The Hesitancy Conversation Has Changed: New Motivational Strategies for a Fatigued Public

Throughout the pandemic and in the years since COVID-19 emerged, news about the virus’ changes and variants, potential health effects, and impact of the approved vaccines has led to a seemingly never-ending evolution of recommendations. Subsequently, vaccine hesitancy has been a known barrier to public health immunization efforts since the first COVID-19 vaccine was given full approval by the FDA in 2021.

However, study findings published in 2026 indicate that, overall, hesitancy toward COVID-19 vaccination is declining. Importantly, the findings reinforce the concept that the hesitancy was rooted in sincere concerns that can be addressed and overcome with time and a growing body of knowledge.¹

As with influenza, COVID-19 immunization is an annual activity, with vaccine composition guided by FDA recommendations based on circulating variants, immunogenicity data, and current vaccine effectiveness.² The most recent guidance emphasizes shared (ie, individual-based) clinical decision-making that balances the benefit vs risk for an individual patient.³ In general, vaccination is recommended for those 65 years or older and for patients aged 6 months to 64 years with characteristics and chronic conditions that increase their risk for COVID-19–related complications. It is important to recognize that no preference is given for one vaccine over another.³ The choice of vaccine and number of doses are based on age and vaccination history, and, aside from those restrictions, vaccine selection should be based on patient preference and availability.

Recognize and Acknowledge Vaccine Burnout

The need for yearly administration can be particularly challenging to immunization efforts. Findings from at least 3 studies have identified changing efficacy and/or immunization demands as a primary reason for COVID-19 vaccine avoidance.⁴ It is accepted within health care that vaccination is the most effective public health strategy for preventing certain infectious diseases, and there are routine vaccinations for 19 distinct infections recommended across a person’s lifetime.^4,5 Most nonannual vaccine doses are given during childhood, and, with the exception of the diphtheria-tetanus-pertussis vaccine, nonannual adulthood immunizations are usually given either in early or late adulthood.

Historically, healthy adults rarely thought about vaccines for themselves outside of the annual influenza vaccine. In addition to COVID-19, the FDA has approved new adult vaccines for respiratory syncytial virus, pneumococcal disease, and hepatitis B virus since 2021.⁴ Because of these developments, adults who may have received a previous version of a routine vaccine are now being advised to receive the newer vaccine with broader or more effective coverage. Although many patients may not express true vaccine hesitancy—a refusal or delayed acceptance of vaccination—it is understandable that the new phenomenon of vaccination burnout is starting to emerge.⁴

Vaccination burnout is “characterized by emotional exhaustion, depersonalization, or lack of personal accomplishment in receiving repetitive vaccines.”⁴ In short, many patients begin asking themselves whether the vaccines are really providing protection and are worth receiving if they have to keep getting them. Importantly, burnout appears to be a transitory stage and is seen more often in individuals with a provaccination viewpoint.⁶ Multidose vaccine schedules can be easy in childhood when vaccines are building immunity, and for older adults whose immunity has waned with age, but they are more challenging for adults who have grown up with an expectation of maintained immunity protection. Patients may not object to receiving vaccines in general, but can become overwhelmed by the frequency of immunization demands, heightened attention on vaccine adverse effects, misconceptions about infection severity related to the need for vaccination, and a constant barrage of information.⁶

Findings from multiple studies have identified this as a patient-reported barrier to COVID-19 vaccination.^1,4,6 Health care professionals understand why the science evolves with infectious disease and how that impacts our vaccine recommendations. With the complexity and continuously evolving guidance about COVID-19 vaccines, it is understandable that this vaccine could trigger burnout. It is important to understand that the volume and complexity of information can be psychologically exhausting, even for those who work in the health care system.

The first step in managing vaccination fatigue is to acknowledge its presence. After that comes the somewhat daunting task of motivating patients to overcome it. Unfortunately, there is not an extensive amount of literature evaluating strategies for overcoming vaccine fatigue. Most of what has been described are simple approaches rooted in common sense.

Know the Patient and Their Individual Concerns

Never assume a patient’s rationale for vaccine avoidance. Published data indicate that younger age, non-White ethnicity, lower level of education, unemployment, smoking, and previous suspected (but not confirmed) COVID-19 infection are variables associated with higher risks of vaccine hesitancy.^1,7 That should not be interpreted to mean that everyone, or even the majority of people, within those sociodemographic categories is entirely opposed to vaccination. In fact, data from the 2026 REACT study identify a long list of vaccine hesitancy reasons that can, and should be, acknowledged and addressed at the level of the individual patient.¹

Many reasons for vaccine uncertainty have a reasonable foundation. One of the most frequently identified apprehensions involves safety. Over 40% of patients cite concerns about acute adverse effects or long-term health effects as their reason for hesitancy.¹ Furthermore, approximately 21% of women expressed concerns about fertility. When these vaccines were introduced, studies included up to 2 months of safety follow-up in a limited population, and it could be difficult to fully address some patient concerns. However, ongoing safety monitoring is required for all approved drugs, and the time since initial FDA approval has provided years of data with these vaccines in a broader population and the opportunity to identify potential safety benefits and signals not seen (or fully delineated) in clinical trials. It can be helpful to open conversations very generally to gauge how the patient feels about the vaccine or assess their feelings toward the COVID-19 vaccine compared with a vaccine they are more readily willing to receive.⁸

When a patient expresses apprehension about the short- or long-term safety of the vaccine, follow up to determine whether they have particular concerns about specific effects or if their concerns are more general. Evidence indicates that patients initially hesitant for safety reasons were the most likely to eventually be immunized.¹ This points to the effectiveness of using the growing body of knowledge to provide stronger evidence-based counseling and more patient-centered vaccine selection. Finally, legitimate historical grievances and disparities must be acknowledged to validate the patient experience and build trust.

Other reasons for the lack of immunization may be due to time or logistical issues. Patients who are pregnant or breastfeeding have expressed the desire to wait to receive the vaccine until after delivery or the end of breastfeeding.¹ Studies evaluating the safety of COVID-19 vaccines in more than 300,000 pregnant patients do not show an association between vaccination and untoward outcomes, irrespective of trimester or specific vaccine.^9,10 As seen with other vaccines, immunologic data indicate that vaccination during pregnancy provides newborns with passive immunity until they are old enough to be vaccinated themselves.¹¹ Conversely, pregnant patients who become infected with COVID-19 are at higher risk for severe infection and adverse pregnancy and maternal outcomes.¹¹ As a result of this growing knowledge, the American College of Obstetricians and Gynecologists strongly recommends pregnant or breastfeeding patients receive the vaccine.¹¹

Similar concerns exist among nonpregnant patients with chronic comorbidities. Although vaccine safety when administered at a pharmacy or clinic is similar, it may give some patients peace of mind to receive their vaccine during a routine medical appointment, especially if they will be receiving other clinic-administered vaccines. A conversation initiated in the pharmacy is still vaccine advocacy regardless of where the patient ultimately receives the immunization.

For some patients, financial and geographic barriers to vaccine access pose logistical obstacles to immunization.¹ This may be a particular concern in medically underserved areas and pharmacy deserts. Getting somewhere to receive care usually requires planning to accommodate travel. Proactively scheduling immunizations for these patients is preferable to impromptu recommendations.¹

Patients Value Face-to-Face Communication

Communication is the No. 1 contributor to vaccination burnout, but is also the most essential strategy for immunization uptake.⁶ Misconceptions about vaccine effectiveness, uncertainty about acute and long-term infection severity, and misinterpretation of data often contribute to a patient’s decision not to be vaccinated.

Another consideration is how the message is delivered. In response to misinformation and vaccine hesitancy, a wealth of published, digital, and asynchronous educational interventions has been developed. Although these educational initiatives have their place, their overall impact is modest. A comprehensive review of 118 studies and interventions demonstrated only a 10% increase in vaccination rates compared with usual care.¹² Research indicates that these educational efforts increase knowledge, but this does not always correspond to increases in immunization willingness.^12,13 It is important to recognize that mass advocacy and education campaigns, particularly those lacking in new or unique information, may actually cause more harm to immunization efforts than good. When vaccination advocacy relies on consistent messaging frameworks repeated across multiple interactions, audiences may develop an immunity to the persuasive intent, growing indifferent to arguments they’ve encountered before.¹⁴

When asynchronous education is used, careful attention should be paid to ensure that the information provided is not only accurate but also not the same repetitive content that can be found on hundreds or thousands of platforms. It is also important that only materials with up-to-date information be used to avoid inadvertent accuracy issues. Likewise, study findings have found no significant difference in vaccination rates between motivational interviewing/communication and usual care.¹²

On the other hand, personal, open-ended communication in real time from a health care provider is associated with higher odds of COVID-19 vaccine uptake.¹⁵ In particular, the use of 2-sided conversion messages in which the potential benefits and drawbacks are openly discussed between the provider and patient builds high credibility and trust, reduces resistance, decreases feelings of lost autonomy, and increases the likelihood of a hesitant patient converting their stance when they feel the proposition is fair and balanced.^7,16,17 This may integrate some components of motivational interviewing, but it may also be a free-flowing conversation between the patient and the provider.

It may seem counterintuitive that a simple conversation could have a stronger effect than well-coordinated education efforts, but the context is more nuanced. Patients do not want to feel that they are being lectured or viewed as merely a number. It is important to remember that vaccine hesitancy and burnout are strongly emotional, and communication needs to consider emotional well-being and acknowledge the patient’s concerns in order to create and maintain an open line of trust.¹⁸ Research has shown that acknowledging uncertainty about vaccine efficacy and risks, rather than advocating with absolute certainty, is more effective at building trust.¹⁹ Therefore, the combination of intentional, personalized, and data-driven education is essential. Although it can be difficult to reallocate time from other tasks, tailored, in-person communication about the COVID-19 vaccine or any immunizations from a health care provider is one of the few interventions shown to positively impact vaccine acceptance.¹⁵

Recognize What May Not Work

As mentioned previously, not all messaging is effective. Provaccine asynchronous information, especially that found on websites, is often more complex to read than antivaccine messages.^18,19 Many materials also tend to reiterate generic information without offering anything new or unique for the patient to consider. Dramatic narratives leveraging fear are ineffective at improving vaccination rates and, ironically, can facilitate fear of adverse effects.^18,19 Scare tactics, judgmental language, and stigmatization trigger defensive psychological reactions and often serve to reinforce the rationale behind a patient’s hesitancy or burnout.¹⁹

Addressing misinformation is important, but the best strategies use positive messaging that focuses on providing factual knowledge rather than directly addressing or debunking myths or incorrect information.¹⁹ Use of humor-based correction has demonstrated positive effects on dispelling misinformation regarding other vaccines and could be employed with the COVID-19 vaccine as a less aggressive method for repudiating misinformation.¹⁹

Compulsory interventions, particularly those with punitive consequences, are often counterproductive.^6,18 This is true at the patient level, where mandatory vaccines have led to vaccine hostility and nonadoption, and it can also be found at the health care level. Most health care providers understand and appreciate the value and impact of vaccinations. Therefore, it is generally not difficult to recommend immunizations to patients with a sincere belief and enthusiasm that patients can sense. However, when health care providers are required to aggressively promote vaccines in ways they are not comfortable with, it affects the effort, sincerity, and passion with which they communicate.

Conclusion

Immunization advocacy is one of the most important tasks in public health. It is also one of the most mentally demanding and challenging roles in health care. The rise in vaccine hesitancy and burnout after the COVID-19 pandemic not only impacted uptake of the vaccines but also other routine and annual vaccines across age groups. Research indicates that mistrust and hesitancy are beginning to decline, but strategic efforts are necessary to continue the positive trajectory.

Patients want targeted information that addresses their unique needs and concerns, from a credible source that knows and values them as individuals. Although not always easy to accommodate, traditional face-to-face communication has proven to be one of the most effective tools, and its impact should not be underestimated. Ultimately, improving patient acceptance of COVID-19 immunization is not that different from improving adherence to any other drug. By grounding public health initiatives in trust and tailored communication, pharmacists can turn a mentally demanding hurdle into an opportunity for lasting, meaningful patient relationships while reducing the incidence of vaccine-preventable diseases.

About the Author

Marilyn Bulloch, PharmD, BCPS, FCCM, is an associate clinical professor in the Department of Pharmacy Practice at the Auburn University Harrison College of Pharmacy in Alabama.

REFERENCES

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