Understanding Vaccine Hesitancy in Canada: Results of a Consultation Study by the Canadian Immunization Research Network

The aim of this consultation study was to identify the views of Canadian vaccination experts and health professionals concerning the definition, scope, causes, and consequences of vaccine hesitancy in Canada. "Vaccine hesitancy" is a concept that is challenging previously held perspectives in both academic and public health circles that individual vaccination attitudes and behaviours are a simple dichotomy of accept or reject. The World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy defines vaccine hesitancy as a "delay in acceptance or refusal of vaccines despite availability of vaccine services". This definition is focused on a binary behavioural outcome (vaccination or non vaccination), in contrast to definitions usually used in the literature which also include attitudes or beliefs (e.g., vaccination despite important doubts and concerns). The research group identified a need for a common definition of vaccine hesitancy among researchers, public health experts, policymakers, and health care providers to better guide interventions that can more effectively address vaccine hesitancy within Canada.

The research team sent online surveys to 2 stakeholder groups (hereafter named panels): 1) members of the Canadian Association for Immunization Research and Evaluation (CAIRE) and of the Canadian Immunization Research Network (CIRN); and 2) front-line vaccine providers (nurses and physicians). A total of 52 research networks members and 98 front-line vaccine providers completed the first questionnaire (15 open-ended questions), whereas 54 research networks members and 80 vaccine providers completed the second questionnaire (16 closed-ended questions which asked participants to indicate their level of agreement, scored using a 10-point Likert scale, with statements about vaccine hesitancy that were derived from the first questionnaire).

In the first round of data collection, the majority of participants defined vaccine hesitancy as a reluctance to receive (recommended) vaccinations, mainly due to concerns about safety and efficacy of vaccines. Others indicated that vaccine hesitancy was "having doubts" (some indicated unjustified doubts) with regards to vaccines. "The explicit recognition that attitudes and beliefs play an important role in influencing behaviour suggests aspects that could be addressed by public health interventions." In the first round, 91% (n = 41) of research networks members reported that vaccine hesitancy had an impact on vaccination programmes in Canada. These participants reported that low vaccination coverage and vaccination delays and refusals leading to vaccine-preventable diseases outbreaks were the most common results; 87% (n = 85) of front-line vaccine providers reported that vaccine hesitancy resulted in increased time spent discussing vaccination issues with concerned patients.

In the second round, 57% of research networks members and 75% of front-line vaccine providers agreed that vaccine hesitancy is a significant problem in Canada, and 76% of research networks members and 87% of vaccine providers agreed that it is contributing to sub-optimal vaccination coverage rates in Canada. The majority of research networks members (66%) and vaccine providers (78%) agreed that it is crucial to address this issue. Diffusion of negative information online and lack of knowledge about vaccines were identified as the key causes of vaccine hesitancy by the participants.

In the first questionnaire, both panels of participants were asked about the main causes of vaccine hesitancy in Canada. The most frequently mentioned causes were misinformation or lack of knowledge and mistrust and fears around vaccination. In the second round of data collection, for both groups of participants, the diffusion of negative information on vaccination on the internet and social media followed by lack of knowledge about vaccination received the highest mean ranks. For research networks members and vaccine provider participants, respectively, mistrust in the pharmaceutical industry and a lack of confidence in vaccine safety were the third most important cause of vaccine hesitancy.

Front-line vaccine providers were asked to answer specific questions regarding how they deal with vaccine hesitancy in their practice. In the first round of data collection, the majority emphasised that they listen, try to understand the concerns of, and educate vaccine-hesitant patients about vaccines. The majority of vaccine providers (88%, n = 94) did not hesitate to disclose information on vaccination risks because of patients concerns and doubts. In the second round, vaccine providers were asked about their level of agreement with the best practices in counselling vaccine-hesitant patients. The preferred approaches were to listen to concerns, to be non-judgemental, and to correct misinformation. Sixty-nine percent said they were comfortable dealing with vaccine-hesitant patients, and 64% felt capable of counselling them. Vaccine research funded by the government and by academic institutions was more highly trusted than industry funded research.

Reflecting on these findings, the researchers observe that, "[b]ecause research has mainly focused on the metrics of vaccine uptake (coverage rates, delays, refusals), the degree to which vaccine hesitancy influences vaccination behaviours remains an important, though complex, domain for investigation." Thus, "[t]here is an urgent need to develop good techniques to identify and monitor patterns of both 'attitudinal' and 'behavioural' vaccine hesitancy in individuals and populations, and over time....The consensus for most questions found in the current study suggests a common conceptualization and could serve as a basis for the development of such techniques."

Noting that negative and false information about vaccination online and in social media was perceived to be the most important cause of vaccine hesitancy by participants, the researchers note that most studies are descriptive, and though many attribute the increase in vaccine hesitancy to negative vaccination-related content on the internet, they offer limited empirical evidence to support these claims. "Further, social media role in vaccine hesitancy creates a need to develop appropriate strategies for online communication; such strategies should aim to provide vaccine-supportive information, to address misinformation published online, and to correspond to parents' needs and interests..."

As this study has shown, most Canadian vaccine providers support listening to the concerns of vaccine-hesitant patients, reassuring them in a nonjudgmental way, and providing accurate information on vaccination. They thus recognise the importance of maintaining a trustworthy patient-provider relationship, as well as tailoring communication to patients' specific concerns and doubts. [T]he lack of results from studied approaches indicates more research may be needed to identify and implement effective ways to support health care providers' communication with vaccine-hesitant patients.

The researchers conclude (footnote numbers removed): "In the context of declining trust in science and state institutions and increasing consumerist orientation to healthcare, more and more people wish to be - and, indeed, are encouraged to be–engaged in health decisions and to feel empowered to do so, regardless of whether their sources of information are perceived by experts as lacking credibility. It is important for health professionals to recognize the impact of the broader social landscape that 'gives shape to ideas and ideals' about health, prevention and what a good citizen does about vaccination."