Rethinking Vaccine Uptake in Long-Term Care: What If Vaccine Hesitancy Isn’t the Problem?

When vaccine uptake in a long-term care home is lower than we want, one of our first instincts is usually education. We provide another information session, share another fact sheet, reinforce the recommendation, answer questions and try to make sure residents, families and staff have the information they need. There is nothing inherently wrong with that response. After all, if someone does not have enough information to make an informed decision, education is exactly what we should be providing.

But what if lack of information is not actually the problem? What if we have become so accustomed to talking about vaccine hesitancy that we sometimes use the term to describe almost anyone who has not said yes? That distinction matters because once we label something as vaccine hesitancy, we have already started defining the solution. We assume there is a confidence or knowledge problem, which naturally leads us toward more education, more explanation and more attempts to persuade. The uncomfortable possibility is that sometimes we may be trying to solve the wrong problem.

What if vaccine hesitancy isn’t the problem?

There is something appealing about the term vaccine hesitancy because it gives us a relatively simple explanation for a complicated outcome. Someone has not been vaccinated, therefore, they must be hesitant. Human decisions, however, rarely work that neatly. The World Health Organization’s Behavioural and Social Drivers framework takes a much broader view of vaccination, looking at what people think and feel, social influences, motivation and practical issues surrounding vaccination. The underlying idea is useful for long-term care: before deciding how to improve uptake, first understand what is actually influencing the decision.

That creates a more interesting question than simply asking why people are vaccine hesitant. What happens if we ask what is actually happening underneath the decision? Perhaps someone does not trust the recommendation; perhaps they are afraid of a side effect because of something they experienced previously; perhaps they have heard two different answers to the same question and are no longer sure whom to believe, or perhaps their family is strongly influencing how they think about vaccination. Someone may want to speak with their physician because they see this as an individual health decision rather than an infection-control decision, while someone else may simply feel uncomfortable or pressured and have difficulty explaining exactly why.

All of those situations can produce the same outcome in our vaccination numbers: the person is not vaccinated. Yet they are not the same problem, which means they should not automatically lead to the same response. Once we start thinking this way, vaccine uptake becomes much more interesting than a percentage on a spreadsheet. It becomes a window into trust, communication, relationships and how people make decisions when they are uncertain.

What if more vaccine education isn’t the answer?

This is probably where the argument becomes a little more uncomfortable, because healthcare organizations invest significant effort into vaccine education and, appropriately, we want people to have access to reliable information. The argument is not that vaccine education is unnecessary. The argument is that education works best when we know what we are trying to address.

Imagine someone tells you they are worried about a vaccine. Our natural instinct as healthcare professionals is often to start explaining because we understand the evidence, we know the benefits and risks, and we want the person to have accurate information. But there is a step before all of that which can easily disappear: what are they actually worried about? Those two words, “I’m worried,” can represent completely different concerns. One person may be afraid of a particular adverse event, another may have lost trust because of a previous experience, while someone else may feel that everyone is telling them what to do without anyone genuinely asking what they think.

Giving all three people the same presentation is unlikely to address all three concerns. This is why recipient-centred vaccine communication matters. Canadian immunization guidance emphasizes listening, understanding where concerns come from, using a non-confrontational approach and adapting the information to what the individual actually needs. Seen this way, education becomes less about delivering information and more about making sure the information answers the question the person is actually asking.

Perhaps, then, the better first question is not, “What information can I give this person?” It is, “What does this person need from this conversation?” Sometimes the answer will absolutely be more information, but sometimes it may simply be an opportunity to ask a question without feeling judged, to hear a recommendation from someone they trust, or to work through uncertainty without feeling that the conversation has already decided where they are supposed to end up.

Are we sometimes making vaccine conversations harder?

Anyone who has been involved in a difficult vaccine conversation knows how quickly it can become emotional. A resident raises something they saw online, a family member challenges the recommendation, or a staff member questions something that feels scientifically obvious to the person answering them. There can be a very strong urge to correct the information immediately, and sometimes correction is necessary. The question is not whether we should allow inaccurate information to go unchallenged, but whether the way we respond helps the person remain engaged in the conversation.

If every concern is immediately corrected, if several facts are delivered before the person has finished explaining themselves, or if the conversation starts to feel like a debate that someone needs to win, we may end up talking past each other. The information we provide can be completely accurate while the conversation itself becomes less effective. Inconsistent answers can make this worse, as can fear-based messaging, exaggerated promises or language that leaves someone feeling that there is only one acceptable response.

This is why communication approaches such as motivational interviewing are interesting in vaccine discussions. The point is not to create a clever technique for convincing someone to say yes. Rather, the approach emphasizes understanding ambivalence, listening to the person’s reasoning and working through uncertainty without immediately turning the interaction into a confrontation. That distinction matters because there is a meaningful difference between someone hearing our recommendation and choosing to decline it, and someone disengaging from the conversation because they no longer feel heard.

For leaders, this creates a different training question. Are we only teaching staff what they need to know about vaccines, or are we also preparing them for what happens when someone says, “I’m not sure”? Those are very different skills, and knowing the clinical information does not automatically make someone comfortable navigating a difficult conversation.

What if vaccine confidence is built long before we talk about vaccines?

Residents, families and staff are building trust in the home and in their healthcare team throughout the year, long before anyone asks them to make a vaccination decision. They notice whether their questions are taken seriously, whether different members of the team give consistent information, whether uncertainty is acknowledged honestly and whether they feel included in decisions about their care. By the time vaccination comes up, that history of communication and trust may already be influencing how they respond.

Then, at some point, we ask them to make a vaccination decision. It would be surprising if all of those previous interactions suddenly stopped mattering.

This is where vaccine strategy starts to become less about a seasonal educational campaign and more about the environment in which people are being asked to make healthcare decisions. If residents and families only hear from us when a consent form needs to be returned, we should probably not be surprised when some conversations feel difficult. If staff only hear about vaccination once leadership becomes concerned about uptake, we may have missed opportunities to build understanding earlier. And if the answer to a vaccine question depends heavily on which member of the team someone happens to speak with, we may unintentionally create uncertainty while trying to reduce it.

Perhaps a better way to evaluate a vaccine campaign, then, is not only to ask how good the education was. We should also be asking what kind of environment people were making the decision in, whether they had access to people they trusted, whether questions were welcomed, and whether the information they received felt consistent and credible.

What if a refusal is not the end of the story?

Another habit worth reconsidering is what happens after someone declines vaccination. Administratively, the process can feel complete because the decision is documented and the person has refused, so everyone moves on. Human decisions, however, are rarely that permanent. Someone can be uncertain today and more comfortable tomorrow; they may have a question now that gets answered later; they may want to speak to someone they trust; or they may simply need more time to think.

The idea here is not to pressure people. Regulations (and honest healthcare practices) require consent to treatment to be informed and voluntary, and a capable person has the right to give or refuse consent to their own treatment. That principle has to remain central. Respecting a decision, however, does not mean that we turn that decision into a permanent one!

A person can say no and still be open to questions later; they can decline vaccination and still deserve access to credible information; they can change their mind; or they can continue to decline. The important point is that respectful engagement should leave room for informed decision-making without turning every future interaction into another attempt to overcome the person’s refusal.

What if your best vaccine educator isn’t your IPAC Lead?

Those of us working in infection prevention naturally tend to think about expertise. If we want people to understand vaccination, we look for the person who knows the most about vaccines, and in many long-term care homes that may be the IPAC Lead. There are good reasons for that. IPAC Leads understand infection risk, vaccine-preventable disease, outbreaks and the role vaccination plays within a broader infection-prevention program.

But expertise and trust are not always the same thing.

Think about how most people make difficult healthcare decisions themselves. They do not always seek out the person with the greatest technical knowledge in an abstract sense. Often, they turn to the person whose judgment they already trust. For one resident, that might be their physician, for another it may be a nurse practitioner, pharmacist or nurse who knows their health history well. A family member may also play an important role in how someone thinks through the decision.

The IPAC Lead can still play an important role by providing the technical foundation, supporting consistent messaging and helping other members of the team prepare for questions. The most meaningful conversation, however, may happen with someone else entirely. That is not a weakness in the vaccination program; rather, it may be a sign that the program understands that trust and expertise both matter.

Maybe “vaccine hesitancy” is simply too small a question

Vaccine hesitancy is real, and some residents, families and staff will have significant concerns about vaccination. The risk is not in recognizing hesitancy, but in using the term so broadly that it becomes our explanation for almost every instance of lower uptake.

Once we do that, we can become very efficient at solving the problem we assume exists. We produce more education, reinforce the recommendation and train people to answer common questions, yet we may never stop to ask whether any of those actions address what is actually influencing the decision.

Perhaps the more useful approach is curiosity. What is this person actually concerned about, what is influencing their decision, do they trust the person speaking with them, are we answering the question they are asking or the question we wish they were asking, and are we giving them room to think or unintentionally creating a conversation they feel they need to defend themselves from?

Those questions are harder, which is exactly why they may be more useful.

The goal should not simply be to become better at convincing people to get vaccinated. It should be to create an environment where residents, families and staff can have informed, credible and respectful conversations about vaccination, where genuine barriers can be identified and where people can make decisions with access to reliable information and people they trust.

Sometimes that will mean more education, sometimes it will mean changing how we communicate, sometimes it may mean recognizing that the person delivering the message matters almost as much as the message itself, and sometimes it will simply mean listening long enough to discover that what we thought was vaccine hesitancy was actually something else entirely.

Before we assume someone needs more vaccine information, we need to understand what they need from the conversation. Sometimes the most useful place to begin is listening.