Activity Transcript

Segment 1: Updates on COVID-19 Vaccination Roll Out and Vaccine Hesitancy

Miriam Taegtmeyer, BM BCh, FRCP, PhD: Hello. I'm Dr Miriam Taegtmeyer. I'm a professor of global health at the Liverpool School of Tropical Medicine in the United Kingdom. Welcome to this program titled, "Deconstructing COVID-19 Vaccine Hesitancy: Providing Tailored Solutions Across the Spectrum."

In this chapter, I'll cover updates on COVID-19 vaccination rollout and vaccine hesitancy.

Vaccine hesitancy is defined as a delay in acceptance or refusal of safe vaccines, despite availability of vaccine services. A lack of confidence in vaccines for COVID-19 poses direct and indirect threats to health and could derail efforts to end the current pandemic.

With variation across subpopulations and typically lower vaccine acceptance among minority and marginalized communities and women planning pregnancy or who are pregnant, in other words, those of reproductive age. The WHO has now identified vaccine hesitancy as a major threat to global health.

I like to think of the drivers of vaccine hesitancy using this conceptual framework of the 5 Cs. Vaccine hesitancy is complicated. It's context specific. It varies across time and place. And it's influenced by these different factors. It helps me to break it down, to think about confidence. Do people have trust in the vaccines or the health system? Convenience, is it easy to get vaccinated? Are they accessible? Complacency, how people perceive the risks of getting COVID vs the risks of the vaccine and how they feel about themselves in that. Calculation, how people search and use information to make decisions? And whether people's complacency is motivated by the need to protect others, perhaps older family members.

In a UK study, key indicators also included prior behavior. Very importantly, how transparent the process of vaccine development was, and mistrust in science and leadership and individual political views were also influencers that fell under some of these 5 Cs.

It's really important to address vaccine hesitancy because it's a key strategy to achieving population immunity and ending the pandemic. A substantial proportion of adults are still hesitant about or resistant to vaccination for COVID-19. In a British and Irish sample referenced there, only 65% to 69% of respondents were fully willing to get vaccinated.

And important work is required to begin to understand and address this problem. Identifying and understanding vaccine hesitancy within distinct populations could help with our future public health messaging. A lot of work has already been done to understand the problems and drivers and the need to utilize those to inform strategies. Less work has been done on evaluating those strategies and their effectiveness.

Here's a graph of the daily observed deaths in over 60s and the expected numbers modeled in the absence of vaccination. You can see a dramatic decline there. We also see that in our declining numbers in hospitalization and in requirements for intensive care. In the UK, an estimated 10,500 deaths have been averted as a result of the vaccination program up to the end of March of last year already.

The risk of hospitalization is lower for Omicron cases after 2 and 3 doses of vaccine, with 81% reduction in the risk of hospitalization after 3 doses compared to unvaccinated Omicron cases. Even with new variants, vaccinations are effective. Combined with the protection against symptomatic disease, vaccine effectiveness against hospitalization is 88% for Omicron after 3 doses of the vaccine.

Vaccine safety has been another big concern. We're learning more about individuals that weren't included in the original trials through the data that's collected from this mass vaccination activity. For example, pregnant women; for example, individuals with comorbidities, and those that are frail. Preliminary findings from the 3 vaccine safety monitoring systems didn't show obvious safety signals amongst pregnant persons, and those are being born out as mass vaccination continues.

In a recent study in the Lancet assessing pregnancies that have occurred in ongoing clinical trials found no evidence of association with reduced fertility after vaccination.

With all that extra information about effectiveness and ongoing information about safety, vaccination uptake has been slightly better than what people said they would do before the vaccines came onboard. In the graph on the left-hand side, it does show low vaccination uptake, particularly in Eastern Europe, consistent with vaccine hesitancy for childhood immunizations in those countries. UK data on the right show 83% received second dose, and that would put us similar to the dark green countries on the map on the left-hand side.

When we dive down into our data, we find that uptake is not equal across population groups and across parts of the country. Even within Liverpool where I work, within the city, our most deprived wards have the lowest uptake. We also have variation by age.

We've noticed that people are influenced by their home country, so if something is important in the Polish media about vaccination, that will be picked up by the Polish community in Liverpool, and the same for many countries. The low vaccination rates in Eastern Europe are reflected in Eastern European communities here in Liverpool. Similarly, high rates of vaccination in Iran are reflected in high rates in our Iranian population here in Liverpool.

Uptake also varies by ethnicity. Equity of uptake is a more complex issue than can be explained by one of the single factors on a spectrum of vaccine hesitancy, relating to equity of many health services and trust in health systems.

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Segment 2: The Spectrum of Vaccine Hesitancy

Rupali J. Limaye, PhD, MPH, MA: Hello, I am Dr Rupali Limaye. I'm the director of behavioral and implementation science at the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland.

Today, I'm going to talk about the spectrum of vaccine hesitancy. In this chapter, I will focus on the reasons why individuals are hesitant, and some ideas on how to communicate with such individuals.

Let's start in talking about vaccine hesitancy and why it's important for us with regards to vaccine refusal. What does vaccine hesitancy have to do with vaccine acceptance? What we have seen over the last several decades is that those that are hesitant, that might delay or refuse a vaccine, has led to a number of vaccine preventable outbreaks, ie, vaccine refusal. These outbreaks have been increasing over the last several decades.

The question really remains, why are people vaccine hesitant? I want to start why people who were vaccine hesitant before COVID started. There were 4 key concerns. The first had to do with vaccine ingredients, ie, what was in a vaccine. The second had to do with a vaccine schedule, ie, the number of doses and shots a child may receive. The third had to do with the misperception that there was a link between vaccines and severe adverse events, such as autism, for example. The fourth had to do with low levels of risk perception. People did not feel they were susceptible to the disease, and even if they were susceptible, they did not feel as though the disease were severe enough to warrant a response, ie, getting a vaccine.

These drivers have changed during COVID. We still see some of the drivers that we saw pre-COVID, but we see additional drivers as well. There are 3 primary ones. The first focuses on distrust and lack of confidence. During the pandemic, many people around the world have really become more distrustful of their governments. They also have a lack of confidence towards their governments, which impacts whether or not they will engage in the healthcare system and get a vaccine.

The second driver focuses on misinformation and disinformation. There's a lot of unknown information on social media that people consume and make their decision related to vaccines.

The third has to do with the polarization. More and more people are very staunch in their political views, and we have seen that this political divide has gotten wider and wider. As a result, fewer people across the political aisle are engaging with one another and discussing vaccines with one another.

Vaccine behaviors fall along a continuum. They're not necessarily yes or no. As you think about these vaccine behaviors, there are segments of the population that may refuse all vaccines. There are segments that may refuse vaccines, but are unsure about that decision. There are segments that delay and refuse some vaccines. There are segments that accept vaccines, but are unsure. Then there's a segment that accepts all vaccines. What's important here is that we want to focus on those that can be moved, ie, the movable middle. These are individuals that fall in the middle of this continuum.

One way to think about this is that we can group individuals based on their vaccine attitudes. Those that are already going to get vaccinated just need, not much, just a little bit of a nudge to reinforce that decision. The individuals that want the vaccine and may be skeptical, they will require a bit more persuasion. Those that refuse all vaccines typically are those that are not movable, as they are set in their attitudes and values towards vaccines.

Factors that affect vaccine decision making can be classified in a number of ways. One way to think about this is we can think about this with the increasing vaccination model. What people think and feel, social processes, such as what your peers are doing, your motivation and willingness to engage in the behavior, and then practical issues, such as availability, convenience, and costs, and all of these together affect vaccination.

If we think about these in another way, we can think about these different factors in 3 categories. Confidence, whether or not individuals feel as though the vaccine is effective, whether or not they're comfortable with the immunization program and motivation. Convenience, this has to do with practical issues, again, related to cost, insurance issues, availability. Complacency, when people don't necessarily feel as though that the risks of the vaccine are actually greater than the benefits of the vaccine.

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Segment 3: Vaccine-Neutral Individuals

Barbara A. Rath, MD, PhD, HDR: Hello, my name is Barbara Rath, and I'm going to be talking about vaccine neutral individuals today. I'm the co-founder and chair of the Vienna Vaccine Safety Initiative and research director at the University of Bourgogne Franche-Comte in France.

And we are interested to explore what this term even means to start with. So who are vaccine-neutral individuals? This is actually a term that was developed for what we call vaccine sentiment analysis, which is a machine learning technology where people are using predefined terms and keywords to better understand vaccine-related content in social media such as Twitter, for example. And they're using these terminologies that are registered in what's called the Valence Aware Dictionary and sEntiment Reasoner. And there's also a similar system that was developed by the London School of Hygiene & Tropical Medicine. And as you can imagine, if we are very upset about the new vaccine guidelines, then we will use different verbs and adjectives than when we are positive towards it or neutral.

So this is where the term originally came from and this is an example of a publication that came from these analyses. It is used a lot now in the context of COVID to understand people's sentiments around vaccination really.

And one of the groups, of course, that is often studied this way or approached this way are younger adults, last but not least because they're some of the main users of social media nowadays. They often are open to vaccination in principle, but they may be a bit less concerned about the risk of the so-called natural disease, meaning the actual COVID in the unvaccinated case. So if you feel relatively safe -- if I get COVID nothing major's going to happen -- then the incentive to vaccinate is of course a bit lower. And so that's one characteristic of this group, but they're also looking for scientific evidence and the opinion of peers, both online and offline.

A very useful publication on this is issued by the OECD on youth and COVID issued last year and I think it's very useful to look into that if you're interested and you can see those very concrete elements of communication that drive or decrease trust in these so-called neutral individuals. So they can go either way, depending on what they're finding. And if you look at the lack of reliable information and partisan decision-making, these are all things that are abundant right now.

And just today, I've seen 2 very conflicting headlines: one says, now you can infect people even before you have any symptoms of Omicron, then some major public events are planned while indoor mask mandates are also happening and people don't know what to decide for now, especially young people who would like to participate in festivals or activities. That's one of the things they look at media for in order to understand can I go out? Can I party? Can I gather with others? Can I attend a concert? And then the communication here is very vague.

Young adults are very central to mitigating COVID of course, and their behaviors such as the uptake intention vary substantially from the decision-making process of adults. And they also are opinion leaders sometimes, sometimes going against the opinions that they see in adults around them, and sometimes they go with them depending on their relationship to them as well. And public health guidelines, of course, are another authoritarian system surrounding them and they rather participate in something voluntarily rather than because they've been made to do something.

Of course, the attitudes depend on health literacy and the language access to good information and then, of course, the effects of virus transmission if you have young folks who feel safe and transmit viruses during spring break or other activities. So there's often no evil intent, it's just a lack of information or the natural psychology of being a young adult really.

So also the process of decision-making has been studied thoroughly by psychologists. We're currently working with a very good team that works on decision-making processes on the psychological level and we know that there are many components that are important, not just the final decision of do I take a vaccine or not, but before that, there's a lot of lifelong and basic education that has to go into this which feeds into better health literacy and specifically vaccine literacy.

And then that should be embedded in the entire health vaccine communication arena. We often advocate at the Vienna Vaccine Safety Initiative that vaccines should not be seen as something separate from other things we do to keep ourselves safe, such as bicycle helmets or simple road safety, for example.

And then understanding that as part of keeping myself safe in my own interest can lead to what we call vaccine empowerment, which can be suddenly somebody who has been neutral becoming a driver of vaccination efforts when they see sense in it and reason, and that then leads to greater confidence and then if there's trust in the health system, then the decision will be made. So there's a long list of things that need to happen.

Then how does that work in terms of understanding one's own vaccination record? The idea here is how can you get the patient or the vaccine need to a point where they drive the will to vaccinate, even if their clinician is not bringing up the topic by themselves, because they're afraid of it and because they don't feel comfortable, which should not happen of course, but it happens.

So even though WHO mandates that every patient encounter should be used to update the vaccination record or to look at it and to update the vaccines that are missing, this is hardly ever happening in practice. So can we bring the patient or the client, can we bring them to initiate a vaccine dialogue with a healthcare professional?

And the Vienna Vaccine Safety Initiative has worked on that for many, many years, over a decade now. And one of the tools we've developed up out of a design thinking project is the so-called VAccApp vaccination app. And that was a tool for parents, but also young adults for themselves to look at a mobile app that is very playful, where they can pick their own avatar, and that tool guides them through their own vaccination record to see if they can make sense of it and understand what's actually in there.

And then if they are uncertain about certain aspects, some scribbles that they see in there or something that they're not clear about, they can use a traffic light system to remind them that next time they see the clinician, they will bring this up and ask them for clarification and say, "Listen, I've seen this on my vaccination record. What does that mean?"

And that will then leverage a more proactive attitude towards immunization and that's where we want to go. Away from trying to convince people of something that they don't see any reason in to, "I need to do this for myself and I need to make sure I get what I need from my healthcare professional." So this will bring these 2 sides better together and of course, that's the long-term goal.

As you can see in the publication of this project, if you want to read more detail, you can really improve people's literacy on how they are individually vaccinated and protected by using such interventions and this is going to be part of an EU project called Innovative Immunization Hubs, the ImmuHubs, where this is going to be tested in 6 different European countries in very non-medical settings, not in the emergency room anymore, but now in community sites or gatherings.

So how can we increase vaccine uptake? I mentioned most of this already. Confidence is really about collective responsibility, but some people are not convinced by just that being the only driver. So there's always the individual good and there's the common good that both need to be met for somebody to take such an important decision.

And in the next slide, the most important thing I would like you to think about is one of the critical aspects I think in communicating vaccination with young adults and adolescents is to be very clear that we cannot predict your individual risk right now of severe illness. And that is important. So we're not trying to scare people or fearmonger, but if you non-judgmentally explain that, that you should be aware that we cannot predict your individual risk so if you want to be safe, protect yourself. That should be sort of the message rather than say, "This is a horrible threat and it's going to kill us all." You know, that's not going to drive rational decision-making.

So last but not least, we have provided a couple of links to see where you can find additional information about the things I've been talking about. The first one is the Symptom Survey, which is a project with patient organizations and driven by them to understand better the individual subjective importance of COVID or flu-like symptoms to patients and caregivers themselves, which may be very different from the doctor's viewpoint.

Second project, www.seki.eu, will become a one-stop place and hub for vaccine-related education for healthcare professionals in Europe. It is part of the coalition for vaccination, which is an EU initiative to bring different healthcare professional organizations together around the topic of vaccination.

And last but not least, the Immunization Hubs project that I mentioned to you earlier, where we will be using digital and analog interventions to bring marginalized, difficult-to-reach, and isolated populations into the vaccination dialogue, especially those people who usually have lack of access to understanding, to good information, to the healthcare system in general, and to see how we can involve them better.

I thank you very much for your attention and I'll talk to you again another time. Thank you.

Segment 4: Vaccine-Resistant Individuals

Rupali J. Limaye: Hello. I am Dr Rupali Limaye, Director of Behavioral and Implementation Science at the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. In this chapter today, I will cover vaccine resistant individuals.

So when we think about vaccine resistant individuals, we have to remember that vaccine behaviors fall along a continuum. In this continuum, you have individuals that refuse all vaccines. You also have individuals that refuse vaccines, but are unsure about that decision. You also have individuals that delay or refuse some vaccines. You have individuals that accept vaccines, but are unsure about that decision. And finally, you have individuals that will accept all vaccines.

So those that are vaccine resistant are those that typically are in the middle of this continuum. So they might refuse, but are unsure. They might delay and refuse some vaccines, and they might accept some vaccines, but are unsure.

So the role of healthcare providers in communicating with these vaccine-resistant individuals is really quite critical. Healthcare providers still remain the most trusted advisor and influencer of health decisions.

So let's go through some strategies that you can use to talk to individuals that may be resistant toward vaccines. The first is focusing on giving a strong and personalized recommendation. This means that there's communication related to the importance of the vaccine. This also means that you encourage same-day vaccination. This also means to be timely, talk about the strength of the recommendation, and be consistent in your communication. And finally, personalizing the recommendation is quite critical. So discussing your own vaccine decision-making process regarding adult vaccines. Or if you have children, talking about the vaccine decision-making process you went through when you thought about childhood vaccines.

So giving a strong and personalized recommendation has been shown to be quite effective when speaking to vaccine-resistant individuals.

The second key communication strategy that you can employ is the use of presumptive communication. So this kind of communication essentially assumes that the person will vaccinate. So for example, you would say something like, "Your child is due for several vaccines today." And by saying it in this way, you are therefore framing vaccination as the default or the normative behavior.

Let's go through a quick example. So when a parent comes in and their child is due for a vaccine, you, 1: assume the parent will vaccinate. You then, 2: give your strong recommendation, which we just went over. Personalize that recommendation if you're able to. And then, 3: if there are questions or concerns, you listen to and respond to the parent concern.

Another strategy to use is something called motivational interviewing. So this is specifically for those that might have significant questions or concerns about vaccination. Sometimes you need to use a little bit more of a nuanced communication. This includes active listening, reflecting on what the individual is saying, asking open-ended questions, asking permission to provide additional information if needed, and acknowledging autonomy, that the person is in charge of their decision, which therefore then strengthens the perception that the clinician and the patient are working together towards a goal. So in general, motivational interviewing focuses on leveraging an individual's intrinsic motivation for engaging in a behavior.

Finally, you can focus on salience through tailoring. What tailoring is, is essentially matching each individual's beliefs or attitudes or concerns to the message that you provide to that person. This then improves the personal relevance of the information you're providing, and it will increase the likelihood that you can change behavior. So for example, if an individual has a specific concern about ingredients, your framing should focus on why those ingredients in the amount that they are provided in the vaccine are actually quite safe to give, for example.

Safety is a key driver and many reasons why vaccine individuals are resistant. A few things that you can go over is you can confirm with individuals that long-term side effects are side effects that occur several months or years. For all available vaccines that are approved, these side effects typically develop within 6 to 8 weeks of injection. With regards to the COVID vaccines, you could focus on the idea that their body breaks down mRNA vaccines and they disappear within a few hours. You could also say that no current vaccines have been found to cause long-term side effects, and to think about the decades of vaccines against polio, small pox, tetanus, and all the safety that has gone into monitoring those vaccines.

Finally, a key question that we continue to see is that individuals ask, "What is safer, a COVID vaccine or COVID-19?" There are key points you can make here. You can say that COVID-19 is much more likely than the COVID-19 vaccine to cause severe long-term effects. We've also seen that 30% of adults that have had a COVID-19 infection experience long-term symptoms. And finally, 2% to 10% of children under the age of 18 experience long-lasting symptoms. We're also learning more.

With regards to individuals that ask, "Isn't it safer for me to just get COVID?" You can talk about the differences between natural immunity and vaccine immunity. For natural immunity, we know that there is a risk that one could get very sick from infection. We know that natural immunity leads to shorter immunity against COVID. And we know that if you have natural immunity, you're more likely to get reinfected. Compare this to vaccine immunity. We know that vaccines cannot give you COVID. There's low risk of someone getting sick. It also provides longer protection against COVID-19, and also to stress that no vaccine is 100% effective. It's still possible to get COVID. However, you're much less likely to have severe COVID if you get the vaccine.

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Segment 5: Strongly Vaccine-Hesitant Individuals

Miriam Taegtmeyer: Hello, I'm Miriam Taegtmeyer. I'm Professor of Global Health at the Liverpool School of Tropical Medicine. In this chapter, I'll discuss strongly vaccine hesitant individuals.

What about those patients who are adamant in their refusal to accept vaccination? Let's look at strategies for approaching strongly vaccine-hesitant individuals.

It's important to differentiate vaccine hesitancy from vaccine refusal. Vaccine refusal often carries deep political, cultural, and emotional underpinnings that can be very difficult to overcome.

Individuals in this group, often described as anti-vaxxers, tend to congregate in insular communities, whether physical or online, and they're highly resistant to change. The same arguments appear irrespective of the vaccine. It's not necessarily COVID-19 vaccine only.

There's a belief in the superiority of natural immunity and healthy living as a better protection from COVID than a vaccine. There's a belief that vaccine side effects are worse than the diseases they prevent, or a theory that vaccines introduce toxins or cause disease in otherwise healthy people. Mandatory vaccines can infringe on civil liberties or on religious beliefs, and sometimes a theory that doctors are biased or have conflict of interest or engaged in conspiracies with pharmaceutical companies in promoting vaccines.

Total vaccine refusal is far less common than vaccine hesitancy. However, the subtypes are a bit intertwined and there are a range of individual perspectives within vaccine refusal. It can be grounded in insufficient knowledge or a lack of confidence in the benefits of vaccination, but more often the overconfidence in one's ability to avoid the disease or intangible fears about vaccination, concerns about side effects or unconscious associations of vaccines with illness may impact. And particularly important is this distrust and suspicion of the medical system itself or the wider trust in government.

Vaccination refusal can become a social identity and it's hard to trust anyone else apart from other people who may share the same opinion, so it's very difficult for clinicians to change someone's mind, particularly in 1 conversation. Repeated meetings may be necessary and the longer somebody's been opposed to vaccination, the harder it becomes. It becomes more entrenched over time, something that's hard to backtrack on.

If the patient seeks medical advice for something else, it might be easier to engage in communication with them. Or if they want to talk about vaccination, their vaccine refusal, keeping it focused on medical questions is important.

Colleagues of ours at the Erasmus Medical School in Rotterdam have set up a hotline for vaccine doubters and people come to them with a lot of questions. And the training they've given the medics on the hotline is to keep their responses focused to medical questions because they've realized that they don't make progress in prolonged conversations about social identity on anti-vaccination.

Through online communication, anti-vaccination advocates have kind of created a shared culture of constructs that embrace the identity of being an anti-vaxxer, the identity of health information crusader, of critic, of expert. And the community consumes, produces, and distributes information that reframes the mainstream health information and reinforces these shared values, creating a social identity of anti-vaccination.

And when you do digital analysis, publicly available information on who's using which media to identify sources of misinformation, it can often be tracked down to a handful of individuals. And it's a useful way of thinking about how to counter misinformation, ensuring that voice of misinformation is not amplified.

Because what we want to avoid is having this group excessively influence those who are vaccine hesitant or who are seeking more medical information or more information about safety and effectiveness before making their decision.

And attitudes do polarize over time. I mentioned this before. So misinformation spreading on social media is directly related to this increasing polarization, but it becomes harder and harder to change people's opinion over of time. And a study on polarization on Facebook has shown consumption of content is dominated by this echo chamber effect and that has increased over the years, with a majority of users consuming information in favor or against vaccine, not both.

So I would advise not attempting to directly contradict anti-vaccine stances because it only leads to defensiveness and reactions and further reduction and willingness to vaccinate. And it started to stigmatize this group.

People really should feel that their concerns are respected, that they're heard. We should always continue to use scientifically sound language that is simple, that is emotional, that is understandable, that doesn't stigmatize excessively this group, but maintains, initiates, and maintains open dialogues regarding vaccination and gives people dignity if they want to come out of that stance. Not only for COVID, but for other infectious diseases as we move forward.

So it's a challenging group and it needs good communication skills. But we shouldn't be punishing ourselves too much if we are not able to influence them, but rather to support and listen.

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This is a verbatim transcript and has not been copyedited.