Are we having the wrong conversation about vaccine hesitancy? Leading research projects weigh in with recommendations

Sept 28 2023

Last night, the RIVER-EU project and JITSUVAX project, funded by the Horizon2020 research programme, joined forces at the European Health Forum Gastein to discuss the challenge of vaccine hesitancy. Co-hosted by EuroHealthNet , the session explored how vaccine hesitancy is often only a ‘proxy indicator’, not a primary cause, of unequal vaccination coverage. Panellists noted that placing the burden of change on the individual refusing or delaying vaccination is ignoring the important systemic failures which may influence their decision-making. These include political and social inequalities and health system barriers, faced primarily by underserved communities, and which often have an important impact on their beliefs and attitudes. The two projects presented findings from their work, including promising interventions to reduce inequalities in vaccine uptake and new tools to understand the roots of anti-vaccination arguments.

"Vaccine hesitancy is not solely an individual's problem. It is usually not that parents don’t want their child to be vaccinated, but many parents hesitate because the health system is not sufficiently accessible. In RIVER-EU, we aim to address health system barriers faced by underserved populations in order to make health systems more responsive and equitable, with the expectation that this will reduce hesitation and increase vaccine uptake,” stated Prof Danielle Jansen, coordinator of the RIVER-EU project and Associate Professor at the University Medical Center Groningen (UMCG).

Prof Stephan Lewandowsky, coordinator of the JITSUVAX project and Professor at the University of Bristol, stated: “Vaccine hesitancy can arise from people’s deeply-held attitudes that are exploited by disinformers to create confusion about the safety and efficacy of vaccines. We develop conversational techniques that recognize and endorse people’s underlying attitudes, thereby providing the opportunity to engage in a productive conversation to dispel misperceptions.”

Representatives from the WHO Regional Office for Europe and the South-Eastern European Health Network (SEEHN) also provided their insights, focused particularly on how to build and maintain trust in the health system and ensure that no one is left behind.

Specific recommendations included:

Taking a comprehensive approach towards low vaccine uptake, understanding both the physical and psychological barriers that people may face regarding vaccination and acting to reduce these barriers, as necessary, through supportive legislation and increased human and financial resources for vaccination programmes.

More comprehensive training on vaccine communication, so that health professionals can identify and understand the dispositions, both psychological and socio-cultural, that lead people to refuse or delay vaccination.

Tailor communication, both to vulnerable populations (e.g., through translation and attention to health literacy levels), as well as to individuals in all populations (e.g., through empathetic counterarguments and personalised dialogues that specifically address individuals’ psychological and socio-cultural dispositions).


Funded by the Horizon 2020 Research Programme, RIVER-EU (“Reducing Inequalities in Vaccine Uptake in the European Region - Engaging Underserved Communities”) is a 5-year (2021-2026) project coordinated by the University Medical Center Groningen (UMCG). RIVER-EU collects evidence on health system determinants of high and low vaccine uptake in eight specific contexts, which will be used to identify and/or develop interventions to reduce barriers to vaccine uptake in underserved communities and increase trust in the health system.


JITSUVAX is working to develop refutational-based techniques that enhance healthcare professionals’ ability to counter misinformation about vaccines and help people make informed choices, thus enhancing vaccination uptake. The University of Bristol coordinates this project which is funded by the EU Horizon 2020 programme for four years (2021-2025). A core part of our work has been the development of a ‘taxonomy’ of fallacious beliefs about vaccination which identifies the psychological attitude roots behind these beliefs. We are currently field testing our new methodologies with healthcare professionals in several different contexts.

For further information please contact:

Alison Maassen

Programme Manager



Ginny Gould

Research Project Manager



The second JITSUVAX Annual Report

May 2023

At the end of the second year of our project we are moving into field tests of our new Empathetic Refutational Interviewing (ERI) methodology. Read about our progress so far in our JITSUVAX Annual Report 2023

Awareness of global decline in vaccination rates – European Immunization Week 2023

23-29 April 2023

Vaccination is one of the most essential tools available to ensure population health and wellbeing. However, vaccination programmes face enduring challenges, namely inequalities in vaccine access and vaccine hesitancy. The COVID-19 pandemic provoked a regression in routine immunisation coverage, with inequalities between and within countries worsening. For example, since the start of the COVID-19 pandemic, over 1.2 million children in the WHO European Region have missed a vaccination to protect them against measles, mumps, rubella (MMR).

Working together, a group of EU funded projects including JITSUVAX aim to bring awareness to a concerning global decline in vaccination rates and the need for children in particular to catch up on any missed doses. Each of the projects offers unique set of research findings, practical solutions, or policy level recommendations to support European countries to improve access to vaccination services for all.

EU funded projects working together:

RIVER-EU (Reducing Inequalities in Vaccine uptake in the European Region – Engaging Underserved communities)

RIVER-EU collects evidence on health system determinants of high and low vaccine uptake in eight specific contexts, which will be used to identify and/or develop interventions to reduce barriers to vaccine uptake in underserved communities and increase trust in the health system. These interventions will be piloted in Greece, the Netherlands, Poland and Slovakia and the results will be converted into evidence-based guidelines to address equitable access to vaccination across Europe.

PERCH – PartnERship to contrast HPV

18 European countries and 34 partner organisations are working together to increase HPV vaccination coverage specially in regions with low coverage and to optimize data collection to monitor HPV vaccination coverage and the impact of vaccination. The General Objective of PERCH is to contribute to the implementation of Europe’s Beating Cancer Plan, which aims to support Member States’ efforts to extend the roll-out of routine HPV vaccination of girls and boys to eliminate cervical cancer and other cancers caused by HPV in the coming decade.

RISE-Vac • WEPHREN (tghn.org)

The RISE-Vac project aims to improve the health of prison population in Europe by promoting vaccine literacy, enhancing vaccine offer and increasing vaccine uptake. The project consortium is made up of nine partners from six different countries: Cyprus, Germany, France, Italy, Moldova and the UK. We are developing a number of interventions, including educational resources and vaccination models, and are assessing their impact on whole prison vaccination.

AcToVax4NAM (Access to Vaccination for Newly Arrived Migrants)

Access to Vaccination for Newly Arrived Migrants (AcToVax4NAM) is a 3-year project with a mission to improve the vaccination uptake in Newly Arrived Migrants (NAM). The beneficiaries are Newly Arrived Migrants (NAM) regardless of legal status in the first line, transit, and destination EU/EEA countries. The general objective of the AcToVax4NAM project is the improvement of Vaccination Literacy (VL) and access, and thereby vaccination uptake for NAMs, making access conditions more equitable and guaranteed.

Coalition for Vaccination

The Coalition brings together European associations of healthcare professionals and students. It was convened by the European Commission in 2019 based on the 2018 Council recommendation on strengthened cooperation against vaccine-preventable diseases. For the past two years, it was supported by an EU co-funded IMMUNION project. The Coalition regularly organises advocacy campaigns to improve vaccine trust and uptake.

SEKI (Strengthening Education and Knowledge on Immunisation)

SEKI (Strengthening Education and Knowledge on Immunization) is the one-stop access point for European healthcare professionals seeking high-quality educational content on vaccines and immunisation. SEKI screens for training needs and ways to meet them. SEKI will allow busy doctors, nurses and pharmacists to embark on a life-course of vaccine education and training, from beginner-level to expert. We partner with professional associations and educational content providers to bring the best and most up to date content to you. SEKI is a partnership between the Vaccine Safety Initiative (VIVI) and the European Academy of Paediatrics (EAP). SEKI collaborates with the EU Coalition for Vaccination, RIVER-EU, ImmuHubs and other European projects.

ImmuHubs (Innovative Immunisation Hubs)

Paving the way for breakthrough innovation, the ImmuHubs project is interdisciplinary and intersectoral in its approach, across borders. It is a bridge among different stakeholders that work towards the same direction: a sustainable, innovative, culturally sensitive, bottom-up approach to improve trust and vaccine uptake. The ImmuHubs Project aims to reduce transmission of vaccine-preventable diseases through an increased vaccination uptake among disadvantaged, isolated, and difficult to reach population groups. The ImmuHubs Consortium is coordinated by the Vaccine Safety Initiative (VIVI), a scientific think tank and non-profit research institution based in Berlin, Germany. We are a partnership of 9 institutions in 6 European Countries from academia and the non-profit sector, as well as public health, professional association, and civic society/patient representation. The project is co-funded by the European Health and Digital Executive Agency.


SymptomSurvey aims to educate doctors and nurses about what really matters to patients when they experience COVID or flu-like symptoms. When patients communicate their symptoms to healthcare professionals, the message does not always get across. Symptoms that worry patients, may not always get the attention they deserve. The SymptomSurvey provides opportunity to tell healthcare professionals how a patient or caregiver experiences symptoms, i.e. which symptoms are considered most important, what a meaningful improvement looks like, and what recovery means to patients and their families. The SymptomSurvey is conducted by the Vaccine Safety Initiative in conjunction with professional, patient, and civic society organizations.

April 2023

Over the last two years the JITSUVAX team have carried out the groundwork for the creation of the new Empathetic Refutational Interviewingthe project’s main component. We are now at the end of our second year and moving into tests of the effectiveness of the ERI with field tests planned in France, Germany, Portugal and the UK (led by our Bristol node).

In Work Package 1 we gathered information about HCP attitudes to and behaviours around vaccination in the five countries. This work is now reported in two Deliverable reports. Deliverable 1.2 is a quantitative cross-national comparison of HCP vaccination behaviours and attitudes Deliverable 1.3 focusses on the findings of a qualitative study of determinants of HCP’s vaccination behaviour. The results of these studies will be published in peer-reviewed journals; currently in development are papers currently in preparation including ‘Validation of the Pro-VC-Be and comparison of countries’, ‘Endorsement of alternative medicine and vaccine hesitancy among physicians: A cross-sectional study in four European countries’ and ‘Difficulties faced by healthcare professionals from four European countries in rebutting anti-vaccination arguments’. These are in addition to already published work on the development and validation of the French version of the Pro-VC-Be questionnaire.

Work Package 2 got underway with the development of the ‘Taxonomy of arguments against vaccination’ in which the arguments are grouped into themes and related to their underlying psychological attitude roots. This work was reported in Deliverable D2.1. Two peer-reviewed publications resulting from this work, ‘A Taxonomy of Anti-Vaccination Arguments: Systematic Literature Review and Text Modeling’ and ‘Psychological profiles of anti-vaccination argument endorsement’, have been accepted for publication in Nature Human Behaviour and Scientific Reports respectively. Additional papers are in preparation that will report on the modelling work done to validate the taxonomy as well as further evaluations of this work.

Also in WP2 the team carried out a series of experiments to assess the different components of the proposed ERI which is now reported in Deliverable 2.4. This work has also been written up as ‘The Empathetic Refutational Interview to tackle vaccine misconceptions and improve vaccine acceptance’ and submitted for peer review. A preprint of this publication is available. The team has also completed an investigation into the effects of refutational training on HCPs in the UK and Finland, which is reported in Deliverable 2.3. A publication based on this report is in preparation.

The information gathered from these studies was used to develop the ERI methodology. In February 2024 the JITSUVAX team, along with frontline HCPs and policy makers, met in Coimbra, Portugal to undergo training in both ERI and motivational interviewing (MI) techniques and to co-develop the first round of training materials for the ERI which will be used in the field tests in Work Package 3.

September 2022

The last few months have seen a few big acheivements for JITSUVAX. Firstly the development of both the full and short-form Pro-VH-Be questionnaire have been published. This questionnaire will now be used to measure the outcomes of experiments carried out as we work towards the development of the novel empathic refutational interview technique that is the major aim of JITSUVAX.

We have also produced a website which allows healthcare professionals and others to search for information to refute arguments against vaccination. The psychological traits or ‘attitude roots’ which underlie these arguments are described, based on the Taxonomy that has been developed by the JITSUVAX team. The website is informative and can be used on it’s own but longer-term is intended to as a look-up tool alongside the empathic refutational interview.

The JITSUVAX rebuttal website

May 2022

The first annual JITSUVAX report is out now

View it here!

March 2022

JITSUVAX research got off to a flying start after a few months of planning and preparation. We’ve got a lot interest in our research from media, local authorities, and educational institutions across the EU and UK, and members of the team are frequently appearing on TV, radio and in newspapers and online magazines. Below is a brief summary of progress so far.

Work Package 1: Developing a survey
The first aim of WP1 is to create a validated survey to measure vaccine confidence among Health Care Professionals (HCP’s). This survey can then be used to assess HCP attitudes about vaccinations in the five JITSUVAX countries. This work is led by the Finnish and French teams who have done a great job in drawing all of the teams together on this joint effort.
The work to create the first version of this survey in French came from a collaboration between researchers in France, Canada, and Belgium. The JITSUVAX team have developed, translated and adapted to so that now there are country-specific versions for Finland (in two languages), France, Germany, Portugal and the UK.
The information from the pilot survey which has been run in each country has shown that the survey is reliable. Over the next two months the full survey will be running with at least 500 HCP’s in each country taking part.
The first analysis from the pilot studies has given us more understanding about which anti-vaccination arguments are the most challenging for HCPs to counter. This information from each country has been used to develop the final form of the survey, which is going live between March and April 2022.
The data from the full survey will give us a good understanding of how HCP’s who work with vaccines feel about vaccination. We will be able to look at information from the individual countries and see how they compare, as well as analysing the data as a whole.

Work Package 2: Analysis of anti-vaccination arguments
The teams in Bristol, Coimbra and Erfurt Universities worked together to collect all of the arguments against vaccination that they could find. These have been grouped and classified into a ‘taxonomy’ which will be published after peer review. The different groups of arguments have been linked to their underlying roots, the psychological factors that contribute to vaccine hesitancy. These roots include such things as a tendency to believe in conspiracy theories or a belief that diseases are not really serious.
The teams have used this ‘taxonomy’ to create a set of arguments against the common myths about vaccination: for example by giving evidence against the belief that vaccines are not necessary if you live a healthy lifestyle. These arguments will now be used in further work and studies within JITSUVAX. These include an online game being developed by the Cambridge team which will train people to resist misinformation. They are also creating a website which will allow HCP’s to look up vaccination myths and find the evidence to combat them.
We’re looking forward to sharing the results from the survey of HCP’s. We’ll also be releasing both the full survey and a shortened version so that other researchers can also use it. The online game, website and other study results will also be shared as our work continues.