Vaccine Hesitancy

Join Dr. Sharon Brangman, from SUNY Upstate Medical University and Dr. Jorie Butler, from the University of Utah, as they discuss the prevalence of vaccine hesitancy and interventions to reduce it. They discuss patient groups that are likely to have vaccine hesitancy as well as commonly reported reasons why. 

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Transcript

Sharon Brangman, MD, AGSF: Hi, I'm Dr. Sharon Brangman and I am Distinguished Service Professor and Chair of the Department of Geriatrics at [SUNY] Upstate Medical University, where I also direct our Center of Excellence for Alzheimer's Disease. I also serve as one of the national co-PIs for the American Geriatrics [Society] Older Adult Vaccine Initiative.

Today I'm so delighted to be talking to Dr. Jorie Butler, who is an associate professor at the University of Utah in the Division of Geriatrics and the Department of Biomedical Informatics. Dr. Butler is a psychologist and behavioral scientist whose research interests specialize in sociotechnical implementation research, which connects people and technological tools that support health, wellbeing, and healthcare processes. 

We're delighted to have her here today because there's no one better to discuss Vaccine Hesitancy. [00:01:00] So welcome, Dr. Butler. 

I guess what we should talk about is we learned a lot about vaccine hesitancy with the COVID pandemic. So maybe we should start out with you just describing what is vaccine hesitancy and how prevalent is it?

Jorie Butler, PhD: Absolutely. Thank you. So vaccine hesitancy is reluctance or refusal to be vaccinated when vaccines are available, and this really includes a spectrum. So that can be intention not to be vaccinated, or deliberation about whether to be vaccinated. You know, maybe, maybe I should do it, maybe not now. So one way to look at it is considering it as a decision process with different points where we might be able to talk to folks differently is helpful.

So vaccine hesitancy varies widely by vaccine type [00:02:00] and by demographics and location. In general, we see prevalence estimates between 5% and 75% of vaccine hesitancy. We also know that when we look by age, we can see that older people 65 and older are generally a bit more willing to get vaccines, so have less vaccine hesitancy.

We also know that they're more likely to actually receive their vaccines. So you know, a little bit better. But nonetheless, vaccine hesitancy is an issue with older adults, and if we look at lots of older adults in a systematic review of 15 studies of older adults 60 and older, and there were over 9,000 in multiple countries, 27% were unwilling to be vaccinated and an [00:03:00] additional 19 were uncertain about vaccination for the COVID vaccine.

Sharon Brangman, MD, AGSF: So what would you say to help us understand what are some of the most commonly reported reasons for people to be hesitant about taking vaccines? 

Jorie Butler, PhD: Yeah, that's a great question. 

So we can think about this in a few different ways. So sometimes when we look at vaccine refusal, that refusal can vary in strength, like absolutely not- never, to you know, not today. And both of those count as refusal, but they'll have a different strength.

Sometimes when folks are deliberating, they're waiting for specific information, or they may just not be very interested because they may perceive low risk of disease. And many have pointed to the importance of [00:04:00] engagement at the time of, you know, conversations about vaccine hesitancy.

In general, we know that people are not terrific at judging our own personal risk. We usually judge our own risk to be lower than the risk of others. So if we look at, we ask people to estimate the average risk of being in a car accident compared to their own personal risk of being in a car accident, we're a little bit less realistic. So we usually don't feel as at risk as we think the average population is. 

We also are subject to confirmation bias. We find evidence to confirm beliefs that we already hold, and we notice easily available information, which is called the availability bias. So we might hone in on media accounts of negative events.

[00:05:00] So those are general things to think about, but we also know that when we ask people or look at facets about people, there are different characteristics that may be associated with vaccine hesitancy. 

Sharon Brangman, MD, AGSF: So if we take a look a minute at the COVID pandemic, and I think that is probably the, the most recent issue that's been on our, our forefront, you know, with all the stuff related to the pandemic. And there was a lot of confusion about what should happen and who should get the vaccine, and I found there were many patients who just didn't know what to do.

So what was some of the, the issues that you saw specifically related to COVID-19? 

Jorie Butler, PhD: Great question. So one of the things that has been found is that there are a lot of safety concerns. And usually when people are mentioning [00:06:00] safety concerns, that refers to kind of concerns about immediate or long-term side effects.

There's also an impact of institutional trust. How much trust someone feels in the government, how much trust they feel in the scientific community, and how much trust in medical providers. We know that trust can vary by race and ethnicity, and trust in the scientific community is the best predictor of receiving vaccines across groups.

So people of Native Alaskan and indigenous ethnicity are the least trusting in the government and black and Hispanic or Latino individuals are less likely to receive the vaccine than white people. So we, we know that it's very important to understand experiences that community members might have. 

We also [00:07:00] know that experience with COVID influences people's beliefs. So experience with COVID-19 infection and impressions of others' experience or that feeling of personally being susceptible. There's been work looking at experience with the vaccine rollout and with communication. However, we also know that attitudes are not necessarily tied directly to experience. So sometimes even, you know, a good experience isn't necessarily associated with reduced trust. 

One of the things that we see is that people have lower institutional trust if they believe in conspiracy beliefs such that COVID is manmade. We sometimes see misunderstandings, and then we see [00:08:00] behavior that's related to lower levels of institutional trust, like uncontrolled or unregulated information sources like YouTube or advice from friends. And part of the reason for this is the distinction between disinformation and misinformation. 

Sharon Brangman, MD, AGSF: So can you explain how that is, cuz I know some of my patients would tell me they read something, say on Facebook, but then we also had political leaders telling us that COVID wasn't anything worse than the flu and you didn't really need to do anything for the flu.

So tell me how those two portals of information might differ. 

Jorie Butler, PhD: Yeah, I think that's a such an important distinction. So misinformation is false information that may or may not be intentionally misleading. So this is the kind of thing that we might see on social media or that we might hear from [00:09:00] a friend.

"My sister got the COVID vaccine and died the next day." 

So information can be misleading. It makes a tie when there isn't necessarily one. Correlation is not causation, but the person who's providing the information may truly believe what they're saying. 

Disinformation is more insidious. It's a deliberate and intentional plan to mislead for gain. And we have seen that in the COVID space with people leveraging disinformation for political gain and focusing on things that weren't true, like the vaccine was developed too fast to be safe. 

Sharon Brangman, MD, AGSF: So I think that was something that was really very evident during the whole rollout of the COVID vaccines.

So what can we do as healthcare providers to help reduce this hesitancy and help our patients feel that they can [00:10:00] trust the information that we give them? 

Jorie Butler, PhD: Absolutely. So we know from a National Science Foundation study, it was an experimental survey study, and they provided some messages to understand what was most powerful in influencing someone's intention to get the vaccine.

And they looked at reasons for getting the vaccine, like harm reduction, having it be the right thing to do recommendations from scientists, or for the good of the country or patriotism. And the key message was when your personal physician recommends. And when people got that message, they were much more likely to say that they had the intention to get the vaccine.

We know that personal physicians and primary care providers can really make a difference. It may not always feel [00:11:00] like that on a day-to-day basis, but it is true. And as healthcare providers, your job is to be a trusted source of information, which is not the same as being able to change everyone's mind. You won't be able to change everyone's mind.

But we know that some things that help are pre-planning a time window for conversations. Sometimes we kind of start the conversation at the very end of the visit and earlier, maybe better. 

We wanna communicate with patients clearly and without judgment. It can be a good thing to sort of assume that the patient is going to be willing. So when you're about to set up the consent procedure in clinic to say, "Hey, you're due for your vaccine today. Which arm would you like it?" And of course then the patient, you know, will, will go through the informed consent procedure, but you sort of are helping to put them in this space where they might. [00:12:00] 

This may also help address concerns that someone might have that are relatively minor, where they might say, "Okay, I've got one question, but you know, I'm, I'm okay. I'm, I'm ready to have my vaccine." And so that can be helpful in helping you as a provider distinguish between people who do have more concerns. 

So when you see that there may be a concern where the patient is refusing or gives you some sign that they're not interested in being vaccinated so you wanna communicate clearly and without judgment, so ask questions to understand the why of the hesitancy. 

"You said you aren't interested in getting vaccinated. Can you tell me why?" 

Another thing to do is to know when to push and when to stop asking. And the best way to do that is generally to ask the patient, just to ask [00:13:00] the patient if they're open to hearing more. And if they say no, then further conversation at that time may not be helpful. However, remember that vaccine hesitancy can be thought of as a process, and so, because you may not be able to make a difference today, that doesn't mean next time you can't. So, you know, you may make a note to yourself to, to circle back at another time, you know, when the patient may be willing to hear more. So those are some broad tips. 

And then you wanna address information that you provide to the patient's specific concern. So provide you know, if they express concern about the vaccine impacting their DNA or something like that, you just wanna address that specific concern. 

You might see something like, "I hear you are concerned about the vaccine [00:14:00] impacting your DNA. The vaccines use mRNA technology. They contain a piece of genetic code that tells your immune system how to create very specific antibodies against the COVID-19 virus. This code is destroyed after helping your body create the antibodies. The mRNA vaccines do not affect or change your DNA at all." And there are a lot of great sources where you can get very specific kind of, you know, answers about common concerns if you wanna use those.

If a patient has encountered misinformation, you might wanna handle that a bit differently from the disinformation, so focus on facts. You know, you don't have to restate misinformation and acknowledge with misinformation that the intent is not clear. So a friend that told your patient [00:15:00] to be, you know, to stay away from that vaccine may still have good intentions, but good intentions can still result in misinformation.

I think we should handle disinformation a bit differently. So approach communicating about disinformation very directly. You know, "I hear your concern and that is not true. Here are the facts kind of being more directly focused." 

Sharon Brangman, MD, AGSF: So it really sounds like it's up to us as providers, as trusted sources of information to spend time in face-to-face discussion with our patients, and maybe not rely on pamphlets or any of the media campaigns that are going on. And it's really an individualized session where you're answering those questions that patient might specifically have. 

Jorie Butler, PhD: That is really where you have the most chance to make the biggest [00:16:00] difference, is in one-on-one conversations. There are successful interventions that can impact vaccine uptake and in increase in knowledge, but face-to-face communication is a feature of almost all of those. 

We also know that mandates are successful information campaigns that target specific groups, like people with specific diseases or ethnic groups like Hispanic or Latino people. Community-based actions, including support from local leaders, religious and others, and directly targeting unvaccinated populations. So those things do also work, but all of them work best with face-to-face communication and face-to-face communication is the, you know, leading influence. 

We can also help by providing healthcare providers with [00:17:00] training. Embedding knowledge about vaccines into hospital or clinic procedures. So, you know, using your whole staff to help in this message and, and making vaccines convenient and easy to do and we can improve access to vaccination. And all of those things are, are pretty successful. 

Mass media campaigns can work. They tend to be less effective in general in terms of having a smaller effect. A smaller difference, more like 10% increase in vaccine uptake rather than 25% increase that we would see in a more successful intervention.

Brochures and pamphlets can work. They tend to work better for patients who have, you know, little information, and that may be better than people who have strong objections that you know are not necessarily based on just lack [00:18:00] of information. 

We also know that general incentives can be helpful, like providing food or goods upon vaccine, things like that.

But face-to-face communication is the best strategy. It's the one that's most important, and it's the one that can really impact the health of your patients. 

Sharon Brangman, MD, AGSF: Thank you so much for talking with us today, Dr. Butler. And I would like to remind our audience that you could read more about this subject as well as other subjects related to our initiative for vaccines in older adults. It can be found at vaccines.AGS.CoCare.orgv. Thank you so much for listening today.