A study in Patient Education and Counselling explores the experiences of primary care physicians (PCPs) with vaccine-hesitant patients in the hope that specific challenges can be addressed to support efforts to increase vaccine acceptance. All the PCPs who participated understood the significance of discussing COVID-19 vaccination, but they found strategies targeting people’s thoughts and feelings were “generally ineffective”. They also expressed “frustration” at their interactions with vaccine hesitant patients, which sometimes led them to “truncate their communication with these patients”.
Fostering acceptance and increasing uptake
The authors describe vaccine hesitancy as a “major public health threat” as demonstrated in the COVID-19 pandemic; an estimated 234,000 deaths could have been prevented through vaccination between June 2021 and March 2022 when COVID-19 vaccines were “widely available” in the United States. Despite this availability and evidence of vaccine effectiveness, around 20% of the US population is undervaccinated against COVID-19.
“Strategies to foster vaccine acceptance and increase COVID-19 vaccination are needed.”
Many evidence-based strategies for healthcare organisations to promote vaccine uptake put health care providers (HCPs) at the centre, with doctors “consistently cited” as a trusted source of information. However, the perspectives of primary care providers (PCPs) are a research gap. Thus, the authors identified a need to generate a “more in-depth understanding” of PCPs’ experiences communicating with vaccine hesitant patients. This understanding is a “critical first step to maximising the potential for PCPs to promote COVID-19 vaccination”.
The study
The study was intended to describe PCPs’ experiences and perspectives on COVID-19 vaccine communication with patients, with a focus on COVID-19 vaccine hesitant patients. The researchers conducted focus groups with PCPs from 3 healthcare systems in central Massachusetts. Acknowledging prior research that documents higher rates of COVID-19 vaccine hesitancy among members of racial/ethnic minority groups and those with socioeconomic disadvantage, the authors chose clinics from 3 health systems that serve higher proportions of patients who are a member of a racial/ethnic minority group, primarily speak a language other than English, and/or are insured through MassHealth.
Nine focus groups, conducted for around an hour over Zoom between December 2021 and January 2022, involved 40 PCPs. These included 23 attending physicians, 10 resident physicians, 6 nurse practitioners, and 1 physician assistant. Experiences were characterised by the following themes:
- Importance of and perceived responsibility for discussing COVID-19 vaccination with their patients
- Strategies for promoting COVID-19 vaccination
- Challenges PCPs encountered
- PCPs’ reactions and emotions
- Tailored communication according to degree of hesitancy
- Resources that would be helpful to support these conversations
The findings were integrated with the Increasing Vaccination Model, but the authors added the challenges encountered among “staunchly vaccine hesitant patients” and resultant frustration, truncated communication, and shifting priorities.
Study findings
All participants perceived discussing COVID-19 vaccination with their unvaccinated patients as “extremely important” and described feeling responsible for providing patients with accurate information about vaccination and recommending vaccination to all their unvaccinated patients. However, most PCPs did not feel responsible for whether their patient chooses to get vaccinated.
The focus groups revealed a range of communication strategies for influencing COVID-19 disease risk appraisal and/or increasing confidence in the vaccine. For example, facts and statistics appeared “ineffective”, directing PCPs to other strategies such as emphasising a patient’s risk of disease, sharing stories of other patients who experienced serious illness, and highlighting the risk of Long COVID. Some PCPs acknowledged “explicitly trying to induce fear about COVID-19″.
The main strategy for increasing vaccine confidence across PCPs was sharing information, including referring to studies and/or CDC information, answering questions, acknowledging risks, and addressing myths and misconceptions. Many PCPs presented vaccination as a risk/benefit calculation, emphasising safety by comparing the small number of vaccine-related adverse events with the number of people who had received the vaccine. They also put the risk of vaccine-related adverse events into the context of the larger risk of dying of COVID-19 or risks inherent in everyday activities.
PCPs explored various relationship-based strategies to promote COVID-19 vaccine uptake, including making personalised recommendations for vaccination, leveraging pre-existing relationships, sharing personal decisions to be vaccinated, and building trust. Common approaches to build trust included avoiding making patients feel stigmatised, acknowledging concerns and uncertainty, encouraging repeated discussions, empathising with concerns, and being explicit that PCPs are motivated by the patient’s interests. Although many offered patients a chance to ask questions, only a few reported trying to find common ground and empathise with concerns. However, those who did found it helpful.
“COVID-19 vaccine availability in clinic was consistently cited by PCPs as one of the most influential factors in getting their COVID-19 vaccine hesitant patient vaccinated.”
PCPs observed that vaccine availability overcame practical barriers, and those who worked at clinics without vaccine availability described it as a “major barrier”. Other practical challenges included inadequate time and competing medical priorities, as well as difficulty following ever-changing information on COVID-19 and vaccinations.
Efforts to influence the most “staunchly vaccine hesitant” patients’ thoughts and feelings were “generally ineffective”. Many PCPs reported struggling to overcome strongly held beliefs based in misinformation or conspiracy theories. For some, patients refused them a chance to discuss it, including those who prevented PCPs from leveraging their relationships.
“All PCPs felt frustrated and defeated with not being able to convince some patients to get vaccinated.”
This experience was compounded by the “disheartening” transition between attending to critically ill patients with COVID-19 in the ICU and being unable to get through to patients who have access to a preventative intervention. PCPs also expressed “frustration and anger” with unvaccinated patients who sought treatment for COVID-19 and described “emotional exhaustion” with trying to discuss vaccination with hesitant patients.
“Recognising that most of their strategies were ineffective among the most staunchly hesitant patients, most PCPs tailored their communication according to the degree of COVID-19 vaccine hesitancy.”
Patients were broadly categorised as those who were:
- Very easy to convince or just want PCPs’ confirmation
- Undecided but open to and seeking information
- Staunchly opposed to vaccination
The “staunchly opposed” group demanded the most time and effort, often rejecting data and/or science and having fixed belief systems informed by misinformation, politics, and personal experience. Most PCPs therefore limited the time they committed to discussing COVID-19 vaccination with patients who seemed staunchly opposed. This was also influenced by a desire to maintain relationships and ensure patients continue to seek care for other conditions.
The participating PCPs felt “ill-equipped” to communicate with their most hesitant patients but commented on the value of focus groups for learning from peers and feeling less alone in facing challenges. They expressed interest in easy-to-understand patient-facing educational materials to address common myths, questions, and concerns in multiple languages. They also indicated a desire for accurate, up to date, and easy to find information sources for their own reference. It might also be valuable to develop system-level resources to identify unvaccinated patients, conduct outreach, and offer professional counselling.
Implications and conclusions
“As the spread of medical misinformation and disinformation is expected to persist and potentially increase, our study illustrates the need for innovative and effective strategies for refuting misinformation related to vaccination, and health misinformation more broadly.”
The authors comment that “very few PCPs” in the study described empathising and expressing understanding with their vaccine hesitant patients, but the few who did found it “quite effective”. Expressing empathy and understanding the viewpoint of a staunchly vaccine hesitant patient are “necessary first steps to establishing trust with this population” before refuting misinformation. However, this is “understandably difficult” for healthcare providers.
The paper identifies a need for training in effective approaches for countering misinformation and communication. As a presumptive-style recommendation is the “most well proven provider-based strategy” for encouraging vaccine uptake, PCPs should be trained in making presumptive-style recommendations. However, the effects of this training could be limited if COVID-19 vaccine availability in primary care clinics is “inconsistent”. Efforts should focus on increasing in-clinic availability as an “important first step”.
Associate professor of medicine at UMass Chan Medical School and principal investigator, Dr Kimberly Fisher reflected that the key message from PCPs was “universal frustration” at the number of patients they “couldn’t get through to, despite their pre-existing relationship and feeling like the patients really trusted them”. This challenge continues as advice changes.
“In the early communication, public health officials obviously didn’t know that it would be required every year, and so I think there is a degree of frustration among patients about actually needing to get one every year, like a flu shot.”
Dr Fisher recognised the importance of tempering vaccine advocacy with maintaining a trusting relationship.
“Maybe they won’t get vaccinated. But you could still convince them to get a mammogram or colonoscopy or something else.”
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