How to Talk to People About COVID-19 Vaccines

In December 2020—a mere 9 months into the COVID-19 pandemic—the United States embarked on the most ambitious vaccination campaign in our nation’s history. When the first COVID-19 vaccines became available, the main challenge was that demand greatly exceeded supply. Millions of Americans waited anxiously for appointments to become available and willingly rolled up their sleeves for the “jab.”

Now, the main challenges are figuring out how to decrease hesitancy among the unvaccinated and build and reinforce confidence in COVID-19 vaccines. Addressing these challenges requires a more personal approach grounded in listening and understanding—engaging with people on an individual level to address their specific concerns and counter rampant misinformation.

The concerns and misinformation are far more wide-ranging than the fears typically associated with vaccine hesitancy (e.g., the falsehood that childhood vaccines cause autism). In fact, the concerns reflect almost all of the determinants of vaccine hesitancy identified by the World Health Organization Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy (Figure 1), including¹:

• Contextual influences that arise due to historic, socio-cultural, environmental, health system/institutional, economic, or political factors.
• Individual and group influences that arise from personal perception of the vaccine or influences of the social/peer environment.
• Issues related directly to a vaccine or vaccination.

Figure 1. World Health Organization SAGE Determinants of Vaccine Hesitancy

SAGE = Strategic Advisory Group of Experts
Source: Reference 1

Not Everyone Is Hesitant

A good opening question for a COVID-19 vaccination conversation is, “Have you considered getting a COVID-19 vaccine?” For some people, what looks like vaccine refusal may be more of an issue of convenience or access, or they may just have questions about the vaccines (“vaccine contemplators”).

Keep in mind that asking questions is not the same as being “anti-vaccine.” An inviting question from the pharmacist could be met with a response such as, “Oh yes, I’ve been meaning to look into that…,” or “I have some questions about the vaccine.”

During the early weeks of vaccine rollout in 2021, it could be challenging to know when individuals qualified for a vaccine and how to make an appointment. Some people simply gave up and decided to wait. In a Kaiser Family Foundation poll conducted in March 2021, half of the people in the “wait and see” category said they were more likely to be vaccinated if it were easier to do while going about their daily lives—for example, as part of a routine medical appointment.² An offer from a pharmacist or pharmacy team member to vaccinate a person on the spot—or to help make the appointment—could be all the convenience the person needs. Pharmacies offer increased access points, whether inside the practice setting or through outreach into communities.

Some People Need Information

Pharmacists likely view the COVID-19 vaccines as an extraordinary success story—a triumph of modern science. However, some members of the general public might view these new vaccines as having been created in a suspiciously short amount of time, using unproven technology, and having uncertain adverse effects and troubling political overtones.

Some people merely need information and assurance. They may be anxious, uninformed, or misinformed. They need a safe space to voice their questions and concerns and get accurate information from a trusted source.

Start from a place of empathy and understanding. The first step is to acknowledge how stressful the pandemic has been for all of us, along with the disruption COVID-19 has caused in all our lives. Make it clear that it is natural and understandable to have questions, concerns, or fears about new vaccines.

If you had concerns of your own when the vaccines first became available, don’t hesitate to share your personal experience. You might say something like, “I wasn’t sure about the vaccines when they first became available, because they were so new. But I did some reading that answered my questions and made me feel much more comfortable.”

Listen and respond to patient questions. It is important to address each person’s actual concerns—not what you assume those concerns are. Your willingness to listen to a person’s concerns will go a long way in building trust in you and your recommendation.

The motivational interviewing skill “Elicit–Provide–Elicit” provides a useful framework for these conversations:

• Elicit: Ask what the person already knows or would like to know.
• Provide: Provide additional information.
• Elicit: Ask the person for an interpretation or reaction to the information.

A simple way to initiate the conversation (Elicit) is to ask, “What are your concerns?” or “What makes you hesitate to get vaccinated?” Allow the person to share as much as possible without interrupting or attempting to correct what the person says.

To address the person’s concerns (Provide), ask permission to share information (“May I share some information?” or “Is it okay if I share what we know?”) and then provide an accurate explanation in a neutral, nonjudgmental fashion. Avoid criticizing the person’s information sources. Use phrases such as:

• “What we know is…”
• “What we’re learning is…”
• “Research suggests...”
• “Studies have shown...”
• “Folks have found...”

Keep your sharing as simple and focused as possible, ideally addressing the specific root cause of each concern. For example, if a person is worried about getting COVID-19 from the vaccine, explain that the vaccine does not contain coronavirus or any other live virus—there’s nothing in the vaccine that can infect people.

End by asking for the patient’s interpretation (Elicit). You might phrase this as “What do you make of that?” or “Where does this leave you now?” or “What else would you like to know?” Continue with this Elicit–Provide–Elicit cycle until all of the person’s concerns are addressed.

Give your strong recommendation. The Centers for Disease Control and Prevention considers your strong vaccine recommendation to be the most important part of the conversation. Let the person know you recommend COVID-19 vaccination for all eligible persons to protect their own health as well as the health of those around them. Personalize the recommendation as much as possible—for example, “This shot is especially important for you because of your [job/underlying health condition].”

You also might share your personal decision to get a COVID-19 vaccine. For example, “I believe in this vaccine so strongly that I got vaccinated as soon as I was eligible, and I made sure that everyone in my family did the same.”

Wrap up the conversation. Ideally, after you respond to the concerns and answer the questions, the person will decide to get vaccinated—perhaps on the spot if you can offer a vaccine. If you are unable to administer the vaccine at that moment, help the person make an appointment or provide resources on where the vaccine is available.

If the person remains hesitant, express that you are open to continuing the conversation. You may have to keep answering questions and have several conversations until the decisional balance tips, and the “pros” outweigh the “cons.” Remain optimistic that with your repeated messaging, the person will arrive at the decision to be vaccinated.

Information Won’t Work for Everyone

When you encounter resistance to an evidence-based message, it is tempting to keep explaining the scientific evidence to the other person as clearly as possible, as though the problem is a failure to understand. Unfortunately, simply providing information is unlikely to sway the 20% or so of adults who have consistently said they will not get vaccinated or will do so only if required. Even worse, there is some evidence that providing information can backfire and strengthen resistance to vaccination.³

It is very, very difficult to change pre-established beliefs, even when those beliefs are not upheld by evidence. Part of the challenge is the powerful cognitive bias known as confirmation bias: our tendency to look for and accept information that supports what we already believe and disregard or reject information that goes against what we believe. This is compounded by attitude polarization: rather than appraising evidence in an open-minded fashion, people assimilate the information in a biased way that reinforces (rather than challenges) what they already think.

Instead of wondering why people would reject the compelling evidence about COVID-19 vaccines, we should ask, “Why would people want to reject the evidence?” In a 24-nation investigation, Hornsey and coworkers⁴ found that people with antivaccination attitudes were most likely to:

• Have a conspiratorial worldview (i.e., believe it is common for shadowy networks of people with malevolent intentions to execute mass hoaxes on the public in near-perfect secrecy).
• Be high in reactance (i.e., see themselves as nonconformists who are skeptical of consensus views and intolerant of people telling them how to think).
• Have heightened “disgust reactions” to needles, hospitals, and blood.

Another challenge is conformity bias: our tendency to take cues for proper behavior from the actions of others, rather than exercise our independent judgment. It generally is important to people that they fit in and gain social approval. Hearing from friends, family members, or social network contacts who choose not to become vaccinated can decrease motivation. In the highly charged political environment surrounding the pandemic, resistance to vaccination can be a way of adhering to a social identity or acting in defiance of a disliked rival group.

If you seek to engage in dialogue with a person who is strongly vaccine hesitant, you cannot go into the conversation with the goal of achieving immediate persuasion. Instead, let the person know of your sincere interest in other points of view and welcome the opportunity to have an honest and frank conversation. Then truly listen with an open mind, rather than trying to come up with a retort. This will set a courteous and respectful tone more conducive to productive interaction.

After the person’s viewpoint has been shared with you, reflect on what you heard and ask for confirmation (e.g., “Did I get that right?”). Then pose an open-ended question such as, “What would need to be true for you to want to get a COVID-19 vaccine?” The person’s response may offer clues to a line of questioning or information you could share that might lessen resistance. Use the Elicit–Provide–Elicit framework for sharing information and be sure to ask for both permission (“Would it be okay if I told you what we know about that?”) and interpretation (“What do you make of that?”). Emphasize that the decision to get vaccinated ultimately is theirs and theirs alone.

One reason why anti-vaccination messages are so successful is that they play into fear. However, fear works best when you are trying to get someone not to do something. A better motivator for inducing action (e.g., getting vaccinated) is the promise of a positive reward, ideally in the near future. Consider asking an open-ended question such as, “What kinds of things have you missed doing during the pandemic?” People may mention an activity that might only be possible for fully vaccinated individuals (e.g., traveling to certain locations, attending a cultural or sporting event).

Hornsey and Fielding³ propose a “jiu jitsu persuasion” approach that “uses the opponents’ force against them, rather than trying to defeat it head-on”; in other words, tailor the message so that it aligns with a person’s specific motive for rejecting the science. For example, for a person with conspiratorial thinking, you would acknowledge the possibility of conspiracies but raise the possibility that the real conspiracy is trying to obscure the benefits of vaccination and exaggerate the dangers. You could explore the idea that the opposite of the person’s existing belief might be true using a “what if?” question: “What if the real conspiracy is trying to keep people from getting vaccinated? What do you think they would gain from that?” A person who is high in reactance might consider a query such as, “It sounds as though all of the people around you are telling you not to get a vaccine. Isn’t that just as bad as being told to get the vaccine? Don’t you think you should decide for yourself what’s best for you?” People who fear needles or blood might avoid vaccination as a short-term anxiety reduction strategy. You could remind them of the worse alternative: “What if you get COVID-19 and end up in the hospital? That’s going to mean a lot of needles and blood.”

With all of these approaches, it is crucial to keep the exchange respectful and polite and to be curious and nonjudgmental about the person’s responses. It is also essential to recognize when it’s best to “cut your losses” and accept that some individuals are unlikely to change their mind during the current conversation. Especially with the COVID-19 vaccine, vaccination conversations can take time and may need to continue over multiple encounters—a marathon rather than a sprint. Remain cordial, acknowledge that vaccination is their decision, and let them know you are open to continuing the conversation during future visits.

You Can Make a Difference

From the beginning, pharmacists and the pharmacy team have been at the forefront of the nation’s response to the COVID-19 pandemic. Now pharmacists are in a prime position to ensure that all eligible people are vaccinated and stay up to date with their vaccines.

A strong recommendation from a trusted health care provider is critical for vaccine acceptance. Armed with the information in this Vaccine Confident Playbook, you will be well-equipped for personalized, empathetic interactions that can motivate people to accept the recommendation.

References

1. World Health Organization Strategic Advisory Group of Experts on Immunization. Report of the SAGE Working Group on Vaccine Hesitancy. October 1, 2014. Accessed April 11, 2022. https://www.asset-scienceinsociety.eu/sites/default/files/sage_working_group_revised_report_vaccine_hesitancy.pdf
2. Hamel L, Lopes L, Kearney A, Brodie M. KFF COVID-19 Vaccine Monitor: March 2021. Kaiser Family Foundation; March 30, 2021. Accessed April 11, 2022. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-march-2021/
3. Hornsey MJ, Fielding KS. Attitude roots and Jiu Jitsu persuasion: understanding and overcoming the motivated rejection of science. Am Psychol. 2017;72(5):459–473. doi: 10.1037/a0040437
4. Hornsey MJ, Harris EA, Fielding KS. The psychological roots of anti-vaccination attitudes: a 24-nation investigation. Health Psychol. 2018;37(4):307–315. doi: 10.1037/hea0000586