Vaccine hesitancy in the office: what can I do?

Clinical question

What office-based interventions in primary care help reduce vaccine hesitancy?

Bottom line

Clinicians should explicitly recommend vaccination and focus discussion on the disease-prevention benefits to the individual more than correcting misinformation or on the benefits to society. Interventions are more likely to be effective in those with neutral attitudes toward vaccination than in those opposed.

Evidence

Presented evidence focuses on RCTs of interventions that can be implemented in primary care.

• In one study, 315 participants online were given information on measles, mumps, and rubella (MMR) risk; information correcting a vaccine-autism link; or control. The baseline vaccine attitude score was 4.84 (6-point scale, higher more likely to vaccinate).¹

  • - Improvement in vaccine attitude score was 0.25 for MMR risk information (statistically different), 0.08 for autism risk information (not statistically different), and 0.05 for the control group.

  • - Re-analysis² showed biggest change was among participants with “neutral” baseline vaccine attitude scores.

• In another study, 1759 participants online were randomized to 1 of 4 provaccination messages (correcting misinformation [ie, autism risk], MMR illness education, visual images of MMR, a sick child story) or control.³

  • - No intervention improved intent to vaccinate.

  • - In those with the least favourable vaccine attitudes, correction of misinformation decreased intent to vaccinate from 70% (control) to 45%.

• Another study randomized 802 participants online to receive an information statement on MMR (control), the statement plus information on benefits to the child, the statement plus information on societal benefits, or all 3.⁴

  • - Likelihood of vaccinating the child with MMR vaccine (on a 100-point scale) was 86.3 (control), 91.6 (benefits to child), 86.4 (benefits to society), and 90.8 (benefits to child and society).

  • - Only statements including benefits to the child were statistically different from control.

• Limitations: studies looked at proxy measures (eg, intention to vaccinate), not vaccine uptake; no study was completed in a primary care office with a trusted health care provider; and no RCTs involved COVID-19 vaccines.

Context

• Hesitancy is a spectrum, not a binary “pro” or “anti.”⁵

• “Strong” physician recommendations are associated with higher likelihood of vaccination.^6,7

• Discussion about vaccination ideally begins during pregnancy and continues in the neonatal period.⁸

• A presumptive approach (eg, “Jane is due for her vaccines today”) is recommended over a participatory approach (eg, “Are we going to do Jane’s vaccines today?”).⁹

Implementation

As of 2017, 2.35% of Canadian children were completely unvaccinated,¹⁰ but concerns about vaccination are common and heterogeneous.¹¹ Physicians are considered the most reliable source of information on vaccination by two-thirds of Canadians.¹² In general, a motivational interview approach is recommended that identifies an individual’s specific concerns, provides empathetic and nonjudgmental reassurance, and focuses on benefits of vaccination to the individual. If vaccination is declined, remain respectful and nonjudgmental, and revisit the issue at future visits.^4,6