Vaccine hesitancy in primary care: Strategies for nurses and ANPs

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Reference: May-June 2026 | Issue 3 | Vol 19 | Page 60

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Vaccination remains one of the most effective public health interventions for preventing infectious disease, reducing morbidity and mortality, and improving population health outcomes.

Despite the proven benefits of immunisation programmes, vaccine hesitancy has emerged as a significant challenge for healthcare systems worldwide.

The concept of vaccine hesitancy refers to the delay in acceptance or refusal of vaccines despite the availability of vaccination services. It is recognised as a complex and context-specific phenomenon that varies across time, geographic settings, and specific vaccines.¹

Several frameworks have been proposed to explain the determinants of vaccine hesitancy. The World Health Organisation Strategic Advisory Group of Experts developed the widely used 3Cs model, identifying three key drivers: Confidence, complacency, and convenience.^1,2

Confidence relates to trust in vaccines, healthcare providers, and public health systems. Complacency occurs when individuals perceive the risk of vaccine-preventable diseases as low, reducing perceived need for vaccination. Convenience refers to structural or logistical barriers such as access, cost, or service availability.^{2, 3}

More recent research has expanded this model. Studies exploring Covid-19 vaccine hesitancy in Ireland suggested a 4Cs framework that includes communication as an additional factor influencing public attitudes.⁴ Communication includes the influence of media narratives, misinformation, and public health messaging on vaccination decisions.

Understanding these drivers is important because different forms of hesitancy require different responses. Concerns about safety, mistrust in institutions, and practical barriers to access require tailored interventions rather than a single universal strategy.⁴

Vaccine hesitancy as a public health challenge

In Ireland, vaccination uptake remains generally high, particularly within childhood immunisation programmes. Childhood immunisations protect children from serious diseases such as measles, mumps, rubella, diphtheria, tetanus, pertussis, polio, Hib (Haemophilus influenzae type b), hepatitis B, meningococcal B and C, pneumococcal disease, rotavirus, and human papilloma virus (HPV).

Decades of research and real-world experience have consistently demonstrated the safety and effectiveness of these vaccines. In addition to extensive research demonstrating vaccine safety and efficacy, government agencies regulate vaccines to ensure their safety. However, episodes of declining uptake associated with misinformation or safety concerns have occurred.¹

Ireland is not immune to the influence of vaccine hesitancy. The decline in uptake of the HPV vaccine across the country between 2015 and 2017 highlighted the impact that misinformation and loss of public trust can have on vaccination programmes.

Recovery of HPV vaccination rates required sustained public health campaigns and engagement with healthcare professionals, including nurses and general practitioners.⁵

Despite historically strong immunisation uptake, recent observations suggest declining coverage for routine childhood vaccines, prompting public health concern. Measles, which had been effectively eliminated in Ireland in 2015, has seen resurgence, with notified cases rising markedly in recent years.⁶

The national uptake of the measles, mumps, and rubella (MMR) vaccine for junior infants dropped from 91.2 per cent in 2018/2019 to 87.5 per cent in 2021/2022, with only a partial recovery to 89.8 per cent in 2022/2023 – figures that remain below the 95 per cent threshold required for herd immunity.⁶

Another report found that Ireland had one of the lowest childhood vaccination coverage rates in western Europe in 2023, with 91 per cent of children fully vaccinated and nearly 5,000 receiving no vaccines at all.⁷ These trends signify not only missed protection for susceptible individuals but also a broader vulnerability to outbreaks of vaccine-preventable diseases.

The pandemic highlighted the influence of hesitancy in real time. National surveys revealed that large proportions of the Irish adult population were initially uncertain or resistant towards Covid-19 vaccination. In one study, 26 per cent of Irish respondents were hesitant and 9 per cent were resistant to the Covid-19 vaccine, figures that mirror international hesitancy patterns.⁸

Research also suggests that the public often underestimates vaccine effectiveness and may not fully appreciate dynamics such as waning immunity, complicating public confidence in vaccination programmes.⁹ These observations reinforce the need for effective primary care engagement strategies tailored to the populations that nurses serve.

Primary care clinicians, particularly practice nurses and advanced nurse practitioners (ANPs), play a central role in vaccination delivery and patient education, and have an important role in shaping patients’ perceptions and decisions about vaccination. As trusted healthcare professionals who frequently interact with patients and families, nurses are uniquely positioned to address vaccine hesitancy through effective communication, education, and evidence-based counselling.¹⁰

Epidemiology and determinants of vaccine hesitancy

Understanding the prevalence and determinants of vaccine hesitancy is important for designing interventions that resonate with communities. In Ireland, vaccine hesitancy has been documented across population groups, including adults and parents of young children. A nationally representative study of the general adult population found that approximately 26 per cent were hesitant and 9 per cent were resistant toward Covid-19 vaccination, with similar patterns noted in pooled research.⁸

Internationally, systematic reviews have identified a constellation of factors consistently associated with hesitancy, including demographic characteristics, perceptions of vaccine safety, trust in health authorities, misinformation exposure, and previous experiences with healthcare systems.¹¹

Sociodemographic correlates such as age, gender, and socioeconomic status have been linked to vaccine hesitancy. Younger adults and women have demonstrated higher rates of vaccine uncertainty in some studies, while individuals from lower socioeconomic backgrounds may harbour greater mistrust or face informational barriers.¹²

Psychological and behavioural correlates also play significant roles. Those who exhibit hesitancy often rely more heavily on nonauthoritative information sources such as social media, where vaccine misinformation proliferates, and are less likely to seek information from conventional public health channels.⁸ Perceived risk of disease, civic attitudes, peer influence, and perceived vaccine benefits have emerged as strong predictors of vaccine intentions.¹²

Barriers to vaccine uptake are not evenly distributed. In certain subpopulations, such as people with chronic neurological conditions such as multiple sclerosis, vaccine hesitancy stems from specific concerns regarding safety and interactions with disease-modifying treatments, alongside gaps in clinician-delivered vaccine promotion.¹³

Among healthcare workers themselves, hesitancy can be influenced by similar factors, with younger age, female sex, and nonclinical roles associated with lower uptake, highlighting that hesitancy is not confined to the general public but affects the healthcare workforce as well.¹⁴

For nurses, metaanalytical evidence suggests that safety concerns, complacency, and logistic barriers contribute to hesitancy, indicating the need for targeted professional support to enhance vaccine uptake among providers.¹⁵

Together, these findings illustrate that vaccine hesitancy is a multifactorial challenge shaped by information, social context, individual beliefs, and prior experiences. Addressing these determinants requires multifaceted approaches that extend beyond simple education to include communication, trustbuilding, and system-level interventions.

Impact of declining immunisation coverage in Ireland and globally

The decline in vaccination coverage has palpable implications for public health in Ireland. The resurgence of measles serves as a stark reminder of the consequences of sub-optimal immunisation. After achieving elimination, Ireland witnessed only a handful of measles cases for several years.

However, last year notified cases soared to 208 from just four in 2023, while pertussis notifications climbed dramatically from 18 confirmed cases in 2023 to 713, highlighting a deteriorating immunisation environment.⁷ Such increases highlight the fragile nature of herd immunity and the ease with which vaccine-preventable diseases can re-emerge when uptake falters.

Globally, stalled progress in childhood immunisation coverage has placed millions of children at risk of preventable illness and death, with declines reported in both low- and high-income settings. A Lancet analysis found that while vaccination coverage doubled globally between 1980 and 2019, progress has stagnated or reversed in many countries since 2010, partly due to vaccine hesitancy and disruptions from the Covid-19 pandemic.¹⁶

In Ireland and across Europe, sustained or rising levels of hesitancy threaten to undermine population health, increase healthcare costs, and erode public trust in health systems.

These epidemiological trends highlight the urgency with which primary care practitioners must act to prevent further erosion of immunisation coverage. Nurses and ANPs in primary care are ideally positioned to influence vaccine decision-making through trusted relationships, routine care encounters, and ongoing patient education.

Strategies for addressing vaccine hesitancy in primary care

Addressing vaccine hesitancy in primary care requires a nuanced blend of communication skills, clinical knowledge, cultural awareness, and system support. Practical, evidence-based strategies pivot on four overlapping domains: Communication and counselling, education and training, building trust and partnerships, and system-level interventions.

Effective communication is central to addressing vaccine hesitancy. Nurses and ANPs should use patient-centred dialogue that explores concerns without judgement and promotes trust. Open-ended questions and reflective listening allow patients to express fears and beliefs while helping clinicians build rapport. A presumptive communication style presenting vaccination as a routine part of care has been shown to increase uptake compared with more tentative approaches.^10,15

Motivational interviewing is also valuable in vaccine discussions. This approach helps patients explore their own motivations and resolve ambivalence by emphasising autonomy, empathy, and collaboration rather than persuasion.¹⁷

Clinicians trained in motivational interviewing may be more effective at addressing concerns without alienating patients. Clinicians should answer questions clearly and honestly. Admitting uncertainty when evidence changes can build trust, while dismissing concerns may increase hesitancy. Presenting information fairly, with risks and benefits explained, helps patients make informed decisions.

Patient education is central to addressing vaccine hesitancy, particularly where misconceptions about safety or effectiveness exist. Nurses can use clear, accessible information to address common myths, explain vaccine safety monitoring, and outline the established risk profiles of vaccines. Providing context on the potential complications and community impact of vaccine-preventable diseases also supports informed decision-making.

Professional education is important. Many nurses and other clinicians report feeling underprepared for conversations about vaccine hesitancy due to limited training in communication and behavioural strategies.¹⁸ Incorporating vaccine communication training into continuing professional development, including guidance on misinformation, motivational interviewing, and patient engagement, can improve clinicians’ confidence and effectiveness.

Trust strongly influences vaccine acceptance. Patients who trust healthcare providers and public health institutions are more likely to follow vaccination recommendations. Building this trust requires consistent messaging, transparency about risks and benefits, and cultural sensitivity. In diverse or marginalised communities, collaboration with community leaders and local organisations can help ensure messages are relevant and credible.

Nurses and ANPs should also recognise the role of social influences in vaccine decisions. Peer influence, civic responsibility, and perceived social norms can shape vaccine intentions.¹² Highlighting strong community uptake and framing vaccination as a contribution to collective health may help encourage acceptance.

System-level strategies can strengthen vaccination efforts beyond individual consultations. Reminder and recall systems, such as automated messages for due vaccines, improve timely uptake. Integrating prompts into routine reviews or key consultations also ensures vaccination discussions occur regularly.

Recording patient concerns in electronic records supports continuity and follow-up.¹⁹ Interprofessional collaboration is important. Consistent messaging from GPs, nurses, ANPs, pharmacists, and public health professionals helps prevent confusion. Practice audits of vaccination rates can identify gaps and guide targeted quality improvement initiatives.¹⁹

Challenges and barriers in clinical practice

Notwithstanding the availability of effective strategies, nurses and ANPs face barriers in implementing them. Time pressures in primary care can limit the depth of conversations about vaccination. They may also encounter resistance rooted in deep-seated beliefs that are resistant to brief educational efforts.

Structural issues such as limited access to culturally appropriate resources and language barriers further complicate engagement. Recognition of these challenges highlights the need for organisational support, protected consultation time for vaccine discussions, and access to multidisciplinary resources for complex cases.²⁰

Future directions and research need

Ongoing research is needed to improve strategies for addressing vaccine-hesitancy in different populations. Long-term studies can identify the main factors behind hesitancy beyond short-term crises like Covid-19. Digital health tools that counter online misinformation offer new ways to influence vaccine beliefs widely.

Evaluating educational programmes for nurses and ANPs can help determine the most effective training and support. At policy level, using behavioural science in national immunisation plans can better address community concerns.²¹

Conclusion

Vaccine hesitancy is a major challenge to maintaining high immunisation coverage and protecting public health. Nurses and ANPs play a key role in addressing this through clear communication, patient education, trust-building, and engagement in primary care. Evidence-based strategies such as motivational interviewing, empathetic dialogue, tailored education, and system-level supports can improve vaccine acceptance. By using these approaches in routine practice and supporting organisational frameworks, nurses and ANPs help strengthen immunisation programmes and protect communities from vaccine-preventable diseases.