Learning and practicing an array of effective communication strategies is key to clinicians’ ability to effectively practice vaccine care. Patients may be on a spectrum of vaccine hesitancy, ranging from uncertainty to refusal; accordingly, clinicians should acquire a spectrum of strategies.
The Centers for Disease Control and Prevention (CDC) partnered with the American Psychological Association (APA) to develop suggestions for clinicians dealing specifically with COVID-19 vaccinations. The technique at the center of their recommendations is motivational interviewing, which the APA defines as “a client-centered yet directive approach for facilitating change by helping people to resolve ambivalence and find intrinsic reasons for making needed behavior change.”1
With regards to vaccinations, the CDC describes the use of motivational interviewing as “an evidence-based and culturally sensitive way to speak with unvaccinated patients about getting vaccinated.”2 The process includes several steps.
First, clinicians should come from a place of empathy and collaboration. Foster curiosity about the patient’s feelings and take into account sociocultural and family situations that could influence a patient’s opinions about vaccines.
Next, ask permission to talk about vaccines with an introductory phrase such as, “If it’s alright with you, I’d like to take a little time talking about vaccines.”
If the patient says no, respectfully end the conversation. Let them know that because you care about their health, you hope they’ll talk with you about it next time.
If the patient says yes, ask them a scaled question, such as “On a scale of 1 to 10, how likely is it that you will get a COVID-19 [or other] vaccine?” If the patient gives a low number, use your curiosity to ask follow-up questions such as why they chose this number, why they didn’t choose an even lower number, or what would help them switch to a higher number. Ask them to voice what the benefits of vaccination might be. When asking these questions, the goal is for the patient to speak out loud, because that can change how they navigate their choices.
Finally, to the best of your ability, respond to any questions about vaccines or related topics, including mental and physical health.
Pivoting the Focus
The American Academy of Pediatrics (AAP) partnered with the FrameWorks Institute, a think tank that helps organizations “communicate about social issues in ways that build public will to support progressive change.”3 Together, they agreed on 2 evidence-based recommendations:
- Focus on the collective rather than on the individual. Point to the common good as a benefit of getting vaccinated. Be intentional with the order; begin by explaining the collective benefits of vaccination, and then connect those to the individual benefits. It may also be helpful to educate people about inequities when it comes to access to vaccinations.
- Focus on how the immune system uses vaccines to train itself to fight disease, instead of on how vaccines fight disease. Emphasize the long-term benefits to health and wellbeing enabled by vaccination.
The AAP also describes 2 metaphors that could assist clinicians with their recommendations:
- To describe how the immune system improves its performance through vaccinations, use a computer updates metaphor: Getting regular software updates helps a device fend off viruses.
- To explain how the immune system uses vaccinations to learn, use a literacy metaphor: Learning to read and write is a skill that can be retained. The immune system remembers what to do about a virus even after the vaccine is no longer in the body.
For further insight into specific approaches with which clinicians are finding success, we spoke with Mark E. Horowitz, MD, a primary care physician at Downtown Family Medicine in New York, New York. He identified effective strategies for several different categories of vaccine-hesitant patients.
Patients Who Doubt the Safety of COVID-19 Vaccines Because of Their Novelty
“Those [patients] could be persuaded to take the vaccine when they were apprised of the fact that the mRNA technology wasn’t invented in December of 2020, but rather had been around for some time. And those vaccines that use the RNA technology were developed for SARS, MERS, and other potential pandemic viruses in the years leading up to COVID.”
Patients Who Thought Contracting COVID-19 Gave Them Immunity
“A number of those people could be persuaded on the basis of the fact that most viral immunizations require multiple doses. And I point out to them, when you were a child, your parents took you for 4 total doses of the polio vaccine before you were allowed into school, or 2 doses of measles, mumps, and rubella before you were allowed to school. There are very, very, very few vaccines that fully protect an individual with 1 dose alone. And therefore, having had COVID, you have to think of yourself as having only a single dose, and a second dose would boost that immunity.”
Patients Who Distrust the Health Care System
These patients belong to communities that have historically been mistreated by the health care system. Dr Horowitz noted that this category includes older Black patients, who may recall the Syphilis Study at Tuskegee.
“I found by acknowledging [patients’] feelings about the health care system as being legitimate, not denying them, and pointing out to them that people of color and people with less access to the health care system were getting sick and dying at a higher rate than other people, I was able to convince some of those patients [to receive vaccinations].”
To get help giving COVID-19 vaccines to undocumented or recent immigrants, Dr Horowitz partnered with Epicenter-NYC, a media organization focused on building community. By becoming a trusted partner to whom the organization referred patients, he was able to bridge the fear and uncertainty this patient population might feel about being apprehended and deported if they tried to obtain a vaccination.
To learn more about this community partnership process, we spoke with Mitra Kalita, co-founder of Epicenter-NYC. Kalita is a former managing editor of the L.A. Times and former senior vice president at CNN.
Build Long-Term, Trusting Relationships
Kalita noted that Dr Horowitz “played the role where anybody I gave to him, not only did he have the expertise, but he also had the patience to help them through their fears.” She and her colleagues were able to tell their clients, “Look, this is a doctor who’s trusted to us. Go to him, and he will help you.”
Partner with Pre-existing Community Institutions
Kalita pointed to the broad skepticism common in the discourse in the United States and pointed to a simple solution: partnering with established institutions, such as schools and places of worship.
“I think you have to be willing to say, well, these people have already built a community, and I have something they need, but they also have something I need.” Community partnerships are one way in which clinicians pressed for time can effectively navigate vaccine communications with patients in need.
Help Patients Navigate Complex Systems
For low-income or low-resource patient populations, the fact that technology is now inherent in most medical processes can be a barrier. “I think the [COVID-19] vaccine is a primary example, where just getting an appointment required being able to navigate online,” said Kalita. “That requires digital skills, but also it requires the time to navigate a system.”
She pointed out that clinicians can foster “a willingness to engage with multiple parts of the system that are not speaking to each other. So, for example, navigating technology [as well as] navigating language and bureaucracy and systems.”
In all, effective communication with patients about vaccination involves a multipronged approach that includes research, empathy, conversational tools, metaphors, tailored resources, and long-term connections to the community.
- American Psychological Association Dictionary of Psychology. Motivational Interviewing. Accessed June 22, 2023. https://dictionary.apa.org/motivational-interviewing.
- Centers for Disease Control and Prevention. Talking with Patients about COVID-19 Vaccination. November 3, 2021. Accessed June 18, 2023. https://www.cdc.gov/vaccines/covid-19/hcp/engaging-patients.html.
- FrameWorks Institute. About. Accessed June 21, 2023. https://www.frameworksinstitute.org/about/.
- American Academy of Pediatrics. Communicating About Vaccinations: Evidence-Based Recommendations to Shift the Narrative. Updated February 9, 2023. Accessed June 20, 2023. https://www.aap.org/en/patient-care/immunizations/communicating-with-families-and-promoting-vaccine-confidence/communicating-about-vaccinations-evidence-based-recommendations-to-shift-the-narrative/.
- Centers for Disease Control and Prevention. The U.S. Public Health Service Syphilis Study at Tuskegee. Reviewed January 9, 2023. Accessed on June 18, 2023. https://www.cdc.gov/tuskegee/index.html.