Vaccine Confidence

Vaccine confidence concerns the belief that vaccination – and by extension the providers and range of private sector and political entities behind it – serves the best health interests of the public and its constituents. The Oxford English Dictionary defines confidence as “the mental attitude of trusting in or relying on a person or thing”.  In light of that, we are not examining the well-studied domain of supply and access barriers to vaccination, but rather what is typically called the “demand” side of immunisation. However, our focus on confidence takes the “demand” rubric a step further than the more traditional notion of building demand through increasing knowledge and awareness of vaccines and immunisation to understanding what else drives confidence in vaccines, and the willingness to accept a vaccine, when supply, access and information are available. In other words, understanding vaccine confidence means understanding the more difficult belief-based, emotional, ideological and contextual factors whose influences often live outside an immunisation or even health programme but affect both confidence in and acceptance of vaccines.

VCP Mission

The purpose of the project is to monitor public confidence in immunisation programmes by building an information surveillance system for early detection of public concerns around vaccines; by applying a diagnostic tool to data collected to determine the risk level of public concerns in terms of their potential to disrupt vaccine programmes; and, finally, to provide analysis and guidance for early response and engagement with the public to ensure sustained confidence in vaccines and immunisation. This initiative also defines a Vaccine Confidence Index™ (VCI) as a tool for mapping confidence globally.

The VCI is a measure, based on a select number of factors identified from extensive analysis of areas of both low and high vaccine coverage. This index is useful for informing the design of immunisation programmes and strategies and understanding more explicitly where to target both human and financial resources, which will allow for more efficiency. The VCI is an important tool for routine immunisation as well as the introduction of new and underutilised vaccines.  Further information is available on our research page.

Despite the historic success of immunisation in reducing the burden of childhood illness and death, episodes of public concerns and rumours around vaccines have occurred around the world, spreading quickly and sometimes seriously eroding public confidence in immunisation and ultimately leading to vaccine refusals and disease outbreaks.

Although reports of public concerns and questions around the safety and relevance of vaccines have been on the increase, aside from monitoring of adverse events following immunisation (AEFI), there is neither a systematic monitoring of broader public vaccine concerns nor a tool to assess risk levels of rumours and concerns to potential programme disruptions, vaccine refusals and potential disease outbreaks.

This project seeks to address these unmet needs and monitor public confidence in immunisation programs by listening for early signals of public distrust and questioning and providing risk analysis and guidance to engage the public early and pre-empting potential programme disruptions.

Research Team

Prof. Heidi Larson

Prof. Heidi J. Larson is an anthropologist and Director of The Vaccine Confidence Project™ (VCP); Professor of Anthropology, Risk and Decision Science, Dept. Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine; Associate Clinical Professor, Institute of Health Metrics & Evaluation, University of Washington; and Chatham House Centre on Global Health Security Fellow. Dr. Larson previously headed Global Immunisation Communication at UNICEF, chaired GAVI’s Advocacy Task Force, and served on the WHO SAGE Working Group on vaccine hesitancy. The VCP is a WHO Centre of Excellence on addressing Vaccine Hesitancy.

Prof. Larson’s research focuses on the analysis of social and political factors that can affect uptake of health interventions and influence policies. Her particular interest is on risk and rumour management from clinical trials to delivery – and building public trust.  She served on the FDA Medical Countermeasure (MCM) Emergency Communication Expert Working Group, and is Principle Investigator of the EU-funded (EBODAC) project on the deployment, acceptance and compliance of an Ebola vaccine trial in Sierra Leone.

Dr. Pauline Paterson

Dr. Pauline Paterson is a Research Fellow and co-director of The Vaccine Confidence Project™ with Dr. Heidi Larson at the London School of Hygiene and Tropical Medicine, UK. The Vaccine Confidence Project™ conducts global research on vaccine confidence, examining local and global dynamics which influence vaccine decision-making.  Dr. Paterson, together with Dr. Larson, established a global, internet-based information surveillance system on public concerns around vaccines and vaccination programmes. The Vaccine Confidence research group has been conducting qualitative research on specific vaccine confidence issues and risk perceptions globally since 2010.

Dr. Paterson is a member of the NIHR Health Protection Research Unit in Immunisation and has an honorary academic contract with Public Health England. Specific activities include qualitative research on factors influencing vaccination uptake among ethnic minorities during pregnancy, parental reasons for not vaccinating their child with influenza vaccine, and a study of a Jewish orthodox community in London, UK, to understand reasons for childhood under-vaccination.  Dr. Paterson previously worked in strategy at The Global Fund to Fight AIDS, Tuberculosis and Malaria, and carried out her MBA project in Thailand in collaboration with WHO. Dr. Paterson has a PhD in Epidemiology, MBA and MSc from Imperial College London.

Jay Dowle

Jay Dowle is a former journalist who worked on national newspapers and magazines in London, Hong Kong and Australia before starting a medical publishing business. In 1999, he moved to Geneva to work as a communications/publications office for WHO (malaria), moving to New York to work for UNICEF in New York (immunisation) before returning to Geneva to work for UNDP (environmental and climate change issues) and UNEP (Green Economy). More recently he worked at the Global Institute for Health (AIDS/HIV) before joining the Vaccine Confidence Project™ part-time.

Richard Clarke

Richard is currently conducting his PhD research on the information seeking behaviours of mothers as they make a vaccine decision during pregnancy. In his studies Richard applies research from the psychology of decision making, trust and the field of information science to quantitatively investigate how mothers engage in information gathering to aid decision making with respect to the pertussis vaccine currently offered during pregnancy.  

Prior to starting the PhD Richard worked as a psychology lab technician, aided in the design of psychology experiments, and lectured and ran seminars on an undergraduate psychology programme. In 2010 he received an MSc in Psychological Research Methods from The University of Exeter.   

Emilie Karafillakis

Emilie is a research fellow for the Vaccine Confidence Project™. She has a background in public health, infectious disease control, and health systems and policies and holds a Masters degree in the Control of Infectious Diseases from LSHTM and a BSc in European Public Health from Maastricht University. Her work focuses on understanding determinants of vaccine hesitancy in European populations, including healthcare workers, and strategies to effectively address concerns about vaccination. She is involved on media monitoring and analysis of concerns about HPV vaccination. Emilie is also a PhD Candidate at the school – her research project focuses on the impact of post-factual societies on HPV vaccine confidence in France.

Dr. Antonis Kousoulis

Dr. Antonis Kousoulis is the Deputy Director for Innovation & Development Programmes at the Mental Health Foundation, where, as part of the Leadership Team, he oversees the development, testing and delivery at scale of new evidence-based interventions in public mental health across the life course. Previously, he was Deputy Director for Development at CPRD within the UK Department of Health. At the School, Dr. Kousoulis is undertaking a Doctorate in Public Health with his dissertation focusing on the population neglected and emotional determinants that impact on the uptake of interventions in large scale epidemics.

Dr. Kousoulis qualified in Medicine at the University of Athens, Greece, and has completed an MSc at Imperial College London before joining the London School of Hygiene & Tropical Medicine. His work experience includes time in industry and, mostly, academia where he has been an investigator in various research programmes, including clinical trials as well as, among others, at University College London, Harvard School of Public Health, Liverpool University and the University of Crete. He has published over 60 papers in international scientific journals, presented in over 120 scientific meetings, and taught at the Oxford University Department of Primary Care.

William Schulz

Will is an affiliated researcher of the Vaccine Confidence Project™, and is currently a PhD student in Political Science at Princeton University. He holds an MSc in Public Health from the London School of Hygiene & Tropical Medicine, as well as a BA in Political Science from Swarthmore College.  His research interests include political psychology, public policy, medical anthropology, graphic design and science communication. A portfolio of Will’s work is available at his personal website.

Clarissa Simas

Clarissa is a Psychologist and Research Assistant for the Vaccine Confidence Project™. She has a professional background in Global Health and Development and holds an MSc in Medical Anthropology from University College London (UCL) and a BSc in Psychology from University of Brasília. She is currently investigating social impacts of the Zika epidemic in Brazil, the Ebola vaccine trial  deployment, acceptance and compliance, impact of new digital technology in health communication, public acceptance of health interventions, with a particular focus on vaccine confidence in South America, outbreak preparedness, risk perception and its impact in decision making, psychogenic adverse reactions to vaccines globally, and have investigated acceptance of HIV/STI prevention interventions amongst European youth. Her research interests include risk perception, rumours, trust and mistrust dynamics, health psychology, vaccines, Medical Anthropology, Postcolonialism, structural violence, digital epidemiology, community engagement, health communication, and new social media.

Dave Smith
Dr. David Smith

Dr. David Smith’s area of expertise is in the study of complex systems, in particular, complex networks. These systems typically describe or comprise the interaction of many objects. Dr. Smith has introduced, developed and implemented a range of measures and techniques for the analysis and construction of networks. These include acceleration as applied to evolving networks and descriptions of the correlations inherent in networks. Additionally, Dr. Smith has studied systems where functional processes on networks and the evolution of the structure are coupled, introducing the concept of Network Automata to implement such systems. Dr. Smith’s D.Phil. thesis, “Agents, Games and Networks”, was conducted in the Mathematical Department at Oxford University with subsequent post-doctoral positions held in the Physics Department, the Complex Agent-based Dynamic Network Group at the Saïd Business School and the Centre for Mathematical Biology, all at Oxford University.

Dr. Neisha Sundaram

Dr. Neisha Sundaram is a Research Fellow with the Vaccine Confidence Project™ at LSHTM, and a Visiting Research Fellow at the Saw Swee Hock School of Public Health, National University of Singapore. She currently holds a personal award fellowship from the Swiss National Science Foundation. Dr. Sundaram’s research interests lie in the prevention and control of infectious diseases, with a focus on vaccine confidence and acceptance. Her research focuses on human papillomavirus (HPV) vaccine implementation in Southeast Asia and global mapping of HPV vaccine confidence. Her research portfolio includes identifying individual and institutional determinants of influenza vaccination among healthcare workers in Singapore, evaluating tuberculosis control in Cambodia, pandemic influenza vaccine acceptance and influenza control in Western India, and sociocultural determinants of oral cholera vaccine acceptance in Kenya, Zanzibar and Democratic Republic of Congo. She has a growing interest in behavioural economics and economic evaluation of vaccines and a special interest in the integration of qualitative and quantitative research methods. Dr. Sundaram has a PhD in Epidemiology from the Swiss Tropical and Public Health Institute and University of Basel, Switzerland.

Dr. Elizabeth Smout

Dr. Smout is a medical doctor with a background in maternal health and infectious diseases. She is currently a Research Assistant at the Health Protection Research Unit in Immunisation, based at the London School of Hygiene & Tropical Medicine. Her research focuses on monitoring social, cultural and political issues affecting the Ebola response in West Africa. She has previous experience of working with antenatal and postnatal populations in both Cape Town and Johannesburg, South Africa, where she has conducted research into factors affecting adherence to PMTCT programmes in HIV-positive pregnant women currently experiencing intimate partner violence. She has also previously developed an algorithm to predict preterm birth in high risk populations. Dr. Smout has a medical degree and BSc in Maternal and Foetal Health from King’s College London, and an MSc in the Control of Infectious Diseases from the London School of Hygiene & Tropical Medicine.


Journal articles

Larson HJ; Clarke RM; Jarrett C; Eckersberger E; Levine Z; Schulz WS; Paterson P; (2018) Measuring trust in vaccination: A systematic review. Human vaccines & immunotherapeutics. pp. 1-31.  

Karafillakis E.; Larson H.J.; on behalf of the ADVANCE consortium. 2017. The benefit of the doubt or doubts over benefits? A systematic literature review of perceived risks of vaccines in European populations. Vaccine 35(37):4840-50.

Kummervold P.E.; Schulz W.S.; Smout E.; Fernandez-Luque L.; Larson H.J. 2017. Controversial Ebola vaccine trials in Ghana: a thematic analysis of critiques and rebuttals in digital news. BMC Public Health 17:642.

Paterson P.; Meurice F.; Stanberry L.R.; Glismann S.; Rosenthal S.L.; Larson H. Vaccine hesitancy and healthcare providers. Vaccine. (2016) 34 (52): 6700-6706.

Philip, R.K.; Shapiro, M.; Paterson, P.; Glismann, S.; Van Damme, P. Is it time for vaccination to ‘go viral’? The Pediatric Infectious Disease Journal. (2016) 35 (12): 1343-1349.

Becker, B.F.; Larson, H.J.; Bonhoeffer, J.; van Mulligen, E.M.; Kors, J.A.; Sturkenboom, M.C. Evaluation of a multinational, multilingual vaccine debate on Twitter. Vaccine, 2016.

Karafillakis, E.; Dinca, I.; Apfel, F.; Cecconi, S.; Wűrz, A.; Takacs, J.; Suk, J.; Celentano, L.P.; Kramarz, P.; Larson, H.J. Vaccine hesitancy among healthcare workers in Europe: A qualitative study. Vaccine, 2016.

Peprah, D.; Palmer, J.J.; Rubin, G.J.; Abubakar, A.; Costa, A.; Martin, S.; Perea, W.; Larson, H.J. Perceptions of oral cholera vaccine and reasons for full, partial and non-acceptance during a humanitarian crisis in South Sudan. Vaccine, 2016; 34(33):3823-7.

Enria, L.; Lees, S.; Smout, E.; Mooney, T.; Tengbeh, A.F.; Leigh, B.; Greenwood, B.; Watson-Jones, D.; Larson, H.  Power, fairness and trust: understanding and engaging with vaccine trial participants and communities in the setting up the EBOVAC-Salone vaccine trial in Sierra Leone. BMC Public Health, 2016; 16(1):1140.

Larson, H.J.; de Figueiredo, A.; Xiahong, Z.; Schulz, W.S.; Verger, P.; Johnston, I.G.; Cook, A.R.; Jones, N.S.  The State of Vaccine Confidence 2016: Global Insights Through a 67-Country Survey.  EBioMedicine, 2016.

de Figueiredo, A.; Johnston, I.G.; Smith, D.M.; Agarwal, S.; Larson, H.J.; Jones, N.S.  Forecasted trends in vaccination coverage and correlations with socioeconomic factors: a global time-series analysis over 30 years. Lancet Glob Health, 2016.

Larson, H.J.; Schulz, W.S.; Tucker, J.D.; Smith, D.M.  Measuring vaccine confidence: introducing a global vaccine confidence index. PLoS Curr, 2015; 7.

Peretti-Watel, P.; Larson, H.J.; Ward, J.K.; Schulz, W.S.; Verger, P.  Vaccine hesitancy: clarifying a theoretical framework for an ambiguous notion. PLoS Curr, 2015; 7.

Wilson, R.J.; Paterson, P.; Jarrett, C.; Larson, H.J.  Understanding factors influencing vaccination acceptance during pregnancy globally: A literature review. Vaccine (2015) ; DOI: 10.1016/j.vaccine.2015.08.046; PMID: 26320417.

Jarrett, C.; Wilson, R.; O’Leary, M.; Eckersberger, E.; Larson, H.J.; SAGE Working Group on Vaccine Hesitancy; COLLABORATORS: Eskola, J.; Liang, X.; Chaudhuri, M.; Dubé, E.; Gellin, B.; Goldstein, S.; Larson, H.; MacDonald, N.; Manzo, M.L.; Reingold, A.; Tshering, K.; Zhou, Y.; Butler, R.; Duclos, P.; Guirguis, S.; Hickler, B.; Schuster, M.  Strategies for addressing vaccine hesitancy – A systematic review. Vaccine, 2015; 33(34):4180-90.

Larson, H.J.; Jarrett, C.; Schulz, W.S.; Chaudhuri, M.; Zhou, Y.; Dube, E.; Schuster, M.; MacDonald, N.E.; Wilson, R.; SAGE Working Group on Vaccine Hesitancy; COLLABORATORS: Eskola, J.; Liang, X.; Chaudhuri, M.; Dubé, E.; Gellin, B.; Goldstein, S.; Larson, H.; MacDonald, N.; Manzo, M.L.; Reingold, A.; Tshering, K.; Zhou, Y.; Butler, R.; Duclos, P.; Guirguis, S.; Hickler, B.; Schuster, M.  Measuring vaccine hesitancy: The development of a survey tool. Vaccine, 2015; 33(34):4165-75.

Karafillakis, E.; Hassounah, S.; Atchison, C.  Effectiveness and impact of rotavirus vaccines in Europe, 2006-2014. Vaccine, 2015; 33(18):2097-107.

Hawkes, S.; Kismödi, E.; Larson, H.; Buse, K.  Vaccines to promote and protect sexual health: Policy challenges and opportunities. Vaccine, 2014; 32(14):1610-5.

Larson, H.J.; Jarrett, C.; Eckersberger, E.; Smith, D.M.; Paterson, P.  Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007-2012. Vaccine (2014) ; DOI: 10.1016/j.vaccine.2014.01.081; PMID: 24598724.

Larson, H.J.; Wilson, R.; Hanley, S.; Parys, A.; Paterson, P.  Tracking the global spread of vaccine sentiments: The global response to Japan’s suspension of its HPV vaccine recommendation. Hum Vaccin Immunother (2014) :1-8; DOI: 10.4161/21645515.2014.969618; PMID: 25483472


Apfel, F.; Cecconi, S.; Oprandi, N.; Larson, H.; Karafillakis, E.  Let’s talk about hesitancy. Enhancing confidence in vaccination and uptake. Practical guide for public health programme managers and communicators. 2016. PDF

Larson, H.; Karafillakis, E.  Rapid literature review on motivating hesitant population groups in Europe to vaccinate. ECDC Technical Report. 2015. PDF

Larson, H.; Schulz, W.  The state of vaccine confidence 2015. 2015. PDF

Wilson, R.; Paterson, P.; Chiu, J.; Schulz, W.; Larson, H. HPV Vaccination in Japan. The Continuing Debate and Global Impacts. A Report of the CSIS Global Health Policy Center. April 2015. Center for Strategic & International Studies. PDF

Wilson, R.; Paterson, P.; Larson, H.J. The HPV Vaccination in Japan. Issues and Options. A Report of the CSIS Global Health Policy Center. Center for Strategic & International Studies. May 2014.  PDF


Vaccines Work: Advocacy for Immunisation

“This is a space for those who are working to improve immunisation systems and access to vaccines, particularly in resource-poor settings. It aims to help you to find ideas, resources and guidance to advocate for strengthened commitment to vaccines and immunisation to save lives.”

US Centers for Disease Control and Prevention: Vaccines and Immunizations

This page provides an excellent, authoritative source of information on immunization schedules, side effects and safety of vaccines, and answers to many common questions.

NHS Choices: Vaccinations

Quick and easy access to information about the NHS vaccination schedule, vaccine safety, and clear explanations of how vaccines work and what ingredients they contain.

A centralised access point to many US government resources related to flu and flu vaccination.

HPV Prevention and Control Board

Provides evidence-based guidance on key technical and strategic issues, and monitors the progress of HPV control programs at the country and regional levels.

WHO Global Vaccine Safety

Information on vaccine safety and the Global Vaccine Safety Initiative (GVSI) from the World Health Organization.



Brighton Collaboration
Chatham House
European Medicines Agency
Gallup International
Imperial College London
International Pediatric Association
International Vaccine Institute

LVCT Kenya
National University of Singapore
Public Health Foundation of India
Sabin Vaccine Institute
University College London
University of Washington, Seattle
World Health Organization


Literature Literature archive

EM. Valido, IS Laksanawati, A Utarini 2018 BMC Research Notes 11:661
V Toffolutti M McKee A Melegaro W Ricciardi D Stuckler 2018 European Journal of Public Health, cky178

Videos Video archive

Key figures share their perspectives on a controversy that led to the suspension of Ebola vaccine clinical trials in Ghana.

Drs. Heidi Larson and Pauline Paterson of the Vaccine Confidence Project join episode 50 of the Public Health United podcast with Nina Martin, November 2017.

Drs. Larson and Paterson join a discussion on vaccine confidence at Hong Kong University.  September, 2015.

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