What is vaccine hesitancy and what factors contribute to vaccine hesitancy?
It may be difficult for clinicians to understand why patients would avoid vaccinating themselves or their children. However, in order to respect a patient’s right to make their own decisions about their health and speak to them about their concerns without making them feel disenfranchised, it is important to extend an empathetic understanding of what factors might be contributing to their hesitancy — and to do so, it is crucial to define what exactly vaccine hesitancy is.
In “The Vaccine-Hesitant Moment,” a paper by Dr. Heidi J. Larson et al. published in the New England Journal of Medicine, the authors define “vaccine hesitancy as a state of indecision and uncertainty that precedes a decision to become (or not become) vaccinated.” They note an overall lack of consensus on the definition of vaccine hesitancy:
“In 2015, Peretti-Watel and colleagues pointed to the ‘ambiguous notion’ of vaccine hesitancy and noted that definitions of vaccine hesitancy ‘tend to be very broad and to embrace heterogeneous people/situations and many different explanatory factors,’ and they proposed that vaccine hesitancy be considered ‘a kind of decision-making process.’”
“Whereas vaccination is an action,” the authors explain, it is important that clinicians understand that vaccine hesitancy is not defined by a single moment but is instead seen as an “attitude or sentiment” that can shift. This can benefit a clinician trying to promote vaccination, as “the period of hesitancy and indecision is a time of vulnerability, as well as opportunity.”
Not all patients have the same reason for being nervous about or avoidant of vaccination, and even for a single patient these reasons can shift, the authors continue:
“The mutable nature of vaccine hesitancy calls for new modes of analysis to characterize not only the temporal features of hesitancy but also the spatial (e.g., regional) features and the many behavioral manifestations and their effects on vaccine uptake. [...] Real-time data [allows] investigation into contextual events that can help us understand the drivers of hesitancy.”
What is the most significant driver of the recent spike in vaccine hesitancy? The answer, as explained by Dr. Larson et al., may not surprise you: the Internet, especially social media sites including YouTube. In an era where patients seek out medical information on their own, they are vulnerable to platforms where anyone can write whatever they please. This creates “a landscape of confusing misinformation and disinformation alongside accurate, scientifically based information” without providing patients with the basic knowledge or ability to discern one from the other. Disinformation easily spreads across borders, with “the hyperconnected digital landscape [offering] a new opportunity for people with shared beliefs to self-organize across geographic regions, influencing and sometimes disrupting public confidence and cooperation.”
In addition to the Internet, the Dr. Larson et al. also cite concerns about side effects (such as debunked claims of the MMR vaccine causing autism), distribution methods (i.e., a fear of needles), and ingredients (including preservatives or adjuvants that boost vaccine effectiveness). Additional “contextual factors” include,
“A wider decline in trust of expertise and authority, and different modes of belief-based extremism. Political polarization, as well as libertarian views and alternative health care advocacy, triggers public questioning about the importance, safety, and effectiveness of vaccines.”
It is important to get an awareness of the reasons behind patient vaccine hesitancy, Dr. Larson et al. suggest:
“Health care providers need to offer support and encouragement and listen to what matters from the patient’s perspective. Equipping physicians with information on the nature and scope of circulating concerns in their communities may help them address such concerns in the clinic, while also informing appropriate interventions at the community level.”
COVID-19’s impact on vaccine hesitancy
In addition to being region-dependent, vaccine hesitancy also shifts depending on the illness being treated as well as public perception of the vaccine and the danger posed by the illness it prevents. This was demonstrated when the first COVID-19 vaccine and subsequent booster vaccines emerged, explained Dr. Larson et al.:
“Sentiments concerning whether to undergo vaccination can change, and change again, as evidenced in multiple surveys showing that Covid-19 vaccine sentiments are influenced by factors such as a new report of vaccine risks or perceptions of increasing or decreasing disease threats.”
A timely understanding of the aforementioned “drivers of hesitancy” can be crucial, the doctors continue, since “vaccine acceptance can be increased, but responsiveness to emerging concerns is key”:
“Timing is everything regarding both the personal moment and the historical moment when it comes to making a decision about vaccination. The uncertainty and constantly evolving nature of the Covid-19 pandemic and response measures, the rapid introduction of new vaccines, emerging variants, and the volatility of the surrounding politics and polarization have all contributed to public questioning and the trends in vaccine hesitancy.”
Patient age, race/ethnicity, and income also make an impact on vaccine hesitancy, as shown in “Willingness to Get a COVID-19 Vaccine and Reasons for Hesitancy Among Medicare Beneficiaries: Results From a National Survey.” In this study, which was performed at the tail end of the first year of the pandemic, Dr. Huabin Luo et al. noted,
“Close to 40% of Medicare beneficiaries [surveyed] were hesitant about getting a COVID-19 vaccine, and the hesitancy was greater in racial/ethnic minorities [and those with lower income levels]. Medicare beneficiaries were concerned about the safety of the vaccine, and some appeared to be misinformed. [...] Among those who were hesitant, more than 40% reported that mistrust of the government and side effects [were] the main reasons.”
What health care providers can do for vaccine-hesitant patients
Clinicians at every level can learn to counter vaccine misinformation. The growing prevalence of vaccine hesitancy has changed how medicine is taught, with programs for medical students now incorporating evidence-based training techniques for addressing the vaccine-hesitant such as role-playing. It is crucial, explained Miriam Frisch et al. in “Addressing COVID-19 Vaccine Hesitancy: The Role of Medical Students,” that this approach is “grounded in knowledge of the science behind vaccines as well as an understanding of historical racial and structural biases that contribute to hesitancy.”
Early training is important because of how impactful the opinions of clinicians can be on patients’ decision-making despite rising levels of vaccine hesitancy, said Dr. Larson et al.:
“Physicians and other health care providers are still among the most trusted persons when it comes to health care advice. The Wellcome Global Monitor surveyed people in 140 countries and found that 73% of the respondents said that they would trust a doctor or a nurse more than others; the percentage was 90% in the higher-income countries.”
Digital analytical tools can act as a means of understanding the localized spread of vaccine hesitancy over time in a clinician’s geographical care area such as in this study of COVID-19 vaccine hesitancy in Missouri. Dr. Larson et al. explained that,
“New methodologies are needed to monitor emerging vaccine concerns over time and place in order to better inform appropriate responses. Mapping vaccine hesitancy at a local level is one important step toward addressing it, along with other needed interventions at the individual and community levels.”
What actionable steps can clinicians take to address vaccine hesitancy without disenfranchising patients? Drs. Jamie Loehr and Margot Savoy have several suggestions in “Strategies for Addressing and Overcoming Vaccine Hesitancy” in American Family Physician, starting with curiosity towards and non-judgmental awareness of the patient’s hesitancy:
“Most patients [...] are not truly resistant to immunization, and parents largely want clarification and reassurance. Some persons will have specific safety concerns, and providing education that addresses these areas can lead them to follow your recommendations. Discuss vaccine safety in a nonjudgmental way by expressing curiosity, seeking first to understand before pressing to be understood.”
Certain clinicians, such as Drs. Shixin Shen and Vinita Dubey in their article “Addressing vaccine hesitancy,” suggest that personal, storytelling-based communication may be effective as it “has commonly been used by the [anti-vaccine] movement, [and may] supplement evidence-based information.” Though some studies conflict with this supposition, they suggest,
“According to a survey [in the U.S.,] the most common communication practices deemed very effective for convincing [skeptical] parents were personal statements by physicians about what they would do for their own children and about their personal experiences with vaccine safety among their patients, [which] improved attitudes toward vaccination [...] especially for individuals who had lower confidence in vaccines.”
Some approaches to managing vaccine hesitancy, such as the three Cs, the CASE approach, and the three As, focus on physician-targeted communication training. However, Drs. Loehr and Savoy cite studies suggesting that these models are “overall of low quality and generally lacking in impact,” namely that “physician-targeted communication training had no detectable effect on vaccine hesitancy.” This doesn’t downplay the importance of boosting communication skills overall, however, as “patients may be less likely to trust physicians who communicate poorly, [so] honing your motivational interviewing skills and practicing active listening does not take away from your ability to talk to patients about vaccine-related decisions.” Specifically, they suggest changing the way you bring up vaccinations:
“Opening the immunization conversation with a presumptive approach rather than a participatory approach (e.g., saying “We have to do some shots,” rather than asking, “What do you want to do about shots?”) can dramatically decrease resistance to vaccine recommendations. In one study, 83% of parents resisted recommendations with a participatory approach vs. only 26% with a presumptive approach, both in vaccine-hesitant parents and in the overall study population. Persistence matters. Nearly one-half of parents who initially resisted following immunization recommendations ultimately accepted them when physicians continued to pursue their recommendations. Conversely, a 2014 systematic review showed that a lack of a health care professional's recommendation was one of the top three reasons children did not get the human papillomavirus vaccine.”
What if, despite following guidelines, listening with compassion, and providing information, patients are still hesitant? Be patient, said Drs. Loehr and Savoy, and remember that vaccine hesitancy is not a single moment in time but rather a decision-making process that may shift:
“A small percentage of patients will refuse one or more vaccines. We encourage preserving your relationship with the patient and tabling the conversation for another day. In the United States, the parent or patient has the right to make medical decisions, and [...] the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend against asking patients or their families to leave your practice if they refuse to immunize. [...] Children need health care beyond immunizations, as well as a medical home. In addition, continuing care allows for an ongoing relationship, which might lead to parents being more willing to vaccinate in the future.”
Continuing Education on Vaccinations and Immunization Guidelines
It’s crucial to stay informed about immunization guidelines for your patients so that you can openly address their concerns. Get up to date with our latest vaccine CME collection to inform yourself on how to approach vaccine hesitancy with patience and compassion.
