Nurse talking with patient

The reasons for vaccine hesitancy — a delay in acceptance or refusal to be vaccinated — can be boiled down to five important factors that may help clinicians understand and better approach this issue, according to a group of London-based physicians.

The news comes as some long-term care providers struggle with low vaccination rates among staff members.

“Reversing and mitigating the ongoing damage wrought by COVID-19 is largely contingent on a successful worldwide equitable vaccination strategy,” according to Mohammad S. Razai, M.D., from the St. George University of London, and colleagues. An estimated 60% to 70% of the world’s population needs to be vaccinated to achieve a level of immunity that will significantly reduce the risk of transmission and outbreaks, the doctors wrote in and article published Wednesday in the Journal of the Royal Society of Medicine article.

Image of Mohammad S Razai, M.D.
Mohammad S. Razai, M.D.

To encourage more vaccination in skeptical or fearful adults, Razai and colleagues propose that clinicians attend to what they’ve dubbed the “Five C’s” of vaccine hesitancy, summarized here:


Confidence in vaccine safety, efficacy and importance is crucial when addressing hesitancy. This factor is highlighted by recent concerns about possible links between the AstraZeneca and Johnson & Johnson vaccines and very rare blood clots such as cerebral venous sinus thrombosis. “Members of the public need to understand that these events are extremely rare (estimated four per million people vaccinated). The risk of getting cerebral venous sinus thrombosis if you contract COVID-19 may be up to 10 times higher than getting it due to vaccination, and for most people the benefits of vaccine vastly outweigh the risk,” the authors stated. 


Complacency is strongly associated with lower vaccine uptake, Razai and colleagues wrote. “Addressing complacency through repeated risk communication is crucial to facilitate informed decision-making. It is important to emphasize the greater societal benefits of population level immunity and the protection it offers to those who are vulnerable, their families and friends.”


“According to the World Health Organization, the world is also fighting an ‘infodemic’ of ‘a few facts, mixed with fear, speculation and rumour’ which … has been amplified through technology and social media platforms,” the authors wrote. “Genuine transparent dialogue backed by community engagement is required to address the public’s concerns and build confidence. It also is important to acknowledge uncertainties,” they added.


The context of vaccine hesitancy is often overlooked, and may include ethnicity, religion, occupation and socioeconomic status, Razai and colleagues wrote. “The problem starts with the term vaccine hesitancy itself … [which] does not take account of the powerful structural factors such as systemic racism and access barriers which may lead to low vaccine take-up in some groups. Further, it places an emphasis on individual agency and implies a degree of blame.”


“Vaccine hesitancy is complex, variable and shaped by multiple contextual factors,” the authors explain. “Strengthening local capabilities to mobilize diverse communities by addressing the Five C’s of vaccine hesitancy through tailored, appealing, culturally competent and multilingual messages is supported by evidence and could have the highest chance of success,” they concluded.