Addressing vaccine hesitancy in immunization programs, clinics and practices

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Immunization is well recognized as a key public health intervention for improving health outcomes world-wide^[1]. Sadly, Canada does not rank well compared with other developed countries in achieving optimal acceptance of vaccines among children and youth^[2]. Increasing vaccine hesitancy, defined as delays in accepting or refusing vaccines despite the availability of vaccination services, is a problem undermining uptake rates^[3]. This practice point offers evidence-based guidance at the provincial/territorial level for immunization programs, clinics and office practices, on how best to address hesitancy and improve vaccine uptake rates. Companion documents to this practice point include two for clinicians, entitled ‘Working with vaccine hesitant parents: An update ^[4] and ‘Canada’s eight-component vaccine safety system: A primer for health care workers’^[5]

1.  Detecting and addressing vaccine-hesitant subgroups

The reasons underlying vaccine hesitancy are multiple, variable and not necessarily confined to particular groups or communities^[1][3]. Even within a given province or territory, vaccine hesitancy is not uniform but tends to occur in clusters or pockets (e.g., in a religious community or group focused on natural or non-traditional medical practices). Immunization rates can also vary among population groups based on many factors, including geography, culture,  and ethnicity. Lower vaccine coverage has been noted among children living in remote areas ^[6] and from some racialized backgrounds^[7]. For example, vaccination rates are lower among Black families and higher among Chinese or Filipino families compared with non-racialized families in Canada. No significant difference in rates has been identified between Indigenous and non-Indigenous children at 2 years of age^[7]. 

In some racialized and Indigenous communities, lack of trust in the health care system contributes to vaccine hesitancy ^[8][9]. Determining what factors underlie hesitancy in a particular locale and how best to intervene are critical steps toward improving uptake.

For provinces and territories, a resource developed by the WHO, entitled Tailoring immunization programmes to reach underserved groups – the TIP approach’, could be particularly helpful. While guidance would need to be adapted to fit Canadian contexts, its application to different European subgroups has improved vaccine uptake significantly ^[10][11]. The first key program step is to detect under-immunized subgroups in Canada. Identifying such targets is best served by having searchable provincial/territorial electronic immunization databases ^[12]. In a clinic or office practice, under-immunized patient files can be flagged when electronic medical records are kept, along with any common underlying factors identified by health care providers (HCPs). A survey tool developed in the United States to identify vaccine-hesitant parents ^[13] could also be adapted for Canadian contexts and used at the clinic level.

2. Educating all health care providers involved with immunization on best practices

Studies from many different countries have repeatedly shown that HCP beliefs around immunization have a strong influence on patient vaccine acceptance ^[14]-[16]. The more confident HCPs are about vaccine safety and efficacy, the more parents connected with them share these beliefs. Additionally, when  HCPs are trusted, counselling regarding the necessity of vaccines is more likely to be believed. Mistrust of HCPs impacted COVID-19-related vaccine intentions largely by increasing vaccine concerns ^[17].  An HCP’s own immunization status tends to find reflection in their patients’ vaccine records. Not only do the perceptions and beliefs of HCPs have an impact on parental decision-making around immunization, but their attitudes and behaviours when working with families can also influence whether they will come forward with concerns or accept immunization ^[18]. Studies following the COVID-19 pandemic have examined the consequences of divergent COVID-19 vaccination positions on health care teams, patients, and families, further emphasizing how such variances can erode trust ^[19].

For optimal outcome, parents need to receive consistent and accurate information about vaccine safety and benefits from all their HCPs, and this information must be conveyed in a respectful, positive manner. It is essential that an HCP’s personal position on a particular vaccine not influence their presentation of the vaccine’s science, efficacy, and safety information to families ^[5][20]. To ensure continuity, immunization programs, clinics and office practices must keep all associated health care providers up-to-date with their immunization status and train them to relay information accurately and positively, especially because studies have shown that some HCPs are vaccine-hesitant themselves ^[21]. All  HCPs need to be well educated on immunization benefits and safety issues, with  those who are directly involved in delivery being additionally conversant regarding: best practices; the specific and serious risks of vaccine-preventable diseases; possible vaccine side effects; Canada’s adverse event surveillance systems; the importance of clear language, ‘framing’ (i.e., presumptive versus participatory approaches) and motivational interviewing techniques; and pain mitigation strategies ^{[4][5][22]-[24]}. Given the many pressures on health care providers to stay up-to-date in different areas of practice, immunization updates should be short, attractive and easily accessible.

3. Utilizing evidence-based strategies known to increase vaccine uptake

A review of strategies known to increase vaccine uptake include:

• Targeting under-immunized subgroups with tailored interventions ^[1][25][26].
• Making vaccine services more convenient and accessible (e.g., clinic hours and locales that better meet patient needs). Delivering the seasonal influenza and COVID vaccines through pharmacies has increased access in a number of jurisdictions^[27].
• Engaging community leaders, including (in specific circumstances) religious leaders, in communities with significant rates of vaccine hesitancy, to promote vaccination ^[1].
• Reminding patients by text, email or regular mail, as appropriate. Such prompts need to be built into office practice wherever routine immunizations are delivered predominately by physicians, and into public health clinics, where public health nurses give vaccines ^[28].
• Ensuring uniformity of information across Canada, especially regarding vaccine benefits and risks, would be helpful ^[29]. Contradictory information from different jurisdictions can be confusing for parents and health care providers.
• Promoting and using strategies to minimize immunization pain ^[24].
• Consider mandates and/or incentives for immunization. They have been used in different jurisdictions in Canada and elsewhere but their value and effectiveness are not always clear ^[30], especially in communities where trust in HCPs has been historically betrayed. 
• Building trust between the immunization program and the community is foundational and can help mitigate community vaccine confidence crises ^[31]. Inclusion of a healthcare team member who is a visible minority, where possible, may further help to promote trust.

4. Educating children, youth and adults on the importance of immunization for health

Knowledge-building around immunization is a recognized factor in increasing vaccine uptake ^[25],^[26], but knowledge alone is not enough. Shaping positive beliefs about immunization, among individuals and within the community, is an important contributor to uptake. Targeting hearts and minds and emphasizing vaccine acceptance as the social norm can help but more may be needed ^[32]. Effective communication campaigns are possible even for ‘hard to reach’ groups, as has been demonstrated in Australia ^[33]. In developing a campaign it is important to remember that the same message can be heard very differently by different population subgroups ^[34]. A key element in any campaign is to evaluate its impact and then readjust as needed ^[31]. Messaging and tools should be pre-tested to ensure they are efficacious and likely to reduce hesitancy in the target group. Sharing ‘lessons learned’ and proven-effective tools and resources across jurisdictions can optimize use of time and monies. Resource-sharing becomes especially relevant when messaging non-dominant subgroups (e.g., rural remote or vulnerable inner-city youth, or a specific religious group). Evidence-informed guidance on how to address vocal vaccine deniers in a public forum is available ^[35]. Helping to shape the students’ vaccine beliefs and acceptance behaviour through weaving immunization information into the school curriculum may well garner similar benefits as has been found with curriculum on environmental issues, bullying and science advocacy ^[1]. Ontario has incorporated child and youth vaccine education into their Immunization 2020 modernization plan.  Evidence is also accruing that suggests that highlighting consensus among medical scientists on the effectiveness and safety of vaccines can increase public support for vaccines ^[36]. Pre-emptively highlighting false claims, refuting potential counterarguments in advance and highlighting tactics being used by science deniers has shown benefits in inoculating the public against the rhetoric of climate change skeptics ^[37]. The same may hold for countering vaccine skeptics.

5. Working collaboratively

Certain provincial/territorial immunization program needs are best fulfilled in collaboration with the federal government ^[5] and/or with leading nongovernmental organizations, such as the Canadian Paediatric Society or Canadian Public Health Association. Collaborating with respected community leaders can also broaden community support for immunization and improve uptake rates ^[1]. A review of the major world religions found that most doctrines support caring for others, preserving life and community responsibilities. Only Christian Science specifically does not support immunization and even this is not rigid ^[38]. Doctrinal support of immunization needs to be more widely recognized and used, not only at the immunization program level but by front-line health workers. When an objection to a vaccine is raised locally, collaborative work between a cultural or religious community and allied health care professionals may help to address the issue ^[39][40]. Religious leaders communicating in partnership with health authorities during a disease outbreak can have a powerful effect, and has led to significant increases in vaccine acceptance in some communities ^[40].

In summary, addressing vaccine hesitancy at the provincial/territorial level through an immunization program, clinic or office practice needs planning and the involvement of multiple stakeholders and elements. Collaboration, tailored communication, evaluating outcomes and sharing lessons learned are key to improving immunization rates in Canada.

Acknowledgements

This practice point was reviewed by the Community Paediatrics Committee of the Canadian Paediatric Society.

CPS INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE (2018)

Members: Natalie A Bridger MD; Shalini Desai MD; Ruth Grimes MD (Board Representative); Timothy Mailman MD; Joan L Robinson MD (Chair); Otto G Vanderkooi MD
Liaisons: Upton D Allen MBBS, Canadian Pediatric AIDS Research Group; Tobey Audcent MD, Committee to Advise on Tropical Medicine and Travel (CATMAT), Public Health Agency of Canada; Carrie Byington MD, Committee on Infectious Diseases, American Academy of Pediatrics; Fahamie Koudra MD, College of Family Physicians of Canada; Rhonda Kropp BScN MPH, Public Health Agency of Canada; Nicole Le Saux MD, Immunization Monitoring Program, ACTive (IMPACT); Jane McDonald MD, Association of Medical Microbiology and Infectious Disease Canada; Dorothy L Moore MD, National Advisory Committee on Immunization (NACI)

Consultant: Noni E MacDonald MD

Principal authors: Noni E MacDonald MD, Eve Dubé PhD

Updated by: Michelle Barton MD, Cora Constantinescu MD, Dorothy L. Moore MD

References

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.