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December 2022, Volume 72, Issue 12

Primary Care Diabetes

Vaccine hesitancy in primary care: Building bridges by understanding barriers

Sanjay Kalra,  ( Department of Endocrinology, Bharti Hospital, Karnal, )
Madhur Verma,  ( Department of Community Medicine, AIIMS, Bathinda, )
Navneet Agrawal  ( Department of Diabetology, Diabetes Obesity and Thyroid Centre, Gwalior, India. )

Adult vaccination is an accepted part of health care and diabetes care. In spite of evidence regarding the efficacy and utility of vaccination in preventing disease, we continue to encounter vaccine hesitancy and vaccine skepticism. As physicians, it is our duty to encourage the public to get vaccinated. In this article, we create a simple framework which helps assess the barriers to vaccine acceptance, and create bridges to overcome vaccine hesitancy and skepticism. We use an interesting mnemonic, NARCO, to remind ourselves, and our readers, of the appropriate hierarchy of interviewing related to vaccine acceptance.

Keywords: Adult vaccination, COVID 19, Diabetes, Hepatitis vaccine, Immunization, immune-compromise, Influenza vaccine, Pneumococcal vaccine, Vaccination.






Adult vaccination has always been part of diabetes care, with influenza and pneumococcal vaccines being included as standard of care.1 The current COVID 19 pandemic, however, has brought the need for vaccination to centre-stage.2 In spite of evidence regarding the efficacy and utility of vaccination in preventing. COVID-19, a lot of vaccine hesitancy3 and vaccine skepticism4 is encountered. As primary care physicians, it is our duty to encourage the public to get vaccinated. In this article, we create a simple framework which helps assess the barriers to vaccine acceptance, and create bridges to overcome vaccine hesitancy and skepticism.


Perception and vaccines


Attitudes towards vaccination are based on perception.5 Perception, in turn, relies upon past experiences, as well as current interaction with the society and environment at large. One unpleasant encounter with the health care system, for example, may create a perception of dislike or hatred for all medical interventions. An anecdotal story of an adverse event following vaccination can lead to a perception of lack of safety of all injections. Perceptions can be biased; these biases are often based on misinformation and can easily perpetuate misunderstanding.

It makes sense, therefore, to evaluate perceptions of our patients, while discussing vaccination with them. Identification of the underlying reasons for wrong perceptions helps in addressing the root cause of vaccine hesitancy and skepticism.


Approach to vaccine perception


Table highlights the common barriers to vaccine acceptance, and suggests ways of bridging them. We must remember that communication skills are important tools in motivating people to change their perceptions. Primary care physicians shoulder the responsibility of motivating and encouraging the general public to accept and adopt appropriate health-related behaviours. Physicians who work in diabetes care are well versed with insulin resistance. They are also attuned to using motivational strategies in their day-to day practice. These strengths can be utilized in tacking vaccine hesitancy and skepticism across the world.



Hierarchy of questioning


A step wise history taking helps in assessing the reasons for vaccine hesitancy, and in planning one's educational strategy. Questions should be asked according to the order listed in the table. Taking pneumococcal vaccine as an example: " />


Vaccine motivation


Motivation for vaccination should be done in an empathic manner. Patient concerns and complaint should be addressed in a simple and easy-to-understand manner. Motivation is a sustained activity6 which must address all stakeholders, including policymakers, planners, physicians, the public at large, and persons needing care. The concept of immune optimization and immunovigilance, can be used to highlight the need for immunization. Corollaries can also be drawn with childhood vaccination, and its beneficial effect on child health. Proverbs such as "a stitch in time save nine", are effective ways of explaining the concept of immunization. Religious verses can be used to motivate people to seek, and accept, appropriate health interventions.

For those who are concerned about risk or cost, appropriate information and explanation, using analogies and metaphors, helps in promoting vaccine acceptance. "Penny wise, pound foolish" is one approach that may be useful.




Vaccine hesitancy can be overcome by assessing and understanding the barriers to vaccine acceptance, and creating bridges to overcome them. Motivational strategies should target all stakeholders, while focusing on the specific issues that cause vaccine hesitancy.




1.       Husein N, Chetty A. Influenza, pneumococcal, hepatitis b and herpes zoster vaccinations. Can. J. Diabetes. 201; 42: S142-4.

2.       Mathieu E, Ritchie H, Ortiz-Ospina E, Roser M, Hasell J, Appel C, et al. A global database of COVID-19 vaccinations. Nature human behaviour. 2021; 5:947-53.

3.       Troiano G, Nardi A. Vaccine hesitancy in the era of COVID-19. Public health. 2021; 194:245-51.

4.       Browne M. Epistemic divides and ontological confusions: The psychology of vaccine scepticism. Hum Vaccin Immunother. 2018; 14:2540-2.

5.       Lin C, Mullen J, Smith D, Kotarba M, Kaplan SJ, Tu P. Healthcare providers' vaccine perceptions, hesitancy, and recommendation to patients: a systematic review. Vaccines. 2021; 9(7):713.

6.       Su Z, Chengbo Z, Mackert M. Understanding the influenza vaccine as a consumer health technology: a structural equation model of motivation, behavioral expectation, and vaccine adoption. J. Healthc. Commun.. 2019; 12:170-9.

7.       Ashraf H, Faraz A, Raihan M, Kalra S. Fighting pandemics: inspiration from Islam. J Pak Med Assoc. 2020; 70:S153-S156.

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