No Room for Doubt: Overcoming Seasonal Influenza Vaccine Hesitancy Across Care Settings

Key Takeaways

• In the primary care/ambulatory care setting, a systematic vaccination approach can present influenza vaccination as routine care, fostering acceptance through presumptive recommendations.
• In the inpatient care setting, vaccines should be offered at discharge, with an emphasis on broader health benefits, such as reducing cardiovascular risks.
• In the nursing home/long-term care setting, standing orders streamline vaccinations, though family influence can play a role on vaccine hesitancy and can be addressed through presumptive recommendations.

Here are my tips for addressing seasonal influenza vaccine hesitancy in 3 different settings: nursing homes, inpatient care, and ambulatory care.

Primary Care/Ambulatory Care Setting

In the primary care or ambulatory care setting, our practice implements a systematic approach for all ACIP-recommended vaccines, including the seasonal influenza vaccine. When patients present to the clinic, they get registered, their vitals are taken, and then their next stop will be at the vaccine station. We emphasize that this is a “best practice” and our standard of care.

This method serves several key purposes. First, it initiates the presumptive recommendation, a statement phrased under a presumption that patients will want to get the best preventive measures available that we recommend for all of our other patients, and will be ready to accept their vaccines during that visit. You can provide reasons and rationale for receiving the vaccine while using this strategy, but the key is that presumptive recommendations are direct statements, rather than suggestions or questions. This reinforces the expectation that vaccination is routine and essential. For example, instead of saying “We recommend you get your flu vaccine today, to protect yourself and those around you,” we say “We’ll also give your flu vaccine today, to protect yourself and those around you.”

Second, implementing this systematic approach to vaccination establishes a procedure that streamlines the process of vaccine acceptance, making it much more efficient and allowing clinicians to focus more on patient care.

Third, for those patients who are vaccine hesitant or have concerns, this approach opens the door for more in-depth conversations with a clinician. These conversations allow patients the opportunity to ask questions and voice their concerns while maintaining the streamlined vaccination process. As part of this process, we also systematically screen patients for allergies or contraindications prior to vaccination.?

Common Patient Concerns

When patients express hesitancy toward receiving the influenza vaccine, their questions typically fall into a few categories. One common question is, “Do I have to get it now?”

My typical response is “No, but since you’re here, let’s do it now. The vaccine works better in your arm than sitting on the shelf!”

Another frequent question involves uncertainty regarding side effects and their severity. I reassure patients that for flu vaccines, the side effects are generally mild, with the most common being a sore arm, which occurs in the majority of cases and usually only lasts a day or two. Interestingly, older patients are less likely to experience a sore arm, but even if they do, a sore arm can be seen as a positive sign that the body is responding appropriately to the vaccine, indicating its effectiveness.

In general and when indicated, we aim to administer two vaccines at once, increasing the chances that patients stay up-to-date on all their recommended vaccines. However, patients with previous adverse reactions to vaccines may have reluctance toward certain vaccines or vaccination in general. In such cases, if the patient is concerned about receiving two vaccines at the same time (eg., flu and COVID-19 vaccines), we can offer to give them at different times to minimize potential side effects. Administering the less reactogenic flu vaccine first and delaying a more reactogenic alternative, like the COVID or RSV vaccine, might yield a more positive experience with immunization, and in turn foster a willingness to return for future vaccinations.

Inpatient Setting

In the inpatient setting, our approach typically focuses on offering vaccinations at the time of discharge. This moment strikes me as one when patients are more receptive to vaccination as part of their “recovery package,” as this will help them stay out of the hospital. Beyond mitigating infection risk, I like to discuss additional benefits of vaccinations, such as cardiovascular risk reduction.

Respiratory infections, which include influenza, COVID-19, and RSV, are known to increase the risk for heart attacks. Many patients assume they are simply protecting themselves from a respiratory infection, but I emphasize that influenza vaccination, for example, also reduces the risk of heart attacks. In my practice, I explain that receiving a flu shot can lower this risk, just like quitting smoking or taking cholesterol or blood pressure medications.

In addition, I often encounter patients who say, “I never get the flu,” to which I respond, “If you didn’t have any symptoms, how would you know?” It’s important to inform patients that they could still have silent infections that can put close family members at risk and increase their risk of cardiovascular outcomes. By framing the conversation this way, patients often realize the broader implications of vaccine-preventable disease.

Incorporating the aspects of cardiovascular risk reduction and family protection into the story, we typically see an increase in vaccine acceptance. In my experience, a systematic, multimodal approach, with strong presumptive recommendations by their clinical provider, will increase the vaccine acceptance rate.

Ensuring that our healthcare staff are all vaccinated and actively involved in these discussions also plays a critical role. Staff vaccination leads to more confident and persuasive recommendations, whereas a hesitant or unvaccinated staff member may dilute the effectiveness of a presumptive recommendation. We aim for comprehensive vaccination among staff, as well as consistent messaging, to maximize patient vaccine acceptance.

For healthcare providers who are hesitant to engage in these discussions, it’s important to lead by example. If the provider is vaccinated, they can share their personal experience to reassure patients and address any concerns patients may have about potential side effects. Providers can also help patients plan around the side effects, so they feel more in control of the process.

Nursing Home/Long-term Care Facility

In nursing homes or long-term care settings, providers benefit from having standing orders for ACIP-recommended vaccines, including seasonal influenza vaccines, as part of routine care that begins at the time of admission. These protocols streamline the vaccination process and reduce the need to request consent annually, easing the workload for staff.

However, while these protocols help, vaccine hesitancy, often shaped by family influence, remains a challenge. In particular, COVID-19 vaccine hesitancy can influence hesitancy for other vaccines, such as the seasonal influenza vaccine. For instance, family members might discourage a resident from receiving a vaccine, even if the resident initially agrees.?

To address this, I prefer to use a presumptive recommendation approach, framing vaccination as part of the standard of care and primary prevention. This method reinforces the expectation that vaccines are routine and essential while still allowing residents the right to decline it. By maintaining consistent messaging about the benefits of vaccination for both individual and community health, we can better navigate vaccine hesitancy.

Conclusion

I often use analogies to make vaccine education easier for patients. For instance, a common comparison I make is between the influenza vaccine and a seatbelt. While a seatbelt does not prevent car accidents, it significantly reduces the severity of injuries when one occurs. Similarly, the influenza vaccine does not completely eliminate the risk of infection, but it greatly reduces the risk of severe complications. So, although some individuals may still suffer fatal injuries despite wearing a seatbelt, and some people still get sick after receiving the influenza vaccine, both are preventative measures that can markedly reduce the likelihood of serious harm.

Want more content like this? Click here to join 2M+ HCPs learning for free with CCO.

Your Thoughts?

How do you address vaccine hesitancy in your practice? What strategies have worked for you in increasing vaccination acceptance? Share your experience by posting a comment.