Vaccine hesitancy — the Australian GP approach

Vaccine hesitancy in Australian general practice

Vaccine hesitancy — delay in acceptance or refusal of vaccines despite their availability — sits on a spectrum that ranges from cautious questioning through to committed refusal. The WHO SAGE Working Group defined and characterised it in 2014 and the WHO listed it as one of the ten greatest threats to global health in 2019 — placing it alongside antibiotic resistance, climate change, and pandemic influenza.

In Australia, national childhood vaccination coverage approaches 95% (the herd-immunity threshold for most vaccine-preventable diseases) in most age cohorts nationally. However, coverage falls below 90% in geographic clusters including some inner Melbourne suburbs, parts of Northern NSW (including the Byron Bay region), the Sunshine Coast, and Adelaide Hills. Aboriginal and Torres Strait Islander childhood coverage is approximately 93% — a gap that is narrowing but persists. Adult vaccination coverage is substantially lower: adult influenza uptake sits at 40–50%, and COVID-19 booster coverage declined sharply after the 2022 acute phase of the pandemic.

The RACGP guidance on vaccine hesitancy (AJGP 2024), ATAGI’s Australian Immunisation Handbook, and SKAI (Sharing Knowledge About Immunisation) provide the clinical communication framework used here.

A. Core clinical — the AU general-practice framework

Understanding hesitancy — the 3Cs and 5Cs

The WHO SAGE 2014 report proposed the 3Cs model of hesitancy drivers:

• Confidence — trust in the vaccine’s safety and efficacy, and trust in healthcare providers and the healthcare system
• Complacency — low perceived risk of the disease; if the disease is invisible or rare, its seriousness is underestimated
• Convenience — barriers of access, cost, location, literacy, and reminder systems

Razai et al. (BMJ 2021) extended this to the 5Cs model:

• + Calculation — active information-seeking before deciding; some parents want to research before accepting
• + Collective responsibility — willingness (or reluctance) to vaccinate for the protection of others, not just oneself

Further drivers increasingly relevant in Australia include cohort and community norms (social group identity strongly predicts vaccination behaviour), constraints (structural barriers disproportionately affecting ATSI, refugee, low-SES, and language-diverse populations), and conspiracy thinking (generalised institutional distrust that resists information-based approaches).

The spectrum of hesitancy

Hesitancy is not binary. Vaccine-hesitant families include:

• Cautious acceptors — accept vaccines but only after questions are answered and reassurance provided
• Selective hesitants — accept some vaccines but refuse or delay others (commonly HPV, COVID-19, varicella, and combination vaccines)
• Delayers — agree vaccines are beneficial but want to space the schedule, creating windows of preventable-disease vulnerability
• Committed refusers — decline all vaccines; the smallest group but the most challenging to engage

The presumptive opening — what the evidence shows

Opel et al. 2013 demonstrated in observational research that the way a GP initiates the vaccine discussion has a profound effect on acceptance. Presumptive framing — “Today she’ll get her 6-month vaccines” — produced significantly higher vaccine acceptance at that visit compared with participatory framing — “What do you want to do about her vaccines today?” A follow-up RCT by Opel et al. 2015 confirmed this finding.

The mechanism is that presumptive framing positions vaccination as the default clinical recommendation — consistent with all other recommended preventive activities — rather than as a consumer choice under deliberation. Participatory framing inadvertently signals that refusal is an equally valid option.

In practice:

1. Use a presumptive opening for all routine vaccination visits
2. If the parent expresses hesitancy or resistance, pivot to motivational interviewing — do not double down on the presumptive approach
3. If resistance is met at this visit, document, preserve the relationship, and revisit at every subsequent contact

Never label a hesitant parent as an “anti-vaxxer” — this is both inaccurate (most are on the spectrum, not committed refusers) and counterproductive (RACGP 2024). The label damages trust and entrenches resistance.

Motivational interviewing — the OARS approach

Motivational interviewing (MI) is the most evidence-supported communication strategy for vaccine hesitancy. Gagneur (CCDR 2020) reviewed the AIMI/PromoVac trials, which showed approximately 6% absolute increase in vaccination coverage from a single MI conversation — an effect that persisted at 7 months.

The OARS technique in the vaccine context:

• Open questions — “What have you heard about the MMR vaccine?” / “What’s been on your mind about the HPV vaccine for your daughter?”
• Affirmations — “You’re clearly putting a lot of thought into protecting your child.”
• Reflective listening — “So you’re worried that getting multiple vaccines at once might overload her immune system.”
• Summarise — reflect back what you’ve heard before offering information

The Elicit–Provide–Elicit (E-P-E) sequence is the vehicle for accurate information: first elicit what the person already knows or believes, then provide brief tailored information, then elicit their response — “What’s your thinking now?” This avoids the monologue.

Roll with resistance. When a parent pushes back, don’t argue. Explore the ambivalence: “I can hear you have concerns. Tell me more about what’s making you uncertain.” Listen for change talk — expressions like “I do worry about whooping cough in the community” or “I want her to be healthy” — and reflect and reinforce these.

History — understanding the specific concern

Begin every hesitancy conversation with an open question before providing any information:

• “What’s on your mind about the vaccines today?”
• “Tell me what you’ve been reading or hearing.”

Listen for: the type of concern (safety, ingredients, schedule, specific vaccine, general distrust), the source of information (social media, peer, family member, previous healthcare encounter), the type of hesitancy (delayer, selective, refuser), and the underlying values driving the concern (protecting the child, body autonomy, distrust of pharmaceutical companies, religious belief).

Affirm and reflect before responding. “I hear that you’re worried about [specific concern]. That’s worth talking about — let me make sure I understand what you’re thinking first.” This builds trust before information is exchanged.

B. Addressing specific concerns — common myths and the evidence

Concern	What the evidence shows
MMR causes autism (Wakefield 1998)	Wakefield’s paper was retracted following investigation; he was struck off the medical register. Madsen NEJM 2002 (~500,000 children), Taylor Vaccine 2014 meta-analysis (~1.2 million children), and Hviid Ann Intern Med 2019 (~657,000 Danish children) all found no association. This is one of the most replicated findings in vaccine safety research.
Thiomersal / mercury causes harm	Thiomersal (used as a preservative in multidose vials) was removed from all routine Australian childhood vaccines in 2000. It is retained only in some multidose influenza vials — preservative-free formulations are available. Large studies have found no association with neurodevelopment or SIDS.
Aluminium adjuvants are toxic	Aluminium salts have been used in vaccines for over 70 years. The aluminium dose in the entire childhood schedule is a fraction of typical daily dietary aluminium intake. No neurotoxicity has been found at vaccine doses per the ATAGI Handbook.
HPV vaccine causes infertility or ovarian insufficiency	No association has been found in pharmacovigilance surveillance covering approximately 3 million doses and in subsequent cohort studies. HPV vaccination does not affect ovarian function or fertility.
COVID-19 mRNA vaccines cause serious myocarditis	A real but rare signal exists in young males (particularly aged 12–17) after the second mRNA dose — approximately 1:15,000 to 1:30,000 (Mevorach NEJM 2021; Husby BMJ 2021). Nearly all cases were mild and self-limiting. COVID-19 infection itself carries a substantially higher myocarditis risk. Novavax is an alternative for those with specific concerns about mRNA technology.
Too many vaccines overwhelm the immune system	Vaccines stimulate only a tiny fraction of immune system capacity. A child encounters thousands of antigens from environmental exposure daily. Combination schedules have been studied extensively and are safe and effective.
Natural immunity is better	Natural immunity from disease infection comes at the cost of disease morbidity and sometimes mortality. For many pathogens, vaccine-induced immunity is equally or more durable. Some diseases (such as HPV) confer poor natural immunity even after infection.

A critical communication principle from Lewandowsky et al. (J Appl Res Mem Cogn 2017): When correcting misinformation, do not lead with the myth — “MMR does NOT cause autism” — because restating the false claim strengthens its memory trace. Instead, lead with the accurate information: “MMR is one of the most studied vaccines in history — over 1.2 million children in research show no link to autism.”

C. Communication strategies that work

Loss-aversion framing

People respond more strongly to losses than to equivalent gains. Framing disease risk as loss is more motivating than framing vaccination benefit as gain. Compare:

• “Pertussis vaccination in pregnancy gives your baby 90% protection.” (gain framing)
• “Whooping cough in newborns carries approximately a 1-in-200 risk of death in affected infants under 3 months. Maternal vaccination in pregnancy reduces the risk by 90%.” (loss framing with specific numbers)

The second framing consistently produces stronger protective motivation.

Identifiable-victim narrative

Abstract statistics are processed cognitively; narratives about specific individuals activate emotional reasoning. A real (anonymised) account of a baby hospitalised with pertussis, or a child who survived measles with permanent hearing loss, is more persuasive than population-level statistics alone. Use carefully and with sensitivity — the aim is truth, not fear-mongering.

Tailor to values

People with different underlying concerns need different framings:

• Protecting the child → focus on disease risks to the child
• Body autonomy → frame vaccination as empowering the child’s immune system with the preparation it needs; autonomy through protection
• Distrust of government or pharmaceutical companies → acknowledge the concern, point to independent safety monitoring such as AusVaxSafety which uses patient self-reporting, and to ATAGI as an independent expert committee

Provider trust is the strongest single factor

Across the Australian vaccine hesitancy literature, provider trust consistently outperforms information quality as the predictor of vaccine acceptance (RACGP 2024). A calm, non-judgemental, ongoing relationship in which the GP openly shares their own vaccination choices and those of their family is more persuasive than any clinical argument. MyMedicare registration — which supports continuity of care — directly supports this.

D. Australian operations — policy, MBS, and resources

No Jab No Pay and No Jab No Play

No Jab No Pay (Federal, 2016): The Family Tax Benefit Part A end-of-year supplement and the Child Care Subsidy are contingent on AIR-confirmed vaccination status. Conscientious objection was removed as a valid exemption. Only medical exemptions — based on ATAGI-listed contraindications signed by an authorised provider and recorded on AIR — are accepted. Beard et al. (MJA 2018) found that No Jab No Pay increased documented vaccination coverage and substantially reduced the number of AIR-recorded objections.

No Jab No Play (State-level): Most states have childcare/preschool vaccination requirements:

• Victoria (Public Health and Wellbeing Act 2008 amendment)
• New South Wales (Public Health Act 2010 amendment)
• Queensland (Childcare Services Vaccination Policy)
• South Australia and Western Australia have equivalent requirements
• Northern Territory, Tasmania, and ACT operate softer notification frameworks

Australian Immunisation Register (AIR)

The AIR is a national register tracking all vaccinations from birth regardless of whether they are NIP-funded or private. It is accessible to providers through PRODA/HPOS, to patients through MyHealthRecord and Medicare Online, and provides the data source for No Jab No Pay assessments.

GPs can view vaccination history, identify gaps, record administered vaccines, and record medical exemptions and refusal codes on AIR. Recording refusal codes accurately is important for No Jab No Pay assessments and supports audit trails.

MBS items in the vaccine hesitancy consultation

Standard GP attendance items 23, 36, 44 apply — a hesitancy conversation may justify a Level C (36) or D (44) attendance if extended counselling is provided. Key additional opportunities:

• ATSI Health Assessment — item 715: vaccination status review embedded; culturally safe framing essential
• 75+ Health Assessment — item 705: pneumococcal, shingles, RSV, and influenza review
• GPCCMP — items 965 and 967: vaccination plan integrated for chronic-disease patients
• Practice nurse — item 10997: practice nurse vaccine administration
• Better Access MHCP — items 2715/2717: if vaccine hesitancy is driven by anxiety, needle phobia, or trauma-related avoidance

Medical exemption process

A medical exemption for vaccination in Australia requires:

• One of the narrow ATAGI-listed clinical contraindications (true anaphylaxis to a vaccine component, specific severe immunocompromise, active inflammatory bowel disease on specific biologics, or other ATAGI-specified scenarios)
• Documentation by an authorised provider (GP or immunology specialist)
• Recording on AIR using the correct exemption code

Allergy and anaphylaxis hesitancy is common but usually unfounded: egg allergy is not a contraindication for current Australian MMR or influenza vaccines per ATAGI Handbook. Most prior adverse events described by parents as “reactions” are normal local or febrile responses — not contraindications. Take a careful history and refer to ATAGI-listed contraindication criteria before supporting a medical exemption request.

Consumer resources for parents

• SKAI (Sharing Knowledge About Immunisation) — Australian-developed, research-informed parent and provider resources; available in multiple languages
• AusVaxSafety — real-time active vaccine safety surveillance using patient self-reporting via SMS; a transparency tool that reassures data-seeking parents
• ATAGI Australian Immunisation Handbook — the clinical authority; includes catch-up calculators for missed doses
• Department of Health vaccination resources — consumer-focused explanations
• HealthDirect — Immunisation — accessible consumer resource

E. Special populations

Aboriginal and Torres Strait Islander communities

Vaccination hesitancy in ATSI communities is less often ideological and more often driven by structural and logistical barriers — remote access, disrupted records, and historically well-founded distrust of health systems. Engagement with Aboriginal Health Workers and Aboriginal Liaison Officers is the primary strategy. Family-centred and community-centred approaches using storytelling formats are more effective than individual information delivery. ATSI Health Assessment (item 715, every 9 months any age) embeds vaccination review. Use the ATAGI Catch-up Calculator for disrupted schedules.

CALD and refugee communities

Newly arrived people from refugee and humanitarian backgrounds often have incomplete vaccination records from disrupted healthcare. Use the ATAGI Catch-up Calculator to plan catch-up. Engage TIS National (131 450) for professional interpreters. Seek culturally appropriate written resources from SKAI. Some communities have specific concerns about specific vaccine ingredients (porcine gelatin in some formulations is relevant for Muslim and Jewish families; gelatin-free alternatives are available) — discuss directly and without assumption.

Refugee Health Network of Australia and state-based refugee health services provide specialist post-arrival assessment pathways including structured immunisation review.

Adolescent autonomy — Gillick competence

In Australian law, a young person with sufficient maturity and understanding to give informed consent may do so regardless of parental wishes. Gillick competence (and the Australian equivalent under state laws) applies to vaccination. In practice, for most adolescents aged 14 and over, if they independently seek and understand vaccination, the GP can proceed. Document the capacity assessment. This most commonly arises with HPV vaccination and COVID-19 vaccination where parents have objected.

Religious and cultural considerations

Most major faith traditions support vaccination. Catholic, Anglican, Jewish, Muslim, Hindu, and Buddhist authorities all endorse immunisation. Documentation of a specific religious objection is appropriate where stated. The porcine gelatin issue in some vaccines (varicella, some MMR brands) warrants direct discussion with Muslim and Jewish families — ATAGI provides guidance on which formulations contain gelatin and which alternatives are available.

When to escalate

Most vaccine hesitancy is managed within the general practice consultation and requires patience and relationship maintenance rather than escalation. Situations requiring specific action:

• True prior anaphylaxis to a vaccine component → refer to clinical immunology/allergy for formal assessment and advice before re-vaccination. Do not assume re-exposure is safe without specialist guidance.
• Severe immunocompromise → specific live-vaccine contraindications apply; ATAGI provides condition-specific guidance; immunology or treating specialist input before live vaccines (MMR, varicella, rotavirus, live attenuated influenza)
• Outbreak exposure (tetanus post-wound, measles exposure, hepatitis B exposure) → urgent post-exposure prophylaxis may be required; document any refusal clearly with medical-legal implications explained
• Severe needle phobia → psychology referral via Better Access MHCP; graded exposure and anxiety management before vaccination; consider oral or nasal vaccine options where available
• Vaccine-preventable disease presenting in unvaccinated child → state public health unit notification (mandatory for scheduled diseases including measles, pertussis, meningococcal disease); public health contact tracing support

What this article is and is not

This is general health information drawn from current Australian general practice guidance — RACGP AJGP 2024, the ATAGI Australian Immunisation Handbook, SKAI, and key vaccine communication research including Opel 2013 and Gagneur 2020. It does not constitute personal medical advice and does not create a doctor–patient relationship.

For parents with specific vaccine concerns, the best starting point is a direct conversation with your GP, who knows your child’s medical history. SKAI provides accessible, research-informed parent resources developed specifically for the Australian context. AusVaxSafety provides real-time Australian adverse event monitoring data.

For vaccine adverse event reporting: TGA DAEN and AusVaxSafety — serious reactions should be reported by the administering provider.

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Sources cited

1. WHO SAGE Working Group — Report on vaccine hesitancy 2014
2. WHO — Ten threats to global health 2019
3. Razai MS et al. — Covid-19 vaccination hesitancy. BMJ 2021;373:n1138
4. Opel DJ et al. — Provider-parent vaccine discussions. JAMA Pediatr 2013
5. Opel DJ et al. — Impact of childhood vaccine discussion format (2015)
6. Gagneur A — Motivational interviewing for vaccine hesitancy. Can Commun Dis Rep 2020
7. Taylor LE et al. — Vaccines not associated with autism: meta-analysis. Vaccine 2014
8. Hviid A et al. — MMR vaccination and autism: nationwide cohort. Ann Intern Med 2019
9. Madsen KM et al. — MMR vaccination and autism: population-based study. NEJM 2002
10. Mevorach D et al. — Myocarditis after BNT162b2 mRNA vaccine. NEJM 2021
11. Husby A et al. — SARS-CoV-2 vaccination and myocarditis: nationwide cohort. BMJ 2021
12. Beard FH et al. — No Jab, No Pay and No Jab, No Play. MJA 2018
13. Lewandowsky S et al. — Beyond misinformation. J Appl Res Mem Cogn 2017
14. ATAGI — Australian Immunisation Handbook 2024
15. Australian Department of Health — National Immunisation Program
16. Australian Immunisation Register (AIR)
17. SKAI — Talking About Immunisation
18. AusVaxSafety
19. RACGP — Vaccine hesitancy practical guidance (AJGP 2024)
20. TGA DAEN — Database of Adverse Event Notifications
21. Refugee Health Network of Australia
22. HealthDirect — Immunisation