Beyond Vaccine Hesitancy: Five Operational Strategies Pediatric Practices Can Use to Improve Immunization Performance

Editor’s Note: The Strengthening Immunization Reporting: Smarter Data, Better Outcomes webinar, hosted by Blue Shield of California Industry Initiatives, originally scheduled for Aug. 18, has been postponed. Stay tuned for a new date and registration information.

Vaccine hesitancy remains a persistent challenge for pediatric practices across the country, but hesitancy should not be the default explanation for low immunization performance. Through the California Quality Collaborative’s (CQC) work with practices in the California Advanced Primary Care Initiative, we learned that operational barriers account for the majority of the challenges affecting performance. Incomplete or hard-to-use data, unclear team roles, missed opportunities during visits, scheduling friction, and inconsistent outreach can all leave children behind even when families intend to vaccinate.

Before assuming a care gap reflects refusal, practices should first ask whether their systems make the recommended action visible, easy, and reliable. The following five evidence-based strategies reflect lessons from CQC’s work and are consistent with our approach to immunization improvement: strengthen the operational foundation while ensuring staff are prepared to support families who are genuinely uncertain.

1. Train the Entire Care Team to Deliver Consistent Messaging

Vaccine conversations do not begin and end with the clinician. Families interact with multiple staff members throughout their visit, and inconsistent messaging can unintentionally undermine trust. Our work with practices has shown that this is an operational issue: staff need shared language, clear roles and a defined process for responding when questions arise.

How practices can implement this:

• Develop shared talking points or scripts for common vaccine questions.
• Provide staff with guidance on how to respond when families express hesitancy and when to escalate a concern to a clinician.
• Reinforce the practice’s vaccine philosophy and staff roles during team meetings or huddles.

When families hear the same supportive message at every touchpoint, vaccines are framed as routine, expected, and important.

2. Use Motivational Interviewing to Guide Vaccine Conversations

Once a practice has ruled out operational barriers and identified genuine uncertainty, motivational interviewing (MI) gives the care team a structured way to respond. MI is a patient-centered communication technique that can improve vaccine acceptance by addressing ambivalence rather than attempting to “convince” families.

MI focuses on listening, validating concerns, and guiding families toward their own motivations for change. It is particularly useful for parents who are unsure or hesitant but not firmly opposed to vaccines.

How practices can implement this:

• Train clinicians and appropriate care team members on core MI skills, such as asking open-ended questions, reflective listening, and affirmations.
• Encourage staff to identify the family’s primary concern and ask what information would be most helpful.
• Connect the vaccine recommendation to a parent’s stated goals, such as protecting their child’s health or keeping their family safe.

By building MI into a defined escalation pathway, practices can reserve longer conversations for families who need them while keeping routine vaccination workflows moving.

3. Set Expectations Early with a Vaccine Acknowledgement Policy

Setting expectations early is a powerful way to address vaccine hesitancy while supporting patient autonomy. A vaccine acknowledgement policy allows practices to be transparent about their immunization philosophy and gives families important information before they establish care.

Huntington Plaza Pediatrics, one of the pediatric practices CQC supports through the California Advanced Primary Care Initiative, implemented a vaccine acknowledgement policy for all new patients that clearly communicates the practice’s commitment to following recommended immunization guidelines. Rather than waiting for a clinical visit, vaccine expectations are introduced during the new-patient intake process.

Every new family who calls the practice has an upfront vaccine conversation with the care team. Staff explain the practice’s vaccine stance, answer questions, and ensure families understand expectations before scheduling an initial visit. This proactive workflow helps prevent surprises later and gives families space to determine whether the practice aligns with their values.

 Why this works:

• Builds trust through early transparency.
• Reduces tension and avoids using limited clinical time for foundational expectations.
• Empowers families to make informed choices before establishing care.
• Creates a consistent process for staff rather than leaving the conversation to individual discretion.

By embedding vaccine expectations into onboarding, Huntington Plaza moved the conversation upstream, creating clarity for families and consistency for the care team.

4. Provide Focused, “Just-in-Time” Education

Providing more information is not always the same as removing the barrier. Overloading families with broad vaccine materials can be counterproductive, particularly when their question is about one vaccine or one decision. Focused, timely education helps a practice respond to the concern that is actually present.

How practices can implement this:

• Use brief handouts, visuals, or portal messages tailored to the vaccines due at that visit.
• Address common myths with concise, evidence-based explanations tied to the family’s stated concern.
• Offer trusted external resources for families who want to learn more after the visit.

Making education specific and timely respects the family’s time and allows the care team to distinguish an information need from a scheduling, access, or workflow problem.

5. Use Default Scheduling and Reminder Systems

Many children fall behind not because a family refused vaccination, but because the next dose was never scheduled, the recommended interval was unclear, or outreach began only after the child was already overdue. Default scheduling and reminder systems reduce that friction and make follow-through part of the practice’s standard work.

How practices can implement this:

• Pre-schedule vaccine visits at checkout so families leave with the next appointment already on the calendar whenever timing allows.
• Use automated reminder-and-recall outreach through text messages, patient portals, phone calls, or mailed notices.
• Run regular EHR or registry reports and, when possible, age-banded lists to identify children who are missing a dose or will need one soon.

By reducing reliance on family memory and beginning outreach before a measure deadline, practices can prevent avoidable gaps while maintaining patient choice.

The central lesson from CQC’s work was not that communication matters less; it was that communication works best when the surrounding system is reliable. Low immunization performance may reflect hesitancy, but it may also reflect a missed opportunity, inconsistent workflow, scheduling barrier, incomplete data, or outreach that began too late.

That lesson continues to guide CQC’s approach to immunization improvement: strengthen the operational foundation first while preparing teams to support families who are genuinely uncertain. When reliable workflows and respectful conversations work together, practices can improve vaccination rates, reduce staff burden, and strengthen trust without treating hesitancy as the default diagnosis.

Learn about CQC’s California Immunization Improvement Project.