Understanding barriers to vaccination uptake in underserved communities

Despite their many benefits, vaccines continue to be seen with suspicion in some disadvantaged communities and their uptake remains low. To reduce this phenomena, we need to first go to the root of the problems and understand the barriers to vaccination that these communities face. 

Low levels of vaccination uptake are an issue of global concern. Despite the benefits of vaccination and the overabundant supply in vaccines among the European Union countries, the uptake of recommended vaccinations is still low for many vulnerable groups of people1. It remains crucial to understand what are the barriers that these underserved communities are facing, in order to achieve the development of efficient strategies to improve the levels of overall immunization.

To understand the barriers, we first have to be aware of who vaccine underserved populations are and what barriers they face; Research shows these populations include disadvantaged and vulnerable individuals such as low-income people, jobless and marginalized social groups, immigrants and refugees, individuals experiencing poor health, older people and social groups under the risk of exclusion or experiencing poverty 1. Barriers may vary depending on a person’s cultural or ethnic background, where they live, where they work or their socioeconomic and educational status. But barriers may also be common for vulnerable groups for example and in particular when they reflect healthcare system insufficiencies. These barriers can contribute significantly to vaccination hesitancy.

Vaccination hesitancy refers to “the delay in acceptance or refusal of vaccine despite availability of vaccination services2. At an individual level, vaccination hesitancy arises due to lack of awareness, social environment influences, personal perceptions about vaccination, lack of trust towards pharmaceutical companies, the government or even medical science and also due to political and/or cultural influences3. People are often not adequately informed and consequently are led to believe rumors, inconsistencies or fake news. They may also be afraid of vaccination as a medical action, and/or they may even feel that they do not need vaccination gearing more towards alternative prevention methods. Additionally, they may mistrust or feel doubtful about health institutions and relevant research findings. Vaccination-related costs (vaccine purchase, travel cost and no compensation for the loss of a working day) are also mentioned as vaccination barriers3, 4. In terms of healthcare system level barriers and how these contribute to vaccination hesitancy the following are often mentioned: lack of appropriate and culturally sensitive vaccine communication methods, insufficient continuous training of healthcare professionals and absent or incomplete health system legal framework and policies about vaccination in underserved communities3, 5. Especially, during the current COVID-19 pandemic, other vaccine promotion campaigns which needed to be promoted by the healthcare systems have been neglected placing threats for other vaccine-preventable diseases.  

A comprehensive approach is needed to address vaccine hesitancy especially among vulnerable groups including addressing system level vaccination barriers. Multicomponent strategies are suggested to be most effective and successful, particularly when the intervention is tailored to a specific population that addressed their specific concern(s)6, 7. IMMUNION has adopted such an approach; the project aims to enhance vaccine literacy by identifying and breaking down barriers in order to provide health care professionals with the education and resources they need to communicate about vaccines effectively. IMMUNION aims to deliver specially customized tools/strategies to train health professionals and allow them to more easily transfer their knowledge and advice properly the underserved communities. IMMUNION is working towards using the results of previous relevant projects to enhance vaccination rate such as BRAVE8, PROMOVAX and HProImmune. In addition new ongoing projects, such as RIVER-EU, AcToVax4NAM and ImmuHubs, are working towards improving vaccine uptake through better understanding the barriers specific EU vulnerable groups are facing and by building around them new, more target-customized tools.




  1. European Union Agency for Fundamental Rights, 2021. Coronavirus pandemic in the EU-fundamental rights implications: vaccine rollout and equality of access in the EU. Bulletin #7. https://fra.europa.eu/en/publication/2021/covid19-rights-impact-june-1
  2. MacDonald NE; SAGE Working Group on Vaccine Hesitancy, 2015. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 14;33(34):4161-4. doi: 10.1016/j.vaccine.2015.04.036..
  3. Karafillakis E, Simas C, Jarrett C, et al., 2019. HPV vaccination in a context of public mistrust and uncertainty: a systematic literature review of determinants of HPV vaccine hesitancy in Europe. Hum Vaccin Immunother. 15(7-8):1615-1627. doi:10.1080/21645515.2018.1564436
  4. Bertoncello C, Ferro A, Fonzo M, et al., 2020. Socioeconomic Determinants in Vaccine Hesitancy and Vaccine Refusal in Italy. Vaccines (Basel). 8(2):276. doi:10.3390/vaccines8020276
  5. Prospero E, Galmozzi S, Paris V, et al., 2019. Factors influencing refusing of flu vaccination among pregnant women in Italy: Healthcare workers' role. Influenza Other Respir Viruses. 13(2):201-207. doi:10.1111/irv.12600
  6. World Health organization. TIP Tailoring Immunization Programmes, 2019. (https://apps.who.int/iris/bitstream/handle/10665/329448/9789289054492-eng.pdf)
  7. Jarrett C, Wilson R, O’Leary M, Eckersberger E, Larson HJ; SAGE Working Group on Vaccine Hesitancy. Strategies for addressing vaccine hesitancy — a systematic review. Vaccine. 2015;33(34):4180-4190. doi:10.1016/j. vaccine.2015.04.040
  8. Calabrò GE, Carini E, Tognetto A, Mancinelli S, Sarnari L, Colamesta V, Ricciardi W, de Waure C and The BRAVE Project Expert panel, 2021. Developing an Evidence-Based Tool for Planning and Evaluating Vaccination Strategies Aimed at Improving Coverage in Elderly and At-Risk Adult Population. Front. Public Health 9:658979. doi: 10.3389/fpubh.2021.658979