Prevention and management of vaccine hesitancy

Vaccine hesitancy refers to the delay in accepting or refusing vaccines despite the availability of vaccination services. Well-conducted studies and trials reviewed in this article support methods both to prevent and manage vaccine hesitancy. Clinicians should know which vaccines their patients are due to receive and should use every encounter to address this issue. Research shows clinicians’ recommendations increase vaccine uptake. Recommendations that patients perceive as stronger have a greater effect in increasing vaccine uptake. Using presumptive language to phrase the recommendation is more effective than presenting the vaccine conversationally as an option for the patient. When the patient counters the strong recommendation with hesitancy, the clinician should engage the patient with motivational interviewing, perhaps using a four-step process called the “Four A’s”.

INTRODUCTION

Vaccine hesitancy is the delay in accepting or refusing vaccines despite the availability of vaccination services. It is a complex and context-specific issue varying across time and location. Additionally, vaccine hesitancy is not uniform: parents may accept some vaccines but delay or refuse others. Factors that influence this phenomenon include complacency (a low perceived risk of the disease), convenience (access to immunizations), and confidence (trust in vaccines, healthcare providers, and policymakers). Motivations range from safety concerns and distrust in institutions to misinformation and personal beliefs. This review presents an evidence-based approach for preventing and managing vaccine hesitancy.

MATERIALS AND METHODS

We conducted a focused literature review to identify current trends in global vaccine hesitancy, analyzing research studies on methods to improve vaccine uptake in clinical settings.

Vaccine hesitancy in the 21^st century

Immunization has made vaccine-preventable diseases far less common. This success paradoxically eliminated their own apparent need. Furthermore, immunization schedules are complicated and evolving, varying between organizations and medical authorities. Parents often question the need for vaccines, the timing, and the number of immunizations recommended to their children. These questions can lead to misunderstandings, with incomplete and untrue “facts” from unverified sources, further increasing the hesitancy.

The World Health Organization called vaccine hesitancy a global problem in 2019 [1]. The organization highlighted vaccination as one of the most successful and cost-effective public health tools, preventing millions of deaths each year. Vaccine hesitancy was identified as not just a local or ideological problem, but one that could undermine decades of progress in controlling preventable diseases. Vaccine complacency, inconvenience in access, and lack of confidence were the key reasons underlying hesitancy, as found by the organization’s vaccine advisory group. Because vaccination coverage in some communities waned, herd immunity thresholds were not being met, leading to outbreaks of vaccine-preventable illnesses such as measles, which had a 30% rise in cases globally the previous year.

The World Health Organization’s call predated the COVID pandemic [1]. Unfortunately, the pandemic aggravated the issues regarding trust in vaccines and medical organizations. COVID-era misinformation heightened vaccine skepticism – social media platforms and echo chambers amplified false narratives, undermining confidence in routine immunizations. Globally, vaccination gains are stalling: one Lancet study reported stagnation or reversal of routine immunization, even in high-income countries, because of hesitancy, misinformation, and COVID-19 disruptions [2]. Surveys of parents and caregivers found that while overall hesitancy did not dramatically change, trust in vaccine information grew more uncertain during the pandemic, and parental attitudes polarized: some became more accepting, while others became more hesitant [3]. Clinicians themselves reported a “spillover” effect from the pandemic: COVID-19 vaccine skepticism extended to routine vaccines, which again was shaped by media, misinformation, and differing trust in health systems [4].

A clinical strategy to improve vaccine uptake

Physicians should use every clinical encounter to provide immunizations to their patients, not just well visits. Busy families may falter in routine preventive care and may only present for acute visits or when specific health concerns arise with themselves or their family members. Both acute-care and chronic-condition visits are key to maintaining an up-to-date vaccination status. Even if a specialty clinic does not carry vaccines, these visits can be a key opportunity to address any hesitancy the patient may have.

To use any and every clinical encounter for vaccination, the clinician will need to access and review the vaccine records for each patient. Careful review of patient vaccination records transforms a passive system into a proactive one. It ensures each patient encounter is an opportunity to protect against vaccine-preventable diseases and reduces missed opportunities. This also provides a foundation for effective communication and trust-building with patients.

Vaccines have very few contraindications [5]. Furthermore, most contraindications are temporary. Parents will often highlight their child’s acute illness as a barrier to vaccination. Adult patients will question getting a vaccine on top of their presenting concern. In reality, illness is only a precaution, not a contraindication to vaccination, and this only if the illness is acute and moderate to severe. More specifically, acute and not chronic, and moderate or severe and not mild. Moderate illness means that the symptoms interfere with daily activities of living, while the symptoms of severe illness prevent daily activities of living.

Clinicians’ recommendations matter [6],[7],[8],[9],[10], and stronger recommendations are more effective [11]. Studies have found that presumptive language signals a clinician’s strong recommendation [12]. Observational studies [12],[13],[14],[15],[16] and interventional trials [17],[18],[19],[20],[21] support this. Conversational, neutral language, such as: “What are your thoughts about vaccination today?” or “Would you like your child to get vaccines today?” is not recommended. Using presumptive language is recommended instead, such as: “You are due for vaccines today.” or “I recommend your child get the vaccines due today.”

The above-mentioned studies and randomized controlled trials demonstrated a dramatic improvement in vaccine uptake when this type of language is used. Why does it work? Voicing a strong recommendation signals to the patient what should be done and that the alternatives are not prudent options. A strong recommendation utilizes the reason why the patient has sought out an encounter with a physician. The patient is trusting the physician’s assessment and recommendations regarding their acute illness or management of a chronic issue. The physician should build on this trust.

If the parent hesitates despite the physician’s strong recommendation, the doctor should not argue, scold, or attempt to educate. Studies have shown that these approaches usually fail [22],[23],[24] and even backfire [25],[26],[27],[28]. These studies have also shown that educational interventions alone – whether they be public service announcements, billboards, waiting room communications, distributed pamphlets, or proffered links to informational web pages – fail to improve vaccine uptake [22],[23],[24]. Several interventional trials have shown that educational efforts can even backfire and increase the recipients’ resolve NOT to vaccinate [25],[26],[27],[28]. The recommendation is to use evidence-based motivational interviewing instead. Randomized trials have shown that this approach in clinical encounters works in improving vaccine uptake [18],[29],[30],[31],[32]. The same trials indicate that this effort takes even less time than trying to educate the family or using other tactics. Studies support the finding that this interviewing technique can give patients and caregivers more confidence in vaccines overall. Participants in these studies have notably highlighted that motivational interviewing improved their understanding of the need for vaccination and even alleviated doubts and concerns.

Motivational interviewing requires the creation of a safe space where everyone feels comfortable being honest. The physician should be empathetic towards the parent or caregiver, avoid conflict, and be an active listener. They should start by asking the parent to name the single greatest concern or fear they have regarding the recommended vaccine. The parents’ concerns or fears should be validated, rather than berated. It is further recommended to ask open-ended questions, to ask permission before giving information, and to be patient. The physician should also reinforce that they are aware that the parent already has certain knowledge and makes good decisions for the well-being of their child.

A helpful way to address vaccine hesitancy through motivational interviewing in the clinical setting is the “Four A’s” approach [33]. As shown in Figure 1, the “Four A’s” mnemonic refers to four tasks that should be accomplished in a specific order.

Figure 1. The “Four A’s” of addressing vaccine hesitancy through motivational interviewing

With the first A, the clinician asks. In this way, the clinician encourages the parent/patient to be specific about their concerns regarding the vaccine and name what they are most hesitant about.

e.g., “What is your main concern regarding the vaccine?”

With the second A, the clinician acknowledges. The clinician recognizes that the patient/parent is concerned and ultimately is the decision-maker for their own, i.e., their child’s healthcare, including whether to vaccinate.

e.g., “In the end, it is your decision. You need to want to do this. I am not going to make you do this.”

The clinician should acknowledge that the patient wants to do the right thing.

e.g., “It’s clear you’ve really thought about this. I can imagine why this would be so concerning to you.”

With the third A, the clinician affirms. The clinician affirms that it is okay to have questions.

e.g., “That’s a great question. I heard that as well, so I investigated that.”

Finally, with the fourth A, the clinician answers, but only after obtaining permission to answer. The clinician should ask whether they might share what they have learned.

e.g., “May I tell you what I learned?”

Alternatively, when the clinician is momentarily stumped with a novel concern, they should acknowledge this and offer to investigate it further.

e.g., “May I investigate your concern and contact you with what I find?”

In using these strategies, the clinician focuses on their relationship with the patient. A debate or confrontation is avoided, and respect for the patient is shown. Yes, the individual may stop the clinician at the first A. If this happens, i.e., if after permission is asked the patient declines, the clinician should respect this and stop. There will be future encounters, and the patient’s trust and confidence in the doctor should matter more than completing the remaining A’s at a particular visit. It is just important that the clinician makes the effort. The patient will sense this and respect the clinician for that.

CONCLUSION

While we have made great progress with the development of vaccines and succeeded in controlling many vaccine-preventable diseases, vaccine hesitancy remains a significant threat – one that has been exacerbated through the management of the COVID-19 pandemic. The pandemic disrupted routine vaccination pathways, amplified distrust, and polarized parental attitudes about immunization. It is the burden and responsibility of clinicians to continue protecting patients from vaccine-preventable diseases. Well-evidenced strategies support making strong recommendations with presumptive language to improve vaccine uptake. While evidence clearly shows that educational efforts fail to resolve vaccine hesitancy, data clearly demonstrate that motivational interviewing directed toward vaccine hesitancy improves vaccine uptake.

The “Four A’s” approach to motivational interviewing provides a helpful framework to guide clinicians during a patient encounter efficiently and effectively. Clinicians are critical in preventing and managing vaccine hesitancy because of their relationship with the patient. Through thoughtful, empathetic, and evidence-based communication, we can rebuild trust in vaccines and continue reducing the global burden of preventable illnesses.

AUTHORSHIP

Dr. Jacobson presented the major findings reported in this paper at the 15th Serbian Diaspora Medical Conference on June 12, 2025. Dr. Reis expanded on the details, created the illustrative figure (Figure 1), and provided citations of the published literature.

CURRICULUM VITAE

Christopher A Reis

Christopher A Reis, MD, FAAP, is a general pediatrician at Mayo Clinic Children’s in Rochester, Minnesota. He graduated from the University of Minnesota, Twin Cities with a degree in biology prior to attending medical school at Oakland University William Beaumont School of Medicine. His postgraduate training was completed at Mayo Clinic, including a residency in pediatrics followed by a fellowship in pediatric infectious diseases. His academic interests include vaccine uptake and hesitancy in primary care pediatrics, as well as quality improvement to enhance vaccine administration through system level interventions and medical education.

Robert M Jacobson

Robert M Jacobson, MD, FAAP, is a primary care pediatrician in the Division of Community Pediatric and Adolescent Medicine at Mayo Clinic and holds joint appointments in the Divisions of Pediatric Infectious Diseases and Epidemiology. He serves as the Medical Directors for the adult and child immunization programs at Mayo Clinic in Southeast Minnesota. He also serves as a co-Chair of the AskMayoExpert Knowledge Content Board for Immunizations and Vaccinations. He also conducts research to improve vaccine uptake and has published 280 peer-reviewed publications. He is passionate about evidence-based medicine, population health science, and preventive care including and especially vaccines.