Physicians encouraged to engage with vaccine-hesitant patients

Key takeaways:

• Vaccine hesitancy and anti-vaccination are not the same.
• Hesitancy is associated with less education, health literacy and socioeconomic status.
• Multi-component interventions may work the best.

ANAHEIM, Calif. — Physicians can engage with patients who have reservations about getting the COVID-19 vaccine, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

“Patients may not trust doctors and scientists, but they trust ‘their’ doctor,” Paul V. Williams, MD, clinical professor of pediatrics, division of allergy, University of Washington School of Medicine, said during his presentation.

These dialogues can counter key messages of the anti-vaccine movement and promote vaccine acceptance, said Williams, who also is the president-elect of the American Academy of Asthma, Allergy & Immunology.

The rise of hesitancy

In 2022, the WHO defined vaccine hesitancy as a motivational state of being conflicted or opposed to getting vaccinated.

“This updated vaccine hesitancy definition connects this hesitancy with a reluctance to receive a recommended vaccine, but in doing so recognizes that hesitancy may not result in vaccine delay or refusal of a recommended vaccine,” Williams said.

Williams also differentiated patients with hesitancy with refusers, who will not get a vaccine no matter what the physician says, and anti-vaxxers, who not only are opposed to the concept of vaccination in general but who also promote anti-vaccine messaging.

“Vaccine hesitancy is not equivalent to being anti-vaxx, and by equating the two, you can actually lead to more vaccine hesitancy,” he said.

Skeptical and negative attitudes toward vaccination date back to the development of the smallpox vaccine in 1796, Williams said, but the modern anti-vaccine movement began around 2010.

“Social media really changed the game, allowing those across the political aisles to unite, grow their ranks and secure funding and organize,” Williams said.

The algorithms behind these platforms also enabled anti-vaccine advocates to deny facts, control trends, conduct highly coordinated attacks on vaccine advocates and impact caregivers and politicians alike.

The COVID-19 pandemic accelerated this organization, Williams said, as anti-vaccine advocates exploited political radicalism to spread misinformation.

“Conspiracy theories about vaccine safety spread further and more rapidly on social media platforms when compared to verified vaccine information from reliable sources,” he said.

The anti-vaccine movement wants to turn vaccine-hesitant patients into anti-vaccine patients, Williams continued, by promoting complacency about COVID-19 and over-emphasizing vaccine risks, in addition to sowing distrust of science and doctors.

These messages capitalize on social media algorithms and are tailored to specific audiences who have expressed vaccine hesitancy, Williams explained.

“It allows them to narrow the targeting of their messages intended to create fear based on an individual’s beliefs, values and situation,” he said.

In fact, Williams said, anti-vaccine messaging is more nuanced and sophisticated than pro-vaccine messaging.

“In addition, these groups establish places online where people can go to get questions answered about vaccine safety,” he said.

Anti-vaccine platforms include the National Vaccine Information Center with 209,000 followers, Children’s Health Defense with 1.3 million followers, and various social media accounts led by Joseph Mercola, DO, with 3.6 million followers.

Also, Williams said, the overall state of vaccine hesitancy in the United States is difficult to quantify due to a lack of systematic and well-funded studies. Yet the WHO has determined that the three key determinants of vaccine hesitancy are:

1. complacency (is the disease serious?);
2. convenience (is the vaccine free and readily available?); and
3. confidence (is the vaccine safe and effective?).

Structural factors may influence vaccine hesitancy as well, Williams said, such as health care and socioeconomic inequalities and inequities, as well as a lack of effective public health messaging.

Also, historical unethical research involving ethnic minority groups, structural racism, faith and religious beliefs, and political identification may influence vaccine hesitancy.

Specifically, patients may be hesitant about COVID-19 vaccines because they are perceived to be new technologies, even though mRNA vaccines have been studied for decades, Williams said. Their rapid development and public visibility also are factors.

“Everybody knew sort of what was going on, but they weren’t always getting the best information,” Williams said. “Communication was poor at times, or often changing, which confused people. Distrust and division became more evident as time went on.”

As the 2020 election approached, Williams said, intent to get the COVID-19 vaccine fell, and reports of adverse reactions with early doses augmented by the rapid spread of misinformation and disinformation contributed to hesitancy too.

“But despite the blowback and pushback, it actually did result in an increase in the number of vaccinations,” Williams said.

Patient profiles

Patients who are vaccine hesitant tend to be younger with less education, lower health literacy and lower socioeconomic status, Williams said.

“They also distrusted doctors, government and news media, but interestingly, did not distrust the internet or social media,” he continued.

Vaccine hesitant patients also tend to be people of color and indigenous people in addition to people who are more conservative politically, although Williams called these data soft.

“Race and ethnicity are not something that was tracked early on with the vaccines,” he said, adding that more recent studies indicated that people of color and indigenous people may be more accepting of vaccines now.

Lower risk perceptions may lead to vaccine hesitancy as well, as people believe the harms of vaccination outweigh the benefits, Williams said. These patients also may believe they already have good health and immunity. They may distrust messaging about the severity of COVID-19. Or, they may have already had COVID-19.

Also, parents are more hesitant about getting the vaccine for their children than they are about getting it for themselves. Mothers are more hesitant than fathers. Younger parents are more hesitant than older parents. Parents are more hesitant when it comes to younger children than older children.

Non-Hispanic parents are more hesitant than Hispanic parents, Asian and Black mothers are more hesitant than white mothers, and parents who primarily spoke English were more hesitant than parents who primarily spoke Spanish.

Williams additionally noted that approximately 20% of health care workers are vaccine-hesitant, typically including nongovernment employees, nurses, allied health professionals and paramedical staff.

“They’re perhaps at increased risk of infection. They’re more likely to be a vector. And importantly, they make recommendations to patients, and their recommendations are likely to be trusted,” he said.

These workers also commonly had nonclinical roles, they were not involved in the care of COVID-19 patients, they had better infection control and adequate personal protection equipment, and they had a negative attitude toward vaccine mandates.

“A lot of this was based on a lack of good information,” Williams said. “It was difficult for the general health care worker and general public to find information that they could readily understand. It wasn’t really presented in a good way.”

Social media and other nonauthentic sources filled this information void, Williams said, especially among younger populations.

People who are hesitant about other vaccines, who are afraid of vaccination or who were pregnant or trying to become pregnant were specifically hesitant to get a COVID-19 vaccine as well, Williams continued. Hesitancy was associated with less social pressure to get the vaccine and anecdotes about negative reactions to the vaccine as well.

People who accepted the COVID-19 vaccine tended to express more altruism and concern about vulnerable family or friends. They also were more likely to have a family member or friend who had experienced COVID-19, especially severe cases of the disease.

“Acceptance in general occurs in people who have a higher risk perception,” Williams said.

In addition to personal experience with COVID-19, Williams said, this risk perception comes with comorbid conditions and older age. These people also have more trust in the health care system.

“Positive interactions with health care providers and previous vaccine acceptance are important,” he said, adding that 85% of adults trusted their own physician to provide reliable information about COVID-19 vaccines.

Acceptance additionally was associated with a sense of solidarity and social responsibility with a goal of protecting family and community and of achieving a sense of normalcy, along with liberal ideology.

Talking with patients

Williams suggested multiple strategies for talking with patients who may be hesitant.

“Keep in mind that patient concerns and parent concerns especially include vaccine safety, the likelihood of getting the disease, and personal, social and political factors,” Williams said.

Williams emphasized the importance of making a strong recommendation for vaccination.

“That’s been shown to increase vaccine acceptance,” he said.

Also, he said, use a presumptive format.

“In other words, ‘You or your child is scheduled to get a vaccine now,’ rather than ‘How do you feel about getting a vaccine?’” he said.

Physicians should pursue adherence, Williams continued, and if patients seem reluctant, they should provide adequate information and make another strong recommendation. Motivational interviewing also may be helpful, he said.

In its Vaccinate with Confidence program, the CDC has built a national framework including 23 professional health associations and national partners to build confidence in COVID-19 vaccines, support Americans who get vaccinated, and engage communities.

“Their components are to build trust by complete and accurate messaging that’s kept up-to-date to empower health care personnel, yours and others, to promote confidence in the decision to be vaccinated and to recommend vaccination,” Williams said. “Listen, build trust, increase collaboration.”

In the office, Williams said, physicians need to be familiar with the mindsets of their patients, including whether they are vaccine hesitant, vaccine refusers or ant-vaccine, keeping the limitations in data pertaining to these populations in mind.

“Most of the data relate to vaccine hesitancy, vaccine intent, but not vaccine behavior. They don’t follow through and see if the patients actually got the vaccine,” Williams said. “It depends to some extent on setting and context.”

Multi-component interventions including printed and online decision aids based on dialogue work the best, Williams said, adding that social media may help too.

“It’s important to amplify factual content, but don’t refute the misinformation,” he said.

Online resources such as the WHO’s Vaccine Safety Net, which includes information from multiple reliable sources, also are helpful, Williams said.

“And discourage patients from engaging with anti-vaxx misinformation online,” Williams said. “It actually spreads that information.”

Physicians also may “nudge” patients toward acceptance via text-based interventions, portal messages, mail or email, infographics presented with the first vaccine, and opt-out instead of opt-in presentations.

“Multi-component interventions probably work the best,” Williams said. “A combination of dialogue and educational materials is likely the most effective approach.”

These interventions may include dialogue targeting specific groups, educational materials and decision aids, enhanced and convenient vaccine access, and engaging religious or community leaders.

“If parents get reinforcement from other parents that they trust, that’s the most effective message that they could get for vaccine acceptance,” Williams said.

But the physician still has a central role in promoting vaccines, he said.

“Empower your staff. Provide correct information and confidence in your recommendation,” he said. “Leverage your trust with patients. Engage them in a discussion about vaccination. Make that strong recommendation.”