How to address vaccine hesitancy

Vaccination prevents around 2–3 million deaths worldwide every year from infectious diseases such as diphtheria, tetanus, pertussis, influenza and measles​[1]​. Despite the efficacy of vaccines, vaccine hesitancy — the belief that a vaccine may be unnecessary, ineffective or unsafe — is common (reported in more than 90 countries, at all income levels), and growing to such an extent that in 2019, the World Health Organization (WHO) listed vaccine hesitancy as one of the top ten threats to global health​[2–5]​.

A recent UK study, involving 32,361 adults, demonstrated that 16% of respondents were distrustful of vaccines in general, while 14% were unwilling to accept a vaccine against COVID-19 and 23% were unsure about doing so​[6]​. These figures were higher in women; people with lower levels of education and income; and among ethnic minority populations​[6]​.

This article aims to provide an overview of vaccine hesitancy and its determinants to help pharmacists and pharmacy teams understand why some individuals are vaccine-hesitant — particularly in the context of COVID-19 vaccines — and how addressing the concerns of patients will increase confidence in, and uptake of, vaccines.

Definition

Vaccine hesitancy refers to delaying or refusing vaccines despite the availability of vaccine services; it is complex and context-specific, varying across time, location and vaccine type, and includes factors such as complacency, convenience and confidence​[7]​. It is a continuum between acceptance of all vaccines and complete refusal of all vaccines, with individuals refusing certain vaccines; delaying others; accepting some vaccines but remaining concerned; or even refusing vaccines for themselves while remaining supportive of vaccinations more broadly​[8,9]​. Individuals can move both forwards and backwards along this spectrum over time (e.g. with emerging news or following consultation with healthcare professionals)​[8,9]​. 

Importance of addressing vaccine hesitancy

Vaccine hesitancy reduces vaccine uptake and compromises herd immunity (i.e. where a high proportion of a population is vaccinated against an infection and thereby protected and, consequently, it is less likely that an infectious individual will have contact with a susceptible individual and transmit the infection)​[10]​. When herd immunity is compromised, disease outbreaks among the unvaccinated population are likely​[10]​. For example, in 2017, measles was eliminated in the UK; however, the elimination status was lost in 2019, as a marked increase in measles cases occurred owing to sub-optimal uptake of the MMR vaccine in the population​[11,12]​. Vaccine hesitancy therefore undermines the effectiveness and success of immunisation programmes.  

The current COVID-19 pandemic, and subsequent development of several COVID-19 vaccines, has highlighted the urgent need to address vaccine hesitancy. While the proportion of a population needed to be vaccinated against COVID-19 to achieve herd immunity has not yet been established, addressing COVID-19-related vaccine hesitancy is expected to lead to greater numbers of vaccinated individuals, in turn resulting in fewer COVID-19 cases, reduced infection transmission and fewer deaths.  

Factors involved in vaccine hesitancy

The ‘3 Cs’ model can be used to conceptualise vaccine hesitancy and includes the following factors:   

• Confidence refers to lack of trust in the safety and effectiveness of vaccines and the system through which they are delivered; this includes the reliability and competence of healthcare professionals, health services and/or the motivation of policy makers who make decisions about vaccines; 
• Complacency refers to the low perceived risk of vaccine-preventable diseases, leading to an assumption that vaccines are not needed;  
• Convenience refers to the degree that physical availability, affordability, willingness-to-pay, geographical accessibility and ability to understand (language and health literacy) influence uptake of the vaccine​[7–13]​.

These factors are context-specific and multidimensional; they overlap and interact, as shown in the Figure. Some specific examples of reasons given by vaccine-hesitant individuals are shown in Box 1​[14–25]​.

Figure:  The 3 Cs model of vaccine hesitancy

More recently, other researchers have replaced convenience with constraints, added calculation (engagement in extensive information searching) and collective responsibility (willingness to protect others) and developed a 5C model​[26]​.    

Some healthcare professionals are hesitant about vaccination personally and for their patients, citing reasons such as vaccine safety and adverse effects as well as their own lack of knowledge, confidence and time​[21]​. For example, in a survey of around 1,500 nurses in France, self-reported vaccine coverage ranged from 27% (for seasonal influenza) to 96% (for BCG), and the prevalence of vaccine hesitancy was 44%​[27]​.

Discussing vaccines and addressing vaccine hesitancy

Advice and recommendations from healthcare professionals is the most common reason for vaccine-hesitant parents changing their minds and is one of the strongest predictors of vaccination acceptance​[15,29,30]​. Conversely, people have cited a lack of GP recommendation as the cause for being vaccine-hesitant​[21]​. 

To adequately address vaccine hesitancy, it is important for pharmacists and pharmacy teams to understand the factors that contribute to vaccine hesitancy (see Box 1) and how to support patients in their decision-making process to guide them towards vaccine acceptance and confidence as outlined below. 

Listen and communicate effectively

Given that vaccine hesitancy is highly variable and context-specific, the concerns of the patient must be established so that relevant reliable information and advice can be provided. While a lack of information does not correlate with vaccine hesitancy, many patients will seek information and reassurance from pharmacy staff​[31,32]​. Pharmacists should inform, educate and correct vaccine-related misinformation raised by a patient; however, care must be taken to not overload patients with detailed technical information, which is likely to be forgotten, while the simple misinformation narrative is remembered/reinforced​[32]​. Strong risk negation can also increase perceived vaccination risks​[33]​. Pharmacists must take care not to repeat vaccine myths; a randomised trial evaluating the efficacy of messages in vaccine promotion paradoxically found that corrective information about the disproven vaccine–autism link reduced intention to vaccinate among the most vaccine-hesitant parents​[34]​.

Table 1: Do’s and don’ts regarding communication

Be proactive

Addressing vaccine hesitancy needs to be an ongoing dialogue. The pharmacy team can proactively raise the topic of vaccination when opportunities arise: for example, when selling face masks and hand gels; handing medicines to patients; taking drug histories; counselling patients on new medications; or responding to queries about medicines or minor ailments. If a patient does not take up a vaccine at the first invitation, it is important to not be discouraged, but to ‘leave the door open’ and indicate that they can come back to take the vaccine or to receive more information. Continual action will also mean that patients are exposed to positive messages about vaccination, which could help them recognise misinformation.   

Be prepared

Pharmacists and pharmacy teams must be prepared for conversations and keep up-to-date information regarding vaccine efficacy and components, and severity and frequency of adverse effects at hand. Providing information about vaccine safety and efficacy, and educating patients about the benefits of vaccination and the risks of non-vaccination, have been shown as effective strategies for addressing vaccine hesitancy by community pharmacists​[35]​. Pharmacists can answer patients’ queries about vaccines and vaccination and offer advice on how to relieve common adverse effects, such as fever.

The Royal Pharmaceutical Society has compiled a comprehensive guide on COVID-19 vaccines, including information on the excipients, ingredients and side effects, to help pharmacists and their teams assure the public about the safety and efficacy of approved vaccines​[36]​.

Table 2 shows how pharmacists and pharmacy teams can start a conversation or respond to general queries on vaccines or vaccination.

Table 2: Example conversation between pharmacist and patient regarding COVID-19 vaccines

Box 2 further outlines some important messages pharmacists and pharmacy teams should provide patients regarding COVID-19 vaccines.

Cultural concerns

Vaccine hesitancy relating to COVID-19 is greater among ethnic minorities, especially among black African and black Caribbean groups, followed by Pakistani/Bangladeshi​[39,40]​. Barriers to vaccine uptake among minority ethnic groups include perception of risk; low confidence in vaccines; distrust/mistrust of public services, such as healthcare, owing to historical issues and contemporary perceptions of institutional racism; access barriers; inconvenience; socio-demographic context; language; religious and cultural factors and lack of endorsement from community leaders; lack of vaccine availability; or lack of communication from trusted providers and community leaders​[39,41]​.

A recent podcast exploring why some black people are hesitant about COVID-19 vaccines highlighted that vaccine clinical trials included few black participants, and that many black people work in frontline jobs, or in the entertainment industry, where they cannot work from home and/or have no paid leave​[42]​. This may make taking an older parent to a vaccination centre far from home impractical, and the possibility of having to take unpaid time off work if they are unwell with vaccination side effects may be a real deterrent to getting the vaccine. Further barriers include language, mistrust and fear of authority​[42]​.

Pro-vaccination messages are known to lead to greater levels of acceptance if heard from community leaders/members and others trusted within communities, and some faith groups have produced resources related to the concerns of their communities about COVID-19 vaccines (see Table 3)​[7]​. Recently, concerns have been raised about whether getting the COVID-19 vaccine breaks the Ramadan fast. Patients should be advised that the vaccines are safe and religiously permissible during Ramadan.

The tailoring of health messages and advice to reflect local realities — such as the people, services, resources, and social and cultural norms of the target community, which can differ between ethnic minorities and white British communities — is therefore important. The availability of information in various languages will also make health messages more accessible, although it must be remembered that many people who speak a cultural language do not necessarily read it as well. Therefore, spoken resources such as YouTube videos may be more accessible than printed leaflets​[41,42]​. A range of spoken resources have been produced by NHS staff​[43]​.

Table 3: Religious concerns about the COVID-19 vaccines currently licensed in the UK

Best practice

Pharmacists and pharmacy teams can help address vaccine hesitancy by proactively starting conversations about vaccines; listening to patients; answering their questions; providing resources that patients can take away with them; and reinforcing vaccine and vaccination facts when interacting with patients, as outlined above.  

They can also advertise the fact that they have been vaccinated (e.g. by sticking an ‘I’ve had my COVID-19 vaccination’ sticker on their clothing), which can start conversations and demonstrate their trust in the vaccine. 

Useful resources

• COVID-19 vaccine resources
• Public Health Wales: COVID-19 vaccination information
• NHS Scotland: Coronavirus (COVID-19) vaccine deployment plan 2021
• Northern Ireland: Get Vaccinated
• European Centre for Disease Prevention and Control: Let’s talk about protection
• WHO: Vaccination and trust
• How have COVID-19 vaccines been developed so fast?

Health inequalities

The Royal Pharmaceutical Society’s policy on health inequalities was drawn up in January 2023 following a presentation by Michael Marmot, director of the Institute for Health Equity, at the RPS annual conference in November 2022. The presentation highlighted the stark health inequalities across Britain.

While community pharmacies are most frequently located in areas of high deprivation, people living in these areas do not access the full range of services that are available. To mitigate this, the policy calls on pharmacies to not only think about the services it provides but also how it provides them by considering three actions:

• Deepening understanding of health inequalities
  • This means developing an insight into the demographics of the population served by pharmacies using population health statistics and by engaging with patients directly through local community or faith groups.
• Understanding and improving pharmacy culture
  • This calls on the whole pharmacy team to create a welcoming culture for all patients, empowering them to take an active role in their own care, and improving communication skills within the team and with patients.
• Improving structural barriers
  • This calls for improving accessibility of patient information resources and incorporating health inequalities into pharmacy training and education to tackle wider barriers to care.