The key to a successful immunization program in Canada is having people agree to and receive the COVID-19 immunization.

It is critical to engage with patients who are eligible but hesitant to receive the vaccine. This is especially true for our highest risk patients where the benefits of the vaccine are greatest. Multi-pronged interventions can increase immunization uptake by more than 25%. The most effective interventions include discussions with people they trust, such as their primary care provider.

Here are a few approaches and tools that can be combined to engage patients who express hesitancy towards the COVID-19 vaccine.

Identify Reasons for Hesitancy

Understanding Hesitancy

There are many reasons why a patient may be hesitant about receiving an immunization from safety concerns to political values. It’s important to understand different worldviews and to keep the conversation ongoing. You may want to follow the EAASE (Engage, Affirm, Ask, Share, Evoke) steps for motivational interviewing to help navigate conversations around hesitancy.

Historical and Cultural Reasons for Hesitancy

For some people, particularly some minority populations, including black and Indigenous peoples, a history of colonization, experimentation, and systemic racism contribute to hesitancy.

These are important to explore and acknowledge. The proposed plans to offer immunizations earlier to remote communities and Indigenous elders, is seen by some as a sign that this is further testing, instead of a more equity-oriented approach to immunization.

Helping people understand the equity-based rationale (and relative increased risk from COVID-19) may assist in increasing their comfort. Many providers feel uncomfortable raising these topics, but a good place to start is by asking your patients questions about their concerns.

Concerns About Getting “the Jab”

Some patients are worried about getting the injection itself. Immunize Canada and the University of Toronto have adapted best practices into a simple CARD approach to improve the immunization experience for children and adults (Comfort, Ask questions, Relax, Distract).

For specific information related to hesitancy in children, visit:

CARD recommendations have been incorporated into our planning section.

Access and Logistical Barriers

For some, the hesitancies are due to systemic barriers. Understanding what these are and addressing or reducing these can improve access. This will happen through motivational interviewing but could also occur through a more structured approach in your practice.

Examples of barriers that you could discuss and address might be:

  • Time of day – unable to get time off work, no child care, etc.
  • Location – difficult or onerous to travel to the clinic, does not use public transport during the pandemic, etc.
  • Reminders – some patients may just need a reminder to help them. Encourage them to have an immunization buddy to remind them the day of.

Changing schedules, having evening clinics, or ensuring specific slots are open at certain times may help. Mobile immunization clinics may need to be considered for some patients, while for others it might be arranging safer transport through friends, etc.

Have Conversations to Discuss Concerns

Simply providing information on its own is often not enough. Conversation is needed to help with the hesitation. Consider using one of these tools to structure your approach with your patients.

PrOTCT Plan for the COVID-19 Vaccine Discussion

The Centre for Effective Practice and Alberta Department of Pediatrics developed a specific approach for discussing COVID-19 vaccine hesitancy. It is a focused, quick approach that builds trust and shares information.

Brief Motivational Interviewing

Motivational interviewing has been shown to be effective in vaccine hesitancy and many of us are familiar with brief motivational interviewing in primary care. Consider these five techniques as part of brief motivational interviewing with patients:

  • Build on your Relationship – In primary care we have developed longitudinal relationships with our patients. Acknowledge this explicitly as part of connecting and discussing immunizations. Through this you strengthen and build your therapeutic partnership.
  • Use Open Ended Questions and Reflection – Ask open ended questions about the challenges of the pandemic in their lives. You can reflect stated concerns back with additional material on how your patient’s specific concerns link to benefits of the vaccine (e.g. anxiety and need to feel safe is enhanced through being vaccinated).
  • Avoid Defensive Postures – avoid statements that get patients defensive as this can entrench them in their decision not to get the vaccine.
  • Use Affirming Statements – Provide affirming statements validating a person’s higher-level concerns that also link to related benefits of immunization. Get the person to echo this, highlighting abilities they have to make the change.
  • Use Confidence Scales – You can ask using “on a scale from 1-10, how important is this immunization to you?” and then discuss why their number is not lower. This can highlight positive reasons the patient has to be immunized.

Encourage Community Dialogue and Modelling

Community leaders can influence people who are vaccine hesitant. Describing our own rationale for taking the vaccine can be helpful for others, particularly where the rationale are relatable.

Kids can also have a positive influence on their grown ups.

Provide Incentive-based Interventions

For some groups, incentive-based interventions to promote the immunizations have been trialed with some success. Non-financial incentives (e.g. snacks) might encourage attendance.

Provide Information

Vaccine safety and the quality of the science is a significant concern for many. There is a range of conflicting information these days from various information sources, including social media.

Sharing information on the robustness of studies, the review process, and the approval process can all be helpful for those who hesitate due to a lack of information. People may be more trusting of the information provided and endorsed by their primary care teams.

Focus Efforts on Eligible Patients who are Vaccine Hesitant

Finally, we should focus our efforts on those who are hesitant about the vaccine. Those who are keen will simply need the appropriate information and are unlikely to need these specific additional interventions. Those who are truly resistant may also not benefit from this kind of engagement, at least not initially.

Given our limited capacity now, focus initially on those who are in the middle who are hesitant and eligible who need to understand the benefits.

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