Primary Care Clinicians as COVID-19 Vaccine Ambassadors

Abstract

The development of highly efficacious COVID-19 vaccines has brought a feeling of hope to many in the US (United States) and across the globe. However, it is estimated that approximately one-third of the US and international population are hesitant to receive the COVID-19 vaccine. For most Western countries with the economic means to purchase sufficient vaccine for their citizens, the medical community now has the opportunity to lead the vaccination communication campaign. Because frontline clinicians were the first to be vaccinated in the United States (US), they are uniquely positioned to be the most trusted source of vaccine information. Primary care clinicians, more than other groups of clinicians, scientists, government officials, media, etc. have the greatest chance for instilling confidence about the vaccine to their patients, including the most vulnerable and the most distrusting. They are considered credible and trustworthy allies for their patients in the US, however, clinicians receive little to no formal training in communication related to controversial topics, such as vaccine hesitancy. With the increasing worry about highly transmissible COVID-19 viral mutations and possible related vaccine resistance, it becomes even more critical to accelerate vaccination efforts across every community. Educating primary care clinicians regarding the importance of talking to their patients regarding their COVID-19 vaccination plans is essential.

The development of highly efficacious COVID-19 vaccines has brought a feeling of hope to many in the US (United States) and across the globe. However, it is estimated that approximately one-third of the US and international population are hesitant to receive the COVID-19 vaccine.^1,2 For most Western countries with the economic means to purchase sufficient vaccine for their citizens, the medical community now has the opportunity to lead the vaccination communication campaign. Because frontline clinicians were the first to be vaccinated in the United States (US), they are uniquely positioned to be the most trusted source of vaccine information. Primary care clinicians, more than other groups of clinicians, scientists, government officials, media, etc. have the greatest chance for instilling confidence about the vaccine to their patients, including the most vulnerable and the most distrusting. ³ They are considered credible and trustworthy allies for their patients in the US, however, clinicians receive little to no formal training in communication related to controversial topics, such as vaccine hesitancy. With the increasing worry about highly transmissible COVID-19 viral mutations and possible related vaccine resistance, it becomes even more critical to accelerate vaccination efforts across every community. ⁴ Educating primary care clinicians regarding the importance of talking to their patients regarding their COVID-19 vaccination plans is essential.

For the vast majority of the population, getting a COVID-19 vaccine is a top priority and something that most Americans are waiting anxiously to receive as soon as it is their turn. For these patients, it is not critical if they receive their vaccine at a large sports arena or their local pharmacy. Alternatively, for those who are anxious, resistant for one or multiple reasons, the primary care clinician is the best source of reliable and trustworthy information. In addition, patients are always better off receiving medical care in their local community, and from clinicians who are culturally sensitive to the lived experiences of the patient. Given the disparate outcomes of COVID-19 for Black, Indigenous, and People of Color (BIPOC), patients need empathy and trust to discuss their fears and ask questions related to the COVID-19 vaccine. ⁵ A recent study has shown that Black, Hispanic, and those in rural communities are also less eager to take the COVID-19 vaccine than other groups. ⁶ For most patients, talking to their local primary care or other trusted clinician is a great benefit, especially if a patient centered approach is used.^7,8

For a small percentage of patients who are truly distrusting of the healthcare system, other tactics may be important to communicate with this population. This could include: peer to peer counseling, societal influencers, and other educational techniques. Additionally, for many Americans access to primary care is difficult or even not available. Therefore, these individuals may need to access other forms of evidenced based vaccine information, including their local pharmacy, government officials, trusted colleagues and friends, and/or evidence-based written materials.

Vaccine Hesitancy

Vaccine hesitancy was a significant problem in the US and throughout the world-even before the recent spread of COVID-19 misinformation. In fact, the World Health Organization (WHO) listed “vaccine hesitancy” as 1 of 10 threats to global health in 2019 because of a significant increase in measles cases, coupled with the threats to international campaigns to immunize against cervical cancer and also to finally end the spread of polio in Afghanistan and Pakistan. ⁹

It is not surprising that many patients are wary about receiving the COVID-19 vaccine. The many common concerns include: (1) safety and efficacy concerns related to the “warp speed” of vaccine development for this novel virus, (2) the possibility of short and long term side effects, (3) unclear long term efficacy, (4) minority populations not being an integral part of the clinical trials, (5) historical medical experimentation on minority populations, and (6) the politicization of the COVID-19 virus.

As part of preventive maintenance, pediatricians (and other primary care clinicians treating children) consider vaccinations to be a major component of their practice. The measles, mumps, rubella (MMR), and polio vaccine for instance, not only protect the individual patient and his/her family, but the public’s health at large. In one large study, most parents considered their children’s pediatricians to be the best source of vaccination information. ¹⁰

Primary care clinicians who mainly care for adults on the other hand, may spend much of their medical practice focused on chronic disease management and the treatment of pain. They recommend annual Influenza vaccines and various boosters, as well as the Zoster, Pneumococcal and Haemophillus influenza type B vaccines. Although extremely important to an individual patient, the public health risk of a single patient unwilling to be vaccinated with one of these vaccines will not risk the public’s health. Primary care clinicians treating adults have little training in communication regarding vaccination aimed to develop herd immunity. After all, there was no vaccine for the Spanish Flu in 1918 and today’s clinicians were not practicing medicine in 1955 when the Salk polio mass vaccination program began in the US. The roll out of the H1N1 vaccine in 2009 was considerably smaller than today’s COVID-19 vaccination efforts but suffered from similar supply shortages and miscommunication.

Clinicians in the US have been stretched to the limits in every way imaginable, and now they are met with another moral imperative: to ask their patients about their plan for obtaining the COVID-19 vaccine. This might include: (1) empathic listening and kindness to their patients (beneficence), (2) communicating the risk of not obtaining a COVID-19 vaccine (non-maleficence), (3) allowing their patients to make an informed decision without judgment (autonomy), and (4) ensuring that the COVID-19 vaccine is distributed equitably (justice). ¹¹ This is a tall order for clinicians, but the public will surely benefit as clinicians provide the necessary space for this conversation.

Difficult Conversations

Historically, primary care clinicians have had difficulty communicating to their patients about controversial and potentially emotional topics. While some have participated in residency and post-licensure offerings in “Breaking Bad News,” ¹² these programs are usually targeted to oncologic and other sub-specialty clinicians. Suicidality, intimate partner violence, substance use, sexual health, and gender identity are some examples of topics that clinicians receive little training on relative to the importance of these conversations.^13,14 The risk of poor clinician-patient communication may result in less than optimal outcomes for the individual and/or family unit. Now, clinicians are asked to talk to their patients about issues that affect the patient, the public health and even the health of the planet. These include gun safety, climate change, and health and now the importance of the COVID-19 vaccine.

COVID-19 Vaccination Communication Strategies

Because patients have their own personal narrative (including fears, disbelief, mistrust, anxiety, etc.) regarding the COVID-19 vaccination, it is important for clinicians to learn how to communicate with a variety of patients. ¹⁵ In fact, there are strategies for primary care clinicians to consider in the delivery of communication regarding vaccination. ¹⁶ Many patients are hyperaroused and anxious due to the impact of the pandemic, and a discussion of the vaccine is best delivered in a reassuring tone aimed at helping a patient to see that the vaccine is a mechanism toward calm and not something additional to worry about. Conversely, for those who are detached or pessimistic, it is important to speak to the potential dangers of worldwide under vaccination and the consequences if citizens do not do their part in reaching herd immunity through vaccination. For patients who are passive as a result of pandemic forces, it is important to actually introduce anxiety into the situation to trigger them toward taking action.

Vaccine Communication Training Opportunities for Clinicians

There are many possible solutions regarding how primary care clinicians might quickly learn how to effectively communicate with their patients regarding their COVID-19 vaccination and thereby alleviate any fears and distrust that they may have. Project ECHO, a virtual telementoring network, is an example of a synchronous educational training model that could be used to teach clinicians regarding COVID-19 vaccine communication. ¹⁷ For instance, clinicians can attend a one-hour Vaccine Communication ECHO training session to receive guidance from expert clinician communicators to understand how to navigate difficult conversations with their patients. Project ECHO is currently piloting a similar communication ECHO on Climate Change and Human Health to educate clinicians regarding how to communicate with their patients on the interrelatedness of the warming climate and health. Large organizations might also consider placing a short series of videos on their asynchronous “Learning Central” sites so that clinicians can watch scenarios of patient communication encounters regarding vaccination hesitancy. Smaller ambulatory clinics might decide to hold in-person or virtual round-table discussions to communicate the importance of COVID-19 vaccination with their patients to ensure the health of the clinic as well as the surrounding community. Finally, written educational material can be prepared by large medical organizations, such as the American Academy of Family Physicians, the American College of Physicians and the Centers for Disease Control and Prevention regarding COVID-19 vaccination communication strategies for patients. It is important to understand the potential impact that vaccine communication through daily clinical practices may have. While a multi-pronged approach to encourage vaccination is important, and would likely include social media, the role of important societal influencers, and the prosocial communication of returning to pre-pandemic experiences, the literature points to the critical importance of the clinical encounter. ¹⁸

Throughout this pandemic, clinicians, and patients have been navigating this novel virus together, however, bringing a successful end to this pandemic will take enormous collaboration across the global community. Primary care clinicians can be trusted ambassadors for encouraging their patients to obtain the COVID-19 vaccine, but they would benefit greatly from receiving a brief training in vaccination communication skills. Clinicians can successfully act locally in their communities while understanding their value in the global campaign to combat this pandemic. Perhaps soon, we can remove vaccine hesitancy from the WHO’s list of top ten global threats and develop herd immunity with the COVID-19 vaccines. Today is the perfect opportunity for primary care clinicians and patients to work together towards the goal of eradication of the COVID-19 virus and a return to some sense of normalcy.