Children - Key Activity 9A


Provide Caregiver Support to Overcome Vaccine Hesitancy

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; address social needs.


Vaccine hesitancy has been described as a behavior influenced by a number of factors. Vaccine-hesitant individuals are a diverse group with varying degrees of indecision about specific vaccines or vaccinations in general. Clinics may take many approaches to support vaccine-hesitant families of their patients to boost participation rates in well-child visits (WCVs) and immunizations.

Immunizations have resulted in a significant decrease in vaccine-preventable diseases and are one of the single greatest public health achievements of the last century. Over the past decade, however, the value of vaccines has been increasingly challenged. Some parents have concerns about the safety and necessity of vaccines, and those concerns have led to a range of behaviors from hesitancy about some immunizations to declination of all vaccines.

While the minority of parents who refuse all vaccines may be fixed in their beliefs (they may be described as vaccine-resistant), most vaccine-hesitant parents are responsive to vaccine information, will consider vaccinating their children, and are not opposed to all vaccines. Families need support in navigating information and processing the cognitive, emotional and psychological aspects of decision-making about immunizations.

Some populations experience vaccine hesitancy because of distrust of medical systems and research due to historical and existing racism, bias and discrimination. Practices should understand this root cause of vaccine hesitancy and learn from families and their local data if and how racism, bias and discrimination are contributing to vaccine hesitancy and inequities in immunization rates.

Unmet social needs can create barriers to immunization. Empathically assessing for and effectively responding to these needs may improve engagement in WCVs and completion of immunizations.

Additionally, some populations with a disproportionate burden of unmet needs may also be more likely to experience or endorse vaccine hesitancy.[1] Taking a holistic strengths-based and partnered approach to the care of the patient and family may lead to improved social needs and greater uptake of immunizations.

It is important that data fields and workflows are configured to accurately capture vaccine declination in order to understand and manage the problem. Patient outreach and engagement technologies can assist the care team in assessing vaccine hesitancy as well as delivering education, such as clinical templates and/or prompts in the EHR and care coordination applications, to guide provider and care team discussions. Care dashboards and quality reports can be utilized with data analytics to identify trends that might suggest population-level strategies.


Example Of Documenting Reason For Vaccine Declination In Ehr

Action steps and roles

Adapted from: Ensuring COVID-19 Vaccine Equity for Children: Considerations for Pediatric Teams and Community Partners - CHCS Blog [Internet]. Center for Health Care Strategies. 2021. Available from:

1. Determine current immunization completion rates by age group, by key sociodemographic characteristics, and by vaccine.

Suggested team member(s) responsible: Data manager or QI lead.

Segment the practice’s data on immunization and WCV completion rates to identify groups of children who are not meeting goals.


2. Listen to families, communities and clinic staff.

Suggested team member(s) responsible: QI lead and staff.

Identify barriers to immunization completion, including vaccine hesitancy and strengths-based, family-driven solutions, through trusted and authentic partnerships with families and communities. See Figure 16 for a compendium of reasons for vaccine hesitancy.

Also, examine the staff’s current comfort both with immunizations and with addressing parental concerns. Providing a psychologically safe environment for staff to express their own hesitancies and engage in respectful education and dialogue about immunizations can yield greater understanding, buy-in, and support from practice staff.


Vaccine safety:

  • Too many vaccines.
  • Development of autism.
  • Vaccine additives (e.g., thimerosal, aluminum).
  • Overload the immune system.
  • Serious adverse reactions.
  • Potential for long-term adverse events.
  • Inadequate research performed before licensure.
  •  May cause pain to the child.
  • May make the child sick.

Necessity of vaccines:

  • Disease is more “natural” than a vaccine.
  • Parents do not believe diseases being prevented are serious.
  • Vaccine-preventable diseases have disappeared.
  • Not all vaccines are needed.
  • Vaccines do not work.

Freedom of choice:

  • Parents have the right to choose whether to immunize their child.
  • Parents know what’s best for their child.
  • Believe that the risks outweigh the benefits of the vaccine.
  • Do not trust organized medicine or public health.
  • Do not trust government health authorities.
  • Do not trust pharmaceutical companies.
  • Ethical, moral or religious reasons.

Reproduced from Edwards KM, Hackell JM. Countering Vaccine Hesitancy. PEDIATRICS [Internet]. 2016 Aug 29;138(3):e20162146–6.

3. Review current practices to identify key opportunities for improvement.

Suggested team member(s) responsible: QI lead with care team and families.

Catalog and develop process maps for the clinic and care team’s current practices related to presenting and educating caregivers and families on immunizations, addressing concerns and vaccine hesitancy, using support materials related to vaccine hesitancy, and tracking effectiveness of current practices. Consider how the use of standing orders integrates with this process.

4. Share information effectively to build vaccine confidence.

Suggested team member(s) responsible: Care team.

Develop clear, concise and accessible messaging to discuss vaccine safety and efficacy with families and to counteract persistent misinformation campaigns. When possible, review sources of information and misinformation with families who express hesitancy.

One way to quickly incorporate effective communication is to adapt language that has already been crafted to address families' concerns about immunizations. Use culturally sensitive language and tailor existing resources to reach specific communities, including Black and Hispanic or Latino/a communities, as well as refugee, immigrant and migrant communities. See Figure 17 for communication highlights related to vaccine hesitancy, as well as resources for this activity below.


  • Vaccines are safe and effective, and serious disease can occur if your child and family are not immunized.
  • Vaccine-hesitant individuals are a heterogeneous group, and their individual concerns should be respected and addressed.
  • Vaccines are tested thoroughly before licensure, and vaccine safety assessment networks exist to monitor vaccine safety after licensure.
  • Nonmedical vaccine exemptions increase rates of unvaccinated children.
  • Unvaccinated children put vaccinated children and medically exempt children who live in that same area at risk.
  • Pediatricians and other health care providers play a major role in educating parents about the safety and effectiveness of vaccines. Strong provider commitment to vaccination can influence hesitant or resistant parents.
  • Personalizing vaccine acceptance is often an effective approach.
  • The majority of parents accepted the provider’s vaccine recommendations when they were presented as required immunizations to maintain optimal disease prevention.
  • The current vaccine schedule is the only one recommended by the CDC and the AAP. Alternative schedules have not been evaluated.

Reproduced from Edwards KM, Hackell JM. Countering Vaccine Hesitancy. PEDIATRICS [Internet]. 2016 Aug 29;138(3):e20162146–6.

Tip: When talking to parents about vaccines for their child, it is a best practice to be clear and direct about what vaccines are due. For example, instead of asking, “What do you want to do about shots?” state, “Your child is due for three vaccines.” Instead of asking, “Have you thought about the shots your child needs today?” state, “Your child is due for Tdap, Hib, and hepatitis B shots today.”

5. Focus on the care team.

Suggested team member(s) responsible: Director.

Ensure that the care team is comfortable addressing vaccine hesitancy and other family concerns to foster an environment where all families feel supported. Consider offering training, such as the teach-back method.

Help staff vaccinate their own families by offering vaccine drives or additional paid time off. Offering opportunities for the care team to vaccinate their own families provides a space for staff to talk about the experience of vaccinating their families with the community they serve and signals the practice’s commitment to vaccination.


6. Measure progress, consider equity, and continuously improve your approach overall and for key subpopulations.

Suggested team member(s) responsible: Data manager or QI lead.

Whenever possible, track vaccination data in real time and collect disaggregated data by race and ethnicity, as well as by language spoken and geographies. Advocate for practices and policies that drive vaccine equity and benefit all families.

Special consideration for human papillomavirus (HPV): One special circumstance worth noting is the potential divergence between parental and adolescent immunization preferences with respect to HPV vaccination. The adolescent may, unknown to the parent, wish HPV vaccination, but the parent may not provide consent. Practices should adopt a consistent and systematic approach to when and how adolescent HPV immunization will be provided without parental consent, given existing CA law that permits this. Practices may want to be familiar with existing literature on adolescent consent for the human papillomavirus vaccine, including ethical, legal and practical considerations, and the HPV vaccine and parental consent. Most importantly, practices should be aware that California law allows adolescents to consent to HPV vaccination without parental consent.

Evidence base for this activity

  • Edwards KM, Hackell JM. Countering Vaccine Hesitancy. PEDIATRICS [Internet]. 2016 Aug 29;138(3):e20162146–6. Available from:
  • Gilmour J, Harrison C, Asadi L, Cohen MH, Vohra S. Childhood Immunization: When Physicians and Parents Disagree. Pediatrics [Internet]. 2011 Nov [cited 2019 May 5];128(Supplement 4):S167–74. Available from:
  • Maglione MA, Das L, Raaen L, Smith A, Chari R, Newberry S, et al. Safety of Vaccines Used for Routine Immunization of US Children: A Systematic Review. PEDIATRICS [Internet]. 2014 Jul 1;134(2):325–37. Available from:
  • Byington CL. Vaccines: Can Transparency Increase Confidence and Reduce Hesitancy? Pediatrics [Internet]. 2014 Aug 1;134(2):377–9. Available from:
  • Sahni V, Lai FY, MacDonald SE. Neonatal Vitamin K Refusal and Nonimmunization. Pediatrics. 2014 Sep 1;134(3):497–503. Available from:
    Summary: Children whose parents refused vitamin K at birth are 14.6 times more likely to be unimmunized by age 15 mo. This provides an opportunity to identify a subset of likely vaccine-hesitant parents at birth and engage them with information in a focused effort.
  • 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 [Internet]. 2014 Aug 18 [cited 2020 Jan 20];134(3):e675–83. Available from:
    Summary: A survey found that parents who were informed about the MMR vaccine’s direct benefits to their child, rather than the vaccine’s benefits to society as a whole, were more likely to immunize.


  1. Viswanath, K., Bekalu, M., Dhawan, D. et al. Individual and social determinants of COVID-19 vaccine uptake. BMC Public Health 21, 818 (2021).