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Vaccine hesitancy is the delay in acceptance or outright refusal of immunizations, which has evolved into a growing public health threat. In this article, we explore recent trends in vaccine hesitancy in the setting of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic, vaccine-specific variations, social media influence, and sociodemographic factors. During the coronavirus disease 2019 pandemic, the antivaccine movement gained increasing support and generated widespread conspiracy theories and mistrust. This highlighted the importance of enhancing communication between the health care field and general public. While the impact of antivaccine social media is widespread, physicians have also begun to use technology to spread factual information and increase vaccination uptake. There is a growing body of evidence regarding sociodemographic data, including the pervasive impact of medical racism on vaccine hesitancy, with additional studies on age, education, income, and more. Providers must serve as communicators and focus on presumptive language, strong recommendations, and tailored conversations with families who are hesitant about vaccines. [Pediatr Ann. 2025;54(5):e154–e159.]
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Vaccines play a key role in disease prevention in children. The Centers for Disease Control and Prevention (CDC) estimates that among children born between 1994 and 2023, routine childhood vaccinations will have prevented approximately 508 million lifetime cases of illness, 32 million hospitalizations, and 1.129 million deaths, at a net savings of $540 billion in direct costs and $2.7 trillion in societal costs.1 Thus, vaccine hesitancy is a gripping topic affecting patients and their health outcomes due to concern for increased morbidity and mortality resulting from delayed or refused immunizations.
Vaccine hesitancy is defined by the World Health Organization (WHO) as the delay in acceptance or refusal of vaccines despite availability of vaccination services.2 In recent years, there has been increased recognition of vaccine hesitancy as a threat to public health, with hesitation rates varying greatly based on the specific vaccine, ranging from 56% for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine to 12% for other vaccines, such as polio.3 Specific vaccination rates and trends are influenced by multiple factors, including the SARS-CoV-2 pandemic, social media, equity, and social determinants. Headway has been made to identify key approaches to vaccine hesitancy in health care settings and beyond, although a paucity of literature remains about interventions in the examination room that impact vaccination rates. Ultimately, the WHO Immunization Agenda from 2021 outlined multiple goals to reach by 2030, including aiming for 90% coverage of essential vaccines in childhood and adolescence and a 50% reduction in the number of children missing out on all vaccines.4
The Impact of the SARS-CoV-2 Pandemic
In 2020, the SARS-CoV-2 pandemic struck the world, impacting everything from grocery store trips to immunization rates. There was a striking decrease in childhood immunizations during the pandemic, which was influenced by reduced access to health care services, an increased social media presence of antivaccine groups, and growing mistrust of medical organizations.5 When the vaccine against SARS-CoV-2 began distribution, discussions regarding vaccine development, safety, and efficacy were brought to the forefront of conversations.
Antivaccine sentiment that already existed prior to the pandemic had set the stage for worsening vaccine hesitancy. The movement aligned with right-wing politics for more targeted messaging, gained a strong online presence through forums and social media, and targeted medical professionals with harassment as part of an antiscience discourse.6 This ultimately combined to create an environment that antivaccine activists took advantage of by spreading discontent and doubt regarding vaccine trials, with data from UNICEF demonstrating declining confidence in childhood immunizations of up to 44 percentage points in some countries.7
A systematic review found confidence and complacency were key cognitive factors in those who refused the SARS-CoV-2 vaccination. Individuals who were likely to accept the vaccine had higher rates of confidence in government-based decisions, public health recommendations, and vaccine efficacy and delivery. Complacency focused on individuals who believed the disease was low-risk and unlikely to infect them, thus deeming the vaccine unnecessary.8 Furthermore, hesitancy during the SARS-CoV-2 pandemic was exacerbated by social media and the spread of misinformation. Conspiracy theories range from topics, such as technology-related theories (ie, microchips in the vaccine) to secret societies and power structures (ie, influence of Big Pharma).
There are multiple drivers of low SARS-CoV-2 update including low trust of various organizational bodies (ie, government vs health care organizations) coupled with both general and specific conspiracy theories. This introduced a new perspective on public health crises, arguing for the value of improved health communication in future pandemics. Rather than solely aiming interventions at increasing public knowledge, providers must also focus on rebuilding trust and consequently steering the public away from conspiracy theories.9
A Deeper Dive into the Vaccine-Specific Factors Influencing Vaccine Hesitancy
It is necessary to acknowledge that hesitancy is not equal among all vaccines (ie, the human papillomavirus [HPV] and influenza vaccines have high hesitancy rates). The Vaccine Hesitancy Scale, developed by the WHO, has been modified for the HPV and influenza vaccines, allowing for more relevant and accurate assessments of vaccine hesitancy.10
While we will be focusing on HPV and influenza vaccine hesitancy, it is important to note that the measles virus continues to cause more than 9 million cases of disease and 136,000 deaths worldwide every year.11 Disruptions to vaccination programs during the SARS-CoV-2 pandemic resulted in significant setbacks to administration efforts of the measles, mumps, rubella (MMR) vaccine, which have yet to be reversed. In communities where measles outbreaks have occurred, various concerns have been raised, such as adverse reactions, safety, total number of vaccines administered, and immunization schedules. Concerns about the association between MMR and autism spectrum disorder remain pervasive in these communities, despite evidence contrary to this claim.12
Human Papillomavirus Vaccine
The current recommendation from the Advisory Committee on Immunization Practices (ACIP) is for all genders to receive the 9-valent HPV vaccine series (ie, 2 or 3 doses based on age at initial vaccination) starting at age 11 years; although, administration can begin as early as age 9 years.13 Hesitancy toward the HPV immunization has been affected by its history and the sexually transmitted nature of the majority of HPV infections. Controversial political actions, media coverage, and changing recommendations all created confusion among parents and providers, reduced provider recommendations for the vaccination, and created feminization of the HPV vaccine. In the present day, some parents continue to believe there is no benefit to their male children.14 The current trend in HPV immunization rates demonstrates no significant changes from 2022 to 2023, with approximately 61% of teens fully vaccinated and 77% with at least 1 HPV vaccine.15
Parent and physician surveys have demonstrated an increase in physician recommendation to parents for the HPV vaccine since its release. Among hesitant parents, safety concerns increased in all demographic groups with the greatest increase among Black adolescent females. The most common reason for hesitancy varied by sex, race, and ethnicity, with “safety concerns” the highest for parents of White teenagers and “not necessary” the highest for parents of Black adolescent females.16
It is important to recognize that Black and Hispanic women are disproportionately affected by HPV infection and sequelae.17 In a 2023 study surveying 402 Black mothers, 48% of respondents indicated intention to vaccinate their daughters, thus demonstrating the importance of continuing targeted messaging and discussions between physicians and Black parents.17 The number of daughters, the HPV vaccine status of the mother, the perceived benefits and safety concerns of the HPV vaccine, pediatric HPV vaccination peer norms, and doctor recommendations were found to be independent factors of Black mothers' intentions to vaccinate their daughters against HPV.17
Furthermore, among young adults, immunization rates are higher in the LGBTQ+ (lesbian, gay, bisexual, trans-gender, queer or questioning, intersex, asexual) community, which is important to acknowledge given the increased risk of HPV-related cancers in sexual and gender minority groups.18 Pediatricians should continue to be aware of trends in the communities they serve to promote data-driven knowledge about the HPV vaccine.
Influenza Vaccine
The ACIP recommends that all children age 6 months and older receive the influenza vaccine annually. Influenza is highly transmissible and adds a great burden to the US health care system, with approximately $3 billion in direct medical costs and $8 billion in indirect medical costs, such as loss of productivity every year.19 Importantly, racial-ethnic minority groups disproportionately experience adverse flu-related outcomes, with severe outcomes (eg, hospitalization, intensive care admission, death) up to 4 times higher compared with White individuals.20
Influenza vaccination rates have been steadily decreasing since the SARS-CoV-2 pandemic, now down 8 percentage points compared with the pre–SARS-CoV-2 pandemic influenza season. During the 2023–2024 season, only 55.4% of children were vaccinated against influenza.21 In 2023, at least 30% of children had a parent who was hesitant about the influenza vaccine.21
The influenza vaccine is susceptible to increased vaccine hesitancy because it is required annually, is less effective against symptomatic disease compared with other immunizations, and is subject to false beliefs (eg, “the vaccine causes the virus”).22 Studies have demonstrated that providers have the capacity to influence parental intent to vaccinate. Motivational interviewing, use of presumptive language, bundling the influenza vaccine with other shots, and having multiple conversations despite initial parental hesitation has been shown to increase acceptance rates.23 Thus, ongoing discussions among families, particularly those in populations that are more likely to be hesitant, and education for the general public are essential to decrease influenza vaccine hesitancy.
The Spreading Influence of Social Media
Despite decades of immunization safety data, concerns about vaccine safety remain. Vaccine hesitancy has been directly linked to misinformation being spread on social media.24 Studies on social media range from focusing on a single vaccine, on specific vaccination campaigns, or using artificial intelligence to study trends in language. Additionally, health care professionals have started to use social media, various applications, and virtual reality to study and improve vaccination rates in their communities.25–27
Given the scale of antivaccine sentiment on social media that is difficult to counter with face-to-face interactions alone, Wolynn et al.25 created an action-oriented support tool to help health care providers become more adept at leveraging social media. Their goal is to amplify pediatricians' voices to effectively reach patients and their families as part of the solution to decrease vaccine misinformation. The ADEPT (amplify, direct, engage, post, tag) toolbox describes the importance of amplifying trusted voices (eg, CDC, American Academy of Pediatrics [AAP]), directing patients to information resources about vaccine clinics and reputable online vaccine safety (eg, Vaccine Safety Net [
Ruggeri et al.28 compiled a list of evidence-based insights that can help health care providers confront vaccine hesitancy on social media. They highlight the importance of creating targeted messages that address both parents and adolescents. Messages must be high-quality, visible, and incorporate cultural values.28 Lastly—and possibly most importantly—messaging from a trusted source is likely to have a major role in vaccination decisions. Such advocacy through social media may leave health care providers vulnerable to attack from online anti-vaccine groups. Organizations, such as Shots Heard Round the World (
Socioeconomic Factors Related to Vaccine Hesitancy
Vaccination uptake is influenced by both behavioral and social drivers. Barriers to vaccination can be structural (eg, access) and attitudinal (eg, beliefs, perceptions). These structural and attitudinal barriers are subject to fluctuation over time and across population subgroups. Beliefs and perceptions may be informed by historical injustices, trust or mistrust in health care systems, and misinformation.29
Racial discrimination has been directly correlated with increased odds of vaccine hesitancy.30 Padamsee et al.31 explore how medical racism likely affected these trends, causing caution among the Black community in newly introduced medical technologies. However, this vaccine hesitancy was shown to be more easily overcome than that of White individuals.31 Age, sexual orientation, income, education, employment, and health insurance status have also been studied as they relate to vaccination decisions. Findings vary depending on the specific vaccine and the study environment, among other factors.32–34
Ultimately, health care providers and community leaders should focus on susceptibility, severity of infection, benefits of vaccination, safety concerns, and vaccine efficacy. Understanding the unique needs of your specific community will allow providers and policy makers to help address the underlying causes of low uptake, including lack of confidence in vaccines and health care/government services, as well as issues related to access.35
The Pediatrician's Approach to Vaccine Hesitancy
While there are multiple approaches to the family who is hesitant about vaccines, we have compiled alternatives from recent research to provide a starting point for pediatricians and key objectives for educating the future pediatric workforce. First, it is important to note that parents may have skepticism or hesitation but still ultimately be willing to vaccinate their children. The AAP and CDC recommend similar approaches to vaccination, starting with using presumptive language with parents. This sets the default as vaccination and has been shown to increase vaccination uptake.36
Both organizations address the need for providers to give strong recommendations for the vaccines in question, clearly citing why the vaccine is recommended by the medical field and tailoring it with personal additions. Active listening is key to tailor conversations based on parental concerns. Most parents act out of concern and protection of their children, and it is essential to approach vaccination conversations with that in mind. Asking parents specific questions to adapt the dialogue to their hesitations opens the ground for increased trust of providers. These recommendations are summarized in Figure 1.37,38 Yashar-Gershman et al.39 are developing and evaluating a novel process of quickly identifying parental mindsets at point-of-care in order to tailor provider messaging in addressing specific parent/caregiver concerns.
Beyond these key approaches to the vaccine conversations, providers must consider the changing landscape of medical decisions among patients (eg, the rise of conspiracy theories) and must leverage technology for solutions. When myths arise, Limaye et al.40 recommend pivoting the conversation to focus instead on the disease process rather than directly countering misconceptions that may actually reinforce incorrect information. Given safety concerns expressed by parental surveys, providers benefit from understanding the vaccine surveillance system (eg, Vaccine Safety Datalink, Vaccine Adverse Events Reporting System) to help be prepared to address parental concerns.37
Conclusion
Vaccine hesitancy is an ongoing public health concern. It has been greatly influenced by the SARS-CoV-2 pandemic and the rise of antivaccine messaging on social media. Hesitancy is often vaccine-specific, with varying rates of parental hesitancy regarding immunizations to prevent SARS-CoV-2, influenza, HPV, and other childhood diseases. As physicians continue to explore this topic with patients, it is necessary to understand potential sociodemographic factors at play, use presumptive language, give strong recommendations, and apply active listening skills to discuss vaccination concerns.
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