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. 2017 Nov 29;14(1):218–224. doi: 10.1080/21645515.2017.1394533

Addressing barriers to vaccine acceptance: an overview

Noni E MacDonald a,✉, Robb Butler b, Eve Dubé c
PMCID: PMC5791591  PMID: 29048975

ABSTRACT

Addressing the drivers of vaccine hesitancy and the barriers to vaccine acceptance is a complex but important task. While the percentage of hesitant does vary from country to country and in time few, if any, countries are ever free from this problem. Overcoming hesitancy requires detection, diagnosis and tailored intervention as there is no simple strategy that can address all of the barriers to vaccine acceptance. Immunization program managers and health care workers need to become adept at recognizing and tackling hesitancy in all of its incarnations if high levels of vaccine acceptance are to be achieved but must also actively support immunization acceptors in order to build and support vaccine acceptance resiliency. This paper presents evidence-informed strategies to achieve these goals.

KEYWORDS: immunization, vaccine hesitancy, vaccine acceptance, vaccine strategies, vaccine communication

Introduction

Immunization is now well recognized globally as a key strategy for improving health outcomes and life expectancy.1 However, despite overwhelming evidence of the value of vaccines in preventing disease, some parents and adults are hesitant to immunize their children and/or themselves.2 The World Health Organization and United Nations Children's Fund Joint Reporting Form (JRF) in 2014 asked all Member States about the impact of vaccine hesitancy in their country. Of the 194 countries who completed the JRF, 74%% reported that vaccine hesitancy was an issue with “concerns related to the risk and benefit of vaccines” the most commonly cited reason in their country.3 However, vaccine hesitancy is well known to be complex with many factors beyond vaccine safety concerns capable of influencing vaccine acceptance.2,4,5

As hesitancy can vary by time, place, vaccine, subgroup and person, it is not surprising that no simple strategy to effectively address hesitancy in all its incarnations has been found.2,5,7 For example, vaccine information campaigns focused on facts have had only limited impact on hesitancy as risk perception and vaccine decision making are often intuitive, made at the unconscious level and more influenced by emotions and beliefs than facts (Fig. 1).5,8,9 Sadly, ideas and beliefs, including anti vaccine sentiments, just like many infectious diseases, can be very contagious.10 Anti-vaccine crusaders can now widely share their beliefs on the web where they can and do impact viewer's vaccine acceptance decisions.11–13 Newer media such Twitter™ and Pinterest™ are also replete with anti-vaccine sentiments and links to anti-vaccine websites and blogs and their impact on vaccine decision making cannot be ignored.14–16 Communication campaigns, even those using new media, that focus on addressing knowledge deficits alone have not been effective in decreasing hesitancy and improving vaccine acceptance and may, in some instances, even exacerbate the problem.7,17,18

Figure 1.

Figure 1.

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Risk Perception and Vaccine Decisions (adapted from Smith JC et al.8).

Despite the litany of failed attempts to decrease hesitancy through fact and myth busting campaigns, there are evidence based strategies that can address hesitancy factors and increase vaccine acceptance.7 While many interventions have been tested to address one or more of the barriers to vaccine acceptance,7 three points must be emphasized. First, vaccine acceptance does not mean hesitancy is not present.4 This is why activation, setting the social environment for nudge towards acceptance, is important.19 Secondly, tailored multipronged strategies are more effective than single interventions across a broad population.7 Thirdly, what must not be lost in the focus on strategies to increase vaccine acceptance, is the importance of respect with empathy for different perspectives on immunization whether the conversation takes place in a public debate, one on one in a clinic, at a private social event or online.20 As “people rarely change their minds because someone called them stupid and wrong”,20 polarizing views by arguing aggressively about factual misconceptions is decidedly unhelpful in addressing hesitancy to improve vaccine acceptance.

This overview provides a simplified mind map for addressing vaccine hesitancy in its many incarnations – detection, diagnosis and tailored intervention – in order to improve vaccine acceptance at the population and individual patient levels

Strategies to address hesitancy

Table 1 provides a list of six evidence-informed strategies that immunization program managers might consider in addressing hesitancy and working to increase vaccine acceptance in their country/region. Another six further strategies are also listed that are helpful at the individual patient level. Immunization program managers and health care professionals must bear in mind that regardless of the intervention(s) or combination of interventions used, the implementation and impact of the interventions must be evaluated. As the determinants of vaccine hesitancy are highly variable, evaluation is crucial to ensure that interventions work as intended and that adjustment and change can then be made to optimize the outcomes and improve acceptance.2 Immunization program managers and front-line health care workers must remember not to neglect the vaccine accepting group in their zeal to address hesitancy. This large group of acceptors, usually the majority of the population, need to have their vaccine decisions valued and reinforced in order to enhance their resiliency in the face of anti-vaccine messages and sentiments. They can be powerful immunization program allies by advocating its importance for their own family and the community, reinforcing or setting the pro-vaccine social norm to nudge for vaccine acceptance.19

Table 1.

Evidence informed strategies for addressing vaccine hesitancy and improving vaccine uptake.

Immunization Program Focus Individual Patient Focus
Detect and address hesitancy in the population/subgroups Ensure health care professionals know their impact on vaccine decision making
Ensure all health care professionals know and use best immunization practices Don't dismiss hesitant or vaccine refuser
Utilize specific evidence based strategies known to increase uptake Use effective parental discussion techniques
Effective communication Use clear language; be aware of effects of framing
Educate children, on the importance immunization for health Reinforce important role community protection
Work collaboratively Address pain at immunization
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Program focused strategies

Detect and address hesitancy in the population/subgroups

The reasons for hesitancy are diverse as noted above, are not uniform across a population and vary by vaccine and time.2,4 The rate and degree of vaccine hesitancy is also not consistent even within a subgroup of the population. Hesitant families often cluster based upon geography, social networks, religion and/or other factors. The Charedi community in North London21 and the anthroposophical community in Ghent, Belgium22 provide two examples where measles outbreaks occurred in higher rates than in geographically neighboring subgroups due to clustering of unimmunized children. At the program level, these low immunization uptake subgroups must be identified and the cause(s) for their hesitancy determined in order that targeted interventions that address the hesitancy inducing factor(s) can be implemented. The World Health Organization Regional Office of Europe (WHO EURO) developed the Guide to Tailoring Immunization Programs to help countries detect subgroups with low immunization, diagnose the hesitancy factors and then intervene with a tailored program that specifically addresses the factors leading to low vaccine acceptance in the subgroup.23,24

Ensure all health care professionals know and use best immunization practices

Health care workers beliefs about immunization are not uniform- some are hesitant.25,26 Their beliefs can influence whether families under their care come forward and accept immunization as health care workers' immunization recommendations are one of key factors that can influence acceptance (see below).27,28 Hence, immunization programs need to work with partners to optimize training of health care students as well as the ongoing continuing education in vaccinology for health care professionals in practice to ensure they have up to date knowledge about vaccines and best practice.27,28 For optimal outcome, patients need to hear the same message about immunization from all health care workers; consistent and accurate information about vaccine preventable disease risks, vaccine safety and benefits, given in a respectful, positive manner. Hearing another health care worker be negative can undermine the positive work of the patient's own health care professional's immunization recommendation.5

Utilize specific evidence based strategies known to increase uptake

There are several evidence based strategies known to increase vaccine acceptance such as engaging community leaders, religious or other influential leaders to promote vaccination in the community.29 Of note, most major religious doctrines in the world support caring for others, preserving life and having a duty to the community (family, neighbours, each other) and support immunization.30 The exception is the Christian Scientists. Working with religious and other influential community leaders can have a profound positive effect on vaccine acceptance within a community, even one that was predominately hesitant before.31

Improving convenience and access to immunization can also lead to improved uptake rates.19 For example, influenza school programs have higher uptake rates when offered in schools than when only offered in private physician's offices and/or in pharmacies.32,33 A 2015 systematic review showed that postal or telephone reminders to parents that their infant/child needed to come for immunization are effective34 as are text message reminders.35

Whether mandatory requirements, financial incentives or sanctions improve uptake is a more complicated area. Mandatory requirements for immunization, often initiated with good intentions, have sometimes backfired and increased anti-vaccine sentiments, have raised ethical issues, may not be acceptable in some countries with high coverage and may also vary in acceptability depending on the vaccine and context.36–38 Nudge strategies maybe a better route than mandatory in some circumstances.39 The value of financial incentives for health care workers in increasing vaccine uptake is also not straightforward. Although it is a common practice in the United Kingdom, a randomized trial in the United States of paediatricians and human papillomavirus vaccine uptake rates in adolescents did not show benefit.40 A systematic review of the effect of financial incentives for parents on increasing preschooler immunization did not show definitive results41 although this is an accepted strategy in Australia.

Effective communication

To be most effective, communication plans need to be proactive not reactive, have a focus on listening not unidirectional provision of information, be tailored to fit the target audience and the problem being addressed and use techniques that appeal to the target audience including new media and stories not just facts where appropriate.17,42,43 Messages must be targeted and tested. If the communication intervention is targeting a group that is already hesitant, myth busting messages may backfire.17 For instance, too much information on cases of adverse events following immunization that have not been curated to determine if due to the vaccine may actually increase hesitancy and a lower intention to accept vaccine.44 However, a tailored multipronged communication program with messages tailored to fit the values and norms of the targeted subgroup can be very effective.45 Social marketing strategies to address vaccine hesitancy needs to be seriously explored46 and message framing also matters (see below).

Communication plans need to include strategies for addressing anti-vaccine misinformation and vocal vaccine deniers in public. An immunization program's silence can inadvertently imply that the immunization program agrees with the anti- vaccine sentiments. Research on shaping public beliefs on climate change evidence has shown that belief increases as scientific consensus is highlighted and false claims and potential counterarguments are focused on pre-emptive action, i.e. inoculating in advance against misinformation.47,48 These are among the principles that underpin the guidance document developed by the WHO EURO to help those who are thrust into the often uncomfortable situation of having to address vocal vaccine deniers in public.49 This guide emphasizes the importance of staying calm, not demeaning the anti-vaccine crusader in the debate, remembering that the target is the audience listening to the debate, inoculating them against misinformation by focusing on the category of the anti-vaccine argument(s) (e.g., vaccine safety, unmasking the tactic being used (e.g., false expert), misrepresentation of evidence etc) and then providing the evidence in a manner that is respectful and appealing.49 Illustrative stories, not just facts, can be compelling.

Educate children on the importance immunization for health

Given the importance of beliefs in shaping vaccine acceptance decision making, helping to shape these beliefs early (i.e., in primary and secondary schools) may be a way forward.46,49 While not as yet widely tested for shaping immunization beliefs, school based programs have proven effective in other areas such as bullying and the environment. Given that older children and youth are high users of social media, they might also be reached using tailored education campaigns outside of school.43,49

Work collaboratively

Beyond working with local religious and community leaders noted above, working collaboratively with healthcare professional societies, academia, global agencies and other who support immunization can save immunization programs time and pools resources as well as adding positive voices to the immunization public conversation. It can also help enhance the credibility of local health worker vaccine messages to patients when they hear the echo from other trusted sources such as health care professional societies.46,50

Individual patient focused strategies

Ensure health care professionals know their impact on vaccine decision making

Regardless of the setting, high, middle or low income country, the attitude and role of healthcare professionals very much influences the parental decision to accept immunization for their child or for themselves.27,51 Healthcare professionals involved in immunization need to know that parents who have received vaccine information from physicians are less likely to have concerns about vaccines than those who received their information from friends, families, books etc.52 and that vaccine information and assurances from a healthcare professional are the main reason why parents who planned to delay or refuse a vaccine for their child changed their minds.53 In high income countries like the United States, health care workers need to be aware that mothers who did not receive influenza immunization during pregnancy are less likely to accept routine immunization for their infants i.e. a warning flag.54 Overall, however, healthcare professionals need to be careful not to overestimate vaccine hesitancy amongst their patients. Parents with strong anti-vaccine sentiment are a tiny minority and the majority of parents are positive towards vaccination – and their positive attitude need to be reinforced.55

Don't dismiss a family or patient from the practice because are hesitant or a vaccine refuser

Dismissing a family from one's practice because of extreme vaccine hesitancy and vaccine refusal may have some appeal but is controversial.56–58 While dealing with parents who are refusers can be frustrating, there are legal implications and ethical issues at the individual and population levels as well as potential negative population health implications of dismissal from care.58 WHO EURO has developed a guidance pamphlet for parents who choose not to immunize that outlines the parent's roles and responsibilities.59 Sharing this document with parents who refuse immunization can provide clarity on the future care implications of the decision and may provide a foot hold for future discussions.

Use effective parent/patient discussion-communication techniques

Not only does what a health care provider say about immunization have an influence but how they say it also matters. A presumptive approach, e.g., “Sarah is due for immunization today”, is more effective than a participatory approach e.g., “What do you want to do about vaccination?”60 This does not mean that concerns should not be discussed but the topics and discussion needs to be tailored to fit the specific parent/patient. When a parent or patient is indeed hesitant, motivational interviewing can be helpful61 (Fig. 2). This technique has been successful in addressing addictions and other complex problems with behaviour components. Asking “what would it take to move you to a yes to accept immunization?” may also open doors in the discussion to areas of concern the health care provider might not be aware of such worries about as pain on immunization -see below. Health care workers in working with hesitant parents need to be aware and alert to potential family conflicts as there are more intra-family disagreements about immunization in hesitant families than in pro immunization families.62 The person who brings the child for immunization may hold a different opinion to the other parent, grandparent or guardian.

Figure 2.

Figure 2.

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Motivational Interviewing (adapted from Leask J et al.60).

Use clear language; be aware of effects of framing

In discussions with parents and patients about vaccine preventable disease risks, vaccine benefits, risks and their concerns, health care workers need to take care with the language used.61,63 Technical jargon can be confusing and leave the wrong impression.61,64 Pictorial examples of numbers and size may help explain risk better than percentages and fractions. When discussing vaccine benefits and risks and the risks of vaccine preventable diseases, telling the truth is an imperative if trust is to be maintained.

How a message is framed also matters whether this is at the individual level or in the media.63,65,66 In general, individuals tend to avoid risks when considering gains and prefer risks when considering losses. For example, a study of a college student program for human papilloma virus vaccine, found that, in general, an emphasis on the loss-framed messages seemed more persuasive e.g., a focus on the costs of not receiving a vaccine rather than on the benefits.65 With respect to vaccine safety, it is more effective to say this vaccine is more than 99.9% safe than that it has less than 0.1% serious side effects. However, overstating (i.e., emphasizing) no risk can lead to higher perception of risk than a weak negation.67 It also matters who is giving the message and how much they are trusted.67

In summing up the discussion with the parent /patient, it is helpful to remember that adults in contrast to young children remember the gist of the conversation not what was said verbatim. The healthcare provider can help the parent/patient with comprehension and recall by emphasizing the bottom line take home message e.g. the reason this is important is …so the important thing to remember is… .68 Always check to ensure that concerns have been addressed but some may need to time to digest and a follow up appointment may be needed.

Reinforce the important of role community protection

Reinforcing the added value of community protection with many vaccines can be helpful but not at the expense of noting the value to the vaccine for the individual patient.69 Explaining community protection can seem daunting but there are a number of videos, both humorous (http://www.huffingtonpost.com/natalia-reagan/the-true-facts-about-vaccines-and-herd-immunity_b_9775386.html) and serious (https://www.ted.com/talks/romina_libster_the_power_of_herd_immunity), that can help parents understand more fully if interested. Anecdotally, some parents are offended by the term herd immunity as they perceive it to imply that their child belongs to a herd like a cow or a goat. Given that herd protection in a technical term (i.e., jargon), community protection or community immunity is often a more acceptable term to use with parents and patients.

Address pain at immunization

Healthcare workers must remember that fear of needles and of pain on immunization is a concern for many parents and children as well as adults.70 Evidence based ways to mitigate pain on immunization were updated in 2015 and now offer options for all age groups and not just for those in high income countries.70,71 Some interventions, such as distraction and proper positioning for example, add no additional cost or time to the procedure. Decreasing pain on immunization can make the experience more acceptable and future immunization less frightening. This is an important area to address as it can contribute to hesitancy.

Conclusions

Addressing the drivers of vaccine hesitancy and the barriers to vaccine acceptance is a complex but important task. While the percentage of hesitant does vary from country to country and in time, few if any countries are ever free from this problem.3 Overcoming hesitancy requires detection, diagnosis and tailored intervention as there is no simple strategy that can address all of the barriers to vaccine acceptance. Immunization program managers and health care workers need to become adept at recognizing and tackling hesitancy in all of its incarnations if high levels of vaccine acceptance are to be achieved. At the same time, they must actively support immunization acceptors; show that their decision is valued and important not only for themselves and their families but also to their community. Building vaccine acceptance resiliency needs to be part of addressing hesitancy.

Abbreviations

JRF

Joint Reporting Form

WHO EURO

World Health Organization Regional Office of Europe

Disclosure of potential conflicts of interest

The authors report no conflict of interest. Noni MacDonald: Dalhousie University, Halifax Canada, consultant to WHO EURO; Robb Butler: WHO EURO; Eve Dubé: Institut National de Santé Publique du Québec.

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