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Canadian Family Physician | Le Médecin de famille canadien}Vol 67: JULY | JUILLET 2021Tools for Practice
Vaccine hesitancy in the office: what can I do?
Jennifer Potter MD CCFP Adrienne J. Lindblad BSP ACPR PharmD
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 ben- efits to the individual more than correcting misinfor- mation 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 infor- mation on measles, mumps, and rubella (MMR) risk;
information correcting a vaccine-autism link; or con- trol. 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 partici- pants with “neutral” baseline vaccine attitude scores.
• In another study, 1759 participants online were ran- domized 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 vac- cinate 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 (bene- fits to child), 86.4 (benefits to society), and 90.8 (ben- efits to child and society).
-Only statements including benefits to the child were statistically different from control.
• Limitations: studies looked at proxy measures (eg, inten- tion 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 com- mon 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
Dr Potter is a family physician in Winnipeg, Man. Dr Lindblad is Associate Clinical Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
Competing interests None declared
The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.
References
1. Horne Z, Powell D, Hummel JE, Holyoak KJ. Countering antivaccination attitudes. Proc Natl Acad Sci U S A 2015;112(33):10321-4.
2. Betsch C, Korn L, Holtmann C. Don’t try to convert the antivaccinators, instead target the fence- sitters. Proc Natl Acad Sci U S A 2015;112(49):E6725-6.
3. Nyhan B, Reifler J, Richey S, Freed GL. Effective messages in vaccine promotion: a randomized trial. Pediatrics 2014;133(4):e835-42. Epub 2014 Mar 3.
4. Hendrix KS, Finnell SME, Zimet GD, Sturm LA, Lane KA, Downs SM. Vaccine message framing and parents’ intent to immunize their infants for MMR. Pediatrics 2014;134(3):e675-83. Epub 2014 Aug 18.
5. Leask J, Kinnersley P, Jackson C, Cheater F, Bedford H, Rowles G. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatr 2012;12:154.
6. Shen S, Dubey V. Addressing vaccine hesitancy. Clinical guidance for primary care physicians working with parents. Can Fam Physician 2019;65:175-81 (Eng), e91-8 (Fr).
7. Dempsey AF, Pyrzanowski J, Lockhart S, Campagna E, Barnard J, O’Leary ST. Parents’ perceptions of provider communication regarding adolescent vaccines. Hum Vaccin Immunother 2016;12(6):1469-75.
8. Hu Y, Chen Y, Wang Y, Song Q, Li Q. Prenatal vaccination education intervention improves both the mothers’ knowledge and children’s vaccination coverage: evidence from randomized controlled trial from eastern China. Hum Vaccin Immunother 2017;13(6):1477-84. Epub 2017 Feb 21.
9. Opel DJ, Heritage J, Taylor JA, Mangione-Smith R, Salas HS, Devere V, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics 2013;132(6):1037-46.
10. Public Health Agency of Canada. Vaccine coverage in Canadian children: results from the 2017 Childhood National Immunization Coverage Survey (cNICS). Ottawa, ON: Public Health Agency of Canada; 2019.
11. Dubé E, Bettinger JA, Fisher WA, Naus M, Mahmud SM, Hilderman T. Vaccine acceptance, hesitancy and refusal in Canada: challenges and potential approaches. Can Commun Dis Rep 2016;42(12):246-51.
12. EKOS Research Associates Inc. Survey of parents on key issues related to immunization. Final re- port. Ottawa ON: EKOS Research Associates Inc; 2011. Available from: https://www.ekospolitics.
com/articles/0719.pdf. Accessed 2021 Apr 15.
Can Fam Physician 2021;67:516. DOI: 10.46747/cfp.6707516
Tools for Practice articles in Canadian Family Physician are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice@cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.
