Five years ago, Professor Heidi Larson put the finishing touches to her book, Stuck: How Vaccine Rumours Start And Why They Don’t Go Away. She had, by then, built a successful career as an anthropologist studying attitudes to vaccines and vaccination ‒ working at UNICEF and founding the Vaccine Confidence Project at the London School for Tropical Health & Medicine.
However, any hopes that a period of relative calm would follow completion of the manuscript had evaporated before the book went to press. A new chapter in the history of vaccination was about to be written: the SARS-CoV-2 virus was spreading around the world and all eyes were on vaccine experts. How soon could we have a vaccine? And who would get it first?
As hospitals came under pressure and social restrictions were introduced, the idea that some people would refuse the vaccine ‒ and that the pandemic might negatively affect the population’s attitudes to all vaccines ‒ seemed remote to many observers. But, for Prof Larson and colleagues, the turbulence of the pandemic and the role of COVID-19 vaccination in shaping future vaccine decisions, was always high on the agenda.
Now, five years since the first surge of COVID-19 cases, and the wave of lockdowns that followed in the spring of 2020, Prof Larson has led a major 70-country study of current attitudes to vaccines. The Global Listening Project (GLP) asked 1,000 people in each of the 70 countries about their trust in governments and health policies, as well as their views on the safety, effectiveness, and importance of vaccination.
The headline finding is that vaccine confidence has fallen in 9 out of 10 countries. What’s more, people are demanding better healthcare and more information, but trust in vaccines and health institutions is under severe pressure. On a positive note, most people still vaccinate; most trust their own doctor; and there are indications that vaccine uptake could be improved by mobilising peers, community leaders and other local actors.
(A Nature Comment article by Prof Larson and colleagues was published on 8 April.)
We asked Prof Larson to outline some of the key take-aways from this vast dataset which takes the temperature of vaccine sentiment five years post-pandemic.
Key points
- 90% of countries saw a decline in confidence in vaccine safety
- In Europe, Hungary, Romania and Finland reported low confidence
- Young people and women have lower than average vaccine confidence
- Trust in family doctors remains high; as does trust in family/friends
Vaccines Today: The GLP finds that, post-COVID, confidence in the importance of vaccines has fallen in 9 out of 10 countries, reflecting a broad trend of increasing cynicism. Why has the pandemic been followed by a decrease in vaccine confidence and an increase in cynicism?
Prof Heidi Larson: One reason is that, before COVID, there was a group of people aged between forty and sixty years who were not really thinking about vaccines ‒ they had no reason to look for information online. At most, they may have asked their doctor about shingles or the flu vaccination, but they typically were not aware of the nature of the online conversation about vaccines.
During COVID, this changed. Everyone was looking online for information on vaccines. All of a sudden, they were seeing things that made them think twice. It didn’t turn people into extremists, but it put questions in the minds of people who had taken vaccines for granted.
Another factor that was a big deal for some people were the mandates and requirements (to be vaccinated). That wasn’t all about vaccines: it was about a range of control measures, and people took it out on vaccines and started to resent vaccination as a result.
Finally, the fact that vaccines were produced quickly made some people suspicious but many were simply trying to understand a complex and unfamiliar process in real time.
The survey shows that scepticism is more pronounced in countries with robust healthcare systems. Why would this be? Shouldn’t countries with strong health systems have greater trust?
Going right back to when the Vaccine Confidence Project started global monitoring in 2015, we found that France stood out as having a robust healthcare system and yet a vaccine sceptical population. (Editor’s note: In that 2015 study, 41% of respondents in France disagreed with the statement that vaccines were safe. Uptake of most vaccines in France was higher than 41%.)
In the new GLP study, across multiple countries, it seems that young people, women and those with lower education stand out as the most sceptical. How does this build on previous trends you have observed?
Work we had done for UNICEF and for the European Commission had earlier pointed to a decline in trust among younger people, so the new data shows a continuation of this trend. Younger people have seen the biggest decline in confidence in vaccines.
In some countries with low confidence, things are getting worse. What could they learn from countries where things are improving?
The challenge with vaccines—which isn’t new or exclusive to COVID, although the pandemic intensified it—is that vaccine uptake is closely intertwined with public trust in government. The state approves them, regulates them, recommends them, and sometimes even requires them. This is true of medicines more broadly, but because vaccines are often delivered through public programmes and discussed in the context of public health, they are more visible.
So, if you’ve had negative experiences with the government or feel marginalised by institutions, you may be less inclined to trust their health advice. That’s why it’s so important for governments and institutions to actively work to build trust and strengthen relationships with all communities.
A lot of this is not about vaccines; it’s not really about what’s in the syringe ‒ it’s about wider issues. I’d estimate that as much as 50% or 60% of vaccine-related issues are nothing to do with vaccination itself, but contextual and historical issues and trust dynamics.
As to what low-confidence countries can learn from those where trust is higher, it’s hard to draw lessons from one country and apply them to another when everything is so embedded in local government and local histories, but building on local trust relations has shown to be critical to successful programmes.
Who do people trust and where do they search for information?
The GLP is trying to probe and understand trust dynamics more deeply in the sense that we want to look at many more dimensions of trust and who people trust and turn to. The study, and many others before it, show that people trust their own healthcare professionals. In our recent Commentary in Nature, we argue that not enough attention is paid to who else people trust.
One thing we found is that you can have people with 70% confidence in scientists or doctors, but then their trust in family and friends can be 85%. In some countries, religious leaders are even higher. So when we asked Who do you turn to for information about vaccines? The answers were very varied. It’s a combination of employers, religious leaders, family, friends, doctors, neighbours….
Family doctors enjoy consistently high trust, but are some healthcare professionals reluctant to have conversations with patients about vaccines, in case it undermines their relationship and affects other health conditions?
Yes, when it comes to trust, the family doctor got the highest points across the board. And that’s hard [for doctors] because it puts a lot of weight on their shoulders, especially in the current environment where doctors are already pretty stressed in terms of time available for patient consultations. We need to find out how we can better support doctors in addressing the questions they face.
But, you’re absolutely right that healthcare professionals are happy to give information about vaccines, but some may hesitate to engage in extended discussions because they are carefully balancing multiple priorities. And they do not feel they have the time to get into lengthy – sometimes contentious – discussions about vaccines.
Along with health professionals, you’ve mentioned local or micro-influencers as highly trusted sources of information. How could they be mobilised to advocate for vaccination?
The role of local influencers as trusted sources of information was already recognised before COVID-19 pandemic hit, but the COVID-19 response measures really accelerated the influence of local trusted networks. People are looking for local sources. They want information to be as relatable and specific to their areas as possible; not too far away from them or too top down.
We found some of the most relatable influencers were the ones that look and talk like their audience. Microinfluencers are the future.
