The World Health Organization’s Strategic Advisory Group of Experts on
Immunization (SAGE) define vaccine hesitancy as: “[a] delay in acceptance or refusal
of vaccines despite availability of vaccine services. Vaccine hesitancy is complex and
context specific, varying across time, place and vaccines. It is influenced by factors such
as complacency, convenience, and confidence” (WHO, Report of the SAGE Working
Group on Vaccine Hesitancy, 2014). This definition – known as the “3Cs” model of
hesitancy encapsulates the possible drivers of vaccine acceptance or refusal. While
complacency and convenience relate to the perceived risk of disease and the ease with
which vaccine services can be reached (respectively), vaccine confidence is defined as
the trust in the effectiveness and safety of vaccines and trust in the healthcare system
that delivers them. Throughout this report, confidence is measured through perceived
vaccine safety and effectiveness and, in addition, through the perceived importance
and religious compatibility of vaccines.
High confidence in vaccination programmes is crucial for maintaining high coverage
rates, especially at levels that exceed those required for herd immunity. Across the
European Union (EU), however, vaccine delays and refusals are contributing to
declining immunisation rates in a number of countries and are leading to increases in
disease outbreaks. Recent measles outbreaks – the highest in the EU for seven years –
illustrate the immediate impact of declining coverage on disease outbreaks.
In this report we assess the overall state of confidence in vaccines among the public in
all 28 EU member states and among general practitioners (GP) in ten EU member states.
As vaccine confidence varies by vaccine, confidence is assessed for vaccines in general
as well as for the measles and seasonal influenza vaccines, in order to reflect vaccines
targeting different population groups. Confidence in (and demand for) vaccines is
influenced by a number of factors, including the importance, safety, and effectiveness
of vaccines. To examine the extent of public and GP confidence in vaccines, we have
conducted the largest ever study on attitudes to vaccines and vaccination in the EU. We
find a range of novel EU-wide and country-specific insights into vaccination
behaviours that may immediately impact on public policy.
We report a number of key findings. We find that most age groups under 65 surveyed
have less confidence in the safety and importance of both the MMR and seasonal
influenza vaccines (and vaccines generally) than over 65’s. The results of the survey
suggest that a number of member states – including France, Greece, Italy, and Slovenia
– have become more confident in the safety of vaccines since 2015; while Czech
Republic, Finland, Poland, and Sweden have become less confident over the same
period. While GPs generally hold higher levels of vaccine confidence than the public,
the survey found that 36% of GPs surveyed in Czech Republic and 25% in Slovakia do
not agree that the MMR vaccine is safe and 29% and 19% (respectively) do not believe
it is important. We find that the majority of GPs surveyed in these countries report that
they are not likely to recommend the seasonal influenza vaccine, yet Czech Republic,
Poland, and Slovakia all report to the WHO that they recommend the seasonal
influenza vaccine to pregnant women (WHO, Immunization Schedule by Antigens,
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We find a correlation between GP confidence and confidence among general public in
the survey: countries whose GPs hold higher confidence in vaccines tend to have a
larger proportion of the public expressing positive vaccination beliefs. We provide
rankings of member states by overall level of confidence in the safety of vaccines and
provide raw data summaries for each member state.