How to overcome hesitancy for COVID-19 and other vaccines

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doi:doi: 10.12788/jfp.0443

Applied Evidence

How to overcome hesitancy for COVID-19 and other vaccines

J Fam Pract. 2022 July;71(6):239-244 | doi: 10.12788/jfp.0443

By

Nicole L. Mayo, PhD

John P. Cullen, PhD

Ann M. Dozier, RN, PhD

Reza Yousefi-Nooraie, MSc, PhD

Holly Ann Russell, MD, MS

These evidence-based strategies (and list of do’s and don’ts) can help you to increase the likelihood of vaccine uptake in hesitant patients.

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PRACTICE RECOMMENDATIONS

› Focus on personal benefits of vaccination with patients who express strong hesitancy and endorse vaccine myths; refocus the conversation away from myths and back to disease facts. C

› Emphasize personal and collective benefit to patients who are uncertain about vaccination; provide education about herd immunity and local vaccine coverage. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Ten threats to global health in 2019. World Health Organization. Accessed June 17, 2022. www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

2. FDA approves first COVID-19 vaccine. US Food and Drug Administration. August 23, 2021. Accessed June 17, 2022. www.fda.gov/news-events/press-announcements/fda-approves-first-covid-19-vaccine

3. Mathieu E, Ritchie H, Ortiz-Ospina E, et al. A global database of COVID-19 vaccinations. Nat Hum Behav. 2021;5:947-953. doi: 10.1038/s41562-021-01122-8.

4. Ritchie H, Mathieu E, Rodés-Guirao L, et al. Coronavirus pandemic (COVID-19). Our world in data. Accessed June 17, 2022. https://ourworldindata.org/covid-vaccinations?country=USA

5. de Figueiredo A, Simas C, Karafillakis E, et al. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study. Lancet. 2020;396:898-908. doi: 10.1016/S0140-6736(20)31558-0

6. Wang Y, Liu Y. Multilevel determinants of COVID-19 vaccination hesitancy in the United States: a rapid systematic review. Prev Med Rep. 2021;25:101673. doi: 10.1016/j.pmedr.2021.101673

7. Robinson E, Jones A, Lesser I, et al. International estimates of intended uptake and refusal of COVID-19 vaccines: a rapid systematic review and meta-analysis of large nationally representative samples. Vaccine. 2021;39:2024-2034. doi: 10.1016/j.vaccine.2021.02.005

8. Dubé E, Gagnon D, MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Strategies intended to address vaccine hesitancy: review of published reviews. Vaccine. 2015;33:4191-4203. doi: 10.1016/j.vaccine.2015.04.041

9. Sadaf A, Richards JL, Glanz J, et al. A systematic review of interventions for reducing parental vaccine refusal and vaccine hesitancy. Vaccine. 2013;31:4293-4304. doi: 10.1016/j.vaccine.2013.07.013

10. Kim S, Pjesivac I, Jin Y. Effects of message framing on influenza vaccination: understanding the role of risk disclosure, perceived vaccine efficacy, and felt ambivalence. Health Commun. 2019;34:21-30. doi: 10.1080/10410236.2017.1384353

11. Shim E, Chapman GB, Townsend JP, et al. The influence of altruism on influenza vaccination decisions. J R Soc Interface. 2012;9:2234-2243. doi: 10.1098/rsif.2012.0115

12. Sprengholz P, Eitze S, Felgendreff L, et al. Money is not everything: experimental evidence that payments do not increase willingness to be vaccinated against COVID-19. J Med Ethics. 2021;47:547-548. doi: 10.1136/medethics-2020-107122

13. Freeman D, Loe BS, Yu LM, et al. Effects of different types of written vaccination information on COVID-19 vaccine hesitancy in the UK (OCEANS-III): a single-blind, parallel-group, randomised controlled trial. Lancet Public Health. 2021;6:e416-e427. doi: 10.1016/S2468-2667(21)00096-7

14. Hakim H, Provencher T, Chambers CT, et al. Interventions to help people understand community immunity: a systematic review. Vaccine. 2019;37:235-247. doi: 10.1016/j.vaccine.2018.11.016

15. Betsch C, Böhm R, Korn L, et al. On the benefits of explaining herd immunity in vaccine advocacy. Nat Hum Behav. 2017;1:1-6. doi: 10.1038/s41562-017-0056

16. Logan J, Nederhoff D, Koch B, et al. ‘What have you HEARD about the HERD?’ Does education about local influenza vaccination coverage and herd immunity affect willingness to vaccinate? Vaccine. 2018;36:4118-4125. doi: 10.1016/j.vaccine.2018.05.037

17. Pfattheicher S, Petersen MB, Böhm R. Information about herd immunity through vaccination and empathy promote COVID-19 vaccination intentions. Health Psychol. 2022;41:85-93. doi: 10.1037/hea0001096

18. Loomba S, de Figueiredo A, Piatek SJ, et al. Measuring the impact of COVID-19 vaccine misinformation on vaccination intent in the UK and USA. Nat Hum Behav. 2021;5:337-348. doi: 10.1038/s41562-021-01056-1

19. Limaye RJ, Opel DJ, Dempsey A, et al. Communicating with vaccine-hesitant parents: a narrative review. Acad Pediatr. 2021;21:S24-S29. doi: 10.1016/j.acap.2021.01.018

20. Omer SB, Amin AB, Limaye RJ. Communicating about vaccines in a fact-resistant world. JAMA Pediatr. 2017;171:929-930. doi: 10.1001/jamapediatrics.2017.2219

21. Nyhan B, Reifler J. Does correcting myths about the flu vaccine work? An experimental evaluation of the effects of corrective information. Vaccine. 2015;33:459-464. doi: 10.1016/j.vaccine.2014.11.017

22. Nyhan B, Reifler J, Richey S, et al. Effective messages in vaccine promotion: a randomized trial. Pediatrics. 2014;133:e835-e842. doi: 10.1542/peds.2013-2365

23. Steffens MS, Dunn AG, Marques MD, et al. Addressing myths and vaccine hesitancy: a randomized trial. Pediatrics. 2021;148:e2020049304. doi: 10.1542/peds.2020-049304

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26. Cambon L, Schwarzinger M, Alla F. Increasing acceptance of a vaccination program for coronavirus disease 2019 in France: a challenge for one of the world’s most vaccine-hesitant countries. Vaccine. 2022;40:178-182. doi: 10.1016/j.vaccine.2021.11.023

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The World Health Organization (WHO) named vaccine hesitancy as one of the top 10 threats to public health as of 2019.¹ Although the COVID-19 vaccines manufactured by Pfizer-BioNTech and Moderna, first authorized for use in November 2020 and fully approved in August 2021,² are widely available in most countries, vaccination uptake is insufficient.³

As of June 2022, 78% of the US population had received at least 1 vaccine dose and 66.8% were fully vaccinated against COVID-19.⁴ High confidence in vaccines is associated with greater uptake; thus, engendering confidence in patients is a critical area of intervention for increasing uptake of COVID-19 and other vaccines.⁵ Despite the steady increase in vaccine acceptance observed following the release of the COVID-19 vaccine, acceptance remains suboptimal.^2,6

Demographic characteristics associated with lower vaccine acceptance include younger age, female sex, lower education and/or income, and Black race or Hispanic/Latinx ethnicity (compared to white or Asian non-Hispanic).^6,7 Moreover, patients who are skeptical of vaccine safety and efficacy are associated with lower intentions to vaccinate. In contrast, patients with a history of receiving influenza vaccinations and those with a greater concern about COVID-19 and their risk of infection have increased vaccine intentions.⁶

Numerous strategies exist to increase vaccine acceptance; however, there does not appear to be a single “best” method to overcome individual or parental vaccine hesitancy for COVID-19 or other vaccines.^8,9 There are no large-scale randomized controlled trials (RCTs) demonstrating one strategy as more effective than another. In this review, we outline a variety of evidenced-based strategies to help patients overcome vaccine hesitancy for COVID-19 and other vaccines, with a focus on practical tips for primary care physicians (PCPs).

Which talking points are likely to resonate with your patients?

Intervention strategies promote vaccine acceptance by communicating personal benefit, collective benefit, or both to vaccine-hesitant patients. In a study sample of US undergraduate students, Kim and colleagues¹⁰ found that providing information about the benefits and risks of influenza vaccines resulted in significantly less vaccine intent compared to communicating information only on the benefits. Similarly, Shim and colleagues¹¹ investigated how game theory (acting to maximize personal payoff regardless of payoff to others) and altruism affect influenza vaccination decisions. Through a survey-based study of 427 US university employees, researchers found altruistic motivation had a significant impact on the decision to vaccinate against influenza, resulting in a shift from self-interest to that of the good of the community.¹¹

A German trial on COVID-19 vaccine acceptance by Sprengholz and colleagues¹²found that communications about the benefits of vaccination, availability of financial compensation for vaccination, or a combination of both, did not increase a person’s willingness to get vaccinated. This trial, however, did not separate out individual vs collective benefit, and it was conducted prior to widespread COVID-19 vaccine availability.

When speaking with patients who are strongly hesitant to vaccination, emphasizing concrete personal benefit may prove more effective than stressing protection of others from illness.

In an online RCT conducted in early 2021, Freeman and colleagues¹³ randomized UK adults to 1 of 10 different “information conditions.” Participants read from 1 of 10 vaccine scripts that varied by the talking points they addressed. The topics that researchers drew from for these scripts included the personal or collective benefit from the COVID-19 vaccine, safety and effectiveness of the vaccine, and the seriousness of the pandemic. They found communications emphasizing personal benefit from vaccination and safety concerns were more effective in participants identified as being strongly hesitant (defined as those who said they would avoid getting the COVID-19 vaccine for as long as possible or who said they’d never get it). However, none of the information arms in this study decreased vaccine hesitancy among those who were doubtful of vaccination (defined as those who said they would delay vaccination or who didn’t know if they would get vaccinated).¹³

Continue to: When encountering patients who are strongly...