Helping healthcare workers confront vaccine hesitant people

The VAX TRUST consortium was recently established with the aim of addressing vaccine hesitancy in Europe and to help healthcare professionals prepare for meeting with vaccine hesitant individuals. International Hospital speaks to Pia Vuolanto, the head of consortium, about VAX TRUST and the issue of vaccine hesitancy.

International Hospital: Can you tell us a bit about the background of VAX TRUST?

Pia Vuolanto: VAX-TRUST is funded by the European Union’s Horizon 2020 research and innovation programme (Grant Agreement No. 965280). The VAX-TRUST consortium was established for the Horizon 2020 ‘Addressing Low Vaccine Uptake’ call for proposals, which closed in June 2020. VAX-TRUST started in March 2021. The project is carried out in seven countries: Finland, Belgium, Poland, the Czech Republic, Italy, Portugal, and the UK. VAXTRUST is coordinated by Tampere University in Finland. I am the principal investigator of VAX-TRUST, which means that I lead the research consortium comprised of ten partners in the seven countries.

IH: What led to the establishment of VAX TRUST?

PV: Europe stands out as a region where vaccine services are largely available and many vaccine-preventable diseases have disappeared; but despite the good access and well-functioning healthcare systems, some people hesitate to take vaccines. From the point of view of healthcare professionals this means that people are coming to the consultancy rooms with readymade diagnoses and possibly with a negative or critical stance towards vaccinations, medications or other medical treatments. In these situations, healthcare professionals meet more and more challenges in building trust relationships with their patients. For this reason VAX-TRUST was set up to study vaccine hesitancy as a broad societal phenomenon with the primary aim to provide tools and support for healthcare professionals in encountering vaccine hesitant individuals.

IH: Will you be working with other research groups looking at vaccine hesitancy – such as the Oxford Coronavirus Explanations, Attitudes and Narratives Surveys (OCEANS) team?

PV: Yes, we will collaborate with a wide variety of other projects; in particular those funded from the same funding scheme in the EU Horizon 2020 programme, Jitsuvax (Jiu-Jitsu with Misinformation in the Age of Covid: Using Refutation-Based Learning to Enhance Vaccine Uptake and Knowledge among Healthcare Professionals and the Public) and RIVER-EU (Reducing Inequalities in Vaccine uptake in the European Region – Engaging Underserved communities). We are also in the process of establishing links with other related projects, such as IMMUNION (Promoting vaccination uptake across the EU). One of VAX-TRUST’s partners is actively involved in EU-JAV (Joint Action on Vaccination) and we will also communicate with that project. We also have some contacts beyond Europe, such as Canada.

IH: How did you secure funding from the EU Horizon 2020 initiative and how much did you receive?

PV: We received €2.9 million. This funding is shared between ten partners in seven countries. Writing the funding application of the project took many months. It involved very intense collaboration in face-to-face and online meetings between partners. During the preparation work, we went through a great number of discussions about the best strategies for research and carefully designed the project so that it would meet the requirements of the call. We selected countries and regions that would bring out the diversity of healthcare systems and vaccine services in Europe. Our strong expertise in sociological and public health research, in both methodologies and theoretical approaches, must have had an effect on our success. We are also experienced in interventions and their evaluation, which forms a major part of the VAX-TRUST impact.

IH: Is the aim of VAX TRUST to focus on vaccine hesitancy specific to the Covid-19 vaccines – or vaccines in general?

PV: In VAX-TRUST, we focus on vaccine hesitancy in general, not only that related to Covid-19 vaccines. However, Covid-19 could bring recrudescent vaccine hesitant attitudes and accentuate the lack of trust in authorities and institutions. This is why we will consider Covid-19 related challenges and their impact on healthcare professionals’ work throughout the project. I think that the Covid-19 pandemic has been a turning point where Europe has rapidly become aware that there are different ways to take care of health and vaccine hesitancy is an issue that highlights this diversity.

IH: How big of an issue is vaccine hesitancy in Europe?

PV: Most people in Europe are taking vaccines as recommended by healthcare authorities and professionals. In most European countries vaccine coverage of childhood vaccines is over 80%, in many countries more than 90%. Total refusal of all vaccines is still quite rare. But it is true that some people do not take some of the vaccines, or some even do not want any vaccines at all. Many European countries have faced significant challenges because of negative views towards safety, effectiveness, and importance of vaccination. This has resulted in outbreaks of vaccine-preventable diseases. For example, more than 14,000 cases of measles were reported across EU in 2017. There have also been studies showing that confidence in vaccine safety is lower in Europe than in other parts of the world. We must also bear in mind that not all who refuse to take vaccines have strong opinions behind that decision. However, some do have strong opinions and these persons might also promote vaccine refusal to others, which may increase negative views on vaccination.

IH: Why do you think this is happening?

PV: I think a key issue in understanding vaccine hesitancy is that it is not a new phenomenon. Ever since vaccines have been developed, some individuals and groups have questioned the value and importance of vaccines for their health and expressed distrust towards the proponents of vaccines. I think vaccine hesitancy is part of a much larger phenomenon, the changing status of expertise in contemporary societies. This takes the shape of contestation of expertise and expert knowledge in everyday situations and in meetings between healthcare professionals and individuals.

IH: Misinformation is clearly an important element in vaccine hesitancy. What do you think are the roots of this misinformation and what other key issues are behind vaccine hesitancy?

PV: Information is an important issue. There is a wide spectrum of information sources with varying degrees of reliability. As such some of this can be construed as misinformation. And, of course, people use these information sources in multiple ways. It is typical that with regards health issues people compile knowledge from a range of sources: medical and psychological research, and from personal experiences and those of friends or relatives, Facebook groups, blogs, websites, and books and training sessions on alternative medicine, popular psychology, and new spirituality. I think a typical story is that people have for several reasons grown disappointed with the healthcare system. It may be that they have lost trust in healthcare professionals and authorities and, in addition to that, they may have lost trust in information sources offered by the medical establishment. Therefore, they are seeking other sources of information. Another key issue behind vaccine hesitancy is that people are concerned about the possible harm that vaccines may cause. Some people are distrustful of medical research on vaccines and they are suspicious about the role of pharmaceutical companies in vaccine development and research. Some hold health perceptions and practices that diverge from the mainstream, for instance they may take ideas from complementary and alternative medicine.

I think that the Covid-19 pandemic has been a turning point where Europe has rapidly become aware that there are different ways to take care of health and vaccine hesitancy is an issue that highlights this diversity.

IH: Are there common characteristics among people who are vaccine hesitant?

PV: Vaccine hesitancy appears in different societal groups, among people of different educational levels and from various political and ideological backgrounds, and in both women and men. I would say that the most important common characteristic is the loss of trust in medical and public health actors.

IH: Is it more predominant in specific age groups?

PV: There is vaccine hesitancy in all age groups. There is vaccine hesitancy also within the healthcare profession. Of course, the issue of vaccination is more acute for some groups, like parents of small children, than for other groups. So we cannot say that vaccine hesitancy would be particularly related to a certain age, or any other such background factors. Individuals with different backgrounds form their attitudes toward vaccinations in different stages of their life and these attitudes may also vary from one vaccine to another and from situation to situation.

IH: Are there specific regions in Europe where vaccine hesitancy is more predominant? Why do you think this is so?

PV: There are regional differences in vaccination coverage, yes. I think we are just beginning to shed light on these differences. There might be several reasons for the regional differences, and some may be related to macro-level factors rather than individual issues. By this I mean that vaccine services are organised in different ways in different regions of Europe. Availability of vaccines is an issue in some countries and in some others there is difficulty in access to healthcare services for several societal groups. One aspect of this is that vaccinations are administered by different healthcare professionals in different countries. Thus, different professional groups are faced with vaccine hesitancy. For example, in Finland, public health nurses administer most of the childhood vaccines and their role is central in building parents’ trust in vaccinations. In the Czech context, it is paediatricians who administer vaccines. Of course these professional groups have different competences to respond to parents’ questions. They also have varying levels of knowledge about a family’s situation and have differing amounts of time available to listen to parents. Another aspect is that in some regions vaccines are compulsory, whereas in others they are voluntary. Where vaccines are voluntary, it tends to be that vaccine uptake is higher. This points to the view that obligatory vaccines may not be a solution to increase vaccine uptake. However, the situation is more complex than simply the question of whether vaccines should be compulsory or voluntary. These are just some examples of issues that might be behind regional differences, of course. But they hopefully show that it is not easy to state the reasons why vaccine hesitancy is more predominant in some regions rather than others.

IH: What is VAX TRUST planning to do to address the issue of vaccine hesitancy – and what time frame are you working with? What sort of tools do you envision providing health workers to assist them when working with vaccine hesitant individuals?

PV: We have a three-year project, so until the end of February 2024. Healthcare professionals are at the heart of our project. We aim at giving them up-to-date knowledge about vaccine hesitancy especially in their own regional context, but also more broadly in their national and European context, so that they could understand vaccine hesitancy better. The starting point of VAX-TRUST is that healthcare professionals are highly educated experts who are well experienced in diverse communication strategies, highly aware about epidemiological data, and they also have good psychological tools to respond to vaccine hesitant individuals. However, they are really constrained with the working conditions requiring more and more competences across a diversity of expertise ranging from computer programs, online applications, and insurance ‘jungles’. They have the Covid-19 challenges as well. Their struggles culminate in individuals coming to the consultancy rooms with ready-made diagnoses, strong trust in internet information and misinformation, and often with contested attitudes toward the expert healthcare professionals. Therefore, when dealing with the problem of vaccine hesitancy, it is not enough to deal with only communication problems and working conditions, although they are very important related issues. Neither can vaccine hesitancy be boiled down to ‘problem patients’ or ‘professionals’ failures’. There is need for a broader understanding of the societal conditions which affect the daily living and work of healthcare professionals. The knowledge VAX-TRUST provides for healthcare professionals is based on social scientific research. Knowledge will be obtained through: (a) critical review of previous research on vaccine May hesitancy, (b) a quantitative study using existing Eurobarometer 91.2 data (n=27,524 in 28 countries), (c) a quantitative and qualitative media analysis of the period 2019-2021 and (d) qualitative observations and interviews with healthcare professionals and parents at local healthcare centres in specific target regions. The knowledge targets the understanding of vaccine hesitancy in their specific region, nation and in the European context. Learning from this knowledge will hopefully act as a tool to strengthen the expert position of healthcare professionals and help them when meeting with vaccine hesitant individuals.

I think vaccine hesitancy is part of a much larger phenomenon, the changing status of expertise in contemporary societies. This takes the shape of contestation of expertise and expert knowledge in everyday situations and in meetings between healthcare professionals and individuals.

We offer professionals support and peer support for the challenges related to vaccine hesitancy in particular, but also to the contestation of expertise more broadly. Furthermore, we take into account that healthcare professionals may themselves be vaccine hesitant and this is one of the reasons we also want to strengthen the development of strong expertise of future healthcare professionals. This is why we have also planned actions for nurses and medical professionals. We will collaborate with healthcare education institutions in this regard.

IH: In closing, is there anything you’d like to add?

PV: I think there will always be hesitancy, contestation, and challenges to and criticism of medicine. This is why I think it is important to listen to vaccine hesitant individuals and find out their needs with regards information, as well as respond to their questions and address their doubts directly in the situations where professionals and individuals meet. From my own experiences as a nurse, I know that person-to-person communication is really important. Each interaction is a situation where trust of experts and expert knowledge gets built or broken. Strong condemnation of vaccine hesitancy and labelling of vaccine hesitant individuals are not good strategies in addressing vaccine hesitancy. Also, I would stress that healthcare professionals must not be afraid of vaccine hesitant individuals and families. They need to be prepared for the situations where individuals come to the consultancy room with attitudes and demands that contest their healthcare expertise. Exceptions should always be expected and they should not come as a surprise given that in our time it is quite usual to contest experts and be critical of expert knowledge. A critical attitude is even expected from people nowadays; they are expected to make decisions about their health and these decisions are nowadays very complex, requiring a broad knowledge base about what are often really complex biomedical and technological developments. So if people’s questions are bypassed or ignored, their trust will continue to diminish.