Physicians encouraged to use shared decision-making to combat vaccine hesitancy

Key takeaways:

• Vaccine hesitancy is more common among people who seek information from the media and nternet.
• Shared decisionmaking enables and encourages patients to play a role in medical decisions.

BOSTON — Communication including shared decision-making is essential in combating vaccine hesitancy, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

“Second only to sanitized drinking water, I think vaccines are probably one of the most successful public health achievements in the history of mankind,” Dipa Sheth, MD, FACAAI, FAAAAI, section chief, division of allergy and immunology, DC Veterans Affairs Medical Center, said during her presentation.

Vaccination prevents between 2 million and 3 million deaths each year, Sheth continued, but vaccine hesitancy and refusal have led to a resurgence in preventable diseases. In fact, she added, the WHO ranked vaccine hesitancy among the top 10 global health threats in 2019.

“It’s important to use a multi-pronged approach when discussing this with patients,” Sheth said.

What’s driving hesitancy

Sheth defined vaccine hesitancy as a delay in acceptance or refusal of vaccination despite the availability of vaccination services and outlined multiple reasons why patients feel this way.

“A lot of patients have vaccine hesitancy because they worry about aluminum and hear about high levels of aluminum being deposited in their brain and leading to a lot of problems,” she said.

However, Sheth said, people already are exposed to aluminum in the air and in their food and that the amount of aluminum in vaccines is minimal by comparison.

Sheth also noted the approximately 4,000 cases of autoimmune inflammatory syndrome that have been described since 2011. Patients who are genetically susceptible begin producing antibodies after receiving an adjuvant or a vaccine with an adjuvant.

“When this happens, they have symptoms of brain fog, arthralgias, arthritis, chronic fatigue and memory loss,” Sheth said. “It’s important to know and be aware of this syndrome.”

Mistrust of vaccines is not new either, Sheth said, driven by events such as the Tuskegee syphilis study and the 1955 live polio vaccine from Cutter Laboratories given in error, leading to 10 deaths, 200 disabilities and 70,000 cases of mild polio.

Although vaccine hesitancy varies based on the vaccine and on the population, Sheth continued, it is becoming more common, with delays more common than refusals.

Among caregivers of children, Sheth said, vaccine hesitancy is more common among those who seek information from the media and the internet.

“The more information they get from there, the more likely they are to have hesitancy,” she said. “The problem with social media is we do not know the quality of information or the reliability of information.”

Sheth noted the emergence of the “infodemic,” where patients and families faced an excess of both good and bad information.

“It was just overwhelming for patients, and you just didn’t know what was right and wrong,” she said.

Also, algorithms on social media amplified conspiracy theories about COVID-19 and its vaccines.

“There’s just a lot of misinformation out there,” she said.

Sheth added that anti-vaccine tweets were twice as likely to be retweeted as pro-vaccine tweets, as some corporate platforms made billions in revenue from this content.

“There is no incentive to stop misinformation if they’re making that money, so it’s important for us to be fighting as well,” Sheth said.

Vaccine hesitancy also correlates with alternative health beliefs and trust in herbal medication and natural immunity, with associations between caregivers who are vaccine hesitant and naturopathic care.

Sheth also noted that caregivers who trust complementary and integrative health care professionals as sources of vaccine information are more likely to have children who are under-vaccinated.

Further, she said, children who are under-vaccinated are more likely to see naturopathic doctors and have higher rates of vaccine-preventable illness, even though all naturopathic professional associations and schools endorse the CDC immunization schedule.

Shared decision-making

Compared with caregivers who speak with other providers, caregivers who speak with their pediatrician about vaccines are less likely to be hesitant, Sheth said.

Caregivers often feel like they have inadequate information about the safety and side effects of vaccines, she said. For example, there is a perception that vaccines overwhelm the immune system or include harmful ingredients.

Just as children are afraid of injections, she continued, caregivers can be afraid of them too. Caregivers and patients in general also value their autonomy, particularly when they feel like they are being forced to get themselves or their child vaccinated for school or work.

“They don’t want to be told what to do. They want to make that decision themselves,” Sheth said.

But shared decision-making, which enables and encourages people to play a role in the medical decisions that affect their health, can help physicians assuage these concerns, Sheth said.

“Shared decision-making is important because we don’t want them to feel that they’re just being told that they have to do it,” she said. “It’s important to understand, again, where they’re coming from and what they’re seeing.”

All physicians can engage in shared decision-making, Sheth said, adding that compassionate listening without interruption builds trust between patients and providers.

“Building that relationship is really the No. 1 thing that makes a difference in the patient getting vaccinated,” Sheth said. “You may not be able to convince them on that visit on that day, but that long-term relationship in the future will pay off.”

Sheth also encouraged physicians to engage in storytelling with their patients.

“We all love stories,” she said, suggesting that physicians share stories, narratives, anecdotes and metaphors including their own families and friends and how vaccination has impacted them.

“All of us should be fostering this skill,” she said. “If you know somebody that’s a good storyteller, ask them how they do it, or learn from them.”

Physicians should keep these stories simple, Sheth said, based on bullet points. With repetition, she continued, these stories will sound natural during conversations with patients.

“It really does make a difference, because that builds an emotional bond where then they’ll trust you and want to talk to you about this,” she said.

Additionally, Sheth said that “humble inquiry” is essential to these conversations and that physicians should refrain from being judgmental.

“Not saying, ‘Well, I don’t think you understand,’ or cutting them off because your knee-jerk reaction is to say, ‘Hey, wait. Let me tell you the data,’” she said. “Truly, just understanding where they’re coming from and what is it that’s making them upset.”

When patients and families bring up myths or misconceptions about vaccines, physicians should not repeat them, even to debunk them, Sheth continued.

“Hearing a myth from a health care provider’s mouth actually solidifies it,” she said. “Listen to the why, but don’t repeat it. Just then try to steer them towards the correct information.”

The entire health care team should be engaged in these efforts too, Sheth said.

“Make sure your nurses and your [advanced practice providers] are feeling the same way,” she said.

The messaging

When it comes to COVID-19 vaccines, Sheth said, physicians should tell patients and their families that they are nearly 100% effective at preventing hospitalization and death due to the disease.

Also, physicians should say that the technology used to develop these vaccines has been in development for nearly 20 years and that it will help their loved ones not get sick.

“Hearing it from the health care provider helps them make that decision,” Sheth said.

Sheth also advised physicians to keep these messages simple.

“Don’t be complicated about it,” she said.

When patients and families continue to express hesitancy, physicians can refer them to alternative providers including those that practice naturopathic medicine, which Sheth said indicates respect and support.

“Say, ‘You know what? I understand. But if you want to, go talk to them about it. They also follow the CDC guidelines,’” Sheth said. “Trusting and hearing that you’re not criticizing their other provider actually makes a difference.”

Sheth encouraged physicians to engage with community and religious leaders as well as politicians who support vaccines as well.

“All of them do make a difference,” she said.

During these discussions with patients and families, physicians need to remain calm and composed too, even if they are upset with what they are hearing. Similarly, physicians should never accost these patients and families with data or threaten to discharge them from their practice because they are not getting vaccinated.

“We saw a lot of that during COVID-19,” Sheth said.

Further, physicians should not try to pressure these patients and families into getting vaccines by saying it is their social responsibility to do so.

“You actually end up alienating people,” Sheth said. “It’s important just to correct the misinformation and be their guide.”

Physicians should not be shy about their own vaccination status either, she said.

“Something as simple as wearing an ‘I got my flu shot’ or ‘I got my COVID shot’ button shows them that you’re unified in this,” she said.

Next steps

Physicians should focus on three strategies during these conversations about vaccine hesitancy, Sheth said.

“Find and address the cause,” Sheth said. “Did somebody in the family have a bad experience? Just find it, find out why, and then try to understand it and try to steer them the right way.”

Next, physicians should serve as a teacher or guide and just provide patients and families with correct information in a gentle way.

Finally, physicians should “treat the whole person, understanding and respecting their knowledge and beliefs and where they come from,” Sheth said.

Sheth called this shared decision-making crucial in addressing vaccine hesitancy.

“Using the tools that I talked about next time to talk to a patient really does make a difference,” she said.