Vaccine Opposition and Hesitancy

17CHAPTER 3

APPROACH TO THE PATIENT

An ideal vaccine-hesitancy intervention would result in full compliance with vaccination, the patient’s satisfaction with the health

care encounter, and sustained trust in the HCP’s recommendations. On a programmatic level, vaccine-hesitancy interventions

should be multicomponent, dialogue based, and tailored to specific

under-vaccinated populations.

Communicating with vaccine-hesitant individuals can be challenging and time-consuming. HCPs may feel that vaccine-hesitant

patients cast doubt on their personal and professional integrity,

their authority as medical experts, and their competence as communicators. Some HCPs may be reluctant to initiate conversations

about vaccination because of concerns that discussing a sensitive

topic may compromise their clinical rapport with their patients.

Other HCPs may believe that they have not received sufficient

training to confidently recommend vaccines and answer questions.

Discussing vaccines with hesitant patients, while not always easy,

provides an opportunity to honor the principles of patient-centered

care by demonstrating an interest in patients’ opinions, engaging

in dialogue, and ideally increasing patients’ confidence in vaccine

recommendations.

FACTORS IN EFFECTIVE VACCINE RECOMMENDATIONS

Vaccine recommendations ideally should be made within an established, trusting patient–provider relationship in which patients are

comfortable asking questions and voicing concerns, even if their

views on vaccines contradict the HCP’s recommendations. Recommending vaccines requires both provision of information and

effective communication. There is no single “best practice” for

how providers should approach recommending vaccines to vaccinehesitant individuals. In general, all vaccine recommendations

should be (1) strong, making it clear that the provider supports and

recommends vaccination; (2) tailored, acknowledging the vaccine

attitudes and potential concerns of individual patients; (3) transparent and accurate, highlighting the benefits of vaccines while also

communicating the risks; (4) supported by trustworthy information resources that patients can access and review after the clinical

encounter; and (5) revisited, with repetition and reinforcement

during follow-up health care encounters.

Strength of the Recommendation HCPs should make it explicit

(in the absence of medical contraindications) that vaccination

based on the recommended schedule is the best option. While

HCPs should take time to elicit patients’ questions and address

concerns, the recommendation for vaccination should be made in

clear and unambiguous terms.

Tailored Communication Vaccine hesitancy occurs on a continuum (Fig. 3-1). Therefore, it is helpful for HCPs to have some understanding of their patients’ attitudes toward vaccination at the start of

the health care appointment. Unfortunately, vaccine-hesitancy surveys for use as part of vaccine consultation visits have not been validated on a large scale. However, the following are some examples

of questions that can be asked, depending on the setting. (1) Did

you have a chance to review the vaccine leaflet we provided? Did

you have any questions about it? (2) Have you ever been reluctant

or hesitant about getting a vaccination for yourself or your child? If

so, what were the reasons? (3) Are there other pressures in your life

that prevent you from getting yourself or your child immunized on

time? (4) Whom/what resources do you trust the most for information about vaccines? Whom/what resources do you trust the least?

Communication style and content for patients in the activedemand category for vaccination will be different from those for

individuals who are hesitant, late and selective, or strongly inclined

to refuse vaccines. Two communication styles have been proposed

for vaccine recommendations. Evidence shows that a presumptive/

directive approach (“Your child is due for MMR vaccination.”)

results in higher rates of vaccine uptake than a participatory/guiding

approach (“What are your thoughts about the MMR vaccine?”).

However, adopting a strictly presumptive/directive approach may

alienate some patients, especially those who are higher up on the

hesitancy pyramid and who may feel that they are being pressured into vaccination before their concerns have been heard

and addressed. Adopting a participatory/guiding approach and

clarifying receptivity to vaccines may be more suitable for hesitant

individuals with many doubts and concerns, persons with a late

or selective attitude, and those who are strongly inclined to refuse

vaccines. In addition, a participatory/guiding approach provides

an opportunity for ongoing clinical rapport and dialogue between

unvaccinated or under-vaccinated patients and their HCPs, even

when it does not result in immediate vaccine uptake. Regardless of

which approach is used, a strong vaccine recommendation should

be made at each encounter.

Transparency and Accuracy Vaccine recommendations should

be transparent, should include accurate information about both

the benefits and the risks of the vaccine, and should emphasize

why the benefits outweigh the risks. For example, when evidence

supports an association between a vaccine and an adverse event,

the occurrence of the adverse event is often very rare and the event

quickly resolves (Chap. 123). U.S. Federal law (under the National

Childhood Vaccine Injury Act) requires HCPs to provide a copy of

the current Vaccine Information Statement from the Centers for

Disease Control and Prevention (CDC), which describes both benefits and risks of vaccines to an adult patient or to a child’s parent/

legal representative before vaccination.

CDC Vaccine Information Statements should not replace a discussion with the HCP. Depending on the provider and the patient,

a description of benefits and risks may include words and numbers,

graphics, and personal anecdotes (e.g., why the provider vaccinates

his or her own children). Personal anecdotes are powerful, and

many hesitant patients seek and are influenced by them.

A discussion of benefits and risks provides an opportunity to

address specific misconceptions about a particular vaccine or about

vaccines overall. For example, patients may be concerned about

adverse events following vaccination that are not supported by evidence, such as autism following MMR vaccination or myocardial

infarction following influenza vaccination in the elderly.

Most adults—even those whose children are fully immunized—

still have questions, misconceptions, or concerns about vaccines

that should be addressed. A risk/benefit discussion allows HCPs

to describe the vaccine safety monitoring systems in place. Providers should emphasize that vaccines are developed and approved

through a highly regulated process that includes prelicensure clinical trials, review and approval by designated regulatory authorities

(e.g., the U.S. Food and Drug Administration, Health Canada),

strict manufacturing regulations, and ongoing postmarketing safety

surveillance.

Support from Accessible Information Sources All vaccine recommendations should be supported by additional information sources

patients can assess after the health care encounter. HCPs play an

important role as information intermediaries for their patients.

They can navigate information (and misinformation) about vaccines and direct patients toward reliable, appropriate resources.

HCPs should consider what resources will be suitable for a patient

or patient population. Vaccine information resources are available

in different media formats and use a combination of images and

text to communicate the information to various audiences. See

“Further Reading,” below, for suggestions or refer to resources provided by local health authorities.

Revisiting and Reinforcement of Vaccine Recommendations All

health care encounters offer an opportunity to revisit and reinforce

vaccine recommendations. Vaccine-hesitant individuals who do

not accept vaccines but are willing to review information should

be offered a follow-up appointment to reinforce previously made

recommendations and address further questions. Vaccine-hesitant

18PART 1 The Profession of Medicine

TABLE 3-2 Sample Vaccine Conversations

STRONG VACCINE RECOMMENDATION

“We are headed into the flu season. Getting flu vaccine not only protects you, but it helps protect other people around you who can get very sick from flu. I strongly

recommend you get your flu shot. Do you know where to get it?”

“You will be turning 50 next year. This means you will be eligible for a vaccine that prevents shingles, and I strongly recommend you receive it. Have you heard about

this vaccine before? Can I answer your questions about it?”

“I know you are not comfortable getting vaccinated today. I do want to make it clear that I recommend vaccines because I am convinced they are the best way to

protect you from some serious diseases. Is there something that would lead you to think about getting vaccinated in the future?”

TAILORED COMMUNICATION

“I recommend that children and adults stay up to date on recommended vaccines. I see from your vaccine record that you’ve had your childhood vaccines, but

you haven’t gotten any adult vaccines. I wanted to clarify whether this is because you decided not to get vaccines or something else prevented you from getting

vaccinated.”

“I understand that you are here for your pneumococcal vaccine. This is the best way to protect yourself and those around you from pneumonia. Do you have any

questions before I give you the vaccine?”

“I understand you have some concerns about vaccines. What are you most concerned about? Would you like me to explain why I recommend giving your child these

vaccines?”

TRANSPARENCY AND ACCURACY

“Serious side effects can develop after MMR vaccination but are very rare. On average, 3 out of 10,000 children who get MMR vaccine will have a febrile seizure/

convulsion in the days after vaccination. Febrile seizures can be frightening, but nearly all children who have a febrile seizure recover very quickly and without any

long-term consequences. On the other hand, 1 out of 1000 children who get measles will develop encephalitis (brain inflammation) that not only causes seizures but can

also lead to permanent damage.”

“About 10 out of every 10,000 Americans who do not get vaccinated against flu die because of influenza every year, and many more are hospitalized. While flu vaccine

does not prevent all cases of influenza, it is the most effective vaccine we have. By getting the vaccine, you also help protect people around you from getting sick.”

“You are correct, aluminum is used in some vaccines to help the body’s immune system respond. However, aluminum is also present in food and drinking water. In fact,

the amount of aluminum present in vaccines is similar to or less than what is present in breast milk or infant formulas.”

SUPPORT FROM ACCESSIBLE INFORMATION SOURCES

“Your child and other boys and girls his age will be eligible for the human papillomavirus vaccine this coming school year. Have you heard about this vaccine before?

What questions do you have about it? Here’s a list of websites for parents and teenagers that explain what it is about.”

“There’s a lot of information about vaccines on the internet, and a lot of that information is not based on facts. Here is a list of websites that have been reviewed by

health care professionals and accurately describe benefits and risks of each vaccine. The information is written in lay language and includes helpful illustrations.”

REVISITING AND REINFORCEMENT OF THE RECOMMENDATION

“During our last visit, we talked about MMR vaccine for your son and some of the concerns you had about potential side effects. Have you had a chance to look at the

take-home information I gave you? Was there anything else you would like to ask about? I recommend that we vaccinate your child today.”

“During our last visit, we talked about receiving a pertussis booster during pregnancy and where you can get vaccinated. Have you had a chance to get your pertussis

vaccine?”

 “I see that you got your vaccines at the public health clinic last week. How did it go? Did you have any questions?”

“It’s possible that the symptoms you experienced after receiving the vaccine were an adverse reaction to the vaccine. I will report this to the health authority. Let’s

discuss what we can do next time to prevent symptoms from occurring again.”

Note: Specific vaccine recommendations, vaccine eligibility guidelines, and statistics used to communicate benefits and risks will vary with the health jurisdiction

and the country. Several sample statements here are adapted from the Australian National Centre for Immunisation Research and Surveillance website (www.

talkingaboutimmunisation.org.au). For patient vaccine information resources, see also the Immunization Action Coalition website for the public developed in partnership

with the CDC (vaccineinformation.org).

patients who accept vaccines should be seen at a follow-up appointment to confirm and document vaccine receipt (if vaccine is not

given at the point of care), ascertain whether the vaccine was

well tolerated, and reinforce the message about vaccine safety and

effectiveness. Patients who actively demand vaccines usually do

not require much follow-up other than to confirm and document

the receipt of vaccine (if it is not given at the point of care) and to

address additional questions or concerns arising subsequent to vaccination. Often this follow-up can be covered without an office visit.

WHAT TO SAY TO VACCINE-HESITANT PATIENTS

Engaging vaccine-hesitant individuals requires confidence, knowledge, skills, time, and creativity to tailor the approach to each

individual patient. Examples for each part of the vaccine recommendation are listed in Table 3-2.

■ OTHER CONSIDERATIONS DURING CLINICAL

ENCOUNTERS

Missed Opportunities The World Health Organization defines

a missed opportunity for vaccination as “any contact with health

services by an individual (child or person of any age) who is eligible

for vaccination (e.g., unvaccinated or partially vaccinated and free of

contraindications to vaccination), which does not result in the person

receiving one or more of the vaccine doses for which he or she is eligible.”

HCPs who do not offer point-of-care vaccination frequently miss the

opportunity to recommend vaccines to their patients. Missed opportunities for recommending and providing vaccines during routine health

care encounters contribute to under-vaccination. Studies show that up

to 45% of under-vaccinated children could be up to date with all ageappropriate vaccines and up to 90% of female adolescents could be up

to date with human papillomavirus (HPV) vaccination if all opportunities to vaccinate were taken.

Vaccine counseling and vaccination should be incorporated into

clinical care for individuals of all ages, not just young children. Because

many adolescents and adults do not have regular health care follow-up,

providers need to take advantage of every health care encounter to

recommend and provide vaccines. For example, a visit to an emergency

department, a routine follow-up visit at a diabetes clinic, or a visit

planning for elective orthopedic surgery offer opportunities to inquire

about the patient’s vaccination status and to recommend vaccines.

HCPs should make preemptive vaccine recommendations (e.g., initiating discussions about infant vaccines during pregnancy, informing parents about HPV vaccine before their child becomes eligible).

Such advance discussions may be especially helpful in identifying