Evidence Gaps and Challenges in Maintaining and Increasing Vaccine Uptake: A Delphi Survey with Australian Stakeholders

"Social and behavioural insights into vaccine uptake are crucial for how vaccine programmes are organised, services are delivered, health workers communicate, and public access and confidence are sustained with a focus on equity."

In Australia, there has been a decline in the public confidence of childhood vaccines since 2017. Routine vaccine coverage dropped for 12-month-old children from 94.85% to 93.26% between 2020 and 2023. In the context of the post-coronavirus disease 2019 (COVID-19) pandemic landscape, this paper examines the perceptions of immunisation implementers and policymakers to uncover the challenges and evidence gaps in routine immunisation efforts in Australia.

In August and September 2022, the researchers conducted an online two-round modified Delphi survey with immunisation experts, senior public servants, policymakers, policy advisory groups, and representatives from peak bodies from across Australia. The survey asked respondents to outline what they see as the greatest challenges to increasing and maintaining uptake of recommended vaccines in Australia, the most difficult aspects of their work in vaccination, the largest evidence gaps in vaccine uptake, and the kinds of social and behavioural research they would like to see prioritised.

The two most important challenges for increasing and maintaining vaccine uptake were effectively communicating the benefits of vaccines to parents and the public and ensuring accessible and affordable vaccination services. Participants in the survey also emphasised the loss of public trust in vaccines since COVID-19, a sense of what they termed "vaccine fatigue" among the population, and an increased sense of vaccine hesitancy. Managing misinformation and mistrust in vaccines was viewed as a significant challenge by several participants, with some suggesting that confusing government messaging during the pandemic was a factor.

Participants strongly agreed that "communication about the importance of vaccination" was the most difficult aspect of their work. For instance: "Communication is the foundational piece to get right. It has been largely driven by 'campaign comms' through third party 'brand/advertising-focused' agencies, without co-design and without significant socio-anthropological or public health input." Consistently important was the need to better engage specific population groups, such as culturally and linguistically diverse people, pregnant people, at-risk cohorts, and healthcare providers.

Several participants mentioned the need for stronger social and behavioural research to inform these key topics and to help improve vaccine uptake. Several participants discussed the need for more research into the attitudes and perceptions of healthcare workers, especially as they are the source of vaccine information for lots of people. Qualitative data about the social aspects of vaccine behaviour was mentioned in relation to improving communications. Several participants suggested the need for better-targeted communication strategies to ensure equitable outcomes and to avoid stigmatisation of certain populations. 

Reflecting on the findings, the resesarchers note that: "Decisions about vaccination policy are not just a matter for policymakers and government: successful implementation requires cooperation between governments, public health agencies and the community....Social and behavioural insights from key communities help implementers and policymakers understand what influences vaccination uptake at individual, community, service and policy levels and how to increase coverage and sustain public trust in vaccine programmes."

As of this writing, Australia is preparing to launch a Centre for Disease Control. Based on this survey, the researchers recommend the following behavioural and social science research priorities as the Centre is formed:
 

1. Increase vaccine equity for priority populations by identifying the causes of coverage gaps and testing strategies to address them.
2. Improve vaccination communication by generating insights into how communities, professionals, and leaders communicate about vaccines. There is a strong relationship between these challenges and policy processes where dilemmas and trade-offs are encountered.
3. Bring public values into vaccination policy by investigating the ethical and social dimensions of policymaking.

In conclusion: "Findings from this project help provide an understanding of the behavioural, social, ethical, and policy knowledge needs for immunisation policy and implementation in Australia. To respond to vaccine challenges, increase coverage and build public trust in vaccination, policymakers and governments should incorporate social research into vaccination programmes."