Tools and methods for promoting vaccination acceptance and uptake

📜🔗LINK to the source

1. Analytical summary

Context, issues and audiences

The document starts from the observation of a generally high vaccination coverage in the EU/EEA but with pockets of unvaccinated individuals, insufficient rates for measles in children, and a decline in vaccination against flu and COVID-19 among older adults and healthcare professionals since 2023–2024. It emphasises the need to go beyond mere epidemiological data to understand the social, behavioural, and structural determinants that influence the decision to vaccinate, delay, or refuse vaccination. The report primarily targets national and regional public health authorities, vaccination programme managers, health communicators, and social science experts, but also opens up to civil society and policymakers. It is framed within a “life course” approach and identifies key populations as: parents, elderly individuals, pregnant women, at-risk groups, socially vulnerable populations, and healthcare professionals, considered as both recipients and prescribers of vaccination. Part 1 presents the 5C model (Confidence, Complacency, Constraints, Calculation, Collective Responsibility) as a central framework for understanding and monitoring vaccination behaviours.

Operational contributions for stakeholders

Part 2 offers a comprehensive survey tool, based on the 5C model, including sociodemographics, behavioural indicators (vaccinations received, refusals, intention), 15 validated psychometric items, open qualitative questions, and a GDPR-compliant consent model. The report details how to adapt the questionnaire (population, targeted vaccine, translation), choose the sampling method, calculate sample size, conduct descriptive and inferential analysis (mean scores by C, linear/logistic regressions) using Stata/R scripts available online. It also describes qualitative approaches (interviews, focus groups, content and thematic analysis, reflexivity and triangulation) to explain the mechanisms behind the numerical scores. A library of interventions classified by vaccine type and by C (SMS reminders, mobile sites, community mediation, empathic rebuttal interview training, European projects RIVER-EU and AcToVax4NAM) offers a catalogue of tested actions, particularly for underserved populations. Finally, the document articulates its tools with the WHO framework "5 steps for applying behavioural sciences" (Define, Diagnose, Design, Implement, Evaluate) to structure the entirety of a vaccination project, from diagnosis to evaluation.

2. Key points of the document

1. Clarification of concepts and continuum of acceptance (p. 2–4)The report clarifies "acceptance", "reluctance", "vaccination rates" and "vaccination coverage", presenting acceptance as a continuum between outright refusal and full acceptance, which avoids "labeling" individuals as "hesitant" and allows for more nuanced interventions.

2. Centrality of the 5C model as an analytical framework (p. 5–7)Part 1 presents the 5C model (Confidence, Complacency, Constraints, Calculation, Collective Responsibility), detailing the operational definition of each C and explaining how it allows for the diagnosis of psychological and structural barriers and for tracking the evolution of vaccine acceptance over time.

3. Standardised survey tool with validated items (p. 9–17)Table 1 offers a structured questionnaire (consent, sociodemographic questions, vaccination behaviour, 15 items 5C and 7 open questions) developed from psychometrically validated items in the European literature and compatible with automated analysis via pre-written code.

4. Detailed analysis plan to exploit the data (p. 14–21)The report provides a complete example of an analysis plan in three phases (data preparation with recoding, descriptive, inferential analyses), specifying the meaning of a "high score" for each C, the types of suitable regression, and possible groupings of outcome categories.

5. Library of interventions and WHO framework in 5 steps (p. 19–31, 31–33)Tables 3 to 7 list national and European interventions (personalised SMS, vaccination in nurseries, mobile sites with community mediation, JITSUVAX training in empathetic refutation interviews, health promoters from RIVER-EU, AcToVax4NAM tools for migrants) and the section on the WHO framework describes how to combine 5C diagnosis, choice of interventions, and the complete cycle Define–Diagnose–Design–Implement–Evaluate.

3. Action points for local stakeholders

1. Establish a structured local 5C diagnosis (p. 9–18, 31–33)Adapt the ECDC questionnaire to local audiences (for example, parents of young children, elderly people in care homes, healthcare professionals) by translating and contextualising the items, then conduct an online or face-to-face survey to measure Trust, Complacency, Constraints, Calculation and Collective responsibility, with a simple analysis plan (mean scores, sociodemographic cross-tabulations).

2. Combine quantitative and qualitative methods to understand the barriers (p. 17–23)Add to the 5C surveys semi-structured interviews or focus groups with the audiences identified as having problematic scores (High Constraints, Low Trust, Very High Calculation), using the proposed interview guides, thematic analysis and reflexivity to identify concrete obstacles and trust levers.

3. Draw inspiration from the intervention library for targeted actions (p. 19–31)Identify, in tables 3–7, examples close to your context (SMS reminders like in Estonia, vaccinations in childcare settings like in Finland, spontaneous vaccination sites coupled with community engagement work) and adapt them with local stakeholders (local authorities, social structures, associations) rather than developing approaches from scratch.

4. Structure projects using the WHO framework in 5 steps (p. 31–33)Explicitly use the sequence Define–Diagnose–Design–Implement–Evaluate as the framework for your local projects, clearly stating "who should do what, where and when" and then linking each intervention to one or more targeted Cs, with indicators of acceptance and vaccination rates tracked over time.

5. Strengthen the skills of professionals in vaccine communication (p. 13, 24–25, 29–31)Organising training based on empathetic refutation interviews (JITSUVAX approach) and on the principles of benefit/risk communication, working on concrete conversation scripts with distrustful or overexposed audiences to misinformation, and including the question of the biases of the professionals themselves (reflexivity, member control).

4. Additional references 

🔍➕ For more information, see the articles referenced by "Health Practices" on the topic of vaccination ➡️🔗https://pratiquesensante.odoo.com/blog/tag/vaccination-236

1. WHO Guide – behavioural and social determinants of vaccination (BeSD)WHO. Behavioural and social drivers of vaccination – tools and practical guidance (2022, still relevant, used in 2023–2026 in many programmes). This guide complements the ECDC report by providing standardised measurement tools for behavioural and social determinants, compatible with mixed surveys. https://www.who.int/publications/i/item/9789240049680

2. Immunisation Agenda 2030 – Commitment and demand (FR version, recently published)WHO. Commitment and demand – Immunisation Agenda 2030 (strategic document in French, published after 2023, on the official IA2030 website). It provides a comprehensive political and programmatic framework to develop vaccination demand, in line with the trust and equity approaches cited by the ECDC.  https://www.immunizationagenda2030.org/images/documents/SP2Translations/GS_SP2.pdf

3. Playbook "Vaccine Hesitancy: How to Approach It?" (PATH/Busara, 2024, FR)PATH / Busara. Vaccine Hesitancy: How to Approach It? (operational playbook, 2024, French version available for free). It offers practical intervention tools focused on behavioural sciences and communication, which are very complementary to the 5C model and the ECDC intervention library. https://busara.global/wp-content/uploads/2024/07/PATH-Playbook-French.pdf

5. Frequently Asked Questions (FAQ)

1. How can this document help me understand vaccine hesitancy in my population? (p. 2–4, 5–7, 9–18)The document first provides a clear conceptual framework (continuum of acceptance, distinction between acceptance/vaccination rates/coverage) and then the 5C model to structure the determinants of behaviour. The survey tool allows you to measure these dimensions in your target audiences, while the quantitative and qualitative recommendations detail how to interpret these results and make them into actionable diagnostics.

2. I do not have a complete research team: is the 5C questionnaire still usable? (p. 9–13, 18–21)The report recommends a multidisciplinary team, but also indicates that it is possible to focus on the five 'core' items (one per C) in case of resource constraints and to conduct simple descriptive analyses (proportions, mean scores by sub-groups). Even without complex regression, this data already allows for prioritising the Cs to target and guiding actions.

3. How can the tool be adapted to a specific vaccine or group (for example HPV in adolescents)? (p. 12–13, 17)The report proposes to adjust the wording of generic items to a specific vaccine (for example, replacing "vaccines" with "HPV vaccine") and to adapt the sociodemographic options to the local context (school system, age categories). It also recommends a pre-test of the translations with the target group to verify the understanding and cultural relevance of the questions.

4. What qualitative methods are recommended to deepen the quantitative results? (p. 17–23)Two main approaches are detailed: semi-structured individual interviews, suitable for sensitive questions, and group discussions, useful for understanding collective norms and dynamics. The document describes the principles of guide construction, the concept of data saturation, content analysis and thematic analysis, as well as reflexivity tools to limit researcher bias.

5. What types of concrete interventions have shown an impact on vaccine acceptance? (p. 19–31)The tables present interventions such as: personalised SMS reminders for flu and COVID-19, vaccination in early childhood care settings, mobile sites coupled with strong community engagement, health mediators culturally close to the communities, flowcharts and glossaries to facilitate vaccination for migrants. Some projects like JITSUVAX, RIVER-EU and AcToVax4NAM illustrate how to combine organisational changes, mediation and training of professionals.

6. How to articulate this report with the WHO frameworks on vaccination demand? (p. 31–33)The document shows how ECDC tools (5C questionnaire, intervention library) fit into the "5 steps for applying behavioural sciences": defining a behaviour, diagnosing barriers/facilitators, designing, implementing, and evaluating a strategy. This WHO framework is consistent with BeSD approaches and the Immunisation Agenda 2030, which facilitates the alignment of local projects with international guidelines.

7. What ethical and GDPR precautions should be taken during surveys? (p. 9–10, 19)The report provides a model consent text detailing the purpose of the study, anonymisation, data storage, and the right to withdraw, in compliance with GDPR. It recommends submitting the protocol to an ethics committee if required, documenting anonymisation procedures, and limiting data access to authorised researchers.

6. Rewriting in Easy Read

Document title

• Title : Tools and methods to better accept vaccines and increase vaccination.

Easy Read Summary – Context

• There are still too many unvaccinated people in Europe, especially for measles, flu, and COVID‑19.

• The reasons are many: lack of trust, fear, practical difficulties, confusing information.

• The document discusses people's behaviours: why they accept, delay, or refuse a vaccine.

• It is aimed at those who organise vaccinations and prevention actions.

• It explains a model with 5 main factors: trust, low fear of disease, practical barriers, risk calculation, protection of others.

Easy Read Summary – Tools

• The document proposes a ready-to-use questionnaire to ask people about vaccination.

• This questionnaire asks simple questions about age, work, vaccines received, and opinions on vaccines.

• There are also open questions to better understand what people think and feel.

• The document explains how to analyse the responses using simple or advanced methods.

• It provides examples of actions that have already been tested in several countries.

Key points FALC

• Point 1: Understanding the words

  • The document clearly defines the words acceptance, reluctance, vaccination rate, and vaccine coverage.

  • It shows that acceptance can be strong, weak, or somewhere in between.

• Point 2: The 5 important factors (5C)

  • Confidence: believing that vaccines and authorities are safe and serious.

  • Complacency: thinking that the disease is not very dangerous.

  • Constraints: having difficulties getting vaccinated, such as time or location.

  • Calculation: seeking a lot of information and comparing risks and benefits.

  • Collective responsibility: wanting to protect others by getting vaccinated.

• Point 3: Practical questionnaire

  • The questionnaire has short phrases and responses ranging from "disagree" to "strongly agree."

  • It can be adapted to each country, language, and type of vaccine.

• Point 4: Analyzing the results

  • Averages are calculated for each factor, for example, confidence.

  • Results are compared by age, gender, education, or region.

• Point 5 : Move to action

  • The document provides examples of actions: SMS reminders, vaccination in schools, health mediators.

  • It also explains how to prepare, implement, and evaluate an action step by step.

7. Cross-sectional analysis — values of health practices

• Literacy : The document remains technical but offers simple questions, clear Likert scales, and concrete examples, while emphasising the need to adapt the language to local contexts.

• Empowerment : Beneficiaries are involved through open questions, participatory approaches (RIVER‑EU), and the promotion of health mediators from the communities, which enhances their capacity to act.

• Participation : The report highlights the co-design of interventions with target audiences and local stakeholders, particularly through participatory research on the transferability of interventions.

• Community health : Several interventions explicitly rely on community engagement, proximity mediation, and health promoters culturally aligned with underserved communities.

• Ethics : The sections on consent, anonymisation, and researcher reflexivity address the risks of bias and impose transparency and respect for the surveyed individuals.

• Human rights : The report stresses equitable access to vaccination throughout life, specifically targeting migrants, socially vulnerable populations, and underserved groups.

• Intersectorality : The examples of interventions mobilise partnerships between health, social, education, social housing, NGOs and European institutions, showing a structured intersectoral approach.

• Partnership : Formalised collaboration models are emerging around EU-funded projects (JITSUVAX, RIVER-EU, AcToVax4NAM), vaccination coalitions and networks of health professionals.

• Fighting against discrimination : Interventions targeting migrants and underserved communities explicitly address linguistic, cultural and structural barriers, seeking to reduce access inequalities and avoid blame-inducing approaches.

8. Assessment of the reliability of the resource

• Scientific relevanceThe document is produced by the ECDC, the EU's reference agency for public health, and is based on over 15 years of work, including a 2021 report on the acceptance of COVID-19 vaccination. It cites numerous peer-reviewed references, clearly describes the theoretical model (5C), the limitations of the models and provides a transparent analysis plan, with Stata/R code made public, which enhances reproducibility. The publication in 2025 makes it scientifically up to date, incorporating post-pandemic data (2023–2024) on measles, whooping cough, influenza and COVID-19.

• Operational relevanceThe resource is strongly action-oriented, with a directly usable survey tool, adaptation instructions, examples of analysis scripts, recommendations on ethics, and case studies of real-world interventions in various countries. It is particularly useful for public health teams with limited resources but wishing to structure their diagnostics and interventions on vaccination according to evidence-based and behavioural approaches.