Vaccine hesitancy: Moving practice beyond binary vaccination outcomes in community pharmacy

Introduction Unequivocally, vaccinations can be considered one of the greatest global achievements for public health. Since the introduction of the first vaccines, vaccination programs have contributed to a substantial decline in both mortality and morbidity of many previously lethal infectious diseases around the globe. However, high and sustained vaccine uptake is necessary for these efforts to remain successful. Beyond the direct protection provided for vaccinated individuals, high vaccine coverage also induces indirect protection against vaccinepreventable diseases (VPD) at a population level through herd immunity. Yet despite consensus on the public health benefits of vaccination, recent reports of clustered outbreaks and the resurgence of VPDs in underor nonimmunized groups highlight the ongoing challenges. The concept of vaccine hesitancy represents a significant conceptual shift away from the traditional dichotomy of accept or reject, of proor antivaccine. Defined by the World Health Organization’s (WHO) SAGE Working Group as “the delay in acceptance or refusal of vaccination despite availability of vaccination services,” vaccine hesitancy is “complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence.” Vaccine hesitancy highlights the wide spectrum of vaccination beliefs, attitudes and behaviours of a large heterogeneous group of individuals situated between the 2 end points of the continuum (see Figure 1). For example, vaccine-hesitant individuals may refuse some vaccines but accept or delay others; some may accept a vaccine but remain concerned with their decision; and others may even personally refuse all vaccines but remain supportive of vaccinations more broadly. While vaccine hesitancy is not always the root cause of underor nonimmunization, it is listed in the top 10 threats to global health for 2019 by the WHO and remains an important contributor to suboptimal vaccine coverage across many jurisdictions. A large body of interdisciplinary research has explored the factors and determinants that shape vaccine-hesitant beliefs, attitudes and behaviours. From a practice perspective, 3 observations are particularly important: