Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study

Abstract

Background: There is growing evidence of vaccine delays or refusals due to a lack of trust in the importance, safety, or effectiveness of vaccines, alongside persisting access issues. Although immunisation coverage is reported administratively across the world, no similarly robust monitoring system exists for vaccine confidence. In this study, vaccine confidence was mapped across 149 countries between 2015 and 2019.

Methods: In this large-scale retrospective data-driven analysis, we examined global trends in vaccine confidence using data from 290 surveys done between September, 2015, and December, 2019, across 149 countries, and including 284 381 individuals. We used a Bayesian multinomial logit Gaussian process model to produce estimates of public perceptions towards the safety, importance, and effectiveness of vaccines. Associations between vaccine uptake and a large range of putative drivers of uptake, including vaccine confidence, socioeconomic status, and sources of trust, were determined using univariate Bayesian logistic regressions. Gibbs sampling was used for Bayesian model inference, with 95% Bayesian highest posterior density intervals used to capture uncertainty.

Findings: Between November, 2015, and December, 2019, we estimate that confidence in the importance, safety, and effectiveness of vaccines fell in Afghanistan, Indonesia, Pakistan, the Philippines, and South Korea. We found significant increases in respondents strongly disagreeing that vaccines are safe between 2015 and 2019 in six countries: Afghanistan, Azerbaijan, Indonesia, Nigeria, Pakistan, and Serbia. We find signs that confidence has improved between 2018 and 2019 in some EU member states, including Finland, France, Ireland, and Italy, with recent losses detected in Poland. Confidence in the importance of vaccines (rather than in their safety or effectiveness) had the strongest univariate association with vaccine uptake compared with other determinants considered. When a link was found between individuals' religious beliefs and uptake, findings indicated that minority religious groups tended to have lower probabilities of uptake.

Interpretation: To our knowledge, this is the largest study of global vaccine confidence to date, allowing for cross-country comparisons and changes over time. Our findings highlight the importance of regular monitoring to detect emerging trends to prompt interventions to build and sustain vaccine confidence.

Funding: European Commission, Wellcome, and Engineering and Physical Sciences Research Council.

Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Figures

Figure 1

Global trends in perceptions towards the safety of vaccines in November, 2015, and November, 2018 Figure shows model-based estimates of the percentage of respondents strongly agreeing that vaccines are safe (panels A, B), important for children to have (panels C, D), and effective (panels E, F) in November, 2015, and November, 2018. No data were available for countries in grey.

Figure 2

Distributions in absolute confidence changes between November, 2015, and December, 2019 Distributions of model-based estimates in the absolute differences in the proportions of respondents strongly agreeing that vaccines are safe, important, and effective. Positive values denote an increase in confidence between 2015 and 2019. Owing to increased uncertainty around estimates further away from survey dates, some significant changes in confidence over the study period are not captured by this figure.

Figure 3

Trends in the perceived safety of vaccines in the EU and the Philippines (A) Time series of estimated percentages of respondents in EU countries strongly agreeing, strongly disagreeing, or neither strongly agreeing nor strongly disagreeing that vaccines are safe. Lines are means and shaded regions are 95% HPD intervals. Circles show the observed percentage of respondents from raw data (appendix 2). Time series for all countries for all three confidence statements are shown in appendix 1 (pp 12–23). (B) Time series of survey responses across all three survey questions for the Philippines. (C) WHO-UNICEF national immunisation estimates for routine vaccination programmes in the Philippines against tuberculosis (BCG), diphtheria-pertussis-tetanus (DPT1), measles (MCV1), and polio (Pol3). HPD=highest posterior density.

Figure 4

Univariate determinants of vaccine uptake within the Wellcome Global Monitor dataset Global trends in univariate associations between vaccine uptake and confidence in vaccines, demographics and socioeconomic status, sources of trust, and information-seeking behaviours. Each point represents a significant association (95% HPD interval excludes zero) between a variable and uptake in a given country. Boxplots show the median log risk ratio and IQR. All variables (except age, which is continuous) are categorical and baseline groups are specified by each category (eg, high vs low denotes low as the baseline group; see the table for definitions). HPD=highest posterior density.

Figure 5

Association between national level vaccine uptake and vaccine confidence as reported in the Wellcome Global Monitor The solid line represents the mean regression with 70% and 95% HPD intervals shaded in dark and light grey, respectively. Datapoints for (lowest confidence) and the Philippines (case study) are shown, alongside randomly selected countries. HPD=highest posterior density.