PTOW | Immunization Hesitation – Our Role as Nurses in the Community to Promote Healthy Decisions

By: Ashley Placko, BSN, RN and Cydney Calderon, FNP-C, MSN, RN 

Acknowledgements: This practice tip was written in collaboration
with Texas Nurses Association Nursing Practice Committee 

Across the United States, a recent decline in immunization adherence has been observed. This adherence further worsened following the COVID-19 pandemic, healthcare
workers also face unique challenges to immunization adherence within their specific communities.  In Texas, the overall vaccination exemption rate among middle schoolers increased by over 2%, with some counties experiencing up to a 10% increase,
over the 2015 to 2025 school years (DSHS, 2025). Despite vaccination requirements for school attendance, vaccine waivers provide parents with the choice to opt-out. In Texas, vaccine waiver requests have increased significantly over time, with over an
81% increase noted from 2018 to 2022 (DSHS, 2022). Health literacy is an additional challenge driving immunization hesitation amongst Texans. Texas currently holds the 4th lowest literacy rate in the nation with 19% of adults lacking basic literacy skills
(Literacy Texas, 2025). Low health literacy has been linked to poorer health outcomes and poorer acceptance of health recommendations due to lack of understanding and/or mistrust. Lastly, tracking immunization status within the state has created challenges
with adhering to recommended vaccine schedules. While Texas has now implemented a vaccine database to track immunization schedule adherence, standardized use of the database is inconsistent amongst healthcare facilities. Easy access to vaccine exemption
waivers, online vaccine misinformation compounded by poor health literacy, vaccine access barriers, and a lack of standardization with vaccine documentation are ongoing challenges that contribute to immunization nonadherence. 

What Can We Do?  

Provide a Patient-Centered Approach: Patient-centered care is a collaborative and shared decision-making approach between patients and healthcare providers (Wolters Kluwer, 2022). Research
shows that patient-centered care is noted to improve adherence to treatment regimens and patient outcomes. When discussing vaccines, nurses who adopt a patient-centered approach to education may decrease immunization hesitancy among their patients. Offering
guidance that is non-biased, culturally competent, and clarifies misconceptions in a respectful way can help patients feel more comfortable discussing their concerns and support healthy decision making.  

Increase
Health Literacy: Health literacy is an ongoing challenge faced across various fields of nursing and affects all populations. Misinformation about vaccines is readily available and easily accessible on the internet and social media. This misinformation
is often presented in simple terms and short sound bites that are easily understood by the general public. In contrast, much of the vaccine information available from credible, evidence-based sources are written at a higher level or difficult to access.
This difference in content can create a health literacy barrier amongst the general public. In addition to offering traditional forms of vaccine content, offering credible educational content in various forms may help to increase learner engagement and
combat vaccine misinformation. Utilizing popular social media platforms and mirroring popular formatting may offer an effective alternative for dispersing credible vaccine content.  

Reduce Barriers: Nurses should
be aware of the barriers to immunizations that exist across communities. Removing barriers is a vital step toward immunization adherence. Nurses must be knowledgeable of and/or partner with local public health agencies to provide up-to-date information
on available vaccine resources. These resources should include information that aims to increase access to vaccines and reduce vaccine costs to the communities that nurses serve. Examples include promoting and partnering with mobile clinics, school-based
clinics, and public health clinics in addition to offering support to access state-funded vaccine cost reduction programs such as Texas Vaccines for Children and the Adult Safety Net Program.  

Standardize Documentation:
ImmTrac is a vaccine database run by the Texas Department of State Health Services (DSHS). Universal adoption of accurate, prompt, and complete documentation of vaccine administration within the DSHS ImmTrac database helps to provide visibility of
individual vaccination history. To promote standardized use, it is important that all healthcare facilities have staff that are familiar with and have access to ImmTrac. Standardization of ImmTrac use increases prompt access to accurate vaccination data,
promotes vaccine schedule adherence, and reduces vaccine waste caused by immunization schedule inconsistencies.   

Vaccines are vital to preventative healthcare and help to keep our communities healthy. To
address immunization adherence and its unique challenges, healthcare facilities can adopt vaccination adherence committees with nurse champions. These committees can provide an organized platform to identify and provide solutions to challenges faced within
specific communities. Due to the high importance of immunization adherence, it is imperative that nurses work together and offer multifaceted solutions to encourage vaccine adherence to the communities we serve.  

 
References 

DSHS. (2022). 2021-22 Vaccine Conscientious Exemption Report. https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/2021-2022_Vaccine-Conscientious-Exemption-Report.pdf 

DSHS. (2025). Conscientious Exemptions | Texas DSHS. Www.dshs.texas.gov. https://www.dshs.texas.gov/immunizations/data/school/conscientious-exemptions 

Literacy Texas. (2025). Literacy Facts. Literacy Texas. https://www.literacytexas.org/why-literacy/literacy-facts/ 

Wolters Kluwer. (2022, October 5). Why patient-centered care is so important. Wolters Kluwer. https://www.wolterskluwer.com/en/expert-insights/why-patientcentered-care-is-so-important