Addressing Vaccine Hesitancy

INTRODUCTION

As vaccines against the severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) become available, vaccine hesitancy may become a critical public health issue. The Permanente Journal published a case report by Garofalo et al¹ reporting on naturopathic counseling of a family toward appropriate vaccinations for their children through vaccine education. Their case illustration is important for several reasons, but perhaps most importantly it counters a prevalent belief that naturopathic physicians and other complementary and integrative health (CIH) practitioners are “anti-vaccination”.² All accredited naturopathic colleges and universities educate medical students on prevention of vaccine-preventable diseases and the current vaccination schedule recommended by the Centers for Disease Control and Prevention.

VACCINE HESITANCY

Five key predictors of vaccine hesitancy have been identified in recent meta-analyses, including: risk conceptualization; mistrust toward pharmaceutical companies and health care providers; alternative health beliefs about immunity, vaccine scheduling, and risks of vaccinations; varying views on parental responsibility; and parental knowledge.³ All these factors could, at least in part, potentially be modified by a trusting doctor-patient relationship, including patient-centered counseling that allows for assessment of patient knowledge and health beliefs. This counseling should be supported by adequate time spent in respectful and culturally sensitive health education activities. In fact, similar interventions have been recommended in expert reviews focused on increasing vaccine uptake, including a specific recommendation for communication to “focus on listening and not unidirectional provision of information”.⁴ Importantly, CIH practitioners commonly emphasize principles of patient-centered care, including patient preferences in care and patient-centered communication strategies, including motivational interviewing, in their interactions with patients.

Patient preferences in care were also considered in the pertussis case report by Garofalo et al,¹ a concept considered controversial in the context of vaccination,⁵ in which the option of choice is highly discouraged by numerous authorities. Conventional medical doctors, of course, rightly emphasize patient preferences and shared decision making in their clinical encounters as well. Suspending these considerations in the setting of the vaccination discussion, however, can have negative consequences. Clinical situations in which the choices are the most controversial are precisely those situations in which provider-patient trust becomes critical in the doctor-patient encounter. Developing a trusting relationship has the potential to affect choices in care over time. For example, a decision not to vaccinate today may become a decision to vaccinate in the future if patients feel their beliefs and preferences are respected. Likewise, discharging or otherwise refusing care for patients who refuse to vaccinate has the potential to backfire, by perpetuating distrust and fueling antimedical establishment ideologies. A focus on a vaccination-only strategy may also preclude effective delivery of other evidence-based preventive services, such as US Preventive Services Task Force recommendations for behavioral counseling to reduce sexually transmitted infections, including hepatitis B and human papillomavirus.⁶ Informed consent and patient autonomy (not to mention beneficence and nonmaleficence) are cornerstones in medical ethics; ultimately vaccination decisions should be no exception to their mandated inclusion and accuracy, although the best approach to balance societal benefit and individual choice remains unknown and controversial.^7,8

As pointed out by Garofalo et al,¹ findings of several observational studies suggest that undervaccinated children are more likely to receive care by naturopathic doctors (NDs).^9,10 One possible explanation for this finding may be that some NDs do not adhere to or promote recommended vaccine schedules. On the other hand, it may also be the case, as illustrated by Garofalo and colleagues,¹ that NDs are respecting patient preferences for care, facilitating the provision of continued care independently of individual choices and providing sources of other recommended preventive services as strategies to develop trust and establish long-term relationships with those families. In that way, vaccination decisions can be revisited if the knowledge or risk of those families changes. Of course, the actual clinical recommendations delivered in such encounters cannot be determined observationally without access to detailed health records data. Likewise, limited, claims-based observational studies cannot alone inform which pattern of care is more dominant among NDs. Pending further research, uninformed assumptions may lead to erroneous conclusions and suboptimal patient care.

In managing vaccine hesitancy, we recommend applying basic tenets of patient-centered care, which are specifically included in the philosophy of naturopathic medicine: find and address the cause (of vaccine hesitancy), treat the whole person (respecting his/her current knowledge and beliefs), and serve as a teacher (by providing accurate information).

CONCLUSION

Rather than criticize NDs and other CIH practitioners as being antivaccination, the provision of a referral of a vaccine-hesitant patient to such clinicians for vaccine education may provide an important gesture of respect and support to the patient. Coordinated interprovider communication has the potential to influence patients’ vaccine-related choices toward prevention—a goal we all share. This issue may become particularly important as vaccines for SARS-CoV-2 become available.