Building COVID-19 vaccine confidence throughout the immunization neighborhood

CPE

Maria G. Tanzi, PharmD

Introduction

According to CDC’s COVID-19 data tracker, as of press time, approximately 52% of the U.S. adult population was fully vaccinated against COVID-19, and 62.8% of U.S. adults have received at least one dose.¹ Vaccine uptake has continued to increase since the initial authorization in December 2020, but more recent data suggest that demand for the COVID-19 vaccine may be reaching a plateau.²

Many factors may be influencing the public’s perceptions of the new COVID-19 vaccines, including mis- and disinformation on social media and other media, concerns about vaccine safety and the rapid development process, and hesitancy to trust the health care system or providers.³

WHO defines vaccine hesitancy as “a delay in acceptance or refusal of vaccines despite availably of vaccination services.”⁴ Vaccine hesitancy is influenced by factors such as complacency, convenience, and confidence and can span a continuum from high vaccine demand to complete vaccine refusal.This CPE course aims to give pharmacists the tools they need to turn their patients’ vaccine hesitancy into vaccine confidence. It discusses conversational strategies such as motivational interviewing techniques aimed at building vaccine confidence, along with specific information and examples on how to address patients’ COVID-19 vaccine myths, questions, and concerns. In addition, a special focus is on interventions aimed at improving COVID-19 vaccination rates in disproportionately affected groups.

Why are some patients not getting vaccinated?

Data from the April 2021 Kaiser Family Foundation (KFF) COVID-19 Vaccine Monitor cited reasons some patients are hesitant to receive the COVID-19 vaccine.² For “persons who were not going to receive the COVID-19 vaccine unless required,” reasons cited in their decision not to be vaccinated include safety concerns, the potential for adverse effects, newness of the vaccines, and not enough available research. Some persons also stated that they already had COVID-19, believed they didn’t need the vaccine, or simply didn’t want it.

For those who were willing to receive the COVID-19 vaccine but had not yet done so, the KFF data highlighted other issues, such as being too busy, vaccine appointments conflicting with work hours, and not making vaccination a priority.² Some respondents also lacked information about how to obtain the vaccine.

The data also highlighted concerns that were greater in racial and ethnic minority groups (e.g., Black and Hispanic adults) compared with White adults, such as access-related barriers; concerns about missing work because of vaccine-related adverse effects; out-of-pocket costs; difficulty traveling to a vaccination site, and being able to get the vaccine from a place they could trust.

Access-related disparities for the COVID-19 vaccine between urban and rural counties have also been noted, with CDC reporting that coverage rates have been lower in rural communities.⁵ The agency reported that a larger proportion of persons in most rural communities needed to travel to nonadjacent counties to receive the vaccine compared with those in most urban counties.

The BeSD vaccination model

WHO has developed a model, Measuring Behavioral and Social Drivers of Vaccination (BeSD), to help clinicians understand some of the reasons for undervaccination.⁶ The model gathers information on how patients feel and act in relation to vaccination in order to develop strategies that increase vaccine acceptance and uptake. The BeSD increasing vaccination model (Figure 1) measures four specific domains that influence vaccine uptake: 1) what people think and feel about vaccines; 2) social processes that drive or inhibit vaccination; 3) individual motivation or hesitancy in seeking vaccination; and 4) practical issues in seeking and receiving vaccination.

For the first domain, what people think and feel, many factors can be influential in a patient’s decision to receive the COVID-19 vaccine, such as patients’ confidence in the benefits and/or safety of the COVID-19 vaccines, their perceived risk of the disease to themselves and others, and the information they may have seen or heard about the vaccine, especially negative information in the media or on social platforms.⁷

Social processes focus on factors such as trust in vaccine providers, a strong provider recommendation to receive the COVID-19 vaccine, and social norms (e.g., what close family and friends are planning to do about the COVID-19 vaccination, what community leaders think or plan to do). In addition, the ability to travel without restrictions may play a role in patients’ desire to become vaccinated.

Motivation to become vaccinated against COVID-19 can be driven by patients’ readiness, willingness, and intention; or it can become inhibited by their hesitancy to receive the vaccine.⁷ And finally, a variety of practical issues play a role in increasing vaccination against COVID-19, such as knowing where the vaccine is available, ease of access to the vaccine, and the option to get vaccinated at a preferred site (i.e., convenience). For other vaccines, cost can be a barrier, but COVID-19 vaccines incur no cost to the patient. However, many people still believe there is a cost attached to these vaccines, causing additional challenges.

WHO has developed an interim guidance, Data for Action: Achieving High Uptake of COVID-19 Vaccines, which has interview guides that pharmacists can use to assess all the domains of the BeSD model with their patients.⁷

Focus on building vaccine confidence

As noted above, many factors influence vaccine decision making, but building strong confidence in COVID-19 vaccines will result in more people getting vaccinated and ultimately in improved outcomes (e.g., decrease in hospitalizations, fewer deaths).⁸ Vaccine confidence is defined as the trust that patients, their families, and providers have in⁸

• Recommended vaccines
• Providers who administer vaccines
• Processes and policies that lead to vaccine development, licensure or authorization, manufacturing, and recommendations for use

CDC has launched a strategy to build confidence in COVID-19 vaccines.⁸ The agency lists six ways to help build COVID-19 vaccine confidence (see sidebar). Strategies include having discussions with patients to understand their perspective about vaccination; sharing key messages and reliable information about the COVID-19 vaccines; addressing misinformation, and asking providers to make their patients aware of their own decision to get vaccinated.

On its website, CDC also offers a COVID-19 Vaccinate with Confidence framework that focuses on building trust, empowering health care personnel, and engaging communities and individuals (Figure 2).⁹ Clinicians are encouraged to review this framework and other CDC resources on vaccine confidence.

Six ways to help build COVID-19 vaccine confidence

• Encourage leaders in your family, community, or organizations to become vaccine champions.
• Have discussions with your friends, family, and community about vaccination to understand their perspective and encourage their decision to vaccinate.
• Share key messages through multiple channels that people trust and that promote action.
• Help educate people about COVID-19 vaccines, how they are developed and their intensive safety monitoring, and how to talk to others about the vaccines.
• Learn more about finding credible vaccine information and how to respond to misinformation.
• Make visible your decision to get vaccinated and celebrate it.

Communication techniques to build confidence in COVID-19 vaccines

Motivational interviewing

Conversations that guide a patient to explore their own reasons for vaccine hesitancy can help increase confidence and trust in the COVID-19 vaccine.

Motivational interviewing is a collaborative conversational style that is used to strengthen a person’s own motivation and commitment to change, and there is strong evidence supporting its use to address vaccine hesitancy.^3,10 It is less about health care providers speaking to patients and more about providers working with their patients to strengthen a patient’s own personal motivation and commitment to a specific goal.^10,11 This type of communication style is adapted to meet individual patient needs and to address specific vaccine-related concerns and questions. It helps patients explore their own ambivalence, find their own arguments for change, and ultimately make their own informed decision about vaccination.¹⁰

The motivational interviewing technique is based on three main components¹⁰:

• The spirit to cultivate a culture of partnership and compassion and build a respectful relationship with empathy
• The process to foster engagement in the relationship and focus the discussion on the target of change
• The skills that allow health care providers to understand and address individual patients and caregiver concerns

Key motivational interviewing skills for vaccination (summarized in Table 1) include the use of open-ended questions, reflective listening (both simple and complex), affirmation, and summaries.^10,11 Providers use these skills to actively listen to their patients, repackage their statements back to them, and highlight what patients have done well. Patients can freely discuss their concerns about vaccination and ask questions without feeling judged. These types of conversations help build a strong relationship between patients and providers and have been shown to increase vaccine confidence.¹⁰

The Elicit–Share–Verify method (Table 2) is another interaction technique providers can use to explore and share information about specific patient concerns.^10,11 In the first step (Elicit), the provider asks the patient what they know and permission to complete their knowledge. The second step (Share) provides evidence-based information tailored to the patient’s concerns, and the final step (Verify) focuses on verifying understanding and planned behaviors based on the information provided. The Share step is also a good opportunity to provide a strong recommendation for the COVID-19 vaccine and explain the reasons for vaccination.

CDC recommendations on engaging with patients

CDC also provides guidance on how to talk to patients about COVID-19 vaccination.¹² The agency focuses on the following five steps:

• Lead with listening.
• Use patient-centered communication techniques.
• Respond to questions and concerns with empathy.
• Give your strong recommendation.
• Wrap up the conversation.

The five steps incorporate many of the motivational interviewing skills discussed above. CDC notes that providers should not make assumptions about whether patients will choose to get vaccinated or the reasons for their decisions.¹² Instead, they suggest starting the conversation using an open-ended question (e.g., “What are your thoughts on getting a COVID-19 vaccination today?”) and actively listening to understand the patient’s point of view. The agency notes that these conversations can take time and may continue over the course of multiple encounters.

Patient-centered communication techniques use motivational interviewing skills such as open-ended questions to promote dialogue; paraphrase ing information shared to demonstrate understanding; praise measures already taken by the patient; and ask for permission to share more information about the COVID-19 vaccines.¹² The agency notes that providers should frame vaccination as a safe and effective way to help protect patients from getting COVID-19.

CDC also highlights the importance of responding to questions and concerns in a nonjudgmental, respectful, and empathic way.¹² Providers should provide accurate answers to patients using clear, simple language and acknowledge patients’ concerns about what is not yet known about the COVID-19 vaccines. Some patients’ concerns may also stem from mistrust in the medical establishment or the government as result of collective or individual mistreatment and traumas, so acknowledging these past traumas will also help to promote patient trust.

Giving a strong recommendation for the COVID-19 vaccine is critical for vaccine acceptance.¹² Providers should tailor the recommendation to include any relevant reasons COVID-19 vaccination might be particularly important for that specific patient. CDC also encourages providers to talk to patients about their personal decision and experience in getting a COVID-19 vaccine.

Explaining to patients the benefits of vaccination and what they can do once they are fully vaccinated is also recommended.

Examples on CDC’s website of providing a strong recommendation include

•  “I strongly recommend you get a COVID-19 vaccine.”
• “This vaccine is especially important for you because of your [job/underlying health condition/vulnerable family].”
• “I believe in this vaccine so strongly that I got vaccinated as soon as it was available to me, and I recommended that everyone in my family did the same.”
• “I have seen what COVID-19 can do to patients and their families. I want to protect you as best I can from COVID-19 infection and complications.”

Finally, conclude conversations by encouraging patients and parents to take at least one action, such as scheduling a vaccination appointment or reading any handouts provided to them.¹² CDC suggests that if patients decline vaccination, acknowledge that this is their decision, and keep the door open to revisiting the topic during future visits.

Addressing myths

Misinformation about COVID-19 vaccines has affected vaccine confidence. CDC has provided information about these common myths that clinicians can share with patients (Table 3).¹³

Addressing common questions about COVID-19 vaccines

CDC has also provided responses to address other common questions and concerns patients have about COVID-19 vaccines.¹⁴ The rapid process of COVID-19 vaccine development has been identified as a key concern. Clinicians should share data with patients in a digestible format that considers patients’ health literacy. Explain what makes the development process rigorous and safe, but keep the information simple and high level. Share with patients that millions of people in the United States and around the world have received COVID-19 vaccines and that these vaccines have undergone the most intensive safety monitoring in U.S. history.

Another common question involves natural immunity versus vaccine immunity. Clinicians can help patients understand that although getting COVID-19 may offer some natural protection, how long this protection lasts is not known.¹⁴ Inform patients that the risks of severe illness and death from COVID-19 far outweigh any benefits of natural immunity.

CDC recommends that clinicians discuss potential adverse effects from vaccination proactively with patients, as COVID-19 vaccines are reactogenic and patients are likely to have some adverse effects, especially after the second dose.¹⁴ Patients may confuse these adverse effects with COVID-19 symptoms or worry the vaccine gave them COVID-19. Clinicians should have an open and honest discussion with patients about potential adverse effects so patients have realistic expectations and can plan accordingly.

Emphasize that adverse effects are “normal signs your body is building protection against COVID-19” and that “these side effects are generally short-lived.” Stress the importance of returning for the second dose even if adverse effects occurred after the initial injection. Also, it is important to be transparent with patients that long-term adverse effects may not be known but that CDC and FDA are continuing to monitor vaccine safety to make sure any long-term adverse effects are identified.

Other frequently asked questions about COVID-19 vaccines, such as the number of required doses and which vaccine to get, are also addressed on CDC’s website.^14,15 Clinicians are encouraged to review those questions and responses and to refer patients to the CDC website for more information.

COVID-19 vaccination toolkits

Multiple organizations have audience-specific toolkits available that help promote vaccine confidence among a diverse set of groups.^16–18 Organizations such as CDC, the U.S. Department of Health and Human Services (HHS), and the Ad Council, in conjunction with the COVID Collaborative, have developed toolkits to promote vaccine confidence to a diverse audience.

CDC provides vaccination toolkits aimed at building confidence among health care teams, pharmacy teams, and staff.¹⁶ Toolkits available on CDC’s website include a Vaccination Communication Toolkit for medical centers, clinics, pharmacies, and clinicians; a Recipient Education Toolkit to help educate vaccine recipients about the importance of the COVID-19 vaccine; a Long-Term Care Facility Toolkit; and a Health Departments and Public Health Partner Toolkit. Other CDC toolkits address special populations, such as employers of essential workers, staff of organizations serving communities, and school settings and child care programs.

HHS has launched a COVID-19 public education campaign to increase confidence in COVID-19 vaccines and reinforce basic prevention measures.¹⁷ HHS notes that its goals are to explain how Americans can protect themselves from COVID-19; strengthen public confidence in the vaccines so those who are hesitant will be more willing to consider vaccination; and increase vaccine uptake by informing Americans about how and where to get vaccinated.

HHS’s “We Can Do This” slogan (Figure 3) is used throughout a variety of campaign ads. HHS offers more than 30 toolkits on its website that focus on a broad range of groups, such as rural communities, pharmacists, pediatricians, parents of adolescents, nurses, essential workers in agriculture, and much more.

The Ad Council and COVID Collaborative are also leading a massive communications effort to educate the American public and build confidence about the COVID-19 vaccines.¹⁸ Their COVID-19 vaccine educational initiative is designed to reach different audiences, including communities of color that have been disproportionately affected by COVID-19 (see next section). The groups have launched an “It’s Up to You” campaign with toolkits that cover groups such as Black, Hispanic, faith, and public health communities, as well as employers.

Improving COVID-19 vaccination rates in disproportionately affected groups

The impact of COVID-19 in racial and ethnic minority groups has been great, with hospitalizations and death rates approximately nine times higher in Black Americans than White Americans.¹⁹ In addition, the latest CDC data on COVID-19 vaccination rates from June 3, 2021 (for which demographics are known) show that Black Americans (9% with at least one dose) and Hispanic Americans (14.3% with at least one dose) have some of the lowest vaccination rates compared with White Americans (61.2% with at least one dose).²⁰

These low rates may be related to historic racism and racial disparities in care provided to these racial and ethnic minority groups, resulting in a lack of trust in health care providers and systems, as well as to inequitable access to vaccines.19

There may be no convenient locations to receive the COVID-19 vaccines, or patients may be unable to take time off work to get vaccinated or to recover from adverse effects.

Historically, unethical practices in medical research involving racial and ethnic minority groups (e.g., the U.S. Public Health Service Syphilis Study at Tuskegee, among many others) have led to doubt and skepticism about the trustworthiness of science, research institutions, and the government.^19,21

The lack of diversity among providers serving these groups, as well as systemic health care inequalities, has also reduced vaccine confidence.¹⁹

Counseling and building trust

A recent paper by Opel and colleagues highlighted four communication strategies that may help promote trust among racial and ethnic minority groups regarding COVID-19 vaccination.²²

These strategies include leading with listening, tailoring responses to address patient concerns, describing the regulatory and development processes surrounding COVID-19 vaccines using accessible language, and acknowledging uncertainty. Patients want their experiences and concerns to be heard and validated.

It is important to demonstrate an understanding of patients’ concerns before moving forward with more specific information about the vaccines. This can be followed by nonjudgmental and collaborative tailored responses to patient concerns. Never dismiss concerns or suggest they are unfounded.

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Resources to help build COVID-19 vaccine confidence in patients

CDC - www.cdc.gov/vaccines/covid-19/vaccinate-with-confidence.html

APhA - vaccineconfident.pharmacist.com/Learn/Build-Your-Vaccine-Confidence

Immunization Action Coalition - www.immunize.org/vaccines/a-z/covid-19/

HHS - wecandothis.hhs.gov/filter/topic/Building%20Vaccine%20Confidence

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A conversation centered on shared decision making is ideal, but a recommendation to get the vaccine should also be part of the conversation.²² One technique is to ask for permission to make a recommendation, and if granted, stating, “In my view, the benefits of COVID-19 vaccination outweigh the risks. I strongly recommend these vaccines to all my patients.” Other communication strategies are to clearly describe the regulatory and development process of the COVID-19 vaccines in a manner patients can understand. Engage in an honest dialogue about the inclusion of patients from racial and ethnic minority groups in clinical trials. And finally, acknowledge uncertainty (e.g., limited long-term data, optimal timing of booster doses). By acknowledging uncertainty, providers are transparent with patients and can build trust.

As noted above, the Ad Council and COVID Collaborative are leading nationwide communications effort to bolster vaccine confidence among many populations disproportionately affected by COVID-19, including Black Americans.¹⁸ Communication strategies to bolster vaccine confidence include patients receiving a strong recommendation from their pharmacist to get vaccinated and hearing from people they trust—those in one’s personal network or trusted leaders in their communities, such as faith-based leaders.²³ Several authors describe the value of community–academic partnerships in establishing and maintaining trusting relationships with racial and ethnic minority groups.^24,25

It is also important to work with faith-based organizations and acknowledge different faith traditions that may have an impact on COVID-19 vaccine confidence. The Ad Council has a toolkit for Black Faith Communities (blackfaithvaccinetoolkit.org/about), and there is one focused on Christians (www.christiansandthevaccine.com/) supported by a variety of organizations. Not all these faith-based groups are disproportionately affected by COVID-19, but it’s beneficial to be aware of these partnerships and available resources to help build vaccine confidence.

Other guiding messaging principles for Black Americans from the Ad Council and COVID Collaborative include leading with empathy and respect, acknowledging people’s questions and concerns, gaining trust by being honest and transparent; and  presenting information in a clear way.²³

Table 4 summarizes some of the numerous credible COVID-19 vaccine resources that pharmacists can access to help build vaccine confidence in their patients.

Conclusion

Many factors influence vaccine decision making. Building strong confidence in COVID-19 vaccines will result in more people getting vaccinated and ultimately, improved outcomes.

Communication techniques such as leading with listening, tailoring messages to meet patient needs, responding to questions and concerns with empathy, and giving your strong recommendation for the COVID-19 vaccine can turn patients who are vaccine hesitant into those who are vaccine confident.

References

1. CDC. COVID-19 vaccinations in the United States. June 1, 2021. https://covid.cdc.gov/covid-data-tracker/#vaccinations. Accessed June 1, 2021.
2. Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor–April 2021. May 6, 2021. www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/. Accessed June 1, 2021.
3. Gabarda A, Butterworth SW. Using best practices to address COVID-19 vaccine hesitancy: The case for the motivational interviewing approach. Health Promot Pract. 2021;[Epub ahead of print]: doi: 10.1177/15248399211016463.
4. MacDonald NE, SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope, and determinants. Vaccine. 2015;33(34):4161–4.
5. Murthy BP, Sterrett N, Weller D, et al. Disparities in COVID-19 vaccination coverage between urban and rural counties–United States, December 14, 2020–April 10, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(20):759–64.
6. WHO. Meeting report: Measuring behavioural and social drivers (BeSD) of vaccination working group, May 1–3, 2019. www.who.int/immunization/programmes_systems/Meeting_report_May2019.pdf?ua=1. Accessed June 1, 2021.
7. WHO. Data for action: Achieving high uptake of COVID-19 vaccines. April 1, 2021. www.who.int/publications/i/item/WHO-2019-nCoV-vaccination-demand-planning-2021.1. Accessed June 1, 2021.
8. CDC. Building confidence in COVID-19 vaccines. April 5, 2021. www.cdc.gov/vaccines/covid-19/vaccinate-with-confidence.html. Accessed June 1, 2021.
9. CDC. Vaccinate with confidence: CDC’s strategy to reinforce confidence in COVID-19 vaccines. December 6, 2020. www.cdc.gov/vaccines/covid-19/downloads/how-build-hcp-confidence-covid-19-vaccines-508.pdf. Accessed June 1, 2021.
10. Gagneur A. Motivational interviewing: A powerful tool to address vaccine hesitancy. Can Commun Dis Rep. 2020;46(4):93–7.
11. WHO. Communicating with patients about COVID-19 vaccination. https://apps.who.int/iris/bitstream/handle/10665/340751/WHO-EURO-2021-2281-42036-57837-eng.pdf. Accessed June 2, 2021.
12. CDC. How to talk to your patients about COVID-19 vaccination. June 2, 2021. www.cdc.gov/vaccines/covid-19/hcp/engaging-patients.html. Accessed June 2, 2021.
13. CDC. Myths and facts about COVID-19 vaccines. May 24, 2021. www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html. Accessed June 2, 2021.
14. CDC. Answering patients’ questions about COVID-19 vaccine and vaccination. April 5, 2021. www.cdc.gov/vaccines/covid-19/hcp/answering-questions.html. Accessed June 3, 2021.
15. CDC. Frequently asked questions about COVID-19 vaccination. May 23, 2021. www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html. Accessed June 3, 2021.
16. CDC. COVID-19 vaccination toolkits. December 17, 2020. www.cdc.gov/vaccines/covid-19/toolkits/index.html. Accessed June 3, 2021.
17. U.S. Department of Health and Human Services. COVID-19 public education campaign. https://wecandothis.hhs.gov/. Accessed June 3, 2021.
18. Ad Council. COVID-19 vaccine education initiative. www.adcouncil.org/covid-vaccine. Accessed June 3, 2021.
19. Quinn SC, Andrasik MP. Addressing vaccine hesitancy in BIPOC communities—toward trustworthiness, partnership, and reciprocity. N Engl J Med. 2021;[Epub ahead of print]. doi: 10.1056/NEJMp2103104.
20. CDC. Demographic characteristics of people receiving COVID-19 vaccinations in the United States. June 3, 2021. https://covid.cdc.gov/covid-data-tracker/#vaccination-demographic. Accessed June 3, 2021.
21. Scharff DP, Mathews KJ, Jackson P, Hoffsuemmerm J, Martin E, Edwards D. More than Tuskegee: Understanding mistrust about research participation. J Health Care Poor Underserved. 2010;21(3):879–97.
22. Opel DJ, Lo B, Peek ME. Addressing mistrust about COVID-19 vaccines among patients of color. Ann Intern Med. 2021:M21-0055.
23. Ad Council and COVID Collaborative. Black community education toolkit: Create the right message. https://blackcommunityvaccinetoolkit.org/messaging-strategy. Accessed May 3, 2021.
24. Abdul-Mutakabbir JC, Casey S, Jews V, et al. A three-tiered approach to address barriers to COVID-19 vaccine delivery in the Black community. Lancet Glob Health. 2021;S2214-109X(21)00099-1.
25. Peteet B, Belliard JC, Abdul-Mutakabbir J, Casey S, Simmons K. Community–academic partnerships to reduce COVID-19 vaccine hesitancy in minoritized communities. EClinicalMedicine. 2021;34:100834.

This project was funded in part by a collaborative agreement with the CDC (CoAg number 1 NU50CK000576-01-00). CDC is an agency within the U.S. Department of Health and Human Services (HHS). The contents of this resource do not necessarily represent CDC or HHS and should not be considered an endorsement by the federal government.