CPHA Canvax

Vaccine Acceptance in Canada: Building confidence, demand and resiliency

The CANVax Team

Vaccine acceptance has become a growing concern as we see outbreaks of diseases once thought to be under control and on their way to eradication. Despite the tremendous strides made in vaccine development, safety, and access, some parents continue to question the need for vaccines, their safety and effectiveness, and are hesitating to accept vaccines (1). Vaccine hesitancy is defined as the reluctance or refusal to vaccinate despite the availability of vaccines and is both complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, constraints (convenience) and confidence (2).

Factors that can drive negative vaccine concerns, and can influence vaccine acceptance, include (3-5):

  • Vaccine safety: Vaccines have become a victim of their own success. As such, public concerns have shifted from the diseases that vaccines protect against to the risk and safety of the vaccines. 
  • Low science literacy:
    • The academic language used to describe scientific outcomes may be misconstrued by the general public and even by some healthcare practitioners. In addition, research has become more readily available online, making information easier to access, and, in some cases, misinterpreted.

    • Publication of substandard research, such as the retracted paper by Andrew Wakefield that falsely proposed a link between the MMR vaccine and autism, has generated much confusion and fear. Even now, concerns about the MMR vaccine and autism persist and have become widespread, despite the large body of quality research evidence that has demonstrated that the administration of the MMR vaccine and the development of autism are NOT causally linked.

    • Literature is now filled with pay-to-publish non-peer reviewed predatory journals that publish poor science online – making it even harder for the general public to distinguish between quality science and poor science.

  • New vaccine recommendations: The introduction of new vaccines, and changes in vaccine schedules and their recommendations, can generate public concern, adding to the appeal of anti-vaccination messages that vaccines are not necessary.

  • Lack of consistency in recommendations: Variations in vaccine recommendations, schedules, and vaccine information across Canada also contribute to the public’s questioning of vaccines, and can undermine trust in vaccine safety.

  • Increase in number of immunizations, either as combination vaccines or as multiple injections in the same visit: While there have been significant advancements in vaccine development, the increase in the number of recommended vaccines and their antigens during a single visit has contributed to public concern and raised questions about whether the immune system could be overwhelmed. It is important to put into perspective that an infant is exposed to thousands of antigens in a day through exposures in daily life – many more than from vaccines recommended in one visit.

  • Political motivations: Disagreement among political and/or authoritative figures and the purposeful spread of misinformation undermine vaccines, generate confusion and challenge public trust.

Social interactions that bring together like-minded individuals, such as those that have been seen with the anti-vaccine movement, may further amplify individual negative vaccine concerns, experiences, and beliefs. Moreover, in the past decade, advances in internet-based communication technologies (i.e., social media and messaging applications) have fostered the rapid and contagious dissemination of information to large audiences, connecting individuals and communities well beyond their local geographies (6-7). Research has also shown that negative concerns spread farther and faster than positive comments about vaccination (8).

The State of Vaccine Acceptance in Canada

While the vast majority of parents in Canada choose to vaccinate their children, studies have shown that many express concerns and not all are convinced of the science (9-10). Surveys conducted in Canada show that a significant portion of Canadians have negative perceptions of vaccines, with approximately 20% believing that vaccines are linked to autism (11-15). According to the most recent Childhood National Immunization Coverage Survey (2015), 65% of parents and guardians indicated concerns about potential side effects from vaccines, and 37% thought that a vaccine can cause the same disease that it was meant to prevent (1). In addition, a small number of parents and guardians (15%) believed that complementary and alternative practices such as homeopathy or chiropractic treatments could eliminate the need for vaccines.

Results of a survey conducted by the Canadian Immunization Research Network (CIRN) in 2015 found that 70% of respondents believed that as a parent, it is their role to question vaccines, and 19% considered themselves vaccine-hesitant (9). Results of another Canadian study conducted in 2014 demonstrated that 40% of mothers hesitated to have their child vaccinated, most frequently citing safety concerns such as fear of adverse effects, too many vaccines, and weakening of the immune system (16).

Despite all of these concerns, well over 80% of parents accept immunization for their infants and children (1). In Canada, vaccine acceptance is the predominant behaviour – but can this be maintained in the face of anti-vaccine voices that are growing louder?

Building Confidence, Demand and Resiliency

Building and maintaining public confidence in vaccines and the health system that delivers them requires both proactive and reactive processes, monitoring and listening to public concerns, valuing those who accept vaccines and positively reinforcing vaccine acceptance behaviour (17).  

What immunization programs can do at the community level:

1. Target and tailor the message for the population
When developing messages, be certain that they are not only evidence-based but also tailored to fit the target population (18). Campaigns such as Australia’s ‘I immunise’ campaign demonstrate how tailored messaging that engage with the values, ideology, and identity of a community can lead to improved vaccine acceptance in groups who were previously hesitant towards vaccines (19).  

Research has shown that when messages disagree with individual beliefs, this can be polarizing, reinforcing the beliefs they hold (20). Messaging that contains too much information and too strongly educates and/or advocates for vaccination can also be counterproductive, increasing hesitancy.  

Be sure to test messages with the target population in advance to ensure they are working as intended for that group. Evaluation will also be important to assess the effectiveness of messages and identify areas for improvement (18).

2. Emphasize scientific consensus and social norm
Research has demonstrated that emphasizing scientific consensus on the benefit, safety and importance of vaccines can reduce concerns about immunizations (21). Valuing decisions of parents, patients and the community who accept vaccines, and emphasizing that choosing to vaccinate is a social norm, can foster acceptance, nurture demand and grow resiliency (17).

3. Prepare and plan for crisis
To maintain public trust in vaccines, health care providers and the health system require ongoing communication to build knowledge and increase awareness of the risks and benefits of vaccines and vaccine-preventable diseases. Developing a communication plan, including a crisis communication plan, is essential in maintaining vaccine acceptance and uptake during vaccine scares (i.e., adverse events following immunization [AEFI], vaccine recall, media reports, or rumours about a vaccine) and/or changes in vaccine schedules (18).

When developing a communication plan, consider the following (18):

  • Be proactive and not just reactive
  • Understand the concerns
  • Knowledge is important, but it is not enough to change behaviour
  • Target and tailor messaging to fit the population
  • While a wide array of communication tools are available, identify the tools that will reach your target population that are most effective in promoting vaccine uptake
  • Evaluate and identify areas for improvement to reach your target population
What health care providers can do at the individual level:

1. Techniques to discuss vaccination
Conversations with parents and patients who may be vaccine-hesitant can be emotional for all parties involved (22). When talking to parents and patients, consider:

a.     Introducing immunization in a manner that is presumptive rather than in a participatory manner:
Research has shown that it is more effective in introducing immunization in a presumptive manner to promote vaccine acceptance than in a participatory manner (23).

Presumptive: ‘Sarah is due for her routine vaccinations today.’
Participatory: ‘Would you like to do Sarah’s vaccinations today?’

b.    Using motivational interviewing:
Motivational interviewing is a helpful client-centred technique for dissecting and exploring concerns that vaccine-hesitant patients and parents may have towards vaccines (24). This type of interviewing focuses on working with the patient and parent rather than talking to them.

Example of a motivational interview path (18):

  • Open-ended questions: What are your concerns?
  • Affirmation: I understand
  • Reflective listening: Your concerns are…
  • Summarize: To summarize…

2. Health care provider recommendation
Health care providers continue to be the most trusted source for vaccination information and advice among the public. As such, provider recommendations are not only important in building confidence in vaccines but also in driving vaccine acceptance and uptake (11; 25).

Research has shown that people are generally more positive, trusting and receptive toward the information received when it is something that they have heard before or if it is repeated, clear, and easy to understand in both format and language (26).  

When talking to parents and patients, it is important to (18):

  • Avoid jargon that could be misconstrued, e.g., using the term “community immunity” instead of “herd immunity”, which may be off-putting for some.
  • Avoid being technical.
  • Deliver the message in a language and a context that fits the needs of the parent and patient.
  • Use common denominators when comparing rates of an event.
  • Explain single-event probability.
  • Use visuals to help convey the information.

When presenting data, consider (18):

  • Presenting data in absolute numbers (1 in 10 children) instead of relative risk (10% of children).
  • Frame the message. Framing messages as a loss appear more concerning than framing them as a gain.
  • Using stories.
  • Using nudges to encourage vaccine acceptance. For example, noting that the majority of parents choose to accept routine vaccinations because they want to protect their children can nudge them to accept vaccines. Be careful not to plant fear, as this can backfire.
  • Summarizing by providing the gist of the message (i.e., “And the reason this is important…”).

3. Reinforcing Vaccine Acceptance
Health care providers can reinforce vaccine acceptance behaviours by valuing the decisions of parents and patients who accept vaccines, as recommended, on time and on schedule. Further, emphasizing that choosing to vaccinate is a social norm that not only benefits the vaccine recipient but also their family and community (17).

  1. Public Health Agency of Canada. Vaccine coverage in Canadian children: Results from the 2015 Childhood National Immunization Coverage Survey (CNICS). s.l.: PHAC, 2018.
  2. MacDonald NE, and SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. 34, s.l.: Vaccine, 2015, Vol. 33, pp. 4161-4.
  3. Larson HJ, Schulz WS, Tucker JD, and Smith DM.  Addressing the vaccine confidence gap. 9790, s.l.: The Lancet, 2011, Vol. 378, pp. 6-12.
  4. MacDonald NE, and Picard A. A plea for clear language on vaccine safety. 7, s.l. : CMAJ, 2009, Vol. 180, pp. 697-698.
  5. World Health Organization. Best practice guidance: How to respond to vocal vaccine deniers in public. Copenhagen: World Health Organization Regional Office for Europe, 2017.
  6. Larson HJ, Schulz WS, Tucker JD, and Smith DM. Measuring vaccine confidence: introducing a global vaccine confidence index. 7, s.l.: PLoS Curr, 2015, Vol. 1.
  7. The Vaccine Confidence Project. The State of Vaccine Confidence 2015. 2015.
  8. Dunn AG, Surian D, Leask J, Dey A, Mandl KD, and Coiera E. Mapping information exposure on social media to explain differences in HPV vaccine coverage in the United States. 23, s.l.: Vaccine, 2017, Vol. 35, pp. 3033-3040.
  9. Dubé E, Gagnon D, Ouakki M, et al. Canadian Immunization Research Network. Measuring vaccine acceptance among Canadian parents - a survey of the Canadian Immunization Research Network. 4, s.l.: Vaccine, 2018, Vol. 36, pp. 545-52.
  10. Larson HJ, de Figueiredo A, Xiahong Z, et al. The state of vaccine confidence 2016: Global insights through a 67 country survey. 12, s.l.: EBioMedicine, 2016, pp. 295-301.
  11. Dubé E, Bettinger JA, Fisher WA, and Hilderman T. Vaccine acceptance, hesitancy and refusal in Canada: Challenges and potential approaches. 12, s.l.: Can Commun Dis Rep, 2016, Vol. 42, pp. 246-51.
  12. Mainstreet Technologies. 62% say child care facilities should shun unvaccinated. Manitoba: Scribd. [Online] 2015. [Cited: 02 26, 2019.] https://www.scribd.com/doc/255007188/Mainstreet-Technologies-Manitoba-and-Vaccinatons-Poll.
  13. Mainstreet Technologies. 66% say child care facilities should shun unvaccinated. Saskatchewan. Scribd. [Online] 2015. [Cited: 02 26, 2019.] https://www.scribd.com/doc/254907012/Mainstreet-Technologies-Saskatchewan-and-Vaccinatons-Poll.
  14. Mainstreet Technologies. 65% say child care facilities should shun unvaccinated. Alberta. Scribd. [Online] 2015. [Cited: 02 26, 2019.] https://www.scribd.com/document/254904718/Mainstreet-Technologies-Alberta-and-Vaccinatons-Poll.
  15. Mainstreet Technologies. 67% say child care facilities should shun unvaccinated. Ontario. Scribd. [Online] 2015. [Cited: 02 26, 2019.] https://www.scribd.com/document/254901898/Mainstreet-Technologies-Ontario-and-Vaccinatons-Poll.
  16. Dubé E, Gagnon D, Zhou Z, and Deceuninck G. Parental vaccine hesitancy in Quebec (Canada). 8, s.l.: PLoS Curr, 2016.
  17. Dubé E, and MacDonald NE. Vaccination resilience: Building and sustaining confidence in and demand for vaccination. 32, s.l.: Vaccine, 2017, Vol. 35, pp. 3907-3909.
  18. MacDonald NE, and Dubé E. Canadian Guidance on Addressing Vaccine Hesitancy to Help Foster Vaccine Demand and Acceptance: Building Resilient Pro-Vaccine Communities. s.l.: [unpublished guidance report], 2019.
  19. Attwell K, and Freeman M. I Immunise: An evaluation of a values-based campaign to change attitudes and beliefs. 46, s.l.: Vaccine, 2015, Vol. 33, pp. 6235-40.
  20. Nyhan B, Reifler J, Richey S, and Freed GL. Effective messages in vaccine promotion: a randomized trial. 4, s.l.: Pediatrics, 2014, Vol. 33, pp. e835-42.
  21. van der Linden SL, Clarke CE, and Maibach EW. Highlighting consensus among medical scientists increases public support for vaccines: evidence from a randomized experiment. s.l.: BMC Public Health, 2015, Vol. 15, p. 1207.
  22. Berry NJ, Henry A, Danchin M, et al. When parents won’t vaccinate their children: a qualitative investigation of Australian primary care providers’ experiences. 19, s.l.: BMC Pediatrics, 2017, Vol. 17.
  23. Hofstetter AM, Robinson JD, Lepere K, Cunningham M, Etsekson N, and Opel DJ. Clinician-parent discussions about influenza vaccination of children and their association with vaccine acceptance. 20, s.l.: Vaccine, 2017, Vol. 35, pp. 2709-2715.
  24. Reno JE, O'Leary S, Garrett K, Pyrzanowski J, Lockhart S, Campagna E, Barnard J, and Dempsey AF. Improving Provider Communication about HPV Vaccines for Vaccine-Hesitant Parents Through the Use of Motivational Interviewing. 4, s.l.: J Health Commun, 2018, Vol. 23, pp. 313-320.
  25. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, and Bettinger JA. Vaccine hesitancy: an overview. 8, s.l.: Hum Vaccin Immunother, 2013, Vol. 9, pp. 1763-73.
  26. Alter AL, and Oppenheimer DM. Uniting the tribes of fluency to form a metacognitive nation. 13, s.l.: Pers Soc Psychol Rev, 2009, pp. 219-35.