How physicians are rethinking vaccine conversations in an age of doubt

“And now, with these third kids, they are saying they don't want to do any vaccines or very minimal,” she says. “It's a big shift in our families that were fully vaccinating their kids before."

But even as the tenor of exam room conversations is changing, new data suggest the bigger picture is more nuanced. A study published in The Lancet in January, led by researchers at Imperial College London and tracking more than 1.1 million people in England, found that 65% of patients initially hesitant about the COVID-19 vaccine went on to receive at least one dose. 

Jess Steier, DrPH, a public health scientist and founder and CEO of Unbiased Science, which specializes in making complex scientific concepts understandable, is not surprised by the 65% figure.

"The veneer of hesitancy is always larger than its actual impact," she says. "People are understandably confused, given the current climate and discourse around vaccines, but at the end of the day, most want to protect themselves and their families. What looks like firm resistance in a survey often turns out to be uncertainty that resolves once people have time, information, and access."

That uncertainty, and the question of how to navigate it, is a communication challenge for many physicians. Pediatricians are discovering that reaching hesitant families has less to do with the strength of the evidence than with the quality of the relationship between doctor and patient. What matters more than facts is how well practitioners listen and the trust they build with patients over time. 

‘Tell me your biggest concern’

In a 2021 narrative review on ways to increase vaccine uptake, Noel T. Brewer, PhD, a professor in public health at the University of North Carolina Gillings School of Global Public Health, notes that “the most potent intervention for increasing vaccine uptake is a healthcare provider recommendation.” But the way the recommendation is delivered can matter as much as the message itself. 

Lori Handy, MD, associate director of the Vaccine Education Center and an attending physician in the Division of Infectious Diseases at Children's Hospital of Philadelphia, says one of the biggest mistakes clinicians make is assuming they know where a patient is coming from instead of asking.

"We assume we know what their concerns are," Handy explains. "A very powerful statement instead is, 'Tell me your biggest concern.' We have to address that elephant in the room before launching into talking points that may be prepared and correct but do not address the family's questions."

Steier, whose group Unbiased Science recently created The Vaccine Policy Conversation Guides to help physicians navigate vaccine conversations, agrees. More productive vaccine conversations begin “by understanding someone’s concerns before attempting to correct them,” she says. “People rarely change their minds because they got out-argued, and leading with the data tends to put them on the defensive.”

Handy also advises steering clear of shorthand. Many terms and phrases that are commonplace for providers are not part of patients’ everyday lexicon. So rather than recommending a vaccine by its acronym, such as Hib, DTaP, MMR, or HPV, she frames it around the disease it prevents. 

"It is more powerful to say, 'I strongly recommend your child receives a vaccine to prevent meningitis and bloodstream infections' compared to 'I strongly recommend your child receives a Hib vaccine,'" she says. "Most families have never heard of Hib." (It stands for Haemophilus influenzae type B, which is a type of bacterium and is not related to influenza [flu], which is caused by a virus.)

Her go-to phrase for HPV (human papillomavirus) vaccination is, "’I strongly recommend we protect your daughter from cervical cancer today,” [which is] very different from, “Have you considered what you want to do about the HPV vaccine?'"

When parents bring up something she suspects is misinformation, Handy doesn't correct them. Instead, she validates that she's heard the concern. "I say, 'I've been hearing that a lot. Can we talk about that one?'" The phrasing acknowledges the concern without lending it credibility and helps build trust. 

Finding a shared perspective can also be powerful, says Steier. "Our approach is to humanize the science and find common ground—whether that's as a mother, a daughter, someone who's navigated these same decisions for my own family. You have to lead without judgment."

Reading the (exam) room

In the Lancet study that showed that 65% of hesitant English adults went on to receive at least one COVID vaccine dose, the findings suggested that the most common sources of hesitancy—concerns about effectiveness and side effects—were also the most likely to resolve over time. In contrast, participants who reported being hesitant because of a general anti-vaccine sentiment, mistrusting vaccine developers, or having a low perceived risk from COVID, remained reluctant.

Steier draws a distinction between the "movable middle" and those with deeper ideologic objections, arguing that public health messaging needs to adjust accordingly. "For the smaller group driven by deep distrust or ideological opposition, that same empathetic approach won't move the needle and may even backfire,” she says. “Campaigns should invest in reaching the movable middle and not exhaust resources on the truly entrenched at the expense of everyone else."

Schaefer says she can often tell within moments of entering an exam room whether a patient is hesitant or has a strong anti-vaccine stance. "Body language," she says. "I can see when I bring it up, this defensive look comes over their face, and I know right away, ‘okay, this is going to be an interesting discussion.’”

For those parents, she says, the goal shifts. You're no longer trying to vaccinate the child right away. You're trying to preserve the relationship long enough to get there eventually. "You really know who's dug their heels in and who's really not receptive at that moment. You're not really going to make a change that day with what you're saying. You're going to try to build some trust and get them to move the needle a little bit."

Early in his career, Jonathan Weinkle, MD, chief medical officer at Squirrel Hill Health Center in Pittsburgh, learned through experience what happens when relationships break down. "Getting angry or preachy backfires almost universally," he says. "I used to do this regularly in the early years of my career." 

Today, he says, his most powerful tool is conveying to patients that he’s listening and that he cares. "Data doesn't change minds. Stories and relationships change minds,” he says. “Knowing that I care, and then having me ask them to tell me their fears or objections, is powerful."

The trust problem

Another challenge clinicians face: erosion of institutional trust. "People have more access to information now than ever before. They also have lower trust in institutions,” says Handy. “This has changed conversations not just about vaccines, but about many health topics." 

A study published in the American Journal of Epidemiology in January found that vaccine concerns mattered more to people who lacked trust in federal health agencies than to those who trusted agencies like the Centers for Disease Control and Prevention. Those with higher levels of trust were more likely to get additional COVID vaccine doses. 

Lower institutional trust is particularly pronounced in communities that have experienced medical discrimination or systemic inequalities. A recent study published in Vaccine found that, among young Black adults, medical mistrust was significantly associated with lower odds of receiving the COVID vaccine. Medical mistrust was also associated with stronger endorsement of vaccine-related conspiracy beliefs.

Black participants in the Lancet study were three times more likely to express hesitancy than White participants (odds ratio, 3.22), though they were ultimately no less likely to get vaccinated at a later date, suggesting that time, information, and access may help resolve uncertainty.

Mistrust doesn’t always arise from misinformation and conspiracy theories. It can be born out of experience, which supports the case for clinicians listening to patients’ concerns and building trust before making recommendations. 

One parent in Weinkle’s practice had been told that their own serious childhood illness was due to a bad dose of a vaccine, so this family consistently declined vaccinations for their children. Weinkle credits relationship-building with helping the family change their mind about vaccinating against COVID. "Because I was patient with [this family]," he says, "they trusted me not to 'I-told-you-so' when they returned having changed their minds." 

He credits relationship-building with helping the family change their mind about vaccinating against COVID. "Because I was patient with [this family]," he says, "they trusted me not to 'I told you so' when they returned having changed their minds."

'The relationship is the long game'

Vaccines are one of the great public health success stories—a fact that, paradoxically, contributes to vaccine hesitancy. Many parents have never directly witnessed the illnesses that once devastated families. 

“We've done such a good job preventing these diseases that people have forgotten what they look like,” says Steier. “When something feels less threatening, motivation drops.”

Providers who work with patients every day say the best route to boosting motivation is to build good relationships by listening, being patient, and returning to the conversation over multiple visits. “Sometimes the instinct is to lead with volume of evidence,” says Steier, “when what the person needs first is to feel heard.”

The key, say clinicians, is building trust over time. A line in the Vaccine Policy Conversation Guides sums it up perfectly: “The relationship is the long game.”