How to talk to people about COVID-19 vaccines

In December 2020, the United States embarked on the most ambitious vaccination campaign in our nation’s history. A mere 7 months later, more than 57% of Americans 12 years of age or older were fully vaccinated, and two-thirds had received at least one dose of COVID-19 vaccine.1

When the COVID-19 vaccines first became available, the main challenge was that vaccine demand greatly outstripped supply. Millions of Americans waited anxiously for appointments to become available, and they willingly rolled up their sleeves for the “jab.”

Now, with the supply of vaccines having increased significantly and all Americans 12 years of age and older eligible for vaccination nationwide, we have entered a different phase of the vaccination campaign—a phase that focuses on increasing demand for the COVID-19 vaccine. The main challenge now is figuring out how to bolster vaccine confidence among the subset of Americans who are still on the fence, and ideally among the approximately 20% of the population who have consistently said they will not get vaccinated or will do so only if required.2

This new phase requires a more personal approach grounded in listening and understanding—engaging with each person on an individual level to address their particular 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, they 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, including (See Figure 1):3

  • 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:

Contextual Influences

Influences arising due to historic, socio-cultural, environmental, health system/institutional, economic or political factors

  1. Communication and media environment
  2. Influential leaders, immunization program gatekeepers and anti- or pro-vaccination lobbies
  3. Historical influences
  4. Religion/culture/gender/socioeconomic
  5. Politics/policies
  6. Geographic barriers
  7. Perception of the pharmaceutical industry
Individual and Social Influences

Influences arising from personal perception of the vaccine or influences of social/peer environment

  1. Personal, family and/or community members' experience with vaccination, including pain
  2. Beliefs, attitudes about health and prevention
  3. Knowledge/awareness
  4. Health system and providers-trust and personal experience
  5. Immunization as a social norm vs. not needed/harmful
Vaccine/Vaccination-specific Issues

Directly related to vaccine or vaccination

  1. Risk/benefit (epidemiological and specific evidence)
  2. Introduction of a new vaccine or new formulation or a new recommendation for an existing vaccine
  3. Mode of administration
  4. Design of vaccination program/Mode of delivery (e.g., routine program or mass vaccination campaign)
  5. Reliability and/or source of supply of vaccine and/or vaccination equipment
  6. Vaccination schedule
  7. Costs
  8. The strength of recommendation and/or knowledge base and/or attitude of healthcare professionals

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 an issue of convenience or access, or they may just have additional questions. Just because a person has additional questions does not mean they are “anti-vaccine.” A question from the pharmacist could be met with a response along the lines of, “Oh yes, I’ve been meaning to look into that….,” or, “I have additional questions about the vaccine.”

In the initial weeks, the vaccine rollout seemed chaotic and confusing for many people.  It was challenging to know when individuals qualified for a vaccine and how to make an appointment. Some people just gave up and decided to wait.

In one Kaiser Family Foundation poll, approximately half of the people in the “wait and see” category indicated 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.4

An offer from a pharmacist or pharmacy team member to vaccinate a person on the spot—or to help them make an appointment—could be the convenience they were looking for.

Some People Need Information

Pharmacists likely view the COVID-19 vaccines as an extraordinary success story—a triumph of modern science.

The average person may see brand new vaccines created in a suspiciously short amount of time using unproven technology, with unknown adverse effects and troubling political overtones.

Some people just 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, and the disruption COVID-19 has caused in all our lives. Make it clear that it is natural and understandable to have questions and concerns or fears about these brand 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 and research that answered my questions and made me feel much more comfortable.”

  • Listen and respond to patient questions. It is important to address a person’s actual concerns—not what you assume their concerns are. Your willingness to listen to a person’s concerns will play a major role 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 their reaction.

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 them.

To address their 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 the 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 they might get COVID-19 from the vaccine, explain to them that the vaccine does not contain coronavirus or any other live virus—there’s nothing in the vaccine that could infect them.

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 CDC considers your strong vaccine recommendation to be the most important part of the conversation. Let the person know you recommend COVID-19 vaccination for them, to protect their health as well as the health of those around them. Personalize the recommendation as much as possible (e.g., “This shot is especially important for you because of your [job/underlying health condition].”).

    You might also share your personal decision to get a COVID-19 vaccine (e.g., “I believe in this vaccine so strongly that I got vaccinated as soon as it was available to me, and I ensured that everyone in my family did the same.”).

  • Wrap up the conversation. Ideally, once you’ve answered their questions, the person will decide to get vaccinated—perhaps on the spot if you are able to offer a vaccine. If you are unable to administer the vaccine, help the person make an appointment or provide resources on where they can find a vaccine.

    If the person remains hesitant, let them know that you are open to continuing the conversation. Because these vaccines are new, each person’s comfort level with when to get vaccinated will vary. You may have to keep answering questions and have several conversations until the decisional balance tips and the “pros” outweigh the “cons.” Over time, the person will hopefully 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 make resistance to vaccination even stronger.5

It is very, very difficult to change pre-established beliefs, even when they are wrong.  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.

Rather than wondering why people would reject the compelling evidence about COVID-19 vaccines, we should be asking, “Why would people want to reject the evidence?” In a 24-nation investigation, Hornsey et al.6 found that people with antivaccination attitudes were most likely to:

  • Have a conspiratorial worldview (i.e., believe that 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 own 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 that has surrounded 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 convincing the other person. Instead, let them know that you are sincerely interested in their point 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 that is more conducive to a productive interaction. 

After the other person has shared their viewpoint, reflect on what you heard and ask for confirmation (“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 their 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 hope—the promise of a positive reward, ideally in the near future. Remind patients that getting vaccinated is the most important thing they can do to move back toward pre-pandemic activities and provide concrete examples of the increasing number of things they will be able to do when they are fully vaccinated. Consider asking an open-ended question, such as “What are you most looking forward to being able to do when the pandemic ends?” or “What do you miss most since the pandemic started?” The person may mention an activity that might only be possible (e.g., travel, attending a concert or sporting event) or would be easier or safer (e.g., a family gathering) for vaccinated individuals. Conversely, you could ask “What bothers you most about the pandemic?”; the person may mention something that is likely to go away (e.g., mask mandates) when more people are vaccinated.

Hornsey and Fielding7 propose a “jiu jitsu persuasion” approach that “uses the opponents’ force against them, rather than trying to defeat it head-on;” in other words, tailoring 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 the one trying to obscure the benefits of vaccination and exaggerate the dangers. You could explore the idea that the opposite of their existing belief might be true using a “what if?” question: “What if the real conspiracy is one that’s 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?” A person with a fear of needles or blood might be avoiding 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 a person is 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 the course of multiple encounters—a marathon rather than a sprint. Remain cordial, acknowledge that vaccination is their decision, and let the person know that 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 with the end in sight, pharmacists are in a prime position to ensure that every possible person is vaccinated.

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

References

  1. U.S. Centers for Disease Control and Prevention.  COVID-19 vaccinations in the United States.  https://covid.cdc.gov/covid-data-tracker/#vaccinations.  Updated July 28, 2021.  Accessed July 28, 2021.
  2. Kaiser Family Foundation.  KFF COVID-19 vaccine monitor.  https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard/.  Accessed July 28, 2021.
  3. World Health Organization Strategic Advisory Group of Experts on Immunization.  Report of the SAGE Working Group on Vaccine Hesitancy.  https://www.who.int/immunization/sage/meetings/2014/october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf.  October 1, 2014.  Accessed July 28, 2021.
  4. Hamel L, Lopes L, Kearney A, Brodie M.  KFF COVID-19 Vaccine Monitor: March 2021.  https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-march-2021/.  March 20, 2021.  Accessed June 10, 2021.
  5. Hornsey MJ, Fielding KS. Attitude roots and Jiu Jitsu persuasion: Understanding and overcoming the motivated rejection of science. Am Psychol. 2017 Jul-Aug;72(5):459-473. doi: 10.1037/a0040437.
  6. Hornsey MJ, Harris EA, Fielding KS. The psychological roots of anti-vaccination attitudes: A 24-nation investigation. Health Psychol. 2018 Apr;37(4):307-315. doi: 10.1037/hea0000586. Epub 2018 Feb 1.
  7. Hornsey MJ, Fielding KS. Attitude roots and Jiu Jitsu persuasion: Understanding and overcoming the motivated rejection of science. Am Psychol. 2017 Jul-Aug;72(5):459-473. doi: 10.1037/a0040437.

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