Vaccine hesitancy is rarely about information alone. As misinformation spreads and trust in institutions declines, rebuilding confidence depends on dialogue, empathy and the health workers who can bridge the gap. Dawn Holford, Linda Karlsson, and Philipp Schmid from the JITSUVAX initiative discuss.
Vaccination is one of the world’s most successful public health interventions—within 50 years it is estimated to have prevented 154 million deaths worldwide. Yet vaccine hesitancy remains one of the top risks to public health, contributing to declining vaccine uptake and epidemic outbreaks across Europe in recent years. Beyond the cost to human life, the economic costs are enormous: a single measles outbreak in 2012–2013 was estimated to cost £4.4 million (around €5.2–€5.4 million)—20 times the cost of delivering the vaccinations to prevent it.
Vaccine hesitancy is rarely just about a lack of information. People’s decisions are shaped by their values, prior experiences, and—critically—by the systemic barriers many communities face. Those who have experienced discrimination or barriers in accessing the health system may have well-founded mistrust. Alongside beliefs and attitudes, inconvenient clinic hours, fragmented immunisation data, and out-of-pocket costs all strongly influence vaccine decision-making.
Dealing with an infodemic that erodes trust
At the same time, the public must navigate an information environment which makes trust harder to sustain. Platforms that incentivise engagement over accuracy accelerate the spread of misinformation. A single exposure to health misinformation can increase belief in that false information, which then proves difficult to correct. The resulting “infodemic”—the overwhelming volume of both accurate and misleading information—undermines trust in information sources and generates fear, uncertainty, and information fatigue. Addressing infodemics with effective vaccine communication therefore needs to be part of core health system infrastructure, not just a supporting function.
Within this challenging modern landscape, public health communication requires a broad set of tools for communicating effectively about vaccines and addressing vaccine hesitancy and its underlying drivers. An effective response to vaccine misinformation needs to understand its tactics and how it targets people by their psychological profiles. This is because misinformation often exploits people’s values, group identities, and fears—which are known as “attitude roots”. Correcting someone’s misinformed beliefs can thus trigger discomfort and defensiveness if people perceive that correction to be a threat to their attitude roots.
Strategies for addressing misinformation
Research in psychology suggests a number of evidence-based strategies that can reduce the influence of misinformation on people’s beliefs, attitudes, and decisions. First, the source of the correction matters: people are more likely to revise their beliefs when communicating with someone they trust. Second, empathy plays an important role in reducing the threat associated with corrections—while also helping to build trust. Third, debunking a myth must go beyond stating that it is false; it must include a clear alternative explanation for why it is incorrect.
A good way to implement these strategies is through dialogue, particularly with trusted communicators. One technique designed to achieve this is the Empathetic Refutational Interview (ERI). This is an empirically validated conversation framework that sets out four specific steps to promote evidence-based vaccine decision-making. It begins by:
- eliciting an individual’s concerns to better understand the attitude roots that drive them. This is followed by:
- affirming those attitude roots—crucially, this involves acknowledging underlying values, identities, and fears. Starting by establishing rapport allows subsequent pivoting towards:
- correcting the misconceptions the individual may hold with explanations that are tailored to the individual’s attitude roots. Finally, having employed these psychologically based strategies to build trust and correct misconceptions, the conversation can be:
- guided towards informed decision-making and the evidence on vaccination.
When correcting the misconceptions the individual may hold (step 3), best practice guidance recommends repeating key facts, explicitly addressing the misinformation, and explaining its origin alongside an evidence-based alternative explanation. By doing so, people can better remember scientific facts and are more willing to update their beliefs because the debunking does not simply take away misconceptions but replaces them with stronger, better justified alternatives. In mass communication contexts (e.g. flyers, websites, or social media posts), these corrections can be structured using the “fact sandwich”: state the fact, warn about the misinformation, provide a detailed explanation, and repeat the fact. Research in several European countries shows that these corrections can effectively reduce the impact of vaccination misinformation.
Health workers: the critical link between policy and patients
Health workers are among the most trusted influences on vaccine decision-making, and the ERI provides a replicable framework for conversations with parents and patients. Trust and training are not trivial concerns, as health workers may avoid discussing vaccines if they lack confidence in handling such conversations.
Training in the ERI has been found to improve health workers’ confidence and skills in dealing with vaccine concerns. Physicians in Romania who were trained to use the ERI increased their patients’ willingness to vaccinate and saw a 28% higher rate of vaccination bookings compared to a control group of untrained physicians.
Who receives training in conversation skills is also an important consideration. Research has found that shared cultural backgrounds between health workers and communities can foster trust, facilitate communication, and boost vaccine uptake. The Roma Health Mediator (RHM) programme, for instance, embeds trusted community members within Slovakia’s national health system, helping bridge gaps between Roma communities and healthcare services. After RHMs received training on human papillomavirus (HPV) vaccination, knowledge about HPV rose from 15% to 65% among Roma parents and from 30% to 70% among Roma school children.
Building trust is a critical investment
Persistent gaps in vaccination uptake are more than a communication failure. They reflect sustained underinvestment in the health system infrastructure that makes trust possible in the first place. A key piece of that infrastructure is the human workforce: health worker training should go beyond clinical skills to include communication competencies and techniques like the ERI, alongside non-discrimination training and cultural competence to support effective dialogue about vaccination with diverse populations.
These investments matter more in an information environment that systematically erodes trust in institutions. When misinformation floods public discourse, we must rely on and support health workers who can uphold the building blocks of trust: sustained engagement and empathetic dialogue. Trust is one of the strongest predictors of vaccine confidence and acceptance. Investing in systems that support tailored, dialogue-based approaches should be a core component of vaccine delivery infrastructure, not an afterthought.
In focus
- Address all barriers to vaccination by tackling physical and psychological obstacles and investing in stronger vaccination programmes.
- Expand health worker training to improve vaccine communication and address the psychological and socio-cultural drivers of hesitancy.
- Tailor communication through accessible, culturally appropriate information and empathetic, personalised conversations.
Further information
Discover the attitudinal roots identified within the JITSUVAX project here, as well as suggested empathetic refutations that health workers can use in conversations. Training in the Empathetic Refutational Learning technique is available through JITSUVAX Training, a UK-based social enterprise founded on learnings from the JITSUVAX project.
Discover more about work to increase vaccine equity in underserved communities through the RIVER-EU project’s scientific publications and lessons learnt.
