Stuart R. Gallant, MD, PhD

In Danielle Ofri’s recent column in The New York Times “My Patients Used to Be Enthusiastic About the Covid Vaccine.  What Changed?,” Dr. Ofri offers some strategies to discuss Covid-19 vaccination hesitance, including [1]:

• Focusing on the patient’s concerns with open ended questions like “Tell me what’s on your mind.”
• Explaining to patients that Covid-19 virus mutates over time.  As a result, new vaccine boosters are required on a yearly basis.
• Strengthening her own resolve as a doctor by reminding herself of her duty as a health professional to provide clear and accurate health information.

In this week’s post, PharmaTopa asks the question, what is known about the best strategies for addressing vaccine hesitance for Covid-19 and for other diseases?

Why Are People Hesitant About Vaccines?

Vaccines are a staple of medicine that go back as far as medicine has been a scientific endeavor.  In fact, the word “vaccine” has the same linguistic root as the Latin word for cow (“vacca”) because the first common vaccine used cowpox to prevent the spread of the deadly human disease smallpox.  Edward Jenner (17 May 1749 – 26 January 1823) created the smallpox vaccine.  Vaccine hesitance goes back many decades, also.  For those interested in the history of vaccine hesitance, Elena Conis has written a review [2].

Regardless of the history of hesitancy, why are patients declining vaccination at the current moment.  Several researchers have offered insight:

• Anas and coworkers looked at Covid-19 hesitance among patients in Ghana, Denmark, and the United States [3].  Three categories of skepticism were identified:  1) lack of trust in vaccines (particularly, due to speedy development and due to worry over possible side effects), 2) lack of trust in institutions (particularly, due to examples of government and health authority miscommunication and due to the perception that institutions were not willing to take responsibility if and when there might be problems with the vaccine), and 3) cultural and religious beliefs (such as conspiracy theories related to imagined dangers of the vaccines for certain demographic groups and such as the idea that God is responsible for protecting humans).
• Kate and coworkers interviewed more-educated Dutch patients in a study that looked broadly at the topic of childhood vaccination [4].  Vaccine skepticism fell into two broad categories:  1) “neoromantic” ideas that favored “natural” paths of being, including embracing the risk of “childhood diseases” and 2) “critical-reflexive” response which harbors skepticism of science and seeks to minimize perceive risk.
• Levin and Bradshaw analyzed data regarding attitudes toward Covid-19 vaccination from a Gallup survey of American adults [5].  They found a correlation between hesitancy and political and religious conservatism.  They were pessimistic about the ability of public education to reduce hesitancy because, as they said, “…resistance appears ideological.”  Presumably, abandoning vaccine resistance would require politically and religiously conservative patients to abandon other deeply held beliefs.

Each patient carries a set of beliefs that uniquely defined by their experiences as child, education, work experience, and community.  Now that we have a sense of why patients may hesitate to be vaccinated, what do doctors do when confronted with hesitance?

How Do Doctors React to Vaccine Hesitance?

The response of doctors to vaccine hesitancy is far from monolithic.  Opel and coworkers discussed the hypothetical case of a 6-year-old boy whose parents refuse vaccination for childhood illnesses [6].  Several pediatricians were polled on their response to the case of the conjectural child and his parents.  Some of the responses of the six physicians include:

• One pediatrician took a statistical point of view, saying that based on the provided data, that the chance of harm to the boy in question was low.  This physician ruled out strong action such as discharging the family from the practice or reporting the family to child welfare authorities.
• Another pediatrician took almost precisely the opposite view, saying if the family could not be convinced to vaccinate, they should be discharged from the pediatric practice.
• Other points discussed included:  1) the cost to society of treating children infected with preventable diseases, 2) the danger to the child of discharging the family from the practice because they would likely end up at a practice which adheres less strongly to pediatric guidelines, 3) the relative safety of current vaccines, 4) the wide availability of information supporting vaccination through the Centers for Disease Control and other institutions.
• Template informed declination forms from American Academy of Pediatrics (AAP) and the Immunization Action Coalition were recommended as proper documentation of the family’s decision, particularly if the family remains within the practice.

What Works to Overcome Hesitance?

Some data is available on which approaches work best in response to vaccine hesitancy:

• Limaye and coworkers presented evidence that three approaches had a positive effect on vaccine acceptance [7]:
  • Health professionals should speak with presumptive language (“So, she’s due for the two vaccinations today.”)  Speaking in this manner normalizes vaccination.
  • Use of motivational interviewing techniques (including active listening, reflections, open-ended questions, asking permission to provide additional information, and acknowledging autonomy) frames the conversation in a way that doctor and patient are working together toward the same goal.
  • Tailoring information to complement a patient’s beliefs and experiences makes the dialog more relevant to the patient and increases the likelihood of vaccine adherence.
• Kepla and coworkers used a “radionovela” to increase the understanding of HPV vaccination in parents of rural Hispanic parents with daughters age 9 to 17 [8].  This study should the importance of considering the culture of patient families.
• One further idea offered by Salmon and coworkers appears to have promise but also contains risks [9].  One can imagine that computer systems designed to locate clusters of vaccine hesitancy, coupled with systems for documenting the causes of hesitance, could be of great use to public health officials and individual practitioners in communities affected by outbreaks of preventable contagious diseases.  But, given the current concerns with data privacy and digital transparency, careful thought needs to be devoted to design and implementation of such systems.

Conclusions

At the time I attended medical school almost 20 years ago, vaccine hesitancy seemed to be a concern affecting a small minority of individuals with eccentric ideas about medicine.  Recently, Reece and coworkers reported 48.8% of Americans reported some degree of hesitance regarding Covid-19 vaccination [10].  What was a relatively small issue two decades ago has become a significant trend today.  Developing strategies for addressing patient concerns about vaccination will continue to be important for primary care physicians and for specialists, such as cardiologist and pulmonologists, seeking to protect their patients with acute and chronic illnesses.  Medical schools will likely have to redouble their efforts to prepare future physicians for these new realities.

[1] Ofri, D.  “My Patients Used to Be Enthusiastic About the Covid Vaccine.  What Changed?” Jan. 27, The New York Times (2024).  www.nytimes.com/2024/01/27/opinion/covid-vaccine-skepticism-doctor.html

[2] Conis, E.  “Vaccination Resistance in Historical Perspective,” The American Historian (2015).

[3] Anas, A.L., Salifu, M., and Zakaria, H.L.  “COVID-19 Pandemic and Vaccination Skepticism,” Human Arenas, Apr 26 : 1–25 (2023).

[4] Kate, J.T., De Koster, W., and Van der Waal, J.  ““Following Your Gut” or “Questioning the Scientific Evidence”: Understanding Vaccine Skepticism among More-Educated Dutch Parents,” Journal of Health and Social Behavior, Vol. 62(1) 85–99 (2021).

[5] Levin, J. and Bradshaw, M.  “Determinants of COVID‑19 skepticism and SARS‑CoV‑2 vaccine hesitancy: findings from a national population survey of U.S. adults,” BMC Public Health, May 25;22(1):1047 (2022).

[6] Opel, D.J., et al.  “A 6-Month-Old With Vaccine-Hesitant Parents,” Pediatrics 133;526 (2014).

[7] Limaye, R.J. “Communicating With Vaccine-Hesitant Parents: A Narrative Review,” Acad Pediatr, May-Jun;21(4S): S24-S29 (2021).

[8] Kepka, D., et al.  “Evaluation of a radionovela to promote HPV vaccine awareness and knowledge among Hispanic parents,” J Community Health, Dec;36(6):957-65 (2011).

[9] Salmon, D.A., et al.  “Vaccine hesitancy: Causes, consequences, and a call to action,” Vaccine, Nov 27:33 Suppl 4: D66-71 (2015).

[10} Reece, S., et al.  “Hesitant adopters: COVID-19 vaccine hesitancy among diverse vaccinated adults in the United States,” Infect Med (Beijing),Jun; 2(2): 89–95 (2023).

Disclaimer:  PharmaTopo^TM provides commentary on topics related to drugs.  The content on this website does not constitute technical, medical, legal, or financial advice.  Consult an appropriately skilled professional, such as an engineer, doctor, lawyer, or investment counselor, prior to undertaking any action related to the topics discussed on PharmaTopo.com.