Don’t ask “Why?”: a novel approach to vaccine persuasion

Thousands of pages have been written about vaccine hesitancy, refusal, and skepticism, and their meanings. The primary purpose has been to help health care providers, and the population more generally, understand what is happening when people act against scientific and medical evidence. The goal is to increase vaccine uptake. We propose that when speaking with a patient who is hesitant about or refusing vaccination, health care providers should not immediately ask “Why?”.

Two dominant approaches to vaccine persuasion

In Vaccine Rhetorics, Heidi V. Lawrence rejects the deficit model of responding to vaccine hesitancy or refusal. The deficit model figures people who accept vaccines as informed and responsible, and those who refuse vaccines as misinformed and irresponsible, and in need of education.¹ Lawrence is one of many authors — in disciplines from rhetoric (her own), philosophy (Maya Goldenberg²), history (Nancy Tomes³), and medicine (Scott Ratzan and colleagues⁴) — who argue instead for a model that is sometimes called epistemic pluralism. Epistemic pluralism recognizes different knowledges and, in this case, means meeting people who are skeptical about vaccines where they are, discovering the reasons for their skepticism, and inviting a discussion, without judgment.

Given widespread criticism of the deficit model in favour of epistemic pluralism, we might expect that the deficit model would have fallen out of favour, but it has not. For example, writing in 2024, physicians Peter Marks and Robert Califf “urge the clinical and biomedical community to redouble its efforts to provide accurate plain-language information regarding the individual and collective benefits and risks of vaccination.” ⁵ They write, further, “We believe that the best way to counter the current large volume of vaccine misinformation is to dilute it with large amounts of truthful, accessible scientific evidence.”⁵ Marks and Califf’s approach to increasing vaccine uptake is essentially an affirmation of the deficit model. The authors are responding to what they call a “tipping point” in vaccination, and certainly one has been reached. For example, the World Health Organization reported, in early 2024, “a 79% increase in measles cases around the world [in 2023], reaching more than 300,000.”⁶

Public Health Ontario reports the following figures for measles–mumps–rubella vaccinations, measured in a population of 7-year-olds, for the 2019/20, 2020/21, and 2021/22 school years, respectively: 85.0%, 58.6%, and 52.5%.⁷ The rates have already fallen well below the requirements for herd immunity. The urgent situation regarding the re-entry of measles into the North American disease-scape is currently overshadowing concerns about COVID-19 vaccine uptake, but the problem of undersubscription of COVID-19 vaccines remains as well: As of January 2024, the average number of people in the United States dying weekly from COVID-19 was more than 1700, with the US Centers for Disease Control and Prevention reporting that only 21.8% of adults (aged ≥ 18 yr) had received the latest COVID-19 shot. Now that vaccines aimed at currently circulating variants of SARS-CoV-2 are available, COVID-19 vaccine uptake is again a focus of attention in public health.

Writing recently about COVID-19 vaccine hesitancy and refusal, physician Danielle Ofri proffers a revised version of the epistemic-pluralism approach to vaccine persuasion. Patients, she says, have emotional reasons for rejecting vaccines, and these are the reasons health care providers must explore. Ofri’s expansion of epistemic pluralism to include affective knowledge requires, she says, that “health care providers wad[e] into awkward conversations that are less about facts and more about emotions.”⁸ Ofri continues, “So I clear my desk, push myself away from the computer, make full eye contact [and] start with ‘Tell me what’s on your mind’ or ‘What makes you feel differently about the COVID vaccine versus the flu shot?’ … I’ll always respect their choice to disagree with my recommendations, but I do want to understand why” [our italics].⁸ Yet when “emotional reasons” are added to the epistemic-pluralism model, the model is not improved, and may, in fact — given appointment-time constraints — be clinically untenable.

A third approach to vaccine persuasion

In the matter of increasing vaccine uptake, rather than thinking in terms of a deficit model or an epistemic-pluralism model, a more apt distinction may be the more subtle one between information (often decontextualized) and good reasons (contextualized in a person’s life). Marks and Califf suggest that health care providers offer scientific evidence of vaccine efficacy;⁵ we suggest that they instead provide targeted counsel grounded in that evidence. The signal problem for physicians engaging with patients who are hesitant is not that those patients have refutable arguments against vaccination, emotional or otherwise; it is that they often do not. Ofri herself writes, “It’s as though they have a communal case of the heebie-jeebies.”⁸ The “heebie-jeebies” idea makes sense to us, but we think Ofri picks up the wrong end of the stick. If health care providers work to dig down to the source of a patient’s “heebie-jeebies,” they might find that patient unable or unwilling to be entirely forthcoming.

Ofri’s notion of communal “heebiejeebies” suggests why patients, as they attempt to articulate an antivaccination position, may find themselves struggling to come up with an answer to the “Why?” question that truthfully explains their skepticism, even to themselves. Much has been written about social contagion and the relation of social media and personal belief.⁹ The problem of vaccine skepticism hints at a related idea: within the universe of social media, people often cannot explain how they came to believe what they believe. Of course, many people have entirely reasonable explanations for their vaccine skepticism — especially when they have had little cause for confidence in the institutions of government and medicine.¹⁰ Still, we argue that asking, in the first instance, why a person is rejecting vaccination often risks opening a conversation that is more time consuming than it is productive.

A health professional might, therefore, induce vaccine acceptance by sidestepping the “Why?” question and instead proceeding to offer the reasons they believe a vaccine is the best thing that person can do for their health and the health of their family. Good reasons cash out in advice — and advice is most often what people want from their health care provider. It is why, whatever their complaint, they have visited an expert in the first place. For example, in their research on provider–parent vaccine discussions, Opel and colleagues found that parents who were vaccine hesitant were more likely to proceed to vaccination when providers approached the topic with “presumptive (e.g., ‘Well, we have to do some shots’) rather than participatory (e.g., ‘What do you want to do about shots?’) utterances.”¹¹

Because most people, in any case, do not see their health care provider expressly to discuss vaccines, the provider–patient encounter might routinely — and persuasively — go like this: A person consults a physician with a complaint about back pain or persistent indigestion. The physician asks, as a matter of course, “Are you (and your kids) up to date with all your vaccines?”. If the patient’s answer to that question is “No,” the health care provider’s next move in the conversation might be not to ask “Why?”, but rather to say, “Okay. But here’s why I am strongly recommending that you (and they) get vaccinated.”

As the history of rhetoric from ancient times to the present has shown, good reasons — especially good reasons offered by a trusted speaker and tailored to a particular audience — can move the needle on human action. And good reasons for vaccination, in the case of any parent or patient, are readily available: One person with measles can infect as many as 90% of the nonimmune people in their range. If your child gets measles, they run a 5% risk of very serious illness and pose a danger to those close to them. Or, 15% of people who contract COVID-19 suffer from post-COVID-19 condition (long COVID) — and in your case, given your job, that could result in weeks or months of lost pay. So, yes, information is shared, but it is information whose purpose is not to counter objections to the vaccine, but to address the lived experience of the person objecting.

People who are skeptical about vaccines are not always waiting to be filled with information better than the information they have. Nor are they always people who can provide accurate and refutable explanations for their skepticism. Health care providers might, then, proceed directly to their own first obligation — which is not to defend science but to safeguard the health of patients.