EU member states with low COVID-19 vaccine uptake - challenges and actions

Nursing leaders from across EU Member States with relatively low uptake of COVID-19 vaccine met with the European Commission (DG Sante) to discuss the challenges and needs experienced by healthcare professionals (HCP) and students and to explore options for support. While it may be believed that the reasons for low uptake of vaccination are country-specific – and that a common EU approach will not worknursing leaders from Eastern Europe and the Baltic region indicated otherwise.


Within this context, some EFN members discussed and addressed the following question: What experience do health professionals have regarding vaccine hesitancy and how to address it?


The following feedback was received:


From the European Nursing Student Association (ENSA), Edel Marlèn Taraldsen highlighted that vaccine hesitancy is often about “not knowing”. We must address vaccine hesitancy by talking about vaccines and share the facts. We must try to understand why the persons thinks that way, and how we can teach them the correct information without frustrating and confusing the person. We need to remain calm and deconstruct the misinformation the person has. It is important that they understand it the way we do – but maybe not as detailed as we know it.


Milka Vasileva from the Bulgarian Association of Health Professionals in Nursing highlighted that from January 2021, when the vaccination campaign started in Bulgaria, health professionals had the possibility to learn a lot about the vaccines themselves, the way of vaccination, the adverse reactions and the advantage of the vaccination. The professional organisation of the healthcare professionals in nursing organised on-line free courses for their members to educate frontline nurses about the value of being vaccinated against COVID-19, how to communicate with the patients about the vaccination. A lot of nurses were engaged in the vaccination process in the different health settings. However, in Bulgaria, anti-vaccination conspiracy theories spread on social media during the pandemic and the people were very much affected by it. Even on the national TV media, there were specialists stating that it is not necessary to get vaccinated, the vaccine has not been under all investigations, and it is even very dangerous to allow it into one’s body. In this social atmosphere, the nurses were at the front line to convince people to agree and to understand the importance of the vaccination. Finally, and sadly, about 8500 nurses have been infected with COVID-19 and it was a great difficulty to ensure enough nursing staff in the hospitals. Several appeals were sent to the public and to politicians to take stricter measures and to prepare an effective vaccination campaign. Bulgarian nurses have a positive attitude toward COVID-19 vaccination and do their ultimate best to persuade the public to get better awareness, to be better informed and to really understand that vaccination saves lives.


Georgeta Truca from the Romanian Nurses Association, highlighted that the vaccination campaign was not effective from the beginning and there were probably no well-developed strategies. There is and still is reluctance to vaccinate by health professionals and the general public, because those involved in the campaign have not explained to everyone what the role of vaccination is and what is beneficial for vaccination. It is key that health professionals use the language that everyone, ordinary citizens, understands. That is where academics fail. The biggest fear of people is related to the side effects of the vaccine.


Ausra Volodkaite from the Lithuanian Nurses Association, added that the most common reasons of vaccine hesitancy are:

  • Negative information from various sources (disinformation, false articles, movement of opponents of vaccination)
  • Negative attitude from relatives to vaccination (parents, children, dissemination of misinformation, ban on vaccination)
  • Negative experience from relatives (e.g., deaths caused by thrombosis shortly after the vaccination)
  • Negative information from health professionals who do not support vaccination
  • Negative attitudes towards healthcare professionals in the community and lack of trust.  

The authority of family doctors and nurses is very important as well as trust in HCP and proper communication about vaccination benefits.

Lithuania had different incentives like:

  • Financial incentives for elderly patients who have not yet been vaccinated
  • Financial incentives for HCP (doctors, nurses who persuade patients to be vaccinated)

Nurses work very hard and sometimes hear negative comments about their vaccination activities, especially when patients are forced to get vaccinated due to job requirements, the opportunity to travel, to visit shops, and so on.


Dita Raiska from the Latvian Nurses Association said that in the context of the Covid-19 pandemic in Latvia, there was a very high public mistrust of the government and the decisions it has taken. The initial government communication with the public was very unfortunate and also chaotic. Residents had problems getting vaccines against Covid-19 because they weren't available, and the vaccination process itself was very chaotic and incomprehensible. The public also received widespread messaging that vaccines have side effects which could lead to serious health problems, disability and even death. There are still health and life threats for medics supporting vaccination.

However, closer cooperation between government and HCP, especially nurses, in the decision-making process on Covid-19 would be needed. The government also needs more successful communication with the public on issues related to Covid-19.


Gerli Liivet from the Estonian Nurses Union informed the EFN that nurses and other HCP have gotten various reactions regarding the vaccination hesitance. The people who are against the vaccine can roughly be divided into two:

  • the first ones truly believe that the COVID vaccines have been poorly researched and therefore, the actual impact on the human body is unknown. They rather believe the conspiracies circling around social media and they are not ready to listen to the health care workers’ explanations nor actual scientific information.
  • the other group of people have a belief that they would rather get the antibodies via actually being ill with COVID, not through vaccination. COVID is considered to be a disease that is not harmful to younger generations. They are not deterred by the fact that without the vaccination they lack access to, for example, indoor sporting and different entertainment facilities.

But at the same time, there exists a smaller group of people, who are against everyone and everything just for the sake of it. In addition, there are people who tie other people’s fears and hate to their own political ambitions. Such actions mainly grow prejudice against the government and create an environment where the person blames the state and its leaders in all of their troubles. Estonia has family health centres where more than 70% of the patients are vaccinated. But at the same time we are witnessing how the younger generation does not allow the older members of the family to vaccinate themselves. Moreover, conflicts have arisen in families where a teenager (12-18 years old) has the wish to get vaccinated, but the parents will not allow it. There have been cases where young people have vaccinated themselves without their parents knowing about it. That is due to the fact that in Estonia, the child has the right to decide for themselves after a brief decision competence assessment by a family doctor. However, the focus today is on the individual approach. There have been many stories in the media about younger people getting sick and long-term COVID. In addition, the calls for vaccination are still ongoing and constant. However, it’s clearly visible that the interest in beginning the vaccination process in diminishing. If we take a look at the Northern countries, then the people there have a greater sense of collective responsibility while in Estonia a greater emphasis is being put on the right to decide individually.


Jana Gelatiková from the Slovak Chamber of Nurses and Midwives added that in Slovakia, the population was motivated to be vaccinated during the second wave of the pandemic and people were interested in being vaccinated at that time (from February to May). After this time, when there were enough vaccines, the pandemic situation in Slovakia began to improve and at the same time the fight between politicians began to vaccinate or not to vaccinate. We have had vaccination promotion campaigns, including a vaccination lottery set up by the Ministry of Finance (which already ended), and public appearances by health professionals, public figures (including actors, singers).

Concerning solutions, she suggested: 

  • Increasing the number of vaccination centres (though challenging, due to not enough doctors and nurses)
  • Giving more space for professional debate, not political debates
  • Improving vaccination management:
    • the number of people interested in the vaccine has increased and people come to the vaccination center, but the center does not have enough vaccines
    • Centers where advance registration is not required
    • Simplifying access to vaccination information (e.g., older people don’t have internet or computer access)
    • Improving cooperation between local governments


Zuzana Tomášková from the Czech Nurses Association replied that there are still many people in Czech population who do not want to be vaccinated for different reasons. Many people do not discuss and deny other mandatory routine vaccines, but because COVID is medialized too much without appropriate support they feel threatened by government. HCP can feel the danger due to lower vaccination rate on one side, but some of them may feel pushed too much to receive their vaccine and that their freedom and decision-making process is being attacked.


Monika Azman from the Slovenian Nurses Association highlighted two angles: the patient side and the HCP side. From the patient side, there is a lack of credible information. The influence of social media, which seems to be always one step ahead of the profession, is worrying. People’s mistrust in politics/government is also increasing: COVID-19, and in particular, COVID-19 vaccination has been associated with authoritarian rule and using authoritarian communication (at least in the countries with short history of parliamentary democracy). Inappropriate, one-sided campaigns which don't take into consideration non-medical aspects (i.e., anthropological, sociological, psychological, etc.) are not helpful, and there is no single vaccine information portal for the country. The divisiveness of society, the lack of values (such as solidarity and tolerance), which should underpin the social component of the society instead of pure consumerism (egoistic, neoliberal aspect) is worrying. Finally, vaccinations are associated with the big profits of the pharmaceutical industry and its influence on the policy- and decision-makers (which stimulates conspiracy theories).

On the nursing side and HCP side, Monika highlighted the following:

  • Due to more than 30 years of stable conditions and infectious disease control, this area within the health system has been sidelined;
  • For the last 30 years there has been no systemic vaccination promotion at the time of the education of nurses and midwives (i.e., in case of flu, nurses have lower vaccination coverage than the general population);
  • Lack of lifelong vaccination education for all healthcare professionals;
  • Influence of social media (as for the rest of population);
  • Passive attitude from the side of the decision makers – health care was and is not actively involved in planning, decision-making and public speaking bodies despite enjoying the highest reputation among health professionals in the country (while health care simultaneously proved to be the saviour of present situation). The management of the crisis is completely controlled by medical specialists, which shows a lack of teamwork.


Grazyna Wójcik from the Polish Nurses Association said that in order to understand the behaviour of Polish people it is necessary to say that they are a society with low levels of social trust and they generally like to avoid formal rules, recommendations, etc. The social attitudes towards COVID-19 vaccine have changed over the last year. At the beginning, there was a lot of anxiety, fear and hesitancy. People were simply scared, and it was the best time to educate, explain and influence the citizens attitudes. The first months of vaccination were completely lost by the government in the aspect of education and changing social attitudes. The politicians were concentrating on vaccination logistics, marketing their own successes, and fighting against COVID-19, but not looking forward, including how to build trust and acceptance towards COVID-19 vaccination.

At some stage, the vaccination project in Poland was almost dead, and nobody really wanted to change the strategy. Meanwhile, the citizens, who refused to take vaccines were exposed to anti-vaccination fake news, and their hesitancy simply grew. 

On how to address these challenges, there is no one good answer, but multiple. First, politicians are responsible for such situations, if you are not successful in persuading your own citizens, you are simply not good as a leader. Secondly, all professionals with formal roles in society like doctors, teachers, scientists, social workers should be the best example of being responsible for the health and safety of others. Organisations/bodies responsible for professional registration should take adequate actions. Last but not least, at present there is no time for waiting, we should develop different public and economic rules promoting all being vaccinated. For example, a lot of Polish people took the vaccine only because of international travelling.


Finally, an exchange of views took place between some EFN members on what the European Commission and its Agencies could do to support healthcare professionals to better address vaccine hesitancy.


Edel Marlèn Taraldsen ​​​​​​from the European Nursing Student Association (ENSA) highlighted the importance of healthcare professionals to be trained on how to deconstruct misinformation with their patients. Healthcare professionals must teach and use techniques on how to talk about sensitive matters like vaccine hesitancy, and know which approach is better for each situation.


Milka Vasileva from the Bulgarian Association of Health Professionals in Nursing agreed that this is a very difficult question. However, it is up to the national government to tackle the problem. In Bulgaria, the campaign during the summer 2021 was not good enough and now we see the results. They received the necessary amount of vaccines, but people were not convinced to take it. The contradictory information, coming from different research institutions all over the world through the social media played a very bad role in the social thinking and fear took hold in people’s minds. Maybe, if there was a universal European approach signed by the leading specialists from the European institutions to be recommended for the health politicians to lead the vaccination process in the countries, it could be of some help. Healthcare professionals have all sources of information, and they try in every way to speak to people to take vaccination. They informed the public that over 25 nurses lost their life from COVID-19 being infected while working to save other lives. They asked the public to get vaccinated and, in that way, stop the spreading of the awful disease and to return back no normal life.


Georgeta Truca from the Romanian Nurses Association added that the Commission must develop very clear key messages based on scientific research that will enable people to understand and use a universal language for all people; also, to develop visual materials, for everyone to understand.


Ausra Volodkaite from the Lithuanian Nurses Association continued saying that we need to seek to improve communication and patient information. We need projects, she said, to strengthen the authority and image of health professionals, to show that they are trusted professionals, possibly through the sharing of good practice examples and the demonstration of the results of their daily work in the area of prevention and control of infectious diseases.


Dita Raiska from the Latvian Nurses Association argued that healthcare professionals would like the European Commission and the Agencies to share more of the results of scientific research, which would help in the fight against false information about Covid-19. There is also a need for more free mobility of health professionals at transnational level. The importance of nurses in informing the public is not enough assessed.


Gerli Liivet from the Estonian Nurses Union argued that the vaccination process will start moving slower because those who believe that getting sick with the disease is not that bad and as such get more assurance to their beliefs. Strong evidence and clear messages about the necessity of vaccination can potentially help support spreading the message. The restrictions have infuriated the general public and have polarised societies, but at the same time it has increased the amount of people getting vaccinated. The distribution of statistics should be as clear as possible. Shared messages should be standardised and each state should have a concrete understanding about who is spreading the message and in which outlets/social groups. However, too many scientists share their own opinions and knowledge in different media outlets, giving a chance for anti-vaxxers to spread false claims, along the lines of ‘the scientists also do not know exactly’. In addition, the statistics about the ratio of vaccinated to unvaccinated people in hospitals can also prove to be very helpful.


Jana Gelatiková from the Slovak Chamber of Nurses and Midwives added that it is key to strengthening the competences of nurses in the field of vaccination; to address vaccination through the primary sphere not only vaccination centers (trust between doctor/nurse and patient); and, increase the number of health professionals.


Zuzana Tomášková from the Czech Nurses Association responded to the question that the Commission can support frontline workers by providing good education and information about vaccination, including historical data regarding vaccination development processes and mass vaccination processes. People should see data about vaccinated and unvaccinated people admitted to hospitals and intensive care units. There should be an initiative to unify European rules in terms of vaccination, prevention and safety procedures across all countries.


Monika Azman from the Slovenian Nurses Association argued it is key to separate politics from the profession. Nurses should be actively involved in the steering and decision-making bodies (teamworking as basic standard of mission accomplishment). It is important to move towards a respectful rhetoric; in public speaking, credible experts should prevail, politicians with lack of credibility should step aside, and information should be short and clear; experts should accept the possibility of not knowing the answer to a particular question, acknowledging many things are new for science as well; all public speakers should avoid setting unrealistic expectations. Quick information on the verification of the vaccine registration process and side effects is important. Therefore, more investment/support for nurses who represent the “treasury of knowledge, strength, flexibility and who already have a reputation and trust, is urgently needed. Investing in a public health system that has proven to be the foundation of every society and strengthen support pillars (including providing information in the first place) is essential. Creating strategically-targeted campaigns for target groups (i.e., pregnant women, the elderly, teenagers) can be a change agent as forced vaccination will not be well received and will for sure have adverse effect.


Grazyna Wójcik from the Polish Nurses Association added that, first of all, we should develop a strategy for strengthening the ethics within healthcare professionals. It is hard to believe that we can expect acceptance of vaccines in society, if some of the HCP present different attitudes. One of the most effective ways of influencing the population nowadays is social media, but such tools ask for new competencies, which the medical professionals and experts do not always have. So, there is a field for completely new multidisciplinary EU projects. Every society has a different set of values. In Poland the church still has a strong influence on citizens, but this is the most conservative field of our public life, and it would be difficult to change it. The public media are very influential, but as long as the government is not putting public interests in front of its own, there would be no real chance to use them in vaccine campaigns. 


The EFN PresidentElisabeth Adams, concluded the debate that National NNAs have been largely sidelined in the Recovery and Resilience Facility process (RFF), while the national plans are there to build resilience, to combat the ongoing and future pandemics. We need to build a resilient nursing workforce in the countries concerned. Thirty percent of the nurses in the EU left the nursing profession already. This is alarming and the EU needs to act now! The Recovery and Resilience Facility (RRF), which makes up the bulk of the NextGenerationEU plan, with €672.5 billion in loans and grants (out of a total of €750 billion), will be embedded for the first time in the European Semester. So, we need the indicators to measure a resilient health workforce in the EU. Furthermore, EU public health funds need to support Nurses/Doctors/Pharmacist Associations in the EU to build their capacity in vaccination and strategically address vaccine hesitance. EFN can play a coordinating role for the NNAs to guarantee exploitation.

Importantly, if we consider health professionals and the Coalition for Vaccination as a stakeholder in the area of vaccination, it will be key not only to listen to what they have to say, but also to take concrete actions to support them. The Coalition for Vaccination is a powerful initiative, representing health professionals who meet citizens in their daily lives, and the Commission should increase their support to frontline healthcare professionals, so they stay in the profession.


Author: Prof Dr Paul De Raeve, EFN Secretary General