Vaccine hesitancy in the pharmacy: from reflex to strategy

More than half of the Swiss resident population — according to the Federal Office of Public Health’s 2024 study on vaccination literacy, exactly 51 per cent — have difficulty dealing with vaccination information. [1] 63 per cent find it difficult to assess the trustworthiness of that information. The share of committed vaccine critics has fallen slightly since 2018, from 10 to 7 per cent; at the same time the group of undecided, uncertain people has grown markedly, and in the 2018 Wellcome Global Monitor survey 22 per cent of Swiss respondents considered vaccines unsafe — the second-highest figure in Europe after France. [2] In this constellation the Swiss pharmacy has a specific role. It is low-threshold, it is frequently the first — sometimes the only — point of contact between an ambivalent person and a health professional, and from 1 January 2027 pharmacy vaccination (the act of vaccinating and the vaccine) will be covered by compulsory health insurance, provided the vaccination is recommended in the Swiss vaccination schedule. [3] This shifts the counselling question: it is no longer only about whether one may vaccinate, but about how to conduct vaccination conversations so that they have an effect.

Clinical and epidemiological background

Vaccine hesitancy was declared by the WHO in 2019 to be one of the ten greatest global health threats. The WHO defines vaccine hesitancy not as a binary refusal but as a behavioural spectrum between full acceptance and full refusal. Within this spectrum, three groups are clinically particularly relevant: full acceptance with a need for confirmation («I vaccinate, but I just need the confirmation»), ambivalence («I’m unsure») and refusal with a need to be understood («I don’t vaccinate, but I would like to be understood»). The majority of the patients the pharmacy encounters belong to the middle, undecided group. [4]

The Swiss data correspond to this pattern. The 2024 vaccination literacy study shows that 51 per cent of the population have difficulty classifying vaccination information and that 63 per cent find it difficult to assess its trustworthiness; recognising false information is experienced as similarly demanding. [1] At the same time the study shows that doctors, used by 85 per cent, remain by far the most important source of information for vaccination decisions, followed at a considerable distance by health authorities (38%), the personal environment (36%) and internet sources (34%).

Pharmacies are not reported separately in this study, but in reality they are a growing source of advice. Since autumn 2015, Swiss pharmacists with the FPH certificate of competence «Vaccination and blood sampling» or a federal diploma from 2022 onwards have been allowed to administer selected vaccinations in almost all cantons — as of March 2026 the spectrum differs by canton (from influenza and tick-borne encephalitis to HPV, measles, pneumococci, tetanus and hepatitis A/B). [11] The preconditions are a cantonal authorisation, a valid BLS-AED certificate (two years) and appropriate premises. As at 31 December 2024, 7,341 pharmacists with a licence to practise were registered in Switzerland in the MedReg. [10]

The structural hurdle so far has been financing: pharmacy vaccinations had to be paid for by patients themselves or billed through supplementary insurance. With the health insurance act revision of 21 March 2025 this changes: presumably from 1 January 2027, the act of vaccinating and the vaccine in the pharmacy will be covered by compulsory health insurance, provided the vaccination is recommended in the Swiss vaccination schedule. [3] The 2024 pharmaSuisse survey quantified the demand potential: 74 per cent of the population would be vaccinated in a pharmacy under this condition — corresponding to a doubling of current uptake. [10]

The spectrum of vaccine hesitancy: four counselling types

A first, counselling-relevant differentiation of vaccine hesitancy helps to put the conversation on the right track immediately. Clinically and communicatively, four ideal types can be distinguished, which the pharmacy professional typically encounters:

1. Seeking confirmation. These patients are fundamentally willing to be vaccinated but need brief professional confirmation. The conversation is short (one to two minutes) and the task is: brief, factual confirmation, where appropriate a reference to concrete data sources such as infovac.ch or an extract from the vaccination schedule.

2. Uncertain / undecided. This group is by far the largest (around 60 per cent of the population in Switzerland). It is open to a conversation but has specific fears or gaps in knowledge: adverse effects, mRNA technology after Covid, the density of childhood vaccinations, autoimmune diseases, local vaccine reactions. The counselling task here is the most productive — and the most time-consuming. This is where motivational interviewing (MI) is the methodological answer.

3. Selectively refusing. These patients refuse one particular vaccination but not others. Frequent constellations: HPV vaccination for their own child, influenza vaccination for their older self, a Covid booster after the initial course. The counselling task consists in distinguishing the specific refusal from a blanket rejection of vaccination and addressing the selective argument.

4. Refusing in principle. This group is small (about 7 per cent in Switzerland). The pharmacy’s task here is not conversion — the evidence for the chances of success of a single, six-minute counter conversation is slim. The task is respect for autonomy, providing a door-opening question, documenting the counselling and — where clinically indicated — offering a medical consultation.

Motivational interviewing (MI): method and evidence

Motivational interviewing (MI) was developed in the 1980s by William Miller in the context of addiction therapy and has, since the 2010s, also been intensively evaluated in vaccination counselling. [12] It is a patient-centred way of communicating with the aim of strengthening a person’s intrinsic motivation to change behaviour, without pressing them.

The central key is suppressing what the MI literature calls the righting reflex — the professional impulse to correct a piece of misinformation immediately or to convince a person to be vaccinated with arguments. Empirically, this reflex strengthens reactance and refusal. The more effective strategy is a guided (not directive) conversation that follows four principles: partnership, acceptance, compassion and evocation — the «MI spirit» for short. [12,13]

Methodologically, MI operationalises this spirit through four micro-techniques summarised under the acronym OARS:

O – Open questions. Open, non-suggestive questions instead of closed ones. «What concerns you about the vaccination?» instead of «Are you against the vaccination?» An open question opens a space in which the person can articulate their own concerns.

A – Affirmations. Affirming, not flattering, recognition of the effort somebody is making. «It is valuable that you are engaging so thoroughly with this decision.» This lowers reactance and establishes a relationship on equal terms.

R – Reflective listening. Active, paraphrasing mirroring of what has been said. «So you are worried above all that your son, as a boy, is to receive a vaccination that you originally thought was a girls’ vaccination.» Reflective listening signals being understood and gives the person the opportunity to hear their own position and, where appropriate, to modify it.

S – Summaries. Short, summarising reflections at the end of a phase of the conversation, recapitulating the person’s position and building the bridge to the next phase.

One concrete MI technique that works well in vaccination counselling is the importance–confidence scale: «On a scale from 0 to 10 — how important would it be to you that your child receives this vaccination?» With a middling answer such as «5», the productive follow-up question is not «Why not higher?» (that activates defensiveness) but: «What makes you say a 5 rather than a 2?» This stimulates what is known as change talk — the person articulates their own reasons for the vaccination. [13]

Evidence for MI in vaccination counselling: the PROMOVAC study from Quebec (Gagneur et al., BMC Public Health 2018; Lemaitre et al. for long-term coverage, Hum Vaccin Immunother 2019) showed, for a standardised 15-minute MI intervention in the postpartum setting, a 40 per cent reduction in vaccine hesitancy among mothers and a significant increase in infant coverage at 7 months from 74 to 80 per cent; at the same time parental apprehension about vaccination fell from 16 to 5 per cent. [5] An application study published in 2024 in eight US pharmacies (MOTIVE tool by Chen and colleagues, n=362 documented conversations) yielded as immediate outcomes: 35.4 per cent of patients were vaccinated at the same appointment after the conversation, 26 per cent planned an appointment soon, 25.1 per cent continued to consider the vaccination, and only 13.5 per cent remained uninterested. [6] The main reasons for hesitancy in this study were: safety (39%), coordination of care (31.5%) and effectiveness (30.4%).

Practical time frame: MI-compliant counselling does not require 30 minutes. Several studies show that even brief MI of 5–10 minutes’ duration can have significant effects — a time frame compatible with the Swiss pharmacy counter, particularly after the establishment of reimbursed vaccination counselling from 2027.

What is frequently asked at the counter — with concrete MI examples

Four typical counselling situations in the Swiss pharmacy — with concrete MI examples:

1. The HPV-sceptical mother of a 13-year-old boy

A mother, around 38 years old, comes into the pharmacy with a letter from the school doctor. Her son is to receive the HPV vaccination. She says: «My son is a boy. Why HPV? And I’ve read that girls get autoimmune diseases after the vaccination.» — Open question: «What would you like to decide for your son — and what matters most to you in that?» Reflective listening: «So above all you want to be sure that a vaccination makes medical sense for your son and does no harm — that is a good starting position.» Professional confirmation, briefly: HPV vaccination in Switzerland has been a basic vaccination since 1 January 2024 for boys aged 11–14 too, with a two-dose schedule (as for girls); catch-up vaccination at 15–19 years with a three-dose schedule (or off-label two doses), supplementary vaccination at 20–26 years — no longer merely a supplementary recommendation as before. [9] Estimates: 80–180 preventable cancer cases per year in men in Switzerland (anal, penile, oropharyngeal carcinomas). [9] On the autoimmune question: the systematic review by Phillips and colleagues (Drug Saf 2018) evaluated 109 studies, among them 15 population-based studies with more than 2.5 million vaccinated people in six countries — with no consistent evidence of an increased risk of autoimmune diseases or other adverse events of special interest. [14] Preserving autonomy: «You don’t have to decide today. What information would help you decide calmly?»

2. The 67-year-old with diabetes and a pneumococcal recommendation

Mr B., 67, a long-standing regular customer, has type 2 diabetes and takes metformin, insulin glargine and atorvastatin. On his family doctor’s advice he is to receive a pneumococcal vaccination. He says: «My brother-in-law had the jab and was ill for three days. I don’t need it.» — Importance scale: «On a scale of 0 to 10 — how important would it be to you to avoid a severe pneumonia?» Answer: «7.» Follow-up question: «What makes you say a 7 rather than a 3?» Patient: «Well, my father died of pneumonia at 72.» — With that, change talk has been activated. Professional classification: the conjugate vaccine PCV20 has been the recommendation for those aged 65 and over in Switzerland since 2024; the updated statement of the Federal Commission for Vaccination of 23.2.2026 differentiates by age and risk group. [7,8] People with diabetes are among the explicit risk groups. The usual reaction: a local reaction at the injection site, slight tiredness for 24–48 hours — which matches the brother-in-law’s experience.

3. The post-Covid-weary middle-class patient at the influenza vaccination

Ms M., 52, comes in October for the influenza vaccination but visibly has reservations. She says: «After the Covid vaccination I was tired for three weeks. I don’t know whether I want that again.» — Reflective listening: «Three weeks of tiredness is a very unpleasant experience — I understand that.» Not: «But studies show that this is rare.» — that would be the righting reflex. Open question: «What changed for you at the time because of the tiredness?» Listen. Professional differentiation only afterwards: influenza vaccines (inactivated split vaccine or subunit vaccine) are technologically fundamentally different from mRNA vaccines. Reactogenicity is generally milder; clinically documented tiredness after influenza vaccination lasts as a rule 24–48 hours. For Ms M. a «low dose» strategy — an appointment late on Friday afternoon, the weekend to rest — would be a concrete accommodation that respects autonomy and concerns.

4. The younger parents with the infant and the first MMR dose

A mother, around 33 years old, comes into the pharmacy; her 9-month-old son is to receive the first MMR dose (a recommendation brought forward to 9 months in 2019). She says: «So early already? My husband and I are unsure.» — Open question: «What concerns you about the timing at 9 months?» Listen. Frequently what comes up is: concern about infants being too young, the «vaccination load» on children. Affirmation: «You are thinking it through, and that is part of a good parental decision.» Brief professional information: since January 2019, the first MMR vaccination in Switzerland has been recommended at 9 months (previously 12 months), with the second dose at 12 months. Background: earlier studies showed that maternal antibody protection is already insufficient in many infants before the twelfth month of life — bringing the schedule forward is intended above all to close a protection gap. Swiss measles cases in 2024: 87, compared with 0 in 2021/22. [15] National two-dose coverage among two-year-olds was 91% in 2023 — the threshold for herd immunity (95%) has not yet been reached. Preserving autonomy: «If you would like to talk it over at home for a few more days — you can also postpone the appointment with your family doctor or with us here by two weeks without anything bad happening.»

Swiss care and tariff reality

The Swiss care and tariff reality around pharmacy vaccination has taken a tectonic step in the past two years.

The previous tariff reality (up to the end of 2026): pharmacy vaccinations are essentially self-pay services. Patients pay for the act and the vaccine out of their own pocket or through complementary or supplementary insurance. Individual cantons have supported pilot projects; individual health insurers have granted reimbursement through bonus programmes or complementary tariffs. This constellation has in practice limited the demand potential: according to the 2024 pharmaSuisse survey, about a quarter of the Swiss population have at some point been vaccinated or counselled in a pharmacy — interest, at 50 per cent, is twice as high. [10] 74 per cent would be vaccinated in a pharmacy if covered by compulsory health insurance.

The new tariff reality (from presumably 1.1.2027): with the adoption of the second cost-dampening package by parliament on 21 March 2025, the pharmacist service of vaccinating — specifically the act of vaccinating and the vaccine — will be covered by compulsory health insurance, provided the vaccination is recommended in the Swiss vaccination schedule. [3] The precise tariff arrangements (LOA V position, cantonal differentiation, pharmacy assistants under supervision) are currently being worked out by pharmaSuisse, the Federal Office of Public Health and the cantons.

Professional practice requirements for pharmacists who wish to vaccinate in Switzerland: the FPH certificate of competence «Vaccination and blood sampling» or a federal diploma from 2022 onwards (in which vaccination training is part of the basic degree); in addition a valid Swiss Resuscitation Council-recognised BLS-AED certificate (valid for 2 years); a cantonal authorisation per pharmacy; suitable premises with the possibility to lie down, an emergency kit and a container for hazardous waste. [11,16] Continuing education obligations are monitored for FPH holders by FPH Offizin. As at 31 December 2024, 7,341 pharmacists with a licence to practise were registered in Switzerland in the MedReg. [10] pharmaSuisse continuously publishes an up-to-date, canton-specific overview of the permitted vaccinations per canton.

Which vaccinations are administered in the pharmacy? As of March 2026 the most frequent pharmacy vaccinations in Switzerland are: seasonal influenza, tick-borne encephalitis, pertussis (Tdap), hepatitis A/B, MMR catch-up vaccinations, pneumococci, HPV — in individual cantons also RSV (for adults) and travel medicine (typhoid, rabies pre-exposure prophylaxis, cholera). [11] The list varies by canton; pharmaSuisse maintains an updated overview at pharmaSuisse.org/de/impfberatung.

Safety, contraindications, emergency management

Clinical preconditions for pharmacy vaccination in Switzerland: triage by questionnaire before every vaccination; exclusion of pregnancy (for live vaccines), acute infections with fever >38.5 °C, known severe allergies to vaccine components, immunosuppressive therapy (for live vaccines). [16] A seat that can be brought into a lying position, as well as an emergency kit (with an adrenaline auto-injector and an antihistamine), are mandatory in the pharmacy.

Common adverse effects are comparable across vaccine classes: a local reaction at the injection site (swelling, redness, pain) in 20–80%, a mild systemic reaction (tiredness, headache, muscle pain, slight fever) in 10–40%, both self-limiting over 24–48 hours. [7] These reactions are an expression of the desired immune response and should not be played down in counselling but put in context — that strengthens the credibility of the advice.

Anaphylaxis is very rare: the international literature gives the incidence after vaccinations as around 1–5 per million doses (an order of magnitude that varies by vaccine and cohort). [7] It occurs as a rule within 15–30 minutes of the injection — hence the recommendation of 15–30 minutes of observation in the pharmacy (a place to lie or sit is needed). The pharmacy must have BLS-AED-certified staff available and have practised the emergency procedure.

Interactions with long-term medication: clinically relevant interactions are rare with standard vaccines. Caution is required in patients on immunosuppressive therapy (methotrexate, biologics, high-dose systemic glucocorticoids >20 mg prednisone equivalent per day): live vaccines (MMR, varicella, yellow fever) are contraindicated, inactivated vaccines are permissible but may have reduced immunogenicity. With oral anticoagulants (vitamin K antagonists, DOACs), intramuscular injection is possible, but a fine needle and gentle compression after injection are important — the risk of a severe haematoma is minimal and is not a contraindication. [16]

Documentation is central: every pharmacy vaccination is documented in the patient file, in the (digital or paper) vaccination record and — where the canton requires it — in a cantonal system. Electronic documentation, for example through viavac.ch, is increasingly becoming standard.

Practice tool: counselling situations, MI techniques and formulations

Outlook 2026/2027

Three developments will shape vaccination counselling in the Swiss pharmacy in the coming years.

First: the health insurance act revision of 21 March 2025, with the probable activation of reimbursement for pharmacy vaccinations on 1 January 2027, will massively increase uptake — pharmaSuisse expects a doubling. [3,10] Structurally this demands an upgrade of the pharmacy: more space for vaccination counselling, trained staff (the FPH certificate of competence or a diploma from 2022 onwards), emergency equipment, documentation infrastructure. But it also demands an upgrade of the counselling itself — the counter format of a short question and a quick answer is no longer enough. MI-compliant counselling requires 5 to 10 minutes of undisturbed time per patient.

Second: the Swiss vaccination schedule 2026 (published in February 2026) and the announcement that the factsheets will be discontinued from 2026 [7] shift the information and counselling burden more strongly to the low-threshold points of contact — pharmacies, family doctors, school health services. The digital resources Infovac (infovac.ch) and the Federal Office of Public Health bulletin become more central. Pharmacies should have a combined viavac®/InfoVac subscription as a standard in the team (offered by pharmaSuisse at a preferential price of CHF 103). [11]

Third: pharmacy assistants are increasingly being involved in administering vaccinations. Since the Covid pandemic, several cantons have allowed pharmacy assistants to administer vaccinations under a pharmacist’s supervision, provided they have completed specific further training. This delegation can ease the bottleneck of FPH-certified pharmacists and make it possible to scale up pharmacy vaccinations from 2027. [17]

Counselling on vaccine hesitancy is, in 2026, no longer a marginal discipline. It is — alongside acute OTC counselling, medication review and adherence promotion — one of the central clinical competences that will shape the Swiss pharmacy in the coming years. Whoever masters it shapes not only their own tariff but also the reality of care in Switzerland.