Vaccination hesitancy typically originates from concerns about the safety and efficacy of vaccines and from a lack of trust in institutions that promote vaccines, according to Lavanya Vasudevan, PhD, MPH. Other contributors to vaccine hesitancy include inconvenience or costs of accessing vaccines and the notion that some vaccine-preventable diseases (VPDs) are not common or serious. “Widespread vaccinations are necessary to stem the COVID-19 pandemic and prevent the emergence of potentially deadlier virus variants,” adds Dr. Vasudevan. “A key challenge to achieving widespread vaccination is vaccine hesitancy.”

According to published research, VPDs can result in the diversion of public health resources, increased economic burden, and negative societal ramifications from unnecessary morbidity and mortality. Despite these consequences, vaccine hesitancy continues to be an uncomfortable and often controversial topic in healthcare. In a paper published in the North Carolina Medical Journal, Dr. Vasudevan and colleagues described several key challenges in addressing vaccine hesitancy in North Carolina and presented recommendations for mitigation strategies. The challenges and mitigation strategies are generally applicable to other regions in the United States. “The goal was to better understand vaccine hesitancy, examine vaccination gaps, and recognize challenges and opportunities associated with mitigating hesitancy,” Dr. Vasudevan says.

Drivers of Vaccine Hesitancy

According to data from the National Immunization Survey, about 20% of parents in North Carolina are vaccine hesitant. In addition, parents in the state may sometimes choose to delay vaccines for their children rather than follow recommended schedules. “There are gaps in vaccinations across the lifespan in North Carolina,” says Dr. Vasudevan. Coverage for the HPV, influenza, Tdap, and meningococcal vaccines are suboptimal. In addition, many pregnant women decline the vaccines they are offered, suggesting concerns with safety and efficacy rather than convenience or complacency. Reducing vaccine hesitancy is critical to bridging these coverage gaps.

Drivers of vaccine hesitancy are complex and subject to a variety of influences, including exposure to online misinformation and many other factors. “Strategies to educate people about vaccines can help but are not sufficient to mitigate vaccine hesitancy,” Dr. Vasudevan says. “Some of the reasons behind vaccine hesitancy are linked to historical, religious, or structural issues, which may be harder to address in practice. Vaccine-related concerns are among the many factors that contribute to vaccine hesitancy and the vaccination gap, and they are believed to play a growing role in the increasing rates of vaccine hesitancy.”

Approaches to Mitigation

“Current population-level efforts to mitigate vaccine hesitancy are reactive and are typically implemented only after there is an outbreak,” says Dr. Vasudevan. “Health professionals can play an important role in reducing vaccine hesitancy, because they are trusted sources of information for patients. Our review highlights several opportunities and strategies that can be implemented by clinical practices and health professionals to help mitigate hesitancy (Table).”

Dr. Vasudevan and colleagues suggest that collecting and analyzing longitudinal data in a timely manner may help inform tailored interventions to mitigate vaccine hesitancy. Increasing time spent with patients and allowing for reimbursement for additional counseling visits by healthcare providers could also help reduce patients’ reliance on online sources for vaccine information. Additionally, trainings are needed to help clinicians, nurses, and physician assistants navigate potentially difficult conversations with patients on vaccine hesitancy. Community outreach interventions and vaccine education and awareness campaigns may be warranted to help further mitigate vaccine hesitancy.

“Multi-faceted strategies that address the determinants of vaccine hesitancy at the patient, provider, and policy level are necessary for bridging vaccination gaps,” says Dr. Vasudevan. “In parallel, there is a need for sustained and systematic efforts to track vaccine hesitancy throughout the United States. Access to longitudinal data can enable us to better understand vaccine hesitancy so we can develop proactive strategies to mitigate it.”


Vasudevan L, Walter E, Swamy G. Vaccine hesitancy in North Carolina: the elephant in the room? N C Med J. 2021;82(2):130-137. Available at:

Larson HJ, Clarke RM, Jarrett C, et al. Measuring trust in vaccination: A systematic review. Hum Vaccin Immunother. 2018;14(7):1599-1609.

Ozawa S, Portnoy A, Getaneh H, et al. Modeling the economic bur­den of adult vaccine-preventable diseases in the United States. Health Aff (Millwood). 2016;35(11):2124-2132.

Larson HJ, Jarrett C, Schulz WS, et al. Measuring vaccine hesitancy: The development of a survey tool. Vaccine. 2015;33(34):4165-4175.

Edwards KM, Hackell JM, Committee on Infectious Diseases, The Committee on Practice and Ambulatory Medicine. Countering vac­cine hesitancy. Pediatrics. 2016;138(3):e20162146.

Smith TC. Vaccine rejection and hesitancy: A review and call to ac­tion. Open Forum Infect Dis. 2017;4(3):ofx146.