Recognizing and Addressing the Vaccine Hesitancy Continuum

Presentation

[00:00:44]

Dr. Carrico: Welcome to this educational program titled Recognizing and Addressing the Vaccine Hesitancy Continuum. My name is Dr. Ruth Carrico. I am a family nurse practitioner based in Louisville, Kentucky, and I'm also part of the adjunct faculty in the division of infectious diseases at the University of Louisville School of Medicine, and I'm a senior partner with Carrico and Ramirez.

[00:01:09]

Poll 1: How many people do you provide care for in a typical week?

how many people do you provide care for in a typical week?

[00:01:29]

Pretest 1: After a patient refuses a vaccine, how likely are you to discuss vaccination in future visits?

after a patient refuses a vaccine, how likely are you to discuss vaccination in future visits?

[00:01:48]

Pretest 2: I have good strategies to tailor vaccine recommendations to motivate patients towards acceptance.

All right, next tell me I have good strategies to tailor vaccine recommendations to motivate patients toward acceptance.

[00:02:04]

The Vaccine Hesitancy Continuum

All right, let's get started thinking about some of this information.

Now know many of us, when we think about vaccine hesitance across our patient population, we know that there is not a one-size-fits-all, that we may have some individuals who are actively seeking vaccination. They're ready to go.

Others may have a little bit of hesitance. They may accept all that we are recommending, but may have some vaccines for which they are unsure. And then we'll have some patients that will accept some delay some refuse some, they are in kind of this mixed bag of vaccine acceptance and vaccine hesitance.

And then we know some patients will refuse all vaccines, or at least when you discuss vaccines or vaccination with them, they are not ready to be part of any conversation. I think the take-home message from this is that all patients are at different places along this continuum, that there is not simply one idea or one approach that is going to work for all of our patients.

[00:03:14]

BC vs AC: Before vs After COVID-19

So I want you to kind of rethink this journey with me. And if you are like me, I know some of my strategies that I used before covert, or I'll call that BC, are very different in how I address or how I have these discussions now and that is after covert or AC.

So, previously, I would use kind of this typical presumptive approach that I'd go in and announce what my expectation was and what I thought the expectation was, and that that would set the stage then for our conversation. Many times I would have patients that were ready. I would kind of address that low-hanging fruit.

And as then, as some of the vaccine hesitance began to set in or take root, I found that over time, I began maybe to avoid conversations with those who are less likely to agree with vaccination. And not only their vaccine hesitance or fatigue set in, but I found out that mine also began to set in.

So I what is to think of now, where are we at this current time? And I think many of us are realizing that our starting point is at a very different place that we now are thinking about and maybe being impacted more readily by where the patient is. And that really focuses on the importance of recognizing and take advantage of this patient-provider relationship and really rethinking about where my connection is. Where is my starting point?

Because my goal is to engage my patients. I want to understand where they are. I want to acknowledge their concerns, their fears, their questions. I want to have this honesty and transparency about vaccine safety, vaccine confidence, vaccine hesitance, all then taking place with every encounter that I have. And I need to be answering my patients' questions first and foremost.

[00:05:13]

Transcultural Nursing

So many of us, regardless of our particular discipline within health care, we all have some sort of theoretical background.

Now, as a nurse, as I mentioned, in nursing, we have a theory that, I think, is particularly relevant to these types of discussions. And this is Madeleine Leininger's culture care theory. This really was the first theory in nursing that really attempted to highlight the whole perspective about cultural competence.

And that is understanding our patients, that we recognize our patients as unique individuals. We want to really then start our conversations with them, recognizing that uniqueness. And when we think about then cultural competence in terms of vaccines, I think really that we can distill this down to two basic questions our patients may have.

And number one, that is: Is this vaccine safe for me? And then number two, will this vaccine help me? And recognizing this as kind of a starting place for where our patient is helps to set the stage for a more holistic approach.

And that is addressing where the patient is in terms of physical, psychological, social, emotional, spiritual, and in every dynamic, in every way from where that patient really is at that moment. It accounts for then many of the differences that we need to take into account when we are trying to develop a vaccination plan that is personalized for that patient. It also reminds us that many times after hearing about a number of the vaccine hesitance, we also are fatigued.

And that may have caused us to inadvertently be less open to listening to where our patient is. So this is a reminder that we need to hit our reset button and start thinking about how we can remain open-minded to what our patient is telling us. And in many respects, celebrate the fact that they are coming to us with their questions and concerns. That really says that they trust us.

[00:07:29]

Reframing Patient Discussions on Vaccines

So, let's think about how we can reframe our patient discussions on vaccines and vaccinations. And I try to look at this in really four basic stages.

First, set the stage to determine where is my patient's starting point. Then I need to listen and acknowledge. I acknowledge that my patient has concerns and that I've heard them. It doesn't necessarily mean that I agree with them, but I'm recognizing that this is what my patient is telling me. Then I try to answer their questions, provide them with personal stories as a way of demonstrating that I hear them, I understand them. And then stage four is now, what is the plan for this individual patient?

[00:08:11]

Step 1: Set the Stage

Now, let me go into detail a little bit more with each of these.

Number one, setting the stage. Everything the patient says to me is important. So that's my starting point. So I don't announce a plan before I know what the starting point is. So this gives me a chance to acknowledge where that patient is.

It helps me know what their beliefs are. And it helps me then kind of get away from saying it isn't enough. That is, I need to be listening. I need to understand. I need to design a communication approach that fits the needs of my patient and their particular motivations. So really coming away with a concept that my patient's concerns are my concerns.

[00:08:57]

Step 2: Listen to Your Patient

This helps me then move to the next step, and that is really actively listening. I need to understand what my patient is saying and that if they come to me with something that is a concern of theirs, and I know that you may be thinking, oh, my gosh, I've heard them all. I've heard this vaccine is going to be injecting me with something. It's going to hurt me. It's going to do various things to me.

Well, I'm listening to what my patient is saying. And I need to verbalize that, that I understand if I had heard that, I would be concerned too. Or thanks for sharing that with me. Something that builds on this trusted relationship and that lets my patient know that I'm actually listening, and I am hearing.

Please take note that I'm not saying that I agree with what they're saying, but I agree that it is a concern. And I agree that it is something that is a roadblock that I need to be able to move beyond and move with that patient beyond in order to get to a next step.

[00:09:59]

Step 3: Answer Their Questions

So this next stage then is after I have heard what the patient is saying, I'm going to be responding to that. I'm going to be providing them with information. And again, not every patient is going to be the same. There may be some that I can give them some particular data about. There may be some that I can share a study about. But others, I may not be at that point where I can share that level of detail.

So how I address these questions will really be guided by this conversation with the patient. I need to understand where they are, what their concerns are. I need to understand, is this the type of patient that I can share a personal story? Are they interested in that? What is it that will make this a personal thing to that patient? So that means I no longer have a one-size-fits-all approach. Maybe I never had a one-size-fits-all, but many of us kind of have our routine in how we address vaccines and the comments about vaccines or vaccinations.

So now I've got to do a little bit more homework. I've got to take it differently with different patient groups. That means I need to be invested differently in the patient experience and the patient conversation. And I need to make sure that I figure out where is that balance between oversharing and undersharing or giving too much or too little information. So I guess the easy encounters, I guess, are gone. And now we need to look at every encounter as something that may be a little bit more challenging.

[00:11:36]

Step 4: Follow Through

Now, we hopefully will come in this fourth step to a place where we now make a decision. Is the patient ready for vaccination? I've got to follow through. Am I able to provide vaccine at that particular time? Am I going to be looking at costs and insurance coverage and so forth? Am I going to be making a referral if I'm not a vaccinating office?

So I'm making a plan. But at the same time, if that patient is not quite ready, then what are we going to do? How am I going to follow up with them? How am I going to let them know that just like I'm going to ask them about their medication, I'm going to be doing medication reconciliation next time. I'm going to be talking maybe about smoking cessation or diet and exercise next time. I'm also going to be talking about vaccine next time.

So the conversation is never actually finished because we know that regarding a patient in a given age bracket or health risk bracket, there are going to be multiple vaccines that I may be talking about throughout the year. So this is going to be a routine conversation. So I need to let that patient know that, in some way, they're the most important person in the world to me when we're in that room together.

My job is to make sure that I'm providing them with best information so they can make best personal health decisions. That's not going to change or that's not going to stop. It will continue. So how I frame that conversation for actions that will be occurring this time, as well as conversations that we may be having next visit. That's all part of this health care continuum.

[00:13:16]

Additional Considerations

So that means that I need to be thinking about some new considerations. That means I need to be really thinking about my vocabulary. There are some terms maybe that I'll tell my patients, some of these terms have been maybe weaponized. That means if I bring them up, they immediately have a negative connotation or elicit a negative response.

So maybe I've got to think about new terminology to use in my patient conversation. I know I've certainly got to be well aware of my body language, you know, eye contact and making sure I'm not looking at my computer, but I'm looking at my patient. Am I using crossed arms or some things that tend to tell a patient I'm closed to your discussion?

Instead, I'm looking at new ways of making sure that my body language is speaking for me also. And again, it's part of that never give up approach that I'm always going to be wanting to continue to build trust to help them with next encounters, next conversations and keep these pathways open.

[00:14:21]

Reflect on Your Own Practice

Again, this is a time where I reflect on my own practice. We've all heard some of these sayings that time change, and we must change with them. So whatever we have done in the past, our commitment to our patient is to continue to do our best. Is the best what we have always done? Or do we need to make changes to help them demonstrate to patients that we are ready to commit to giving them our best and getting them our best outcomes? What has worked in the past? What hasn't worked in the past?

And just like we are asking our patient to make changes, we need to realize that that may mean us also that we are making changes.

[00:15:04]

No Time?

So, I know that many of us feel like we have been overwhelmed, and we are experiencing burnout at different levels or fatigue at different levels. And that this is a time for us to stand back, take a deep breath, recognize those challenges that we are having, and then think about what is it that we need to be doing to invest in not only our future, but our ability to establish future relationships with our patients.

Many times, this requires that we've got to rethink our approach, maybe look at a new approach. How then do we consider not only what our patients are feeling and what they are concerned about, what they are afraid of, but also think about the same thing for ourselves. What type of new launchpad do we need to enable us to do our best work, bring our best selves, then to work every day?

And what approaches then do we need to be thinking about in terms of setting a new standard for ourselves? That's very easy to say, and I know very difficult to do.

[00:16:14]

Maximize Others in Your Clinic

One approach may be thinking about how we maximize what we have available in our clinics. Who do we have around us? Everyone in our clinic is a participant in this process. Thinking about then what training our staff needs.

Remember, our staff are people too. They may be healthcare workers, but they are people too, and they are experiencing the same challenges that we are experiencing. So, this is a team effort.

Let's think about then what our team needs, invest in them, thinking about what types of challenges, concerns, fears that our staff have themselves, and then what they are hearing in our patient population. So, we're in this together. Getting us all on the same page is a critical part of this journey.

[00:17:06]

How to Improve Immunization Practices

Let me also give you an example of a great resource. Here is an infographic that really helps to simplify some strategies that may be of assistance to you when you are improving immunization practices. So, I think there are a few key points.

Number one, build trust. And we do this by establishing empathy and then establishing and building on our credibility. We know that, from a patient perspective, that many times the best messages are those that we've taken time to personalize.

And then we empower patients to make decisions by providing them with information that is based upon their ability to make an informed decision. And then really think about, as we are having these discussions, realizing that each of our patients is unique, that they will come from a very different starting point. So, think about their own individual health literacy.

And then make sure, as we have these discussions, that we are, again, embracing that whole cultural competency. So, any recommendations that we provide to patients then are personalized and appropriate for them. So, giving that a little bit of additional time to think about where is the patient's starting point in terms of their health literacy, their health knowledge. And then how do we make sure every recommendation is personalized and appropriate for that patient?

Key Take-home Points

So let's think about some of our key points. And I want us to start by rethinking about our approaches with our patients. When we have these conversations about vaccines, let's think about our new starting point with our patients.

Listening and acknowledging what our patient is concerned about, listening to their questions, providing them with answers when we have it, personal stories, letting them know when there is something that we need to follow up with them about. Maybe it's a question they brought up that we don't have an answer for. Are we willing to invest in them and stop, get information, and then touch base with them again?

Let's follow up on vaccination plans. Maybe it means we can vaccinate them today or refer them. Maybe it's something that we are going to have to revisit in the future that our ongoing relationship with our patient is important, and it's a constant process, a constant cycle.

This approach then means that we've got a new launching pad, not only for differences in our patient conversation and engagement, but also rethinking about what does it mean for our practice? What changes do we need to do, not only personally, but also in our team and in our personnel that we have in our office setting? I may need to think about, what is it that I do personally with my vocabulary, my body language? How do I share this information with my staff? I need to invest in my relationship with my patient and realize that we are all tired. We are all changing.

We are all then thinking about what is new, what do I need to do differently? But, you know, don't be discouraged and don't give up. This is a constant professional development process that a phase that we are in now, it is going to help, and I think improve all of us when we rethink our approaches.

But these improvements will not only help us with how we address vaccines, but really in how we address other health-promoting behaviors, other changes that our patients need. For us to discuss with them and consider.

So self-reflect, think about what is and what isn't working, what is it that we need to do differently? And then again, please remember that you are part of a larger whole, not only a whole with your personnel and your staff, but also your professional engagements with others. We are all sharing these same challenges. That means that we have much to learn from each other and to rethink and to reconsider.

And then again, getting to that end point where we are bringing our best self to work, our best self to our patient involvements and engagements. And that together, I think that we can get over this hurdle. And on the other side, I'm confident that we are going to bring then new approaches to providing best practice, evidence-based care for all.

[00:20:13]

Posttest 1: Going forward, after a patient refuses a vaccine, how likely are you to discuss vaccination in future visits?

going forward after a patient refuses a vaccine, how likely will you discuss vaccination in future visits?

[00:20:29]

Posttest 2: I have good strategies to tailor vaccine recommendations to motivate patients towards acceptance.

Our next question, I have good strategies to tailor vaccine recommendations to motivate patients toward acceptance.

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Go Online for More CCO Coverage of Vaccines!

I hope that this has motivated you then to think about how do I learn more? So, to do that, you can go online for more CCO coverage of vaccines information.

[00:21:00]

Poll 2: Do you plan to make any changes in your clinical practice based on what you learned in today's program?

do you plan to make any changes in your clinical practice based on what you've learned in today's program?

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Poll 3: Please take a moment to text in one key change that you plan to make in your clinical practice based on this education

Please take a moment to text in one key change that you plan to make in your clinical practice based on this education.