Rebuilding Vaccine Confidence Through Community-Centered Health Promotion: A Call for Trust, Engagement, and Sustainable Immunization

Abstract

Vaccination remains one of the most effective public health interventions, yet declining vaccine confidence has emerged as a major threat to global immunization programs. Vaccine hesitancy, shaped by misinformation, institutional mistrust, sociocultural factors, and inequitable access to reliable health information and services, has contributed to stagnating vaccination coverage and the resurgence of vaccine-preventable diseases. This Perspective, which draws on a purposive rather than systematic reading of the literature, argues that rebuilding vaccine confidence requires moving beyond predominantly supply-oriented and one-way communication strategies toward sustained, community-centered health promotion, delivered alongside, not instead of, investment in the health systems that communities are asked to trust. Drawing on contemporary evidence, we examine how trusted community health workers, religious and community leaders, health literacy initiatives, school-based education, participatory community dialogue, and culturally competent healthcare provider communication can strengthen public trust and improve vaccine acceptance. We also set out the documented limits of these approaches, including fragile sustainability once external funding ends, elite capture, tokenism, uneven cost-effectiveness, and an evidence base dominated by small, single-site studies. We further discuss the importance of integrating health promotion into primary healthcare, institutionalizing community participation in immunization governance with safeguards for genuine power-sharing, and establishing systems to routinely monitor trust and vaccine confidence alongside vaccination coverage. Particular attention is given to fragile and conflict-affected settings, using Somalia, where approximately 60% of children are zero-dose, to examine how community engagement operates where health systems are weakest and structural barriers most binding. Sustainable vaccine confidence depends not only on vaccine availability but also on long-term investment in trust. Embedding community-centered health promotion within national immunization policies, as a core pillar that complements rather than substitutes for structural investment, can help improve vaccine uptake, reduce health inequities, and strengthen resilience against future public health threats.

Vaccine Confidence: A New Challenge for Global Health

Vaccination stands as one of the greatest achievements in the history of public health. Since the World Health Organization launched the Expanded Programme on Immunization (EPI) in 1974, vaccination is estimated to have averted 154 million deaths, including 146 million among children younger than five years, and to account for 40% of the observed decline in global infant mortality.¹ Despite these remarkable accomplishments, the gains of decades of investment are increasingly threatened by a growing and complex crisis of vaccine confidence that spans both high-income and low-and-middle-income countries alike.²

The consequences of stagnating immunization coverage are both immediate and far-reaching.³ Global coverage with the first dose of measles-containing vaccine (MCV1) declined to 81% during the COVID-19 pandemic, the lowest level since 2008, and remained at 83% in 2022 and 2023, while estimated measles cases increased by 20% worldwide between 2022 and 2023, from 8.6 million to over 10.3 million.³ The number of countries experiencing large or disruptive measles outbreaks rose from 36 to 57 during the same period, underscoring the direct public health consequences of stagnating immunization coverage.³ Declining confidence is only one contributor to these trends; pandemic-related service disruption, strained health systems, conflict, and fragility have also played major roles.⁴

Economic and socioeconomic inequalities compound these challenges.² Analyses combining WHO/UNICEF coverage estimates with Vaccine Confidence Project survey data show that economic- and education-related inequalities in coverage declined between 2015 and 2019, rose in 2020, peaked in 2021, and have declined again since 2022; the same analysis found that countries with higher income or educational attainment reported lower vaccine confidence.² Critically, vaccine-preventable disease incidence and coverage shortfalls are disproportionately concentrated in low-income countries and fragile, conflict-affected, and vulnerable settings, where structural inequities are most profound.³

Vaccine confidence is a multidimensional construct encompassing trust in vaccines themselves, trust in healthcare providers, trust in governments and regulatory institutions, and broader confidence in the health system.⁵ The Strategic Advisory Group of Experts (SAGE) on Immunization has defined vaccine hesitancy as the delay in acceptance or refusal of vaccination despite availability of services, recognizing that hesitancy is shaped by contextual, individual, group, and vaccine-specific determinants.^5,6 These determinants include historical and institutional factors, socio-cultural influences, personal beliefs, risk perceptions, convenience of access, and the influence of information environments.⁵

Critically, vaccine confidence cannot be reduced to the problem of vaccine supply or simple misinformation correction. WHO immunization leaders caution that making services accessible does not by itself ensure that communities will use them, and that supply-side and demand-side factors cannot be cleanly separated, because earlier experiences with the health system shape later demand.⁷ This perspective argues, therefore, that rebuilding vaccine confidence requires a fundamental repositioning of immunization strategy: moving beyond a supply-centric and communication-focused model toward sustained, community-centered health promotion that addresses the social, cultural, and behavioral roots of vaccine acceptance, while treating the structural conditions that erode trust, such as underfunded services, insecurity, and unaccountable governance, as part of the same problem rather than as background.⁸

Scope, Approach, and Contribution of This Perspective

This Perspective is an argument, not a systematic review. It draws on a purposive, narrative reading of the literature: we searched PubMed and Google Scholar and the websites of WHO, UNICEF, and Gavi, supplemented by citation tracking, with emphasis on work published since 2015 alongside foundational sources. We gave priority to systematic and umbrella reviews, global monitoring reports, and normative frameworks. Single studies and programme reports are cited as illustrations of how an approach can work in a particular setting, and we state their design where relevant so that readers can distinguish proof of concept from demonstrated population-level impact. We also deliberately sought evidence on the limitations of community-centered approaches (What Community-Centered Approaches Cannot Do: Limits and Conditions). The cited studies should therefore be read as illustrative rather than as representative of the whole literature.

The Immunization Agenda 2030 (IA2030) already identifies social and behavioral drivers as one of three core barriers to national and subnational immunization targets,⁸ and the Ottawa Charter has long defined health promotion as enabling people to increase control over their health.⁹ Our contribution is not to restate these frameworks but to argue three points that follow from them yet are often lost in practice. First, trust is local and relational, and it is earned or lost through people’s direct experience of services. Second, community-centered promotion cannot substitute for the structural conditions, namely financing, workforce, security, and accountable governance, on which that experience depends. Third, fragile and conflict-affected settings, from which we write, are where both points are tested most severely (The View From Fragile Settings: Somalia as a Test Case).

Why Traditional Immunization Strategies are No Longer Enough

Conventional immunization strategies have relied predominantly on supply-side interventions—expanding cold chain infrastructure, mobile vaccination campaigns, improved service delivery platforms, and periodic immunization days.⁷ These approaches were historically highly effective. When the EPI began, progress was slow: by 1980, global coverage with three doses of diphtheria-tetanus-pertussis vaccine (DTP3) was only about 20%. The Universal Childhood Immunization initiative launched in 1984 nearly quadrupled global DTP3 coverage to 75% by 1990, and coverage in the poorest countries rose from 5% to 62%.⁷ Improvements in delivery infrastructure, disease surveillance, national government commitment, and sustained advocacy underpinned this success.⁷ In our interpretation, these strategies worked because the binding constraint at the time was the absence of services: demand for protection against visible and frequently fatal childhood diseases already existed, and building delivery systems allowed that demand to be met. Since 2000, however, global DTP3 coverage has plateaued at 84–86%, and the children who remain unreached are disproportionately impoverished, living in rural areas, urban slums, or settings of conflict and fragility, and likely to be excluded from other essential services as well.⁷

While these approaches have been essential for reaching previously unvaccinated populations, they are insufficient on their own when the underlying determinants of vaccine refusal or delay are rooted in distrust, misinformation, or socio-cultural concerns.⁸ The Immunization Agenda 2030 (IA2030), adopted by the World Health Assembly, explicitly recognizes that social and behavioral drivers represent one of the three core barriers to achieving national and sub-national immunization targets, alongside shifting leadership priorities and resource constraints and the declining visibility of disease burden.⁸

One-way information campaigns also have clear limits. Correcting misinformation can backfire: in a nationally representative US experiment involving 1,759 parents, refuting the claimed link between the measles-mumps-rubella vaccine and autism reduced that misperception but lowered intention to vaccinate among the parents least favorable to vaccines, and none of the tested messages increased intention overall.¹⁰ Political identity amplifies these effects. In a US survey of 1,757 adults recruited through social media in 2021, both the political leaning of respondents’ preferred news outlets and their own political orientation were strongly associated with COVID-19 vaccination choice (c-statistics of 0.77 and 0.81, respectively).¹¹ Because this was a convenience sample that was predominantly White, female, and politically liberal, these associations illustrate rather than quantify the role of polarization.¹¹

Declining trust in governments and health authorities is itself uneven, and the pattern matters for strategy. The 2026 Edelman Trust Barometer, an online survey of nearly 34,000 respondents in 28 countries, again placed developed markets such as Japan, France, Germany, the United Kingdom, and the United States at the bottom of its trust index, whereas developing markets including China, the United Arab Emirates, India, Indonesia, Saudi Arabia, and Nigeria recorded the highest scores; it also reported that the trust gap between high- and low-income respondents has more than doubled since 2012.¹² Vaccine-specific data show a related pattern. Countries with higher income and educational attainment report lower vaccine confidence,² and although the perceived importance of childhood vaccines fell during the COVID-19 pandemic in 52 of 55 countries studied, it held firm or improved in China, India, and Mexico.⁴

Several drivers plausibly underlie these differing trends. In high-income settings, economic grievance, political polarization, growing access to misleading information, and declining trust in expertise have been implicated.^4,12 The ideology of healthism, which frames health as an individual responsibility and is linked to distrust of health institutions, together with low perceived threat from diseases that vaccines have made rare, has been examined as an explanation for why higher socioeconomic status can be associated with more, rather than less, hesitancy.¹³ In many low- and middle-income settings, stated trust in institutions and vaccines remains comparatively high, but in our view it is easily eroded where it is repeatedly tested by stock-outs, poor-quality services, or conflict, since people’s experiences of the health system shape their subsequent demand.^2,7 National averages also conceal wide variation: country-level economic development, inequality, corruption, and cultural values moderate how strongly satisfaction with health care, trust in political institutions, and conspiracy beliefs translate into vaccination intention.¹⁴ The implication is that there is no single trust deficit to be corrected; the sources of distrust, and therefore the remedies, differ across and within countries.

The proliferation of misinformation through social media has emerged as a defining challenge for contemporary immunization programs.¹⁵ The COVID-19 pandemic was accompanied by an infodemic in which accurate and inaccurate information spread together, with serious consequences for vaccine uptake.¹⁵ Analysis of over one million COVID-19 vaccine-related tweets revealed highly polarized and active anti-vaccine conversations primarily driven by political and non-medical users, while less than 10% of vaccine-related content originated from the medical or public health community.¹⁶ Among adolescents and youths in sub-Saharan Africa, the pooled prevalence of COVID-19 vaccine acceptance across 23 studies was only 38.7%.¹⁷

Vaccine mandates, while sometimes effective in raising coverage rates in specific contexts, carry significant risks of eroding public trust and triggering active resistance.¹⁸ A nationally representative survey experiment in the United States found that mandates were unlikely to change vaccination behavior overall and may increase the likelihood that sizable proportions of populations opt out of mandate-affected activities.¹⁹ In a three-wave German panel, consistent opposition to vaccination was 3.3% when vaccination was voluntary but 16.5% when it was mandated.¹⁸ These findings highlight that coercive approaches may undermine the long-term social contract between health systems and communities, generating backlash that complicates future immunization efforts.

Historical experiences of medical exploitation, colonial healthcare systems, and unethical research practices continue to shape vaccine hesitancy in many communities.²⁰ The most widely cited example is the United States Public Health Service study of untreated syphilis conducted with the Tuskegee Institute in Macon County, Alabama, from 1932 to 1972. Researchers enrolled 600 Black men, 399 with syphilis and 201 without, without informed consent, told them they were being treated for “bad blood,” and did not offer treatment even after penicillin had become the treatment of choice in the 1940s; the study ended only in 1972, after it was exposed in the press.²¹ Its consequences extended well beyond the participants: an economic analysis found that disclosure of the study was followed by increased medical mistrust, fewer physician visits, and higher mortality among older Black men, with an estimated fall in life expectancy at age 45 of up to 1.5 years.²² A systematic review of COVID-19 vaccine hesitancy among Black and African American individuals identified historical mistrust, alongside contemporary institutional mistrust, fear, and information needs, as recurring themes.²⁰ Related patterns have been documented in sub-Saharan Africa: in a survey of 1,000 adults in Cameroon, social media use and medical mistrust were positively associated with belief in COVID-19 vaccine misinformation.²³

Vaccine hesitancy among healthcare professionals further complicates immunization efforts, since providers serve as the primary trusted information source for most patients.²⁴ A systematic review including 221 studies on healthcare worker vaccine hesitancy found that key determinants included gaps in knowledge, personal beliefs, organizational barriers, and communication skill deficits.²⁴ These findings underscore that the challenge of vaccine confidence is not confined to the general public but permeates health systems themselves, necessitating multi-level interventions that address provider hesitancy alongside community-level strategies.²⁵

How, then, can healthcare workers be both a source of hesitancy and, as Community-Centered Health Promotion: Rebuilding Trust in Vaccination argues, a key means of building confidence? We suggest that these realities coexist because provider influence is conditional rather than automatic. The patient-provider interaction is widely regarded as the keystone of efforts to address hesitancy, yet significant proportions of providers, including those who administer vaccines, are themselves hesitant.²⁵ Providers transmit confidence when they hold it, when they have the knowledge and communication skills to answer difficult questions, and when they work in systems that give them time and support; where these conditions fail, the same trusted relationship can transmit doubt.^24,25 Nor is a good relationship with one’s own physician sufficient: in the US survey described above, respondents who accepted and declined vaccination reported similar relationships with their doctors, and vaccine choice aligned more closely with media use, political orientation, and the views of family and friends.¹¹ Evidence from low- and middle-income and humanitarian settings points in the same direction, showing that trust in proximate, familiar actors, such as local health workers, teachers, and community health workers, rather than in distant institutions, is decisive for vaccine acceptance.²⁶ Provider hesitancy is therefore best understood as a health-system problem to be addressed through education, organizational support, and multidisciplinary interventions,^24,27 and it is the first reason why community-centered health promotion must begin with the health workforce itself.

Community-Centered Health Promotion: Rebuilding Trust in Vaccination

Community-centered health promotion represents a paradigm shift from passive vaccine delivery to active community engagement, recognizing communities as partners rather than recipients of health interventions.²⁸ Grounded in the principles of the Ottawa Charter for Health Promotion, which defines health promotion as “the process of enabling people to increase control over, and to improve, their health,”⁹ community-centered approaches emphasize empowerment, participation, equity, and the strengthening of community actions as core mechanisms for health improvement.²⁹ The Charter also names peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity as the fundamental prerequisites for health,⁹ a reminder that health promotion was conceived as a structural as well as a behavioral project, a point to which we return in Policy Directions for Sustainable Vaccine Confidence. When applied to immunization, these principles translate into fostering genuine dialogue, shared decision-making, and long-term relationship building between health systems and communities.²⁶

Community health workers (CHWs) occupy a uniquely powerful position in vaccine confidence promotion, serving as trusted bridges between formal health systems and communities.³⁰ A scoping review covering 25 low- and middle-income countries found that CHWs, who are usually drawn from the communities they serve, contribute to public health surveillance and are among the most effective agents of community engagement, but also face challenges that include insufficient training.³⁰ More broadly, an umbrella review of community engagement for communicable disease control in low- and lower-middle-income countries found that effectiveness depended on the extent of population coverage, shared leadership, and community control over outcomes.³¹ In our view, CHWs’ potential derives from their embeddedness in community social networks, which enables personalized, culturally resonant communication through interpersonal channels that formal campaigns struggle to replicate.

Illustrative evidence comes from a community health club programme among Latina women in the Lower Rio Grande Valley on the Texas–Mexico border, in which CHWs, medical students, and public health experts co-developed a four-session vaccine education curriculum. In a quasi-experimental comparison of 62 participants with a matched control group, program participants had 2.33 times the odds of reporting receipt of at least one COVID-19 vaccine dose, and 97% of participants felt confident in their ability to share learned information with peers, with 90% reporting having shared information with three or more individuals.³² Because the design was non-randomized, the sample small, and vaccination self-reported, these findings are best read as proof of concept for peer diffusion through trusted networks rather than as evidence of population-level effect.

The importance of trusted messengers, including religious leaders, traditional authorities, and community influencers, is supported by experience across diverse cultural contexts.²⁶ In a CDC-funded network of 26 academic Prevention Research Centers, sites recruited trusted messengers with strong community relationships to promote COVID-19 vaccine confidence, and the participating teams concluded that flexible funding and local coordination were essential to create and sustain such partnerships.³³ In Fiji, a Vaccine Champions programme co-designed with the Ministry of Health and UNICEF trained 35 health workers and community influencers; the evaluation found the strongest effects on communication knowledge and self-efficacy, smaller effects on vaccine knowledge and confidence, and improvements in vaccine intentions and trust, while its authors noted that effectiveness evidence for community-based vaccine promotion remains limited.³⁴

School-based health education offers an avenue for reaching children and their parents. A Cochrane review of 67 cluster-randomized trials of the WHO Health Promoting Schools framework, which combines curriculum, school environment, and family or community engagement, found positive effects on outcomes such as body mass index, physical activity, fruit and vegetable intake, tobacco use, and being bullied, although the certainty of evidence was low to moderate and vaccination outcomes were not assessed.³⁵ In low- and middle-income and humanitarian settings, school-based delivery supported by teachers as trusted partners has improved access to vaccination for adolescents, but such programmes need community outreach through CHWs to reach children who are not enrolled in school.²⁶ Whether early, age-appropriate vaccine literacy produces positive attitudes that persist across the life course is plausible but remains to be tested.

Participatory community dialogues can shift immunization discourse from monologue toward shared decision-making. The Vaccinate with Confidence project in New Mexico, a community-academic partnership serving Latino/Hispanic communities, used rapid community assessments of beliefs, barriers, and motivations to co-develop interventions and aimed to move beyond collaboration toward community ownership.³⁶ A comparable community-based participatory process in Washington State followed a Listen, Plan, Act, and Evaluate cycle with urban and semi-rural community organizations.²⁸ These are single partnerships evaluated largely through qualitative and process data; they show how co-design can be done, not that it produces better outcomes than top-down design across settings.

Healthcare provider communication training is a critical but often overlooked component of community-centered vaccine confidence promotion.³⁷ A qualitative study found that 30 ethnic minority healthcare workers in the United Kingdom who completed a digital vaccine education programme reported increased perceived knowledge and confidence and changed vaccine promotion behaviors, highlighting the importance of equipping providers to communicate effectively with diverse communities.³⁷ Given the conditional nature of provider influence described in Why Traditional Immunization Strategies Are No Longer Enough, strengthening communication skills, including empathetic listening, cultural humility, and motivational interviewing, together with organizational support, is a logical investment, although rigorous evidence on its population-level returns remains limited.²⁴

Health literacy is often invoked in discussions of vaccine hesitancy as an individual deficit. We propose instead to treat it as a framework. Nutbeam distinguishes functional health literacy, the basic reading and writing skills needed to act on health information; interactive health literacy, the more advanced cognitive and social skills needed to extract meaning from different forms of communication and apply it; and critical health literacy, the capacity to analyze information critically and use it to exert greater control over one’s circumstances. He also argued that improving health literacy requires more than transmitting information, calling for personal forms of communication and community-based outreach.³⁸ These capacities are distributed unequally across social groups, and their pathways to vaccine attitudes are not uniform. A systematic review associated low education and the influence of social media with COVID-19 vaccine hesitancy,³⁹ yet in a study of 3,360 Slovenian adults, health literacy improved vaccine attitudes both directly and indirectly by reducing belief in vaccine myths, and the effects were stronger among people with healthcare training or higher education.⁴⁰ At the same time, in high-income settings, higher socioeconomic status can coincide with greater hesitancy.¹³

Health literacy therefore helps to explain heterogeneity in vaccine acceptance rather than simply predicting a lower average. Interventions that build functional literacy alone may do little for skeptical but highly educated groups, while generic information campaigns may widen gaps by benefiting those already best equipped to use them.⁴⁰ For vaccine confidence, this points toward critical health literacy, the ability to appraise sources and claims, which connects directly to misinformation appraisal and to the provider communication discussed above, and toward programmes designed explicitly for equity. Health promotion must be understood as an ongoing process of trust-building rather than a reactive, outbreak-driven communication campaign.

Table 1 summarizes evidence-informed community-centered health promotion strategies, their primary targets, mechanisms of action, expected contributions, and the current evidence and key caveats for each.

Table 1.

Community-Centered Health Promotion Strategies for Strengthening Vaccine Confidence

Strategy	Primary Target	Mechanism of Action	Expected Public Health Impact	Current Evidence and Key Caveats
Community health workers	Households	Trusted interpersonal communication and linkage to services	Improved vaccine acceptance and follow-up	Reviews support their engagement role; effect depends on population coverage, training, supervision, and remuneration; sustainability depends on stable funding
Health literacy programs	General population (with an explicit equity focus)	Better understanding of vaccines and reduced misinformation spread through functional, interactive, and critical skills	Reduced hesitancy; informed communities	Benefits may accrue mainly to already advantaged groups unless programmes are designed for equity
Religious and community leaders	Local communities	Social trust and cultural legitimacy	Increased confidence and uptake and negotiated access in insecure areas	Largely descriptive and programme-level evidence; risk of elite capture and exclusion of women and less powerful groups
School-based education	Children and parents	Early vaccine awareness and teachers as trusted partners	Long-term positive attitudes toward immunization (hypothesized)	Health Promoting Schools effects shown for other health outcomes, not vaccination; school-based models miss out-of-school children
Participatory community dialogues	Community members	Shared decision-making and co-ownership of health programs	Greater public trust and engagement	Evidence mainly from single partnerships and qualitative evaluations; risk of tokenism without real power-sharing
Healthcare provider communication training	Health professionals	Improved patient–provider interactions using cultural humility and responses to provider hesitancy	Increased vaccination uptake across populations	Small, mostly self-reported evaluations; effects depend on organizational support and time for consultations

Notes: Strategies and caveats are based on evidence reviewed from peer-reviewed literature and WHO/UNICEF programmatic guidance, as discussed in Community-Centered Health Promotion: Rebuilding Trust in Vaccination and What Community-Centered Approaches Cannot Do: Limits and Conditions. The final column describes the design of the available studies and the main conditions or risks; it does not imply demonstrated population-level effect.

What Community-Centered Approaches Cannot Do: Limits and Conditions

A perspective that presents community-centered promotion as uniformly proven would be neither accurate nor persuasive, and the evidence base is thinner than its prominence suggests. A systematic review conducted for the SAGE Working Group on Vaccine Hesitancy found that only 14% of peer-reviewed and 25% of grey-literature strategies to address hesitancy had been evaluated for their impact on uptake or on knowledge, awareness, or attitudes.⁴¹ A 2026 umbrella review of 39 reviews on community engagement for vaccine delivery in low- and middle-income and humanitarian settings found that engagement was consistently associated with improved uptake, reduced hesitancy, and greater trust, but that definitions of engagement varied widely, the quality of the underlying reviews was mixed, and none of them examined what community engagement could not do.²⁶

Four limitations recur. First, sustainability is fragile. Many community-based programmes depend on short-term external funding, trusted-messenger networks have been described as requiring flexible funding to be sustained,³³ and official development assistance for health has recently declined sharply.⁴² Second, participation is vulnerable to elite capture and persistent hierarchies, and it can become tokenistic, used to secure funding or legitimize decisions already taken; among 102 ministries of health in low- and middle-income countries, only half reported integrating community participation into national maternal and newborn health plans, and only one-third into implementation.⁴³ The umbrella review similarly found that power was rarely analyzed and warned that engagement which works through existing structures risks reaching the most visible or vocal groups rather than the most marginalized.²⁶ Third, cost-effectiveness is uneven and poorly documented: a systematic review of interventions to increase infant vaccination coverage in low- and middle-income countries reported incremental costs ranging from US$0.66 to US$161.95 per additional child vaccinated and concluded that quantitative cost evidence was scarce.⁴⁴ Fourth, community engagement alone may be insufficient to reach zero-dose children if structural determinants such as the availability of health services are not addressed.²⁶

These limitations do not negate the approach; they define the conditions under which it is likely to succeed. The available syntheses point to broad population coverage, shared leadership and real community control over outcomes, multi-component designs that combine engagement with outreach and practical access, and delivery through trusted local figures.^26,31 Conversely, community-centered promotion is least likely to succeed where services are absent, unreliable, or unsafe to reach, because dialogue cannot build trust in a service that people cannot use. Community-centered promotion is therefore necessary but not sufficient: it complements, and cannot replace, investment in the services communities are asked to trust.

Policy Directions for Sustainable Vaccine Confidence

The argument so far implies that the policy agenda must address structural conditions and community trust together. Many of the drivers of low confidence identified in Why Traditional Immunization Strategies Are No Longer Enough, including poverty, conflict, underfunded health systems, historical exploitation, and political interference, are political-economic failures. Reframing them solely as deficits of community trust would risk reproducing, at the community level, the individualizing logic of healthism,¹³ placing the burden of remedy on local actors while systemic determinants recede into the background. The IA2030 recommendations make a similar point: the availability of quality services and adequate financing must go hand in hand with efforts to increase demand, and governance structures and health agencies must be held accountable for inclusive, accessible services.⁸ Health worker density is positively correlated with immunization coverage, yet many governments have not resolved workforce shortages.⁷ Vaccine supply also remains fragile, with 94 countries reporting at least one national stock-out of DTP-containing vaccine between 2015 and 2022.² Community-centered health promotion should therefore be embedded within, not substituted for, structural investment.

Translating community-centered health promotion into durable immunization policy requires deliberate institutional commitment at national and global levels.⁸ The Immunization Agenda 2030 provides a strategic framework for this transformation, explicitly calling for subnational and community-level engagement to ensure local commitment and demand, alongside governance accountability for inclusive and quality services.⁸ National immunization programs must embed health promotion as a core structural component rather than a supplementary activity during crisis periods.⁴⁵

IA2030 positions immunization within primary health care and universal health coverage.⁴⁵ Primary healthcare settings offer continuity of trusted provider relationships, cultural embeddedness, and repeated contact with families across the life course, conditions uniquely favorable for sustained vaccine confidence promotion. Investment in community health worker programs, including adequate remuneration, training, supervision, and career development, is essential for realizing the full potential of CHW-led vaccine confidence initiatives.³⁰

Community participation must be institutionalized within the governance structures of national immunization programs, moving beyond tokenistic consultation toward genuine co-ownership of program design, implementation, and evaluation.²⁸ This participatory governance model aligns with the IA2030’s emphasis on accountability and the need for immunization programs to be responsive to community needs and concerns.⁸ The 2024 World Health Assembly resolution on social participation for health, endorsed by 194 countries, provides a mandate,⁴³ but institutionalization requires explicit safeguards against elite capture: transparent selection of community representatives beyond established leaders, deliberate inclusion of women, displaced people, and less powerful groups, clear metrics to track participation in implementation, and mechanisms through which communities can hold services to account.^26,43

Investing in national health literacy strategies that extend beyond vaccine-specific information is critical for building population-wide resilience to health misinformation.³⁸ Health literacy interventions should be integrated into school curricula, adult education programs, and community health promotion activities, with particular attention to digital health literacy given the central role of social media in contemporary misinformation ecosystems, and should be designed for equity so that they reach those least able to benefit from generic information.⁴⁰ Culturally tailored communication strategies developed with community input and delivered through locally trusted channels including faith institutions, community radio, and peer networks are more effective than generic messaging in reaching hesitant populations.²⁶

Monitoring systems must evolve to track vaccine confidence and trust alongside traditional coverage metrics.⁴⁶ Tools such as the survey instrument developed by the SAGE Working Group,⁵ the Vaccine Confidence Project data used in global analyses,^2,4 and newer instruments that quantify trust in health systems as well as in vaccines⁴⁶ should be routinely integrated into national immunization information systems to provide actionable intelligence on trust trends, enabling early identification and response to emerging hesitancy before it translates into coverage decline. International organizations including WHO, UNICEF, Gavi, and CEPI should dedicate increased technical and financial resources to supporting low-and-middle-income countries in building national vaccine confidence monitoring and health promotion capacities, although recent cuts in development assistance make domestic ownership increasingly important.⁴²

Because country-level economic, governance, and cultural characteristics moderate the determinants of vaccination,¹⁴ none of these directions should be applied as a uniform template; each requires local adaptation informed by formative research with the communities concerned. For conflict-affected and fragile states, adaptation must also confront acute trust deficits and binding structural constraints, which we examine in the next section.

The View from Fragile Settings: Somalia as a Test Case

Fragile and conflict-affected settings are where the arguments above are tested most severely, and Somalia illustrates why. Evidence from Somalia, where approximately 60% of children remain zero-dose and conflict disrupts routine immunization infrastructure, highlights that demand-side barriers including mistrust and misinformation operate alongside supply-side access constraints in humanitarian settings.⁴⁷ District-level zero-dose estimates reach 62% in Lower Juba, and the 2022–2024 drought was associated with more than 70,000 deaths, nearly 40% of them among children younger than five years.⁴⁷ An estimated 1.15 million children remain unvaccinated, half of whom live in areas controlled by non-state armed actors, and only 11% of children have completed the required vaccines.⁴⁸ Barriers include insecurity, checkpoints and blockades that impede humanitarian access, disrupted supply chains, workforce shortages, and a health system divided between federal and state-level ministries.⁴⁷ WHO/UNICEF estimates of national MCV1 coverage rose from 50% in 2000 to 71% in 2024;⁴⁷ the gap between these estimates and the zero-dose figures above itself underlines how difficult coverage is to measure in fragile settings.

In this context, community engagement is not primarily a demand-generation activity; it is part of the delivery infrastructure. WHO’s polio programme reaches children in inaccessible areas through access negotiations with community-level clan elders and relies on a network of village polio volunteers, community-based workers who conduct surveillance and education where outside teams cannot operate.⁴⁹ The Far-Reaching Integrated Delivery project used clan-led access negotiation and mobile health camps offering integrated vaccination, nutrition, and maternal health services across 10 districts of Galmudug and Hirshabelle, and vaccinated 51,168 previously unvaccinated children aged 0–23 months between March and December 2023.⁴⁸ Integrated community engagement strategies that work through existing social structures including community elders, religious leaders, and displaced community networks represent the most feasible pathway to reaching zero-dose children in such contexts.⁴⁷ During the April–May 2025 integrated measles, pneumococcal, and polio campaign, mothers, clan elders, and youth volunteers helped to map households, escort mobile teams, and run feedback sessions, and community-led microplanning with district committees and civil-society groups had earlier been credited with raising adult COVID-19 vaccine coverage from 13% to 42% during 2022.⁴⁷

The Somali experience also exposes the limits identified in What Community-Centered Approaches Cannot Do: Limits and Conditions. These initiatives are documented largely through programme reports and narrative reviews without comparison groups, so they demonstrate feasibility rather than population-level effect.^47,48 They depend on external funding at a time of declining development assistance,⁴² and on the continued cooperation of armed actors and local authorities, which communities cannot guarantee. Working through clan structures is often the only viable route to access, but it carries the risk of elite capture: engagement that runs through established leaders may under-serve women, displaced households, and less powerful groups unless their inclusion is deliberately designed in.^26,43 And where most children have never been reached, trust cannot be built in services that do not arrive. Community engagement can negotiate access and sustain demand, but it cannot substitute for vaccines, cold chain, trained and paid health workers, and security.

Three lessons follow for community-centered promotion where health systems are weakest. First, engagement should be designed as a component of delivery, integrated with services that communities value, such as nutrition and maternal care, rather than as a separate communication activity.⁴⁸ Second, it should be governed by explicit inclusion safeguards, so that negotiating access through local leaders does not reproduce exclusion. Third, it should be evaluated with designs that can distinguish proof of concept from population-level impact, following examples such as the quasi-experimental trial of community engagement combined with conditional, collective, community-based incentives in high-risk union councils in Pakistan.⁵⁰

Future Directions and Conclusion

The evidence presented in this perspective converges on a clear but bounded conclusion: rebuilding vaccine confidence requires substantially more than ensuring vaccine availability or correcting misinformation, and it also requires more than community engagement alone. Sustainable vaccine confidence is built through long-term trust, genuine community participation, empowerment of local actors, and enduring relationships between health systems and the communities they serve, and these relationships depend in turn on services that are funded, staffed, and reliable.⁸ No volume of supply-side investment or communication campaign can substitute for the foundational work of earning and maintaining community trust, just as no amount of community engagement can substitute for services that people can reach and rely on.

Future research must prioritize rigorous evaluation of community-based vaccine confidence interventions across diverse geographic, cultural, and health system contexts, using consistent definitions of community engagement, mixed-methods designs that capture trust as well as coverage, and explicit theories of change.²⁶ Economic evaluations are needed to establish which combinations of approaches offer value for money.⁴⁴ There is a particular need for longitudinal studies that assess the durability of trust-building interventions beyond immediate vaccination events, as well as research that examines the mechanisms through which community health promotion translates into behavioral change.²⁶ Implementation science approaches are needed to identify the contextual factors that enable community-centered models to be adapted and scaled sustainably within different health system architectures, including those affected by conflict.⁵⁰

Validated, standardized tools for measuring vaccine confidence that are sensitive to cross-cultural variation represent another critical research priority.⁵ Existing instruments, such as the survey tool developed by the SAGE Working Group,⁵ and newer tools that quantify trust in health systems as well as in vaccines⁴⁶ should be validated in low-income and fragile settings. Development of culturally adapted confidence measurement tools, co-designed with communities, would substantially improve the ability of national programs to monitor trust trends and evaluate the impact of health promotion interventions.

The political dimensions of vaccine confidence are becoming increasingly consequential and cannot be ignored by public health policy.⁵¹ Political interference in vaccination recommendations as documented in multiple national contexts erodes the institutional credibility of health agencies and creates an information vacuum that anti-vaccine movements rapidly exploit.⁵² Public health agencies must invest in transparent, consistent communication, including candor about uncertainty and trade-offs,⁴² demonstrate accountability through after-action reviews, and build cross-partisan coalitions in support of evidence-based immunization policy.

The routine childhood immunization coverage gaps documented across sub-Saharan Africa, including in the Tamale Metropolis of northern Ghana, where only 35.0% of children aged 12–59 months were fully vaccinated according to the complete national schedule even though crude coverage for vaccines given at 6, 10, and 14 weeks exceeded 70%, underscore the urgency of this agenda.⁵³ In that survey, dropout reached 51.6% for the rotavirus series and missed opportunities for vaccination were common, and the authors called for stronger registries, defaulter tracing, and engagement with healthcare providers.⁵³ Gaps of this kind reflect weaknesses in service continuity as well as in demand, so community-centered promotion must be paired with improvements in service quality. It is therefore best presented not as a proven, universally scalable solution, but as a promising, rights-affirming approach whose effects depend on context and on the strength of the services it accompanies.

In conclusion, this perspective calls on governments, national health authorities, international organizations, and civil society to reposition community-centered health promotion as a core pillar of national and global immunization policy, embedded within, and never a substitute for, investment in health systems, the health workforce, and accountable governance. The challenge of vaccine confidence is ultimately a challenge of trust and trust is built not through mandates or messaging alone, but through sustained, respectful, and empowering engagement with the communities whose lives vaccines protect, and through services that keep their promises to those communities. The case for this investment is strongest precisely where health systems are weakest and the burden of vaccine-preventable disease is greatest.³

Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethics Approval and Consent to Participate

Ethical approval was not required because this Perspective is based on publicly available literature and did not involve human participants.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests.