On 20 January 2025, Medical Humanities; Oxford’s Centre for the History of Science, Medicine, and Technology; and the Uehiro Oxford Institute hosted Professor Katie Atwell for a seminar and interdisciplinary roundtable discussion on ‘Vaccine Hesitancy: The History of an Idea.’ This neatly built upon Stuart Blume’s discussion on ‘The Future of Vaccine Hesitancy’ earlier that day, organised by Oxford’s Vaccines and Society Unit.
Katie Attwell (University of Western Australia) has extensive experience researching and developing vaccination policy in a range of countries, and leads the interdisciplinary VaxPolLab, supporting vaccination social and political research. In her lecture, Katie outlined research conducted with political scientist Adam Hannah (University of Queensland) and interviews with members of the WHO Working Group and associated experts and advisors, reviewing and analysing the process of the WHO-commissioned Working Group set up in 2012 to define the concept of ‘vaccine hesitancy.’ This was followed by a roundtable discussion with experts in the history of medicine (Sally Frampton), clinical science of infectious disease (Philippa Matthews) and social sciences (Isabela Cabrera-Lalinde).
As Katie explained, the Working Group agreed on a “Three Cs” definition of vaccine hesitancy which is commonly referred to in the literature: “delay in acceptance or refusal of vaccination…influenced by factors such as Complacency, Convenience and Confidence”. One problem that Katie emphasized is that this definition seems to place the blame for non-vaccination on individuals who don’t vaccinate – as the term ‘convenient’ seems to refer to ‘making things easy for oneself’. However, she rightly pointed out that what is ‘convenient’ depends on contextual factors that are often beyond one’s control and responsibility. Significant barriers to vaccine access, for example, are not satisfactorily categorized as simply inconvenience or hesitancy. Similarly, cultural and socioeconomic factors as well as trust in science affect vaccination attitudes and decisions in ways not straightforwardly attributable to individual responsibilities.
Katie’s research highlights the ways in which policy necessarily involves coordination, and often compromise, among competing priorities. Different camps within the Working Group, for example, placed different emphases on these different aspects, before reaching an agreement. Indeed, the “Three Cs” definition was a simplified version of a much more complex series of factors the Group identified, comprising 21 types of influences on attitudes to vaccination. At the same time, the 2012 ‘vaccine hesitancy’ definition has since been updated. As Katie explained, the explosion of academic literature and public health messaging referring to the “Three C” definition revealed some of its weaknesses. A new working group established by the WHO in 2018 redefined vaccine hesitancy more narrowly as a “motivational state of being conflicted about, or opposed to, getting vaccinated”.
As Sally Frampton highlighted, “vaccine hesitancy’ is another iteration of the linguistic genealogy that has been used to make sense of tensions around vaccines since the wide-scale introduction of the smallpox vaccine at the beginning of the nineteenth century. The adjective “anti-vaccinists” was soon being applied to those who openly refused the vaccine in the early 1800s. By the 1880s, as resistance to compulsory vaccination (introduced in 1853) increased, groups began to form which congregated around ‘anti-vaccination’ as a form of identity, resulting the formation of several magazines like The Anti-Vaccinator. However, others sceptical of vaccines skirted cautiously around their term, for example the social reformer William Tebb, editor of the carefully named Vaccination Inquirer magazine, who pitched distrust of the procedure as a broader rejection of political compulsion, rather than simply of the vaccine itself.
As pointed out by Philippa Matthews, these terminological issues matter because of the potential impact of negative or pejorative terminology. A similar point can be made about other frequently used terms such as ‘hard to reach populations’. The qualification seems to suggest that the population is the problem, rather than the systemic failings in providing interventions that are accessible, acceptable, affordable. In fact, acknowledging the problems with the ‘3 C’ definition generated by the WHO group, Philippa’s intervention concluded with an alternative proposal of 6 As list to consider: acceptability, accessibility, affordability, awareness, appeal, ambivalence; and noting that these considerations apply to clinical and public health interventions beyond vaccine delivery alone.
More generally, there is a need to tailor vaccine information and delivery to different settings. For instance, community engagement, co-design, peer support/peer navigators could be considered. Community codesign could also be an important contribution to defining and understanding relevant terms (maybe replacing or expanding on ‘hesitancy’). As Philippa suggested, ‘nudging’ policies or alternative ways of delivering vaccines that might avoid ‘needlephobia’ (e.g. oral or nasal vaccines or vaccine patches) could be viable options.
Katie’s analysis of the ways in which the WHO’s terminology and concept came to be defined, deployed, and re-defined also raised broader issues of the relationship between academic research and policy. In particular, as her research highlighted, tensions in the definition of vaccine hesitancy were also shaped by academic demands and interests, including the pressure of publication and citation. As a result, her seminar and the resulting discussion encouraged reflection on academic practices and our responsibility as researchers, as well as the tangled relationship between academic scholarship and public policy.
