Vaccine Update: The Impact of Vaccine Hesitancy and Strategies for Mitigation

Column Author: Christine A. Symes, MSN, APRN, CPNP

Column Editor: Angela L. Myers, MD, MPH | Chief Wellbeing Officer

Vaccine hesitancy (VH) in pediatrics is complicated and requires a comprehensive approach to address it effectively. Hesitancy is a spectrum spanning from worries about one particular vaccine to refusal of all vaccines. A Centers for Disease Control (CDC) National Immunization Survey in 2019 found that 20% of parents in the United States self-reported that they were “hesitant about childhood shots.” Caregivers that refuse vaccines or express hesitancy cite safety as the top concern. Other factors involved include misinformation or lack of information, perceived low risk of disease, distrust in medical and government institutions, religious beliefs, influence of social media, and desire for autonomy. Providers of childhood vaccines should have an understanding of vaccine development and licensure, safety and safety monitoring to discuss concerns with caregivers and adequately answer their questions. There are several resources that provide more detailed information about vaccine schedules, contraindications and precautions, ingredients, and side effects: the CDC’s Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book and Morbidity and Mortality Weekly Report. A helpful online resource is the Vaccine Education Center at The Children’s Hospital of Philadelphia, which can be found at https://www.chop.edu/vaccine-education-center.

The good news is that pediatric health care practitioners are an effective influence on parent’s decision-making around vaccination. They provide vaccine information, are viewed as trusted sources of vaccine safety data, and can positively influence vaccine behaviors.² These conversations can be time-consuming, but it is important to provide the opportunity for an open and honest dialogue, take time to listen, and to welcome concerns and questions. Using strong, clear recommendations that have a presumptive format when recommending vaccines, such as “Billy will get two shots today,” have proven to increase vaccine uptake, even when parents have negative attitudes regarding vaccines.² Using motivational interviewing techniques has also been found to be effective:

• Ask open-ended questions to aid in exploring and understanding a parent’s position on vaccination, such as “Tell me more about what you already know about this vaccine.”
• Use affirmations to improve engagement and provide reinforcement, such as “You are a good mom and care about your son’s health.”
• Provide reflection, such as “You are worried and want to make the best decision.”
• Ask permission to share information, such as “Could I provide you with some information about why this is such an important vaccine?”
• Provide support for autonomy that gives the parent a sense of control over their decisions, such as “Only you can choose what is best for your child.”

The majority of caregivers vaccinate their children according to the recommended schedule. A study of children born in 2017 found that 68.4% of children received early childhood vaccines on the recommended schedule and only 1.3% received no vaccines in the first 24 months of life.³ Conversations about childhood vaccines can start as early as prenatal visits. Providing vaccine information before the initiation of vaccines may allow caregivers to read the information and have clear questions when the time comes to provide vaccines. A recent article in Pediatrics, “Strategies for Improving Vaccine Communication and Uptake,” has specific information to address common myths, advice on how to have vaccine conversations with specific examples, and strategies to improve vaccine uptake. ²

The consequences of VH and refusal increase costs to society, as well as to individual patients. There is a societal cost with the need for public health reporting, interventions, surveillance, communication and labor-intensive targeted vaccine programs. There are also, of course, individual costs that impact the ill child and missed educational learning, but also impact caregivers with loss of work opportunities as they care for an ill child. Payer costs are impacted with a projected cost of $3 to provide care for every $1 not spent on vaccinations.² There are also costs to pediatric medical practices, as they must mitigate risks to other patients when an unvaccinated or undervaccinated child comes to the clinic with a vaccine-preventable disease. These practices face losses due to decreased reimbursement based on value-based care models and the additional time required to counsel caregivers who are vaccine hesitant.

 A multifaceted approach involving effective communication, education, and addressing specific concerns is essential in mitigating VH in pediatrics. Health care providers must be equipped with the necessary tools and strategies to foster trust and promote vaccine acceptance among caregivers. By integrating proven strategies, health care providers can effectively address VH, promote vaccine acceptance, and strive to maintain high immunization rates in pediatric populations.

References:

1. Santibanez TA, Nguyen KH, Greby SM, et al. Parental vaccine hesitancy and childhood influenza vaccination. Pediatrics. 2020;146(6):e2020007609
2. O’Leary ST, Opel DJ, Cataldi JR, et al. Strategies for improving vaccine communication and uptake. Pediatrics. 2024;153(3):e2023065483. doi:10.1542/peds.2023-065483
3. Daley MF, Reifler LM, Shoup JA, et al. Temporal trends in undervaccination: a population-based cohort study. Am J Prev Med. 2021;61(1):64-72. doi:10.1016/j.amepr