Vaccine 33 (2015) 4180–4190

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Strategies for addressing vaccine hesitancy – A systematic review夽

Caitlin Jarrett 1 , Rose Wilson 1 , Maureen O’Leary 1 , Elisabeth Eckersberger 1 ,
Heidi J. Larson ∗,1,2,3 , the SAGE Working Group on Vaccine Hesitancy4
Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: The purpose of this systematic review is to identify, describe and assess the potential effectiveness of
Available online 18 April 2015 strategies to respond to issues of vaccine hesitancy that have been implemented and evaluated across
diverse global contexts.
Keywords: Methods: A systematic review of peer reviewed (January 2007–October 2013) and grey literature (up
Vaccination hesitancy to October 2013) was conducted using a broad search strategy, built to capture multiple dimensions of
Vaccine hesitancy
public trust, confidence and hesitancy concerning vaccines. This search strategy was applied and adapted
Interventions
across several databases and organizational websites. Descriptive analyses were undertaken for 166 (peer
Strategies
Literature reviews
reviewed) and 15 (grey literature) evaluation studies. In addition, the quality of evidence relating to a
SAGE series of PICO (population, intervention, comparison/control, outcomes) questions defined by the SAGE
WHO Working Group on Vaccine Hesitancy (WG) was assessed using Grading of Recommendations Assessment,
Development and Evaluation (GRADE) criteria; data were analyzed using Review Manager.
Results: Across the literature, few strategies to address vaccine hesitancy were found to have been eval-
uated for impact on either vaccination uptake and/or changes in knowledge, awareness or attitude (only
14% of peer reviewed and 25% of grey literature). The majority of evaluation studies were based in the
Americas and primarily focused on influenza, human papillomavirus (HPV) and childhood vaccines. In
low- and middle-income regions, the focus was on diphtheria, tetanus and pertussis, and polio. Across
all regions, most interventions were multi-component and the majority of strategies focused on raising
knowledge and awareness. Thirteen relevant studies were used for the GRADE assessment that indicated
evidence of moderate quality for the use of social mobilization, mass media, communication tool-based
training for health-care workers, non-financial incentives and reminder/recall-based interventions.
Overall, our results showed that multicomponent and dialogue-based interventions were most effec-
tive. However, given the complexity of vaccine hesitancy and the limited evidence available on how it
can be addressed, identified strategies should be carefully tailored according to the target population,
their reasons for hesitancy, and the specific context.
© 2015 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/3.0/).

1. Introduction – is being increasingly studied. Given the growing concern in many

countries about vaccine hesitancy, the Strategic Advisory Group of
The dynamic and challenging period of indecision around Experts (SAGE) Working Group (WG) on Vaccine Hesitancy6 asked
accepting a vaccination – often referred to as “vaccine hesitancy”5 that a review focused on strategies to address hesitancy be under-
taken.
The purpose of this systematic review was to identify strate-
夽 Some of the authors are World Health Organization staff members. The opinions gies that have been implemented and evaluated across diverse
expressed in this article are those of the authors and do not necessarily represent global contexts in an effort to respond to, and manage, issues
the decisions, official policy or opinions of the World Health Organization. of vaccine hesitancy. This review was conducted to inform the
∗ Corresponding author.
E-mail address: Heidi.Larson@lshtm.ac.uk (H.J. Larson).
1
Department of Infectious Disease Epidemiology (IDE), LSHTM.
2
Department of Global Health, University of Washington, Seattle, USA.
3
Member of SAGE Working Group on Vaccine Hesitancy. cific varying across time, place and vaccines. It includes factors such as complacency,
4
Members of SAGE Working Group on Vaccine Hesitancy are listed in Appendix. convenience and confidence” (WHO SAGE meeting, October 2014).
5 6
Vaccine hesitancy “refers to delay in acceptance or refusal of vaccines despite http://www.who.int/immunization/sage/sage wg vaccine hesitancy apr12/
availability of vaccination services. Vaccine hesitancy is complex and context spe- en/ [accessed 02.02.15].

http://dx.doi.org/10.1016/j.vaccine.2015.04.040
0264-410X/© 2015 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/3.0/).
 C. Jarrett et al. / Vaccine 33 (2015) 4180–4190 4181

recommendations of the SAGE WG, building on the previous review based or multi-component), the type of participants, setting and
of determinants of vaccine hesitancy [1]. target vaccine; and the findings related to the outcomes of interest.

2.3.2. Part B (PICO & GRADE) – Study selection, risk of bias &
2. Methods analysis
The SAGE WG identified 15 PICO (Population, Intervention,
2.1. Search strategy Comparator, Outcome) questions [2] [Appendix 3] a priori, to exam-
ine population features likely to influence the effect of different
For the peer-reviewed literature, the following databases were interventions and to assess the quality of evidence for each PICO
searched for the period of January 2007–October 2013: Medline, question using GRADE (Grading of Recommendations, Assessment,
Embase, PsychInfo, Cochrane, CINAHL Plus, Web of Science, LILACS, Development, and Evaluation) [3]. The primary outcome of inter-
Africa-Wide Information (for these, the search range was 2007 to est was defined as the uptake of all vaccines included in routinely
9 October 2013); IBSS (2007 to 19th July 2013) and IMEMR (2007 to recommended immunization.
10 October 2013). The applied search strategy was kept deliberately The 15 PICO questions were developed under three intervention
broad to try to capture the multiple facets of vaccine hesitancy and themes: (1) Dialogue-based, (2) incentive-based (non-financial),
incorporated MeSH or equivalent terms [Appendix 1]. References and (3) reminder–recall. Following an extensive discussion by the
in relevant papers were searched for further relevant studies. WG at the December 2013 meeting, it was decided to focus on
For grey literature, an open-dated search ending, in October the impact of single component approaches and exclude multi-
2013, was conducted across several databases and organiza- component approaches. However, data were included where a
tional websites, which included: OpenGrey, New York Academy multi-component intervention provided suitable data to assess the
of Medicine, Global Health, National Institute for Health and effect of its individual component parts.
Care Excellence (NICE), Department for International Development Theme categories for PICO questions:
(DFID), the Communication Initiative Network and the Polio Com-
munication Initiative Network [see search terms in Appendix 2]. i) Dialogue-based, including the involvement of religious or tra-
Direct email requests were sent to individuals/organizations iden- ditional leaders, social mobilization, social media, mass media,
tified by the SAGE WG. and communication or information-based tools for health-care
workers (HCW);
2.2. Study selection – Part A (Identification, scope of literature ii) Incentive-based (non-financial), including the provision of
and effect of evaluated interventions) food or other goods to encourage vaccination, and;
iii) Reminder/recall-based, including telephone call/letter to
For peer-reviewed literature, studies were included against the remind the target population about vaccination.
following criteria: (i) contained research on vaccine hesitancy; (ii)
included any of the keywords in the title or abstract: “strateg*”, Evaluated primary studies identified earlier (Part A) were
“intervent*”, “campaign”, “evaluation”, “approach” or “program*”; included if they provided direct evidence relevant to one or more
(iii) described or evaluated an intervention addressing hesitancy PICO questions and reported data for comparison groups. Reasons
and reported a measure of the primary outcome, i.e. indicating a for excluding studies are presented in Characteristics of excluded
change in vaccination uptake or the secondary outcome, i.e. indi- studies [4].
cating a change in knowledge/awareness and/or attitudes; (iv)
published between January 2007 and October 2013; (v) pertaining 2.3.3. Assessment of risk of bias
to any vaccines and vaccination programmes; (vi) published in any The Effective Public Health Practice Project (EPHPP) qual-
of the six official UN languages (Arabic, Chinese, English, French, ity assessment tool for quantitative studies [5] was applied to
Russian and Spanish). determine the risk of bias of all eligible studies. Two reviewers
Grey literature was selected based on the following inclusion independently conducted the risk of bias assessment and data
criteria: (i) contained any of the keywords extraction; disagreements were settled through discussion.

“immunisation/immunization”, “vaccine”, “vaccination”, “strat- 2.3.4. Data analysis

egy”, “intervention”, “evaluation”, “hesitancy”, “refusal”, “trust”, For studies which included pre- and post-control and interven-
“confidence”, “acceptance”, “engagement”, “anxiety”, “con- tion groups, only post-data were used to more accurately represent
cern”, “distrust”, “barrier”, “rejection”, “fear”; (ii) published the effect of the intervention. Outcomes reported varied between
anytime up to October 2013; (iii) English only. Literature was studies, so available data were entered into Review Manager soft-
excluded if it was: (i) about non-human vaccines or vaccines ware as individual studies. The fixed-effects model was used for
not currently available (e.g. HIV); (ii) related to research and analysis and results reported as risk ratios between intervention
development of vaccines (e.g. efficacy trials) unless explicitly and control groups.
about public trust, confidence, concern or hesitancy.
The screening of titles and abstracts was shared between at 3. Results
least two authors; a sample of studies was independently coded
by authors to ensure consistency. 3.1. Part A – Identification, scope of literature and effect of
evaluated interventions

2.3. Data extraction The search of peer reviewed publications identified 33023 peer
reviewed articles. After removing duplicates and screening for
2.3.1. Part A inclusion criteria, 1149 articles were included by full-text. Of these,
A data extraction form was developed by the authors and 166 [6–172] evaluated and 983 described, but did not evaluate, an
reviewed by the SAGE WG. For evaluation studies, information intervention. Among the evaluated studies included from the peer
extracted included details about the specific hesitancy issue; type reviewed literature, 115 related to Outcome 1, 37 to Outcome 2,
of intervention (dialogue-based, incentive-based, reminder–recall and 14 to both [Fig. 1].
4182 C. Jarrett et al. / Vaccine 33 (2015) 4180–4190

Fig. 1. Search process flow chart (peer reviewed literature) – Vaccine hesitancy.

The grey literature search identified 4896 records. After remov- vaccine hesitant parents using a multi-component strategy that
ing duplicates and screening for inclusion criteria, 59 articles were focused on education techniques. More often articles used terms
included by full text. Of these, 15 evaluated [172–186] and 44 only such as “refusal”, “distrust” and “acceptance” to discuss vaccination
suggested an intervention. Among the evaluated studies included behaviour. This reflects the relative newness of the term “hesi-
from the grey literature, nine reported on Outcome 1, three on tancy”.
Outcome 2, and three on both [Fig. 2]. The majority (58%) of evaluation studies in the peer reviewed
There were a total of 181 articles that evaluated interventions and grey literature were based in AMR7 (110/1898 ), and primar-
from the peer reviewed and grey literature search, combined. ily focused on influenza, HPV and childhood vaccines. In low- and
The number of peer reviewed studies evaluating interventions middle-income regions, particularly SEAR and AFR, the focus was
peaked in 2011 (at 32 studies) and has remained relatively stable on Diphtheria, Tetanus, Pertussis (DTP) and polio. All regions had
since (28 in 2012 and 25 in 2013) [Fig. 3]. evaluated studies anticipating or researching acceptance of the
Very few evaluated interventions were identified in the grey lit- newly introduced HPV vaccine.
erature with one or two articles annually at most from 1996 to 2012.
In 2013, eight relevant articles (47% of those identified through the
grey literature search) were found [Fig. 4].
Across all the literature reviewed (1208 articles), only five (0.4%) 7
The World Health Organization (WHO) divides the world into six WHO regions,
used the actual term ‘hesitancy’ or ‘hesitant’ with reference to for the purposes of reporting, analysis and administration: WHO African Region
vaccines/vaccination [94,173–176]. These were all found in the (AFR), WHO Region of the Americas (AMR), WHO South-East Asia Region (SEAR),
WHO European Region (EUR), WHO Eastern Mediterranean Region (EMR) and WHO
peer-reviewed literature and were all published in 2013. Only one
Western Pacific Region (WPR).
of these articles evaluated an intervention. This intervention was 8
The total number of articles is more than (n = 166) (peer reviewed) and (n = 15)
carried out in AMR and focused on childhood vaccines, targeting (grey literature) as some articles report on more than one WHO region.
 C. Jarrett et al. / Vaccine 33 (2015) 4180–4190 4183

Fig. 2. Search process flow chart (grey literature) – Vaccine hesitancy.

Most interventions (primarily in AMR and EUR) targeted par- of the HCWs were the primary focus of vaccine and vaccination-
ents, health-care workers (HCWs) and the local community. specific interventions (123/3416 , 36%). The engagement of religious
Interventions in the grey literature from AFR largely focused on and other community leaders was most commonly used to address
the local community and religious leaders. contextual influences such as religion, culture and gender [Fig. 5].
When mapped against the SAGE WG model of determinants In both the peer reviewed and grey literature, across all
of vaccine hesitancy [Appendix 4], interventions addressing indi- regions, most interventions (97/127, 76%) were multi-component.
vidual and social group influences, particularly knowledge and Dialogue-based interventions were common in all regions except
awareness raising, were most common in both the peer reviewed EMR; reminder–recall approaches featured predominantly in
and grey literature (157/341, 46%). Vaccine delivery and the role higher-income regions; and incentive-based interventions were

Fig. 3. Evaluated peer reviewed strategies by publication year (2007–2013) and WHO region (n = 172)*. *Total number of articles is more than (n = 166) as some articles
report on more than one WHO region.
4184 C. Jarrett et al. / Vaccine 33 (2015) 4180–4190

Fig. 4. Evaluated grey literature strategies by publication year (1996–2013) and WHO region (n = 17)*. *Total number of articles is more than (n = 16) as some articles report
on more than one WHO region.

only found in AMR and AFR (single-component), and SEAR (part vaccination [116]; (4) targeted specific populations (e.g. HCW)
of a multi-component approach). [9]; (5) mandated vaccinations or sanction against non-vaccination
[46]; and (6) engaged religious or other influential leaders to
3.2. Which interventions have been most successful? promote vaccination [177]. The greatest increases (>20%) in knowl-
edge, awareness or attitudes (Outcome 2) were observed with
The most effective interventions employed multiple strategies. education initiatives, particularly those embedding new knowl-
The interventions with the largest observed increases (>25%) in edge into routine processes (e.g. hospital procedures), which were
vaccine uptake (Outcome 1) were those that (not in order of impor- most successful at increasing knowledge and changing attitudes
tance): (1) directly targeted unvaccinated or under-vaccinated [105]. For both outcomes, those that tailored interventions to spe-
populations [13]; (2) aimed to increase vaccination knowledge cific populations and their specific concerns were most effective
and awareness [20]; (3) improved convenience and access to [23,38].

Fig. 5. Evaluated peer reviewed and grey literature strategies by the SAGE WG model of determinants of vaccine hesitancy (n = 344). *Interventions could address more than
one determinant of vaccine hesitancy.
 C. Jarrett et al. / Vaccine 33 (2015) 4180–4190 4185

3.3. Which interventions have been least successful? African countries) and polio [3] (Afghanistan) but their impact was
not independently measured from other intervention components.
Interventions associated with a less than 10% increase in uptake Communication tool-based training for health-care work-
included those that focused on quality improvement at clinics (e.g. ers had a positive impact on uptake of EPI vaccines (RR 3.09
improved data collection and monitoring, extended clinic hours [2.19, 4.36]) [92] and DTP3 (RR 1.54 [1.33, 1.79]) [79] in India and
[8,58], passive interventions (e.g. posters, websites [19,24,41] and Pakistan respectively, among rostered patients; evidence quality
incentive-based interventions using conditional or non-conditional was assessed as moderate and low respectively.
cash transfers. It must be noted that incentive-based interventions One study [10] (Turkey) assessed the impact of information-
usually targeted general preventive health and not just vaccination based training for health-care workers on uptake for rostered
[96,98]. Lastly, reminder–recall interventions were associated with patients, with varying results. There was little or no increase in
variable changes in uptake [57,75,88]. uptake of DTP/OPV-1 (RR 0.99 [0.93, 1.06]), DTP/OPV-2 (RR 1.04
[0.97, 1.12]), BCG (RR 1.01 [0.95, 1.08]) and measles (RR 1.02 [0.96,
1.09]), a moderate increase in uptake of HepB-2 (RR 1.63 [1.49,
3.4. Part B – PICO & GRADE
1.79]), HepB-3 (RR 1.89 [1.74, 2.04]) and DTP/OPV-3 (RR 1.42 [1.33,
1.51]), and a substantial increase in uptake of HepB-1 (RR 2.83 [2.6,
Of 129 studies available, only 13 studies met the inclusion crite-
3.08]); but the evidence quality was very low for all.
ria for GRADE evaluation. The methodological quality (risk of bias)
of each is set out in Appendix 5. Further study details are presented
in Appendix 6. 5. Non-financial incentives
The delivery of interventions varied as did the outcomes. Con-
sequently only one outcome (two studies) for a single vaccine The evidence for non-financial incentives for par-
was pooled; meta-analysis was not feasible for any other outcome ents/communities located in low-income settings (India) was
[64,66]. Summary of relative risk ratios (RR) and evidence quality moderate for a large, positive effect on EPI vaccine uptake (RR 2.16
(GRADE) for each question are presented in Appendix 3. Of the 15 [1.68, 2.77]) [92].
PICO questions, only 10 could be addressed, often with only 1 study
with evidence. 6. Reminder–recall interventions

Two studies assessed the impact of reminder–recall interven-

4. Dialogue-based interventions tions in low-income and under-vaccinated populations. The impact
of reminder–recall interventions in low-income settings was posi-
Eleven studies evaluated by PICO and GRADE deployed tive for DTP3 (RR 1.26 [1.13, 1.42]) [146] (Pakistan) with moderate
dialogue-based interventions (explained below). There was appre- quality evidence. For settings with low baseline uptake, the effects
ciable variability in the quality of evidence supporting the use of were large and positive for scheduled childhood vaccines (RR 3.22
these interventions and their impact varied considerably, by type [1.59, 6.53]) [86] (Switzerland) but the quality of evidence was very
of intervention, by vaccine and by setting. low.
For polio, the involvement of religious or traditional leaders
in populations with low baseline uptake indicated a large, posi- 7. Discussion
tive effect (RR 4.12 [3.99, 4.26]) on vaccine uptake but the evidence
quality was assessed as very low [65] (Nigeria). The grey literature 7.1. Part A – Identification, scope of literature and effect of
also reinforced that religious and traditional leader involvement evaluated interventions
can have a positive impact [3,5,177,178] as in west and central
francophone African countries, Afghanistan, India and Europe. While there has been an increase in the number of articles
Four studies using social mobilization among parents in low- on the issue of vaccine hesitancy, of those that include a discus-
income settings found a positive effect on measles (RR 1.63 [1.39, sion on interventions or strategies to address hesitancy, few go
1.91]) [78] (Pakistan), DTP3 (RR 2.17 [1.8, 2.61]) [78] (Pakistan), as far as evaluating them. Furthermore, the specific term “vac-
DTP1 (RR 1.54 [1.1, 2.15]) [106] (Nigeria), and polio (RR 1050.00 cine hesitancy” has only recently been used and the only evaluated
[147.96, 7451.4]) [66] (Pakistan) [64] (India) vaccine uptake. The intervention that explicitly addressed “hesitancy” comes from the
quality of evidence for each outcome ranged from moderate United States.
(measles, DTP3), to low (polio) and very low (DTP1). Two stud- Overall, many of the interventions were not different from tradi-
ies targeting polio vaccination refusals reported large increases in tional strategies to increase vaccine acceptance, with the majority
uptake. In the grey literature, inclusion of social mobilization as a focusing at individual and social group level and interventions
component appeared to have a positive, albeit varied effect and was being largely on knowledge and awareness raising. While knowl-
not always quantified. edge and awareness raising strategies are important, they are
Two studies evaluating social media interventions found a inadequate, as evidenced by the finding that the most effective
positive effect on uptake for MCV4/Tdap (RR 2.01 [1.39, 2.93]) interventions used multi-component strategies. Furthermore the
[102] (Australia) and seasonal influenza (RR 2.38 [1.23, 4.6]) [157] most effective interventions were tailored to specific populations
(Australia) although the evidence was assessed as low and very low and addressing specific concerns, pointing to the importance of
quality. In the grey literature, one study [178] in Slovenia reported understanding the drivers of vaccine hesitancy to inform the inter-
on the use of social media with other strategies for A(H1N1), how- ventions.
ever its effect was not independently measured, achieved low The increasingly recognized domain of vaccine hesitancy needs
utilization, and became a source of negative social media rumours. new interventions to address new issues. In particular, the dearth of
A study on mass media to target parents with low awareness interventions identified in low-income countries needs attention.
of health services found an association with increased uptake of all
routinely recommended vaccines (RR 1.57 [1.4, 1.75]) [179] (India). 7.2. Part B – PICO & GRADE
The quality of evidence was moderate. Three grey literature studies
reported on the use of mass media for A(H1N1) [178] (Europe), rou- Despite the few studies available for GRADE and variability in
tine childhood immunization [177] (west and central francophone the quality of the evidence, several interventions showed some
4186 C. Jarrett et al. / Vaccine 33 (2015) 4180–4190

positive impact on vaccination uptake, including: social mobiliza- greater outcome changes with an intervention. It is possible that
tion, mass media, communication tool-based training for HCW, by addressing basic needs, this intervention simultaneously built
non-financial incentives, and reminder–recall activities. None of confidence and reduced vaccine hesitancy because the target pop-
these interventions were without shortcomings, and given the vari- ulation felt that their other critical needs were being addressed. This
ability in context, target population and outcome, the potential approach could be particularly important for underserved groups.
application of these interventions must be cautiously considered
when applying them in different circumstances. 10. Reminder–recall interventions

8. Dialogue-based interventions Although positive, the relatively low observed effect of

reminder–recall interventions in low-income settings seems to
The impact of religious or traditional leader involvement reflect the limitations of using this kind of intervention alone. In
in populations with low baseline uptake merits further inves- this example, a complex set of issues was identified in the tar-
tigation and evaluation. This type of intervention is important get population but the intervention only addressed one of them.
as it addresses one of the more difficult determinants of vac- Reminder–recall on its own is not enough to tackle multiple causes
cine hesitancy, namely, misconceptions and community distrust. of hesitancy.
This intervention aligns itself with natural community processes –
seeking out community leaders, and encouraging dialogue across 11. Limitations
multiple levels to both inform and influence. The success of the
intervention could be attributed to the efforts made to understand This review may be subject to publication bias, in that unsuc-
the target audience, facilitate open dialogue, and integrate activities cessful interventions may be less likely to be documented in either
with familiar processes and systems. the peer-reviewed or grey literature. Another reason for the paucity
The success of social mobilization interventions for popula- of relevant studies is that the PICO questions emphasize spe-
tions refusing polio vaccination could also be attributed to the tar- cific, single component strategies, but many evaluated strategies
geting of, and dialogue with, a clearly defined population. By com- are neither designed nor presented in this way. Evaluated, multi-
parison, the social mobilization interventions for measles and DTP component interventions were identified but only overall impact
were much less targeted; although positive outcomes appear to be data were presented. Therefore, outcome data for individual strate-
due to meaningful dialogue at both the group and individual level. gies to address vaccine hesitancy were not separately available.
Social media intervention studies suggest that this approach
might work well for those who have already started their vacci-
12. Conclusion
nation schedule, or who are familiar with social media in other
aspects of their lives. However, there is important evidence that
Overall this review has found that, despite extensive litera-
social media are also very open to exploitation if not managed well.
ture searching, there are (1) few existing strategies that have been
Also those who initiate vaccination are probably not the most hes-
explicitly designed to address vaccine hesitancy; and (2) even fewer
itant of populations and those with access to social media are not
strategies that have quantified the impact of the intervention (14%
the most marginalized.
(166/1149) of peer reviewed; 25% (15/59) of the grey literature).
The use of mass media to target populations with low aware-
There is also an uneven geographical spread in the available litera-
ness of health services appears to be effective, however, the limited
ture, with most focusing on AMR and EUR.
impact also suggests that there may be other underlying issues
Efforts to address issues of hesitancy are disparate. While a
affecting the impact that need investigation and more tailored sup-
number of interventions did have a positive effect, wide variation
porting interventions.
was observed in the effect size between studies, settings and tar-
The provision of communication tool-based training for HCW
get populations. In addition, the high level of heterogeneity across
generally had a positive effect (for EPI vaccines, DTP3) but the size
study design and outcomes, coupled with few available studies,
of the effect and evidence quality varied. The observations about
further limited our ability to draw many general conclusions about
this example and mass media suggest that interventions that adopt
the effectiveness of different strategies.
a unidirectional (top down) approach to communication, may be
Nonetheless, interventions to increase uptake that are multi-
successful among some individuals and groups, but not all; success
component and/or have a focus on dialogue-based approaches tend
is dependent on the nature and degree of hesitancy.
to perform better. Together, these interventions suggest that taking
The impact of information-based training for HCW on uptake
a comprehensive approach that targets multiple audiences and lay-
of several vaccines for rostered patients was generally poor. A
ers of social interaction are more likely to bring positive results. The
possible explanation for these results is that there was no clear
evidence for non-financial incentives and reminder–recall activ-
understanding of the underlying reasons for the low vaccination
ities was also of good quality, and carries the potential to bring
uptake and as such, the intervention was not appropriately tar-
positive change by addressing the more practical aspects of vacci-
geted. Nonetheless, the intervention did achieve good success with
nation.
HepB (all doses) and DTP/OPV (dose 3); one possible reason for
Vaccine hesitancy is a complex issue and no single strategy will
this is that the HCW exhibited greater confidence but it is not clear
be able to address it. There are some promising examples using
whether this was an issue prior to the intervention.
uptake as a link, but many are incomplete and most are not directly
comparable. One of the greatest drawbacks of the interventions
9. Non-financial incentives identified is that many operate from an assumption-based rather
than an evidence-based approach; appropriate evaluation is also
The moderate to large effect of non-financial incentives for par- lacking. On a more positive note, there is a growing body of research
ents/communities located in low-income settings on vaccination on the determinants of vaccine hesitancy which can help inform
uptake is promising. In this study the target group was very dis- and refine currently used approaches that look promising but have
advantaged and the food-based incentive, so closely linked with not yet been fully implemented or evaluated.
basic survival, was readily received. Furthermore, the baseline Lastly, there is a clear need for more attention to under-
vaccination rates were very low (2%), and more likely to show standing and addressing hesitancy at the community and social
 C. Jarrett et al. / Vaccine 33 (2015) 4180–4190 4187

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