brings urgency while also giving rise to community doubts about their effectiveness. In some places, these concerns have spilled over to reduce the use of routine childhood vaccination as caregivers fear their children will be forced to get COVID-19 vaccine or take part in illicit experiments.


Photo from M-RITE-led workshop on COVID-19 vaccination with professional, community, and religious organizations in DRC, September 2021

Photo from a workshop on COVID-19 vaccination with professional, community, and religious organizations in the Democratic Republic of the Congo, held by MOMENTUM Routine Immunization Transformation and Equity in September 2021.


What can be done to build confidence and uptake of vaccines?

For a novel vaccine against an unfamiliar disease like COVID-19, there will be earlier and later adopters, and many people are in the “wait and see” category. But given the urgency of the pandemic and the short shelf life of most COVID-19 vaccines, countries need to accelerate the pace of acceptance. While there are no simple solutions, countries can implement a combination of steps to promote acceptance and uptake of both COVID-19 and routine immunization.

  • Identify and understand the reasons for low uptake. Conduct rapid formative research and apply human-centered design methods to identify both the barriers to and enablers of immunization, recognizing that some problems may be rooted in issues of service quality and access. It is especially important to understand health workers’ views. Track rumors regularly to monitor the types of misinformation circulating, get out in front of it before it flourishes. Also explore what is behind the rumors to address what motivates them and makes them believable. Apply the findings to inform communication efforts as well as health worker training and supervision.
  • Develop segmented strategies to promote acceptance and uptake. Different people have different information needs, and messages that speak to their concerns influence their actions. For the general public, simply providing scientific evidence to debunk rumors is likely to fail; it can amplify the rumors by repeating them while giving information that may not be understood or accepted. Messages about how COVID-19 vaccination can improve the well-being of individuals and their families are more likely to be effective, but their content needs to be determined locally. By contrast, messages that provide scientific evidence are important for building confidence among health care providers.
  • Seek community input in microplanning to help ensure that demand generation/communication activities represent community needs. This is especially important when it is not possible to conduct formative research.
  • Engage trusted, influential messengers to spread the word through credible channels. While social media is effective in spreading misinformation about vaccines, interpersonal communication from personally known and trusted individuals is powerful for building trust and reassurance for both routine immunization and COVID-19 vaccine rollout. Use multiple channels to spread key messages so that they are commonly encountered, and update messages for health workers based on rumor tracking and new information.
    • Intensify efforts to build acceptance and active support among health care providers. It has been known for decades that health care providers are powerful messengers in promoting acceptance of vaccines for routine immunization. For COVID-19 vaccination, engagement of the professional associations to which they belong is emerging as a promising approach that can quickly reach many providers through people they respect. Providers can then become adherents and proponents of both routine and COVID-19 immunization.
    • Enlist the support of key influencers, such as entertainers, athletes, educators, and high-level officials to publicize their own acceptance of vaccination and reassure the public about vaccine safety and effectiveness.
    • For COVID-19 vaccine, enlist the voices of early adopters to share their personal experiences around vaccination with those in the “wait and see” category.
  • Seek input and assistance from influential community members, civil society organizations, and non-traditional stakeholders about their concerns, insights, access to priority populations, and ideas for increasing acceptance of and access– both for COVID-19 vaccine and routine immunization. The engagement of local officials and community and religious leaders as full partners changed the direction of the Ebola outbreak in West Africa in 2015–16. They become part of the solution, co-creating contextually appropriate, feasible solutions to address local concerns. Engaging with non-traditional stakeholders, for example in the education or HIV sectors, can expand access to populations have not traditionally been reached by immunization programs.
  • Make it easy to access accurate, current information. Establish mechanisms such as call centers with trained, capable staff who can quickly provide callers with accurate information and compelling language to respond to rumors without repeating them, which perpetuates their spread.
  • Make it easy for people to get vaccinated. Keeping the needs of clients first, map the journey to vaccination faced by the clients and caregivers and the healthcare providers who serve them. This process needs to take into account the gender barriers (such as hidden costs, unsupportive family decision making, and inconvenient services) that hinder uptake for routine childhood immunization and may contribute to the reported lower coverage for COVID-19 vaccine among women. Provide key information and personalized nudges about where and when to go for all doses of vaccines. This requires strong coordination of service delivery, supply chain, and communication efforts. Encourage partnerships with major employers to conduct on-site vaccination drives for their employees. If pre-registration for COVID-19 vaccination is being used, identify those who cannot easily pre-register, provide opportunities for them to receive the vaccine, and communicate that they will not be denied vaccination.
  • Make vaccination a good experience. Information that a vaccination session is well organized and feels welcoming and safe can spread into the community and encourage others to come. Health worker behavior and communication style affect demand.

What tools are available to help?

For building strategies to improve vaccination acceptance and uptake:

For managing misinformation about immunization and communicating about COVID-19 vaccine safety:

Useful websites with more information on these topics include:

Building trust, acceptance, and uptake of vaccination is a complex undertaking that requires ongoing adaptations to adjust to changing circumstances. While the introduction of COVID-19 vaccine has highlighted that vaccine acceptance and uptake is critical to controlling the global pandemic, most of the same actions are needed to improve equity for routine immunization. The rollout of COVID-19 vaccine presents an opportunity to build capacity for improving immunization acceptance and uptake in both the immediate and long term.



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Photo Credits 
In order from top to bottom: Kate Holt/MCSP; JSI/Ghana; MOMENTUM Routine Immunization Transformation and Equity/DRC. 
Copyright © 2021 USAID MOMENTUM, All rights reserved.

MOMENTUM Routine Immunization Transformation and Equity is funded by the U.S. Agency for International Development (USAID) and implemented by JSI Research & Training Institute, Inc., along with PATH, Accenture Development Partnerships, Results for Development, Gobee Group, CORE Group, and The Manoff Group under USAID cooperative agreement #7200AA20CA00017. The contents of this newsletter are the sole responsibility of JSI and do not necessarily reflect the views of USAID or the United States Government.