We know that vaccine coverage across Europe is uneven, and while we continue to lack sufficient comparable data regarding un- and under-vaccinated populations, the most common explanations for these differences in vaccine coverage are often ascribed to either ‘vaccine inequity’ or ‘vaccine hesitancy.’
Both terms can be defined and interpreted in many ways – but we at EuroHealthNet would argue that ‘vaccine hesitancy’ should more frequently be considered as a type of vaccine inequality rather than as a separate issue – and that solutions to ‘hesitancy’ should be less targeted at individual decision-making and more towards addressing systemic political, socio-economic, and health barriers.
Health inequalities are ‘systematic differences in health between social groups’ that are avoidable and unfair. Health inequalities fundamentally result from complex and interlinked ‘determinants of health’ which may be socio-economic, environmental, commercial, cultural, or political. The COVID-19 pandemic vividly exposed many of these underlying determinants, with disadvantaged communities such as minority ethnic groups and people living in poverty experiencing higher burdens of COVID-19 morbidity and mortality.
Once COVID-19 vaccines were made available, a similar pattern of uneven vaccine uptake was observed across Europe. Media and government authorities have frequently cited ‘hesitancy’ as the primary driver of the significant gap in vaccine coverage between Western and Eastern European countries during the initial COVID-19 vaccine rollouts.
However, this emphasis on ‘hesitancy’ places the burden of change on the individuals who choose not to vaccinate while glossing over important, often long-standing political inequalities which have generated a lack of trust in government and government services. Like vaccine hesitancy, political inequality has many definitions, but can be described as ‘structured difference in influence over decisions made by political bodies and the unequal outcomes of those decisions.’
Trust in government is a key enabler of high vaccine uptake, both for COVID-19 vaccines as well as for other routine immunisations. While a recent OECD report found that there is not a simple correlation of vaccine coverage with trust in government, low trust does imply greater vulnerability to mixed messages from other sources (e.g., ‘misinformation’). Additionally, political parties who adopt vaccination as a ‘wedge issue’ also risk further deteriorating trust and politically stratifying vaccination coverage across the population.
Political inequalities experienced by whole populations in Eastern Europe during the Communist and post-Communist era – and by minority populations across Europe (e.g., marginalised Roma and migrant communities) – have generated deep distrust which still today has broad influences on the way some members of these populations choose to interact with government services.
Just as ‘behaviour change’ is a solution favoured by many policymakers to address lifestyle factors influencing health outcomes (e.g., smoking, healthy diet, physical activity), focusing on ‘vaccine hesitancy’ can seem like a convenient solution to improving vaccine uptake. However, both health behaviours and vaccine decision-making are grounded in the wider determinants of health and should be considered as proxy indicators not primary causes which affect our health outcomes.
To improve vaccine uptake, we must be willing to acknowledge and address inequalities both in our political systems and health service provision, and subsequently make upstream, systemic improvements to the way that our governments engage the whole population. This may be the most durable solution both to the challenges of vaccine inequality and ‘vaccine hesitancy’ and our best bet for improving vaccine uptake across Europe.
For more, read the EuroHealthNet Policy Précis : Improving vaccine equity: Addressing barriers and building capacity to improve vaccine uptake.