Vaccine hesitancy, the delay or flat-out refusal of vaccination, is not monolithic—and neither are the vaccine concerns of those individuals who are hesitant. To address their varying concerns, we must engage communities with efforts that go beyond providing facts and figures to connect in a culturally appropriate and empowering way.

Because of safe and effective vaccines, many vaccine-preventable diseases are now “out of sight and out of mind.” However, recent events have forced us to reconsider the role and value of vaccines, including not only the COVID-19 pandemic but also an imported case of polio in New York—the first case in the United States since 2013—and rising case counts of monkeypox, which surpassed 17,000 as of August 26, 2022.

Contributions to Complacency

Historically almost all children received at least most recommended vaccines, largely due to school and daycare entry requirements. However, coverage rates among children have dipped for some vaccines, while the use of adult vaccines has been persistently low for years. Slight declines in coverage pose risks for individuals who are unvaccinated or too vulnerable to get vaccinated.

What’s behind these declines in coverage? Reasons people do not vaccinate include:

  1. Risk-benefit perception of vaccination versus disease. Many people believe that the risk of taking vaccines will do more harm than the diseases they prevent, like polio, measles, and COVID-19. However, many Americans are at higher risk of getting vaccine-preventable diseases and their consequences. Among the vulnerable are the 7 million immunocompromised Americans, the millions of babies born every year, the 1 in 4 Americans with multiple chronic conditions plus 1 in 2 with at least one, and the growing population of older adults.
  2. Deep-rooted mistrust. Historical exploitations and everyday racism in medicine have led to deeply held, systemic mistrust of institutions like the government, healthcare systems, and drug companies. COVID-19 vaccination campaigns amplified this mistrust, particularly in underserved communities hit the hardest by the pandemic. Labeling these communities as vaccine-hesitant misses the complexity of factors that lead to vaccine refusal and fails to address the underlying systems that keep ignoring their concerns.
  3. Structural barriers to initiating or completing a vaccination series. Access to free vaccines is not enough to ensure individuals are fully vaccinated. Long-standing personal, financial, or structural barriers to vaccination (such as poor living conditions, lack of reliable transportation, and poor access to essential routine care) continue to widen health disparities.
  4. Parental attitudes and beliefs. Individuals who are hesitant are that way for a mix of factors mentioned above, including “confidence” in the safety and effectiveness of vaccines, “complacency” about their provider’s recommendation or their own health status, “constraints” in getting vaccinated, or their view of “collective” responsibility and being unwilling to protect others by getting protection.

Given What We Know

The continuum of vaccine attitudes means there is no “one-size” fits all approach to talking about them. Individuals who opts-out of the influenza, COVID-19, and pneumococcal vaccines, for example, may opt in for others like measles or rotavirus. People are on a spectrum of acceptance, somewhere in between “accept all” and “refuse all” with a “moveable middle” of people who are largely unsure or selectively vaccinating.

Anti-vaccination sentiment and vaccine controversies have existed since the first inoculation of smallpox vaccine. However, most individuals who do not vaccinate are hesitant rather than outright against vaccines. The following five actions address the needs of the “moveable middle”:

  1. Create a safe space. It’s important to talk about concerns or barriers to vaccination; keep an open channel of communication to return, especially as new information becomes available; and employ an empathetic approach to reach more people “where they are.” Doing so builds greater trust with institutions and the processes responsible for vaccine innovations and better support individuals’ decisions, particularly in vulnerable and minority communities.
  2. Provide respectful, tailored, and accurate information. To specifically and sensitively help patients get vaccinated, it’s important to understand each patient’s unique concerns and combat any misinformation that influences their hesitancy by giving relevant information is critical. Furthermore, culturally concordant messaging, whether delivered to individuals by someone they identify with or in a trusted setting, can increase acceptance and understanding of provided information.
  3. Acknowledge and identify structural barriers to vaccine access. Ignoring them only widens disparities and creates more barriers to getting vaccinated.
  4. Foster partnerships with traditional and nontraditional public health partners. Using trusted community groups, particularly trusted messengers in underserved communities, supports culturally concordant public health messaging and chips away at the mistrust from everyday racism.
  5. Explore and evaluate interventions to address hesitancy. Scaling and expanding generalizable best practices to other communities, particularly in vulnerable areas, can create more tools to improve access and health decision making even beyond vaccinations.

Moving Forward in a Cyclic Pattern

Hesitancy was around long before COVID became a household word. The lower demand than expected and opposition encountered during the COVID vaccination campaigns offer an opportunity to focus on patients’ perceptions, attitudes, and beliefs for each vaccine. It is not until widespread outbreaks—the frequency of which has been increasing—that many people feel the urgency and the enormity of what vaccines can prevent. When diseases disappear, the risk perception is low and complacency grows, reducing vaccination rates so that the cycle repeats. Our research and experience show that empowering decision making—through conversations rooted in equality, immanent value, and self-determination—is central to building trust. Building a trusted platform for health and vaccine conversations is key to closing the gap in health equity for all Americans.

The study, “Factors Influencing Parental and Individual COVID-19 Vaccine Decision Making in a Pediatric Network,” was published in the Vaccines Journal on July 31, 2022. Authors include Authors include Angela Shen, Safa Browne, Tuhina Srivastava, Jeremy Michel, Andy Tan , Melanie Kornides.


Angela Shen

Angela K. Shen, ScD, MPH

Visiting Scientist, Vaccine Education Center, Children’s Hospital of Philadelphia

Tuhina Srivastava

Tuhina Srivastava, MPH

PhD Student, Graduate Group in Epidemiology and Biostatistics, Perelman School of Medicine

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