title: The State of Vaccine Confidence 2016: Global Insights Through a 67-Country Survey.
abstract: BACKGROUND
  Public trust in immunization is an increasingly important global health issue. Losses in confidence in vaccines and immunization programmes can lead to vaccine reluctance and refusal, risking disease outbreaks and challenging immunization goals in high- and low-income settings. National and international immunization stakeholders have called for better monitoring of vaccine confidence to identify emerging concerns before they evolve into vaccine confidence crises.
  
  
  METHODS
  We perform a large-scale, data-driven study on worldwide attitudes to immunizations. This survey - which we believe represents the largest survey on confidence in immunization to date - examines perceptions of vaccine importance, safety, effectiveness, and religious compatibility among 65,819 individuals across 67 countries. Hierarchical models are employed to probe relationships between individual- and country-level socio-economic factors and vaccine attitudes obtained through the four-question, Likert-scale survey.
  
  
  RESULTS
  Overall sentiment towards vaccinations is positive across all 67 countries, however there is wide variability between countries and across world regions. Vaccine-safety related sentiment is particularly negative in the European region, which has seven of the ten least confident countries, with 41% of respondents in France and 36% of respondents in Bosnia & Herzegovina reporting that they disagree that vaccines are safe (compared to a global average of 13%). The oldest age group (65+) and Roman Catholics (amongst all faiths surveyed) are associated with positive views on vaccine sentiment, while the Western Pacific region reported the highest level of religious incompatibility with vaccines. Countries with high levels of schooling and good access to health services are associated with lower rates of positive sentiment, pointing to an emerging inverse relationship between vaccine sentiments and socio-economic status.
  
  
  CONCLUSIONS
  Regular monitoring of vaccine attitudes - coupled with monitoring of local immunization rates - at the national and sub-national levels can identify populations with declining confidence and acceptance. These populations should be prioritized to further investigate the drivers of negative sentiment and to inform appropriate interventions to prevent adverse public health outcomes.
authors.affiliation: Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, UK; Institute for Health Metrics and Evaluation, University of Washington, Seattle, UK. Electronic address: heidi.larson@lshtm.ac.uk.
authors.forename: Heidi J
authors.initials: HJ
authors.lastname: Larson
authors.affiliation: Department of Mathematics, Imperial College London, UK. Electronic address: alexandre.de-figueiredo07@imperial.ac.uk.
authors.forename: Alexandre
authors.initials: A
authors.lastname: de Figueiredo
authors.affiliation: Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
authors.forename: Zhao
authors.initials: Z
authors.lastname: Xiahong
authors.affiliation: Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, UK.
authors.forename: William S
authors.initials: WS
authors.lastname: Schulz
authors.affiliation: INSERM, UMR912, Economics and Social Sciences Applied to Health & Analysis of Medical Information (SESSTIM), Marseille, France; ORS PACA, Southeastern Health Regional Observatory, F-13006 Marseille, France; Aix Marseille Université, UMR_S 912, IRD, Marseille, F-13385, Marseille, France; INSERM, F-CRIN, Innovative clinical research network in vaccinology (I-REIVAC), GH Cochin Broca Hôtel Dieu, Paris, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Verger
authors.affiliation: School of Biosciences, University of Birmingham, UK.
authors.forename: Iain G
authors.initials: IG
authors.lastname: Johnston
authors.affiliation: Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Department of Statistics and Applied Probability, National University of Singapore, Singapore.
authors.forename: Alex R
authors.initials: AR
authors.lastname: Cook
authors.affiliation: Department of Mathematics, Imperial College London, UK.
authors.forename: Nick S
authors.initials: NS
authors.lastname: Jones
mesh_terms: D005843:Geography; D014943:Global Health / Q000266:history; D049674:History, 21st Century; D006801:Humans; D007114:Immunization; D016017:Odds Ratio; D011159:Population Surveillance; D012959:Socioeconomic Factors; D014611:Vaccination; D014612:Vaccines / Q000009:adverse effects / Q000276:immunology
chemical_list: D014612:Vaccines
keywords: Attitudes; Global immunization; Hierarchical regression; Vaccine confidence; Vaccine safety