Dr Claire Davies explores reasons underlying, and methods of addressing, reluctance to receive COVID-19 vaccination
Read this article to learn more about:
- why vaccine hesitancy may arise, and which patients are more likely to be unsure about vaccination
- using motivational interviewing with vaccine-hesitant patients, and responses to common questions and myths about COVID-19 vaccines
- how to widen access to vaccination against COVID-19.
Read this article online at: GinP.co.uk/455953.article
Vaccines against COVID-19 bring hope of ending the pandemic, yet they arrive in an era of public hesitancy about vaccinations.1 In 2019, the World Health Organization (WHO) had already identified vaccine hesitancy as one of the top 10 threats to global health.2 Although nine out of 10 people hold favourable views about COVID-19 vaccines,3 White people are more than twice as likely as Black people, and 1.5 times more likely than Asian people, to have been vaccinated against COVID-19.4 Vaccine hesitancy is also higher among deprived communities. Barriers to vaccine uptake in minority ethnic groups include:5
- perception of risk
- low confidence in the vaccine and distrust of the medical profession
- barriers to access and lack of vaccine availability
- sociodemographic factors and lack of endorsement
- lack of communication from trusted providers and community leaders.
What healthcare professionals say and how they interact with patients regarding COVID-19 vaccines can have a profound effect on attitudes towards vaccination;6 hence, primary care clinicians have key opportunities to influence patient decisions in consultations and as providers of vaccination clinics.
Why might vaccine hesitancy arise?
Historical mistrust in health services may arise from unethical past practices, such as the Tuskegee Study, in which Black men in the US were denied treatment for syphilis in order for researchers to learn about progression of the disease,7 or from more recent data showing that Black women are five times more likely to die in pregnancy or up to 6 weeks postpartum than White women.8 COVID-19 vaccine hesitancy is more likely to arise in people who are distrustful of doctors, who hold conspiracy beliefs, or who have little faith in institutions.9 People aged 16–29 years are also more likely to be hesitant about COVID-19 vaccinations.3
Hesitancy to vaccination is on a continuum (see Figure 1) and is multifactorial (see Table 1).
|Type of factor||Examples|
Personal and social factors
Factors specific to the vaccine or vaccination
Adapted from: World Health Organization. Health worker training module: conversations with hesitant caregivers. Geneva, Switzerland: WHO, 2020. Available at: www.who.int/immunization/documents/training/en
Reproduced with permission
Working with vaccine-hesitant patients
Motivational interviewing techniques
Motivational interviewing is ‘… a skilful clinical style for eliciting from patients their own good motivations for making behaviour changes in the interest of their health. It involves guiding more than directing, dancing rather than wrestling, listening at least as much as telling. The overall “spirit” has been described as collaborative, evocative, and honoring of patient autonomy.’10 Directive statements—such as ‘but vaccines are good’ —tend to close down the conversation. Vaccine-hesitant patients can be addressed using motivational interviewing techniques. A model discussion (adapted from the WHO training module on vaccine hesitancy) is outlined in Box 1.6
Box 1: Model discussion on vaccine hesitancy6
- Explore the patient’s beliefs about vaccination using open-ended questions—for example: ‘What do you think about COVID-19 vaccines?’
- Reflect and respond—for example: ‘I understand that you are worried about side-effects of the vaccine.’ This can be followed by further questioning, such as: ‘What side-effects are you worried about?’ Other questions you may wish to consider include: ‘What do you know about COVID-19 vaccines?’ or ‘What do you understand about why we are vaccinating people against COVID-19?’
- Affirming strengths may help to move a patient towards change—for example: ‘It is great that you are starting to think about the vaccine.’ Confirming that you have heard their concerns may also be part of the process.
- Provide information on vaccines—for example: ‘Is it ok for me to share some information on the concerns you have raised?’ Try to focus on one concern. Verify what they have understood and ask what they plan to do with the information.
- Determine the course of action—a successful conversation may not necessarily result in an immediate decision from the patient regarding vaccination. People may need time to reflect on the information or may benefit from a series of opportunistic conversations over time.
Created using information from: World Health Organization. Health worker training module: conversations with hesitant caregivers. Geneva, Switzerland: WHO, 2020. Available at: www.who.int/immunization/documents/training/en
If patients are strongly against vaccines, it is important not to start a debate or dismiss them. Inform them of what their personal responsibilities are if they remain unvaccinated, as follows: ‘It is very important that you continue with social distancing, hand washing, and wearing a mask in shared spaces.’ Leave the door open for future discussions—‘I am happy to have further discussions with you again about your decision if you have questions.’
Know your vaccines
It is important to have a good understanding of COVID-19 vaccines in order to answer any difficult questions if they arise.
Be aware of common myths
Awareness of common myths about COVID-19 vaccines and the evidence against them can support healthcare professionals to respond with confidence. Some common misconceptions around COVID-19 vaccination are summarised in Table 2.
‘COVID-19 vaccines cause infertility’
There is no evidence to support a link between COVID-19 vaccination and infertility.11
‘Isn’t it better to be infected with COVID-19 and develop natural immunity?’
Vaccines have been shown to produce more consistently strong and predictable levels of protective antibodies than natural infection, the effects of which may be more variable.12
‘I’ve already had COVID-19. Why should I be vaccinated?’
Previous infection with COVID-19 does not guarantee protection from re-infection.13,14 It is therefore better to be vaccinated. It is likely that, because of the emergence of variant virus strains, we will need regular booster vaccinations over time.15
Be aware of common concerns
Do the vaccines work?
Data published by Public Health England to date show a 60% reduction in symptomatic COVID-19 in patients aged 70 years and over, and a subsequent 35–40% reduction in hospitalisation among patients who develop symptomatic infection, following a single dose of a COVID-19 vaccine. Combining these two risks together yields a vaccine effectiveness against hospitalisation of around 80%.16
Haven’t the vaccines been rolled out too quickly?
The Pfizer–BioNTech and Moderna COVID-19 vaccines are messenger RNA (mRNA) vaccines. Researchers have been studying and using the technology for mRNA vaccines for more than a decade.17 mRNA technology is amenable to rapid creation and manufacture;17 hence, mRNA vaccines are good candidates for COVID-19 vaccines. mRNA vaccines have been studied for many diseases before, including flu, Zika virus infection, and rabies.18
The Oxford University–AstraZeneca COVID-19 vaccine comprises a chimpanzee adenoviral vector. This technology has already been studied in thousands of people to make candidate vaccines against diseases such as flu and other coronaviruses.19
Rapid scaling up of manufacturing facilities in parallel with, instead of after, vaccine development has also enabled swift roll-out of vaccines.
I’m worried about side-effects
Transient, mild symptoms—such as tenderness at the injection site, headache, muscle aches, fatigue, and fever—are common after COVID-19 vaccines.20 Serious reactions—such as anaphylaxis—are very rare, and should be reported via the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card Scheme (coronavirus-yellowcard.mhra.gov.uk).21
Recently, following a small number of reports of cerebral sinus vein thrombosis (CSVT) in young adults following the Oxford University–AstraZeneca vaccine, the MHRA have concluded there is a possible, extremely rare link between this side-effect and the vaccine. Data on this remains under careful investigation and is very likely to be updated.22 It is important to be aware that more than 20 million doses of the Oxford University–AstraZeneca vaccine have been given in the UK without incident. Following this announcement, the JCVI have announced the risk–benefit ratio of giving the Oxford University–AstraZeneca vaccine is less favourable for persons aged under 30 years without health conditions that put them at increased risk of severe COVID-19. These people may be offered an alternative vaccine, where available.23
Convenience, cost, and accessibility
Vaccine uptake is strongly linked to factors such as convenience, cost, and barriers to access,5 particularly for those in low-paid jobs or who work shifts. People may easily be deterred by a long journey, having to pay for transport, or fear of using public transport when COVID-19 cases are high.
Offering flexibility and choice over vaccination appointments—for example, outside normal office hours, at different locations within primary care networks (PCNs), and within communities, such as at places of worship—may all help to improve uptake.
Provide information tailored to cultural, social, and linguistic needs
Information on the vaccines is available in a variety of languages from NHS England and Doctors of the World.24,25 It is, however, important to ensure that there is access to interpreters at vaccine hubs.
Numerous faith leaders have made statements in support of the COVID-19 vaccination campaign. These include the British Islamic Medical Association, the Sikh Council, the Chief Rabbi, and faith leaders from the Church of England and the Methodist, Pentecostal, Evangelical, and Black Majority Churches.26–29 The British Islamic Medical Association has stated that receiving the vaccine during Ramadan does not break the fast.27 Furthermore, the NHS has clarified that none of the vaccines contain alcohol or animal products.30
Patients with learning disabilities and autism may struggle with mass vaccination centres for numerous reasons, such as unfamiliarity or sensory overload. PCNs may consider setting up specific vaccine clinics to support these patients, with a range of adjustments around booking and appointment reminders, quiet environments, accessible information formats, and support from learning disabilities teams.31
A successful vaccination campaign depends on multiple factors and institutions, including public health agencies, professional bodies, the Government, the media, and community organisations. GPs are extremely well placed to hold opportunistic conversations with hesitant persons, as well as to understand community needs when it comes to vaccine provision. Ongoing, collaborative conversations with patients have the potential to reach those most vulnerable to COVID-19 infection who remain unsure about vaccination.
Dr Claire Davies
- de Figueiredo A, Simas C, Karafillakis E et al. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study.Lancet 2020; 396: 898–908.
- World Health Organization website. Ten threats to global health in 2019. www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019 (accessed 23 March 2021).
- Office for National Statistics. Coronavirus and vaccine hesitancy, Great Britain: 13 January to 7 February 2021. London: ONS, 2021. Available at: www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/coronavirusandvaccinehesitancygreatbritain/13januaryto7february2021
- Royal College of General Practitioners website. GPs call for high-profile campaign backed by faith leaders and prominent figures from BAME communities to increase COVID-19 vaccine uptake. www.rcgp.org.uk/about-us/news/2021/february/gps-call-for-high-profile-campaign-backed-by-faith-leaders.aspx (accessed 23 March 2021).
- Scientific Advisory Group for Emergencies. Factors influencing COVID-19 vaccine uptake among minority ethnic groups, 17 December 2020. London: SAGE, 2021. Available at: www.gov.uk/government/publications/factors-influencing-covid-19-vaccine-uptake-among-minority-ethnic-groups-17-december-2020
- World Health Organization. Health worker training module: conversations with hesitant caregivers. Geneva, Switzerland: WHO, 2020. Available at: www.who.int/immunization/documents/training/en
- Centers for Disease Control and Prevention website. The Tuskegee timeline. www.cdc.gov/tuskegee/timeline.htm (accessed 23 March 2021).
- Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK. Saving lives, improving mothers’ care—lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2015–17. Oxford: MBRRACE-UK, 2019. Available at: www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202019%20-%20WEB%20VERSION.pdf
- Freeman D, Loe B, Chadwick A et al. COVID-19 vaccine hesitancy in the UK: the Oxford coronavirus explanations, attitudes, and narratives survey (Oceans) II. Psychol Med 2020: 1–15. doi: 10.1017/S0033291720005188. Epub ahead of print.
- Rollnick S, Miller W, Butler C. Motivational interviewing in health care: helping patients change behavior. New York, NY, USA: Guilford Press, 2008. p 6.
- British Fertility Society and Association of Reproductive and Clinical Scientists. Covid-19 vaccines and fertility. Brentford, Middlesex: BFS, 2021. Available at: www.britishfertilitysociety.org.uk/wp-content/uploads/2021/02/Covid19-Vaccines-FAQ-1_3.pdf
- British Society for Immunology. Immunity & COVID-19. London: BSI, 2021. Available at: www.immunology.org/sites/default/files/BSI_Briefing_Note_2021_immunity_COVID19.pdf
- Widge A, Rouphael N, Jackson L et al. Durability of responses after SARS-CoV-2 mRNA-1273 vaccination. N Eng J Med 2021; 384 (1): 80–82.
- Hall V, Foulkes S, Charlett A et al. Do antibody positive healthcare workers have lower SARS-CoV-2 infection rates than antibody negative healthcare workers? Large multi-centre prospective cohort study (the SIREN study), England: June to November 2020. medRxiv 2021: doi.org/10.1101/2021.01.13.21249642
- Europe PMC website. Vaccine-induced immunity provides more robust heterotypic immunity than natural infection to emerging SARS-CoV-2 variants of concern. europepmc.org/article/PPR/PPR284744 (accessed 6 April 2021).
- Public Health England. Public Health England vaccine effectiveness report. London: PHE, 2021. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/971017/SP_PH__VE_report_20210317_CC_JLB.pdf
- Pardi N, Hogan M, Porter F, Weissman D. mRNA vaccines—a new era in vaccinology. Nat Rev Drug Discov 2018; 17: 261–279.
- Centers for Disease Control and Prevention website. Understanding mRNA COVID-19 vaccines. www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/mrna.html (accessed 23 March 2021).
- University of Oxford website. About the Oxford COVID-19 vaccine. www.research.ox.ac.uk/Article/2020-07-19-the-oxford-covid-19-vaccine (accessed 23 March 2021).
- NHS inform website. Side effects of the coronavirus vaccines. www.nhsinform.scot/covid-19-vaccine/the-vaccines/side-effects-of-the-coronavirus-vaccines (accessed 23 March 2021).
- Public Health England website. COVID-19: the green book, chapter 14a. Available at: www.gov.uk/government/publications/covid-19-the-green-book-chapter-14a (accessed 23 March 2021).
- HM Government website. MHRA issues new advice, concluding a possible link between COVID-19 Vaccine AstraZeneca and extremely rare, unlikely to occur blood clots. www.gov.uk/government/news/mhra-issues-new-advice-concluding-a-possible-link-between-covid-19-vaccine-astrazeneca-and-extremely-rare-unlikely-to-occur-blood-clots (accessed 13 April 2021).
- Department of Health and Social Care. JCVI statement on the use of the AstraZeneca COVID-19 vaccine: 7 April 2021. www.gov.uk/government/publications/use-of-the-astrazeneca-covid-19-vaccine-jcvi-statement/jcvi-statement-on-use-of-the-astrazeneca-covid-19-vaccine-7-april-2021 (accessed 13 April 2021)
- NHS England and NHS Improvement London website. COVID-19 vaccine communication materials. www.england.nhs.uk/london/our-work/covid-19-vaccine-communication-materials (accessed 23 March 2021).
- Doctors of the World website. Coronavirus (COVID-19) vaccine information. www.doctorsoftheworld.org.uk/coronavirus-vaccine-information (accessed 23 March 2021).
- Sherwood H. UK faith leaders join to counter fears over vaccine in BAME communities. www.theguardian.com/society/2021/feb/07/faith-leaders-join-to-counter-fears-over-vaccine-among-bame-communities (accessed 23 March 2021).
- British Islamic Medical Association website. COVID-19 vaccine hub—statements. www.britishima.org/operation-vaccination/hub/statements/#FAST (accessed 23 March 2021).
- The Independent website. Sikh leaders celebrate upcoming holiday with vaccine clinic. www.independent.co.uk/news/sikh-leaders-celebrate-upcoming-holiday-with-vaccine-clinic-sikh-covid-london-boris-johnson-luton-b1820300.html (accessed 23 March 2021).
- Rocker S. Chief Rabbi: it is a ‘religious imperative’ to get vaccinated. www.thejc.com/news/uk/chief-rabbi-it-is-a-religious-imperative-to-get-vaccinated-1.510488 (accessed 23 March 2021).
- NHS website. Coronavirus (COVID-19) vaccine. www.nhs.uk/conditions/coronavirus-covid-19/coronavirus-vaccination/coronavirus-vaccine (accessed 23 March 2021).
- Camden and Islington NHS Foundation Trust website. Supporting service users with learning disabilities to get the COVID-19 vaccine. www.candi.nhs.uk/news/supporting-service-users-learning-disabilities-get-covid-19-vaccine (accessed 23 March 2021).