Since the emergence of the COVID-19 pandemic, the world has not been the same. The objective to “flatten the curve” has led to social distancing guidelines, masking requirements and restrictions on travel. Although the majority have adjusted to the new norm, resistance has sparked political debates, questions regarding infringements on civil liberties and distrust of public health authorities. Although some predict new hope on the horizon with a SARS-CoV-2 (COVID-19) vaccine, vaccine hesitancy could pose a major barrier to protecting individuals from this disease and achieving herd immunity. Therefore, to overcome potential hurdles to vaccine uptake, we must plan accordingly.
Vaccine hesitancy was declared one of the top 10 global health threats by the World Health Organization (WHO) in 2019.¹ However, fear of vaccines is not new. Smallpox vaccine, the first successful vaccine to be developed, was introduced by Edward Jenner in 1796.² He observed that through a process called variolation milkmaids who had been infected with cowpox were less likely to develop smallpox during outbreaks. As illustrated in Figure 1, many people did not trust this new technology, doubting its safety and worrying about a conspiracy by doctors or the government. However, every year, greater numbers of people were vaccinated under this new method, which became the basis for modern vaccination practices. Through widespread vaccination, smallpox was officially eradicated in 1980. As seen in Figure 2, during the 20th and 21st centuries, vaccination has greatly reduced morbidity among many once-prevalent diseases.
Vaccine-hesitant individuals are a heterogeneous group who have varying degrees of indecision about specific vaccines or about vaccinations in general.³ Vaccine-hesitant individuals may accept all vaccines but remain concerned about them; they may refuse or delay some vaccines but accept others; or they may refuse all vaccines. Each group requires different approaches when discussing vaccines and generally responds with different levels of success.
The Healthcare Provider’s Role in Vaccination Compliance
Healthcare providers have an advantage when communicating about the benefits of vaccines. A strong recommendation from a healthcare provider is the strongest predictor of compliance with vaccination.4 How you communicate is key. Research has shown that simply correcting patients’ knowledge gaps—whether through informational brochures, community campaigns or direct provider conversations—often is not enough to address concerns about vaccines.5 This can be a result of disconfirmation bias—when presented with information we don’t want to hear, we try very hard to reject it. That is especially true for beliefs that are central to our identity. We can improve vaccination adherence by focusing on how people think. We need to know our audience.
Perceived uncertainty about vaccines can be improved through communication about the risks and benefits. Risk communication is defined as a science-based approach for communicating effectively in high-concern, high-stress, emotionally charged or controversial situations.6 Risk communication is recognized as two-way and multidirectional communication and engagement with affected populations so that they can make informed decisions to protect themselves and their loved ones. Appropriate channels of communication and collaboration with respected community leaders are critical for building trust. When communicating about vaccines, it is best to avoid a top-down or paternalistic approach. Instead, focus on addressing patient concerns and finding common ground. Below are some tips to help facilitate the conversation.
Don’t Equate Hesitancy with Refusal
Simply having questions and concerns does not mean a patient ultimately will refuse to receive a vaccine. Undoubtably, there will be questions concerning the safety and efficacy of the COVID-19 vaccine considering its expedited approval process.
In 2010, for example, many Americans rejected the H1N1 vaccine out of a belief that the vaccine was “rushed” and thus, unsafe. Learning from experience, we must be prepared and lay the groundwork in advance. We should discuss the vaccine now before it becomes available. By engaging in a two-way discussion, we can learn strategies for increasing vaccine acceptance.
Avoid Jargon—Use Plain Language
Along with the new COVID-19 vaccine, you will need to address questions about vaccine safety and efficacy and dispel common myths. Rather than spewing statistics and facts from medical journals, use plain language. Communication should be comprehensible to nonscientific audiences and should avoid technical jargon.
People want to know that you care before they want to know what you know. Remember to use active listening techniques. Check for understanding. Repeat back what you heard to ensure that you are truly hearing the patient’s concerns.
Don’t Over Reassure
Acknowledge that vaccines, like medications, carry some risks. Keep in mind that once a COVID-19 vaccine becomes available, it may not provide broad immunological protection. Continue to recommend other preventative health measures to decrease the spread of COVID-19 rather than relying solely on the vaccine to be the panacea.
Improve Cultural Competency
“Knowing your audience” is crucial. What do they value? Can those values coincide with the acceptance of immunizations? Answering these questions may involve getting to know your community better or collaborating with outside agencies and stakeholders to help open the lines of communication.
The 2017 measles outbreak in Hennepin County, Minnesota (where there had been an increasing number of Somali refugees), helps to illustrate the value of cultural competency.7 Anti-vaccine advocates held forums to communicate that children would not get autism as long as they did not receive the measles, mumps and rubella (MMR) vaccination. As a result, MMR vaccination rates among U.S.-born children of Somali descent declined.
Health department staff and outreach workers addressed these concerns by working directly with community leaders, health professionals and parents of children diagnosed with autism spectrum disorder. Through this process, the health department developed culturally relevant and effective approaches for addressing vaccine hesitancy in the community. As a result of these efforts, there was an eight-fold increase in the number of vaccines administered to the Somali community in Minnesota (from 200 to 1,600). This success demonstrates that getting to know your audience can help build trust and improve patient outcomes.
Use the Power of Social Media
A critical component of communicating with patients is countering misinformation. The proliferation of social media has engendered the persistence of myths, conspiracy theories and overall fear among those with vaccine questions and concerns. Rather than viewing social media as a barrier, view it as an opportunity. Monitoring social media can assist you with understanding the true reasoning and emotions behind the posts.
In an era when more than 2.3 billion people in 232 countries are active on social media,8 the public health community can correct misinformation by establishing its own social media communities and leveraging established channels to provide facts about the safety and value of vaccines.8 If you have not established a social media presence, now is the time to build it. Expand your presence by encouraging others, particularly those in trusted leadership positions, to use social media regularly. To reach more audiences, tag those you work with. Participate in Twitter or Facebook chats. Responding to questions and concerns to make communication bidirectional can help the public view you on a more personal level.
A Shared Responsibility
There is no one-size-fits-all approach when addressing vaccine hesitancy, but preparation and a multifaceted approach are key. You play a vital role in encouraging patients to receive a COVID-19 vaccine, but you cannot do it alone. Immunization is a shared responsibility. Ultimately, it will take the collaboration of your office staff and public health partners, as well as support from community leaders, to reinforce the benefits of vaccination and the continuation of preventive health behaviors to conquer this pandemic. We are in this together.
Vaccine Hesitancy Resources
Vaccinate with Confidence (CDC)
Clear Communication Index User Guide (CDC)
CDC Provider Resources for Vaccine Conversations with Parents
Children’s Hospital of Philadelphia (CHOP) Vaccine Education Center
Immunization Action Coalition (IAC) Handouts: Vaccine Confidence
World Health Organization: Improving Vaccine Demand and Addressing Hesitancy