Vaccine xxx (xxxx) xxx

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Commentary

Words matter: Vaccine hesitancy, vaccine demand, vaccine confidence,

herd immunity and mandatory vaccination
Matthew Z. Dudley a,b,⇑, Lois Privor-Dumm a,c, Ève Dubé d, Noni E. MacDonald e
a
Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, United States
b
Institute for Vaccine Safety, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, United States
c
International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, United States
d
Quebec National Institute of Public Health, Department of Anthropology, Laval University, 2400, avenue d’Estimauville, 3e étage, Québec, Québec G1E 7G9, Canada
e
Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia B3H 4R2, Canada

a r t i c l e i n f o a b s t r a c t

Article history:
Received 3 June 2019 Ó 2019 Elsevier Ltd. All rights reserved.
Received in revised form 18 November 2019
Accepted 20 November 2019
Available online xxxx

Keywords:
Vaccine
Hesitancy
Demand
Confidence
Herd Immunity
Mandatory vaccination

As pressure grows to improve vaccine uptake in the wake of dis-
ease outbreaks caused by vaccination delays, refusals, or lack of
awareness or availability, the words commonly used to describe
these issues may have become part of the problem. Words and
their interpretations matter when we are trying to respectfully
and productively communicate with each other.
Medical and public health professionals have cited vaccine hesi-
tancy as a major threat to high vaccine coverage. The World Health
Organization (WHO) listed vaccine hesitancy as one of its ten
threats to global health in 2019. Despite global recognition of the
problem, definitions of hesitancy are not always clear and some-
times used interchangeably with other concepts of demand or con-
cerns about resiliency [1]. The term may have different meanings
for health care providers, public health professionals, government
officials, media members, and various sectors of the public, all of
whom see such concepts through different lenses. Furthermore,
to add to the confusion the term hesitancy has been applied to
an individual’s decisions about acceptance of vaccination as well
as to communities with low uptake where individual’s decisions
and rationales are not uniform.
Vaccine hesitancy has been defined in several ways. The Strate-
gic Advisory Group of Experts (SAGE) on Immunization of the
⇑ Corresponding author.
World Health Organization (WHO) defined vaccine hesitancy as a
‘‘delay in acceptance or refusal of vaccines despite availability of
vaccinations services. Vaccine hesitancy is complex and context
specific, varying across time, place, and vaccines. It is influenced
by factors such as complacency, convenience, and confidence”
[2]. This ‘‘3Cs” model was perceived by some as too narrow and
expanded to add utility calculation and collective responsibility
[3]. Even with ‘‘5C’s” there are problems as a multitude of factors
may interact and intersect in an individual’s vaccination accep-
tance decision. One simple single concern is unusual making mea-
surement of and parsing influencing factors in vaccination
acceptance in a community very difficult. As in the parable of blind
men describing different parts of an elephant, some factors may be
prominent, others minimized and still others completely over-
looked as not examined at all. Furthermore, the cultural context
and the specific vaccine adds further complexity to assessing these
factors [4].
Salmon et al. defined vaccine hesitancy as ‘‘concerns about the
decision to vaccinate oneself or one’s children” (i.e. not communi-
ties) and argued that the SAGE definition does not account for
those who vaccinate according to the recommended schedule yet
still have concerns about the decision to vaccinate [5]. Edwards
et al. expanded upon this idea, stating: ‘‘vaccine-hesitant individu-
als may accept all vaccines but remain concerned about them, they

https://doi.org/10.1016/j.vaccine.2019.11.056
0264-410X/Ó 2019 Elsevier Ltd. All rights reserved.

Please cite this article as: M. Z. Dudley, L. Privor-Dumm, È.Dubé et al., Words matter: Vaccine hesitancy, vaccine demand, vaccine confidence, herd immu-
nity and mandatory vaccination, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.056
2 M.Z. Dudley et al. / Vaccine xxx (xxxx) xxx
may refuse or delay some vaccines but accept others, or they may
refuse all vaccines” [6]. Bedford et al. argue that the concept of vac-
cine hesitancy is an individual’s psychological state and should
apply only to ‘‘those parents whose deliberations demonstrate
something akin to indecision” [7]. In contrast, Brewer and col-
leagues emphasize in their ‘‘Increasing Vaccination Model” social
processes including social norms in the community and informa-
tion sharing [8], and the ‘‘Tailoring Immunization Programmes”
developed by WHO Regional Office of Europe Region focuses on
barriers and motivators to vaccination in susceptible communities
(i.e., hesitant communities); not only individual factors but also
social, community and cultural factors [9,10].
Similarly, clear consensus on definitions of vaccine confidence
and demand has remained elusive. Measurements of confidence
are often used interchangeably with vaccine demand or hesitancy,
with other factors such as complacency and convenience not being
considered. The 3Cs model defines confidence specifically as ‘‘trust
in (1) the effectiveness and safety of vaccines; (2) the system that
delivers them, including the reliability and competence of the
health services and health professionals and (3) the motivations
of the policy-makers who decide on the needed vaccines” [2].
The concept of trust is the subject of a large and abundant litera-
ture outside of vaccination, though its importance in vaccine uti-
lization is recognized [11]. SAGE also stated that ‘‘vaccine
hesitancy occurs on the continuum between high vaccine demand
and complete vaccine refusal” [2]. However, MacDonald et al.
noted that ‘‘demand and hesitancy are not completely congruent”,
and ‘‘an individual or community may fully accept vaccination
without hesitancy but may not demand vaccination or a specific
vaccine” [12]. Hickler et al. later defined vaccine demand as ‘‘the
actions of individuals and communities to seek, support, and/or
advocate for vaccines and immunization services” and expanded
by stating that ‘‘demand is dynamic and varies by context, vaccine,
immunization services provided, time, and place. Demand is fos-
tered by governments, immunization program managers, public
and private sector providers, local leadership, and civil society
organizations hearing and acting on the voices of individuals and
communities” [13]. Of note is an acknowledgement that demand
is a function not only of the individual, but of the environment in
which the individual seeks vaccines. Further, the term demand,
as used in this definition, focuses on one extreme of the word’s
range of Merriam-Webster meanings (from simply asking to insis-
tently/urgently/imperiously calling for).
Translation of these terms from English to other languages adds
more confusion and complexity. For example, the word ‘‘demand”
in French translates more closely to a ‘‘gentle ask” in English, with-
out the connotation of authority or insistence. As in other fields,
proper interpretation must factor in the concept and context
behind the term, not just the translation of the term itself. This
has not always occurred. Even with the WHO definition of vaccine
hesitancy included in the WHO/UNICEF Joint Reporting Form, some
country responses to the vaccine hesitancy query suggested a
mixed understanding of the concept [14]. Responses to the
demand question were so disparate that these data were not for-
mally analyzed.
Further, the public may not always appreciate these terms. Mer-
riam-Webster defines hesitancy as ‘‘the quality or state of being
hesitant”, and hesitant as ‘‘slow to act or proceed (as from fear,
indecision, or unwillingness)”. Yet some parents described as ‘‘he-
sitating” by health care providers see themselves as being very
decisive and may perceive the label as demeaning [15]. Similarly,
Merriam-Webster’s definitions of confidence include ‘‘the quality
or state of being certain”; however, parents are often confident in
their decision to say no, and therefore do not lack confidence.
The definition of demand includes ‘‘an act of demanding or asking
Please cite this article as: M. Z. Dudley, L. Privor-Dumm, È.Dubé et al., Words matter: Vaccine hesitancy, vaccine demand, vaccine confidence, herd immu-
nity and mandatory vaccination, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.056
especially with authority”, and in the economic sense, ‘‘willingness
and ability to purchase a commodity or service”. Does this mean
that communities who widely accept vaccines but are not asking
this ‘‘with authority” are therefore not ‘‘demanding” vaccines?
The community itself may see themselves as actively compliant
with vaccine acceptance and see no need to ‘‘demand”, which
may be seen by some as adversarial to authority.
Larson et al. described the utility of the term ‘‘vaccine
hesitancy” as ‘‘de-polarizing earlier attention to ‘pro’- versus
‘anti’-vaccination individuals and groups” [16]. Long-used terms
like ‘‘anti-vaccine” and ‘‘anti-vaxxer” have become loaded terms
that simplify vaccine attitudes into a dichotomy and encourage
an us versus them mentality, pitting vaccinators against potential
vaccinees. Analyses of data on modern vaccine attitudes and beliefs
have consistently found a complex spectrum with more than just
two contrasting viewpoints [2]. Sadly, given the many meanings
of vaccine hesitancy, this term may no longer be the solution for
naming the population between the extremes of pro-vaccine and
full acceptance to anti-vaccine and outright refusal.
Other widely used terms can elicit strong reactions or conse-
quences. One example is the term ‘‘herd immunity”. This term
has long described the concept of high vaccine coverage protecting
not only those who have successfully responded through vaccina-
tion, but those who did not as well as those for whom immuniza-
tion is not recommended due to age or underlying medical
condition. This term, however, can also be considered offensive
by some, likening people to cows. Hence terms such as ‘‘commu-
nity protection” or ‘‘community immunity” may be more agreeable
and accurate when describing this concept for the public. However,
the term ‘‘herd immunity is still the most frequently used in the
public and scientific discourses to refer to the population benefits
of immunization programs.
Mandatory vaccination is another term whose use has different
meanings and may prompt strong reaction [17]. Mandatory has
been applied to situations ranging from soft vaccination require-
ments without penalty or enforcement to very rigid requirements
with only medical exceptions and serious penalties. Some see this
as the government ‘‘demanding” that a vaccine be ‘‘accepted”.
Specifically defining the immunization requirements would be
more helpful than stating it’s mandatory when the meaning is
unclear.
As terms like ‘‘vaccine hesitancy”, ‘‘vaccine confidence”,
‘‘vaccine demand” and recommendations for ‘‘mandatory
vaccination” become ubiquitous due to continued vaccine-
preventable disease outbreaks and increased media attention, it
becomes more important to choose our words wisely. It is unsur-
prising that the terms vaccine hesitancy, vaccine confidence and
vaccine demand are often easily conflated and confused. However,
although these concepts overlap and are interrelated, they remain
distinct ideas and should be understood as such.
In addition, whenever vaccine concerns are raised, this is an
opportunity for dialogue that if handled well can lead to a greater
public understanding of the benefits and importance of immuniza-
tion and corresponding positive influences on vaccine acceptance
and coverage. Using labels that put people and/or communities
in categories like vaccine-hesitant or anti-vaccine is not always
helpful. Having questions before agreeing to receive medication
is natural, and even desirable, as public health professionals have
long tried to empower people to be active decision-makers for
their own health. Those not accepting vaccines on time and on
schedule need to be treated respectfully.
We, as medical and public health professionals, strive for high
vaccine coverage and community support for immunization. Using
words that are demeaning or easily misinterpreted runs counter to
this goal. We must take collective responsibility for addressing
 M.Z. Dudley et al. / Vaccine xxx (xxxx) xxx
vaccine concerns in a manner that strengthens our relationship
with the public and increases the perceived value of immunization,
so that more individuals actively seek out vaccines and promote
them to others. This includes being clear on the use of relevant
terms. The term vaccine hesitancy is now established and may
be difficult to remove from our lexicon, but should only refer to
the specific situation of having concerns about vaccines, regardless
of actual vaccine receipt. Vaccine acceptance implies when pre-
sented with an opportunity to vaccine, either an individual or a
community choses to do so, recognizing that this choice can be
both active or passive. Although neither can be taken for granted,
the latter is a concern when considering resiliency. This is not
the same as vaccine coverage or uptake, which refer to the percent-
age of a population having received a vaccine, regardless of oppor-
tunity. Coverage/uptake is also often referred to as an
immunization rate despite this measure representing prevalence
and not a true rate. Demand, although a well-accepted concept
in the business field, means many things to many people and is
easily misinterpreted. One potential approach, albeit untested thus
far, may be to replace these common terms with short phrases that
are less ambiguous and more easily interpretable, such as ‘‘ex-
pressed no concerns and vaccinated on time”, ‘‘expressed concerns
but still vaccinated on time”, ‘‘delayed vaccination”, and ‘‘refused
vaccination”. Finally, measures of trust and confidence should
not be forgotten. These terms are still useful when analyzing cur-
rent behavior and predicting resiliency, but there must be a clear
recognition that these are only a subset of determinants of
immunization.
Vaccine advocacy and communication efforts should seek to
align definitions, synchronize terminology, and call for clarification
when needed. We should strive to use words that accurately repre-
sent their intended meaning both among the public health com-
munity and the public. We need to examine our descriptions and
test whether they are well understood and fit for their purpose.
Our conversations around vaccines should reflect a shared vision
and common goal of healthy and resilient communities through
optimal uptake of vaccines across the life course in all people.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Please cite this article as: M. Z. Dudley, L. Privor-Dumm, È.Dubé et al., Words matter: Vaccine hesitancy, vaccine demand, vaccine confidence, herd immu-
nity and mandatory vaccination, Vaccine, https://doi.org/10.1016/j.vaccine.2019.11.056
3
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper. All authors attest they
meet the ICMJE criteria for authorship.
References
[1] MacDonald NE, Butler R, Dubé E. Addressing barriers to vaccine acceptance: an
overview. Hum Vacc Immunother 2018;14(1):218–24.
[2] World Health Organization, Report of the SAGE Working Group on Vaccine
Hesitancy. 2014.
[3] Betsch C et al. Beyond confidence: Development of a measure assessing the 5C
psychological antecedents of vaccination. PLoS One 2018;13(12):e0208601.
[4] Quinn SC et al. Measuring vaccine hesitancy, confidence, trust and flu vaccine
uptake: Results of a national survey of White and African American adults.
Vaccine 2019;37(9):1168–73.
[5] Salmon DA et al. Vaccine hesitancy: Causes, consequences, and a call to action.
Vaccine 2015;33:D66–71.
[6] Edwards KM, Hackell JM. Countering vaccine hesitancy. Pediatrics 2016;138:3.
[7] Bedford H et al. Vaccine hesitancy, refusal and access barriers: The need for
clarity in terminology. Vaccine 2018;36(44):6556–8.
[8] Brewer NT et al. Increasing vaccination: putting psychological science into
action. Psycholog Sci Publ Interest 2017;18(3):149–207.
[9] Butler R, MacDonald NE. Diagnosing the determinants of vaccine hesitancy in
specific subgroups: The Guide to Tailoring Immunization Programmes (TIP).
Vaccine 2015;33(34):4176–9.
[10] Dube E et al. The WHO Tailoring Immunization Programmes (TIP) approach:
Review of implementation to date. Vaccine 2018;36(11):1509–15.
[11] Ozawa S, Paina L, Qiu M. Exploring pathways for building trust in vaccination
and strengthening health system resilience. BMC Health Serv Res 2016;16
(Suppl 7):639.
[12] MacDonald NE. Vaccine hesitancy: Definition, scope and determinants.
Vaccine 2015;33(34):4161–4.
[13] Hickler B et al. Efforts to monitor Global progress on individual and
community demand for immunization: Development of definitions and
indicators for the Global Vaccine Action Plan Strategic Objective 2. Vaccine
2017;35(28):3515–9.
[14] Lane S et al. Vaccine hesitancy around the globe: Analysis of three years of
WHO/UNICEF Joint Reporting Form data-2015-2017. Vaccine 2018;36
(26):3861–7.
[15] Reich JA. We are fierce, independent thinkers and intelligent: Social capital
and stigma management among mothers who refuse vaccines. Soc Sci Med
2018.
[16] Larson HJ et al. Understanding vaccine hesitancy around vaccines and
vaccination from a global perspective: a systematic review of published
literature, 2007–2012. Vaccine 2014;32(19):2150–9.
[17] MacDonald NE et al. Mandatory infant & childhood immunization: Rationales,
issues and knowledge gaps. Vaccine 2018;36(39):5811–8.