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AAP report offers strategies to counter vaccine hesitancy

February 26, 2024

You read about a case of measles identified in an unvaccinated individual who recently traveled through your local airport. The next morning, you’re scheduled to have a well-child visit with a 2-year-old who has not received the measles, mumps and rubella (MMR) vaccine because the parents have requested to spread out some immunizations. What are some effective ways to address the parents’ concerns and help ensure the child is immunized against this highly contagious disease?

National coverage for routine pediatric vaccinations has decreased in recent years, including during the COVID pandemic. The decrease may be due not only to missed well-child visits but also to vaccine hesitancy. The 2019 National Immunization Survey showed that 20% of U.S. parents are hesitant about childhood vaccines.

Inadequate vaccination coverage leaves children and communities vulnerable to outbreaks of vaccine-preventable diseases such as measles.

In an updated clinical report, the AAP provides guidance to address the persistent challenge of improving vaccine confidence and acceptance.

The clinical report Strategies for Improving Vaccine Communication and Uptake, from the Committee on Infectious Diseases, the Committee on Practice and Ambulatory Medicine and the Committee on Bioethics, is available at and will be published in the March issue of Pediatrics.

Effects of vaccine hesitancy

A central challenge in vaccine communication is vaccine hesitancy, described as a state of being conflicted about or opposed to vaccination. Vaccine hesitancy can lead to a spectrum of behaviors from refusing all vaccinations (rare) to receiving all or most vaccines despite having some concerns (more common).

The report reviews factors influencing vaccine acceptance, including trust in health systems, and the need to address disparities in vaccine access, confidence and uptake.

Vaccine refusal and delay put children at risk of preventable diseases and have economic costs for society, individual patients and families, payers, and pediatric clinics. The clinical report highlights how uncompensated time spent discussing vaccine concerns, infection-control efforts after a case of a vaccine-preventable disease in the clinic and failing to meet payers’ immunization performance metrics are all financial burdens for pediatric clinics.

Communicating effectively

Studies have shown that parents who refuse or are hesitant about immunization often are concerned about vaccine safety. Therefore, pediatricians must be equipped with knowledge of vaccine safety and effectiveness as well as communication skills to engage in effective dialogue with families. The clinical report provides detailed information and tables that pediatricians can reference to refresh their knowledge of vaccine safety and the recommended immunization schedule.

Pediatricians also can use evidence-based communication techniques to increase vaccine uptake. These techniques include:

  • giving a strong recommendation for vaccination,
  • using a presumptive format to start the conversation,
  • applying motivational interviewing techniques with parents who express hesitancy, and
  • continuing to communicate your support for the recommended schedule in subsequent conversations over time.

Examples of phrases and wording that pediatricians can use are included in the report.

Policies to address vaccine refusal or delay

When families refuse or ask to delay vaccinations, pediatric practices respond in a variety of ways.

A 2019 survey showed that 51% of pediatric offices have a policy to dismiss families who refuse vaccines in the primary series, and 28% have policies to dismiss families who spread out vaccines. 

The report discusses ethical considerations related to dismissal policies, including:

  • the societal benefits of vaccination,
  • potential risks for physicians caring for families who refuse vaccines,
  • how dismissal policies may exacerbate health disparities and affect clinics without dismissal policies, and
  • how dismissal may limit access to general health care outside of vaccination.

Practical considerations related to when and how to consider dismissal from a practice also are summarized.


The report includes tools to support pediatricians in vaccine communication and immunization delivery. These resources include:

  • a summary of vaccine safety monitoring systems,
  • facts and messages to debunk common vaccine myths,
  • a flowchart showing when and how to apply specific communication techniques during a vaccine conversation, and
  • links to websites with detailed information to address common vaccine concerns.

Before seeing the 2-year-old patient who is behind on his vaccinations and his family, you brush up on some basics of MMR vaccine safety and common side effects. You then start the conversation with a strong recommendation for the vaccine, even though the parents have delayed vaccines in the past, and you mention that you are worried about recent measles cases in the community. If parents express hesitancy, you could switch to motivational interviewing and ask them more about their concerns and work together to build on their motivations to protect their child’s health. Even if the parents do not choose vaccination, you can continue the conversation at future visits.

Dr. Cataldi is a lead author of the clinical report.

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