key: cord-0912923-yr0sabg8 authors: Finney Rutten, Lila J.; Zhu, Xuan; Leppin, Aaron; Ridgeway, Jennifer L.; Swift, Melanie; Griffin, Joan M.; St Sauver, Jennifer L.; Virk, Abinash; Jacobson, Robert M. title: Evidence-Based Strategies for Clinical Organizations to Address COVID-19 Vaccine Hesitancy date: 2020-12-30 journal: Mayo Clin Proc DOI: 10.1016/j.mayocp.2020.12.024 sha: 98ddd3ea2b90e8a1b750f69ce6f09d6eca02b1e4 doc_id: 912923 cord_uid: yr0sabg8 The success of vaccination programs is contingent upon irrefutable scientific safety data combined with high rates of public acceptance and population coverage. Vaccine hesitancy, characterized by lack of confidence in vaccination and/or complacency about vaccination that may lead to delay or refusal to vaccinate despite the availability of services, threatens to undermine the success of COVID-19 vaccination programs. The rapid pace of vaccine development, misinformation in popular and social media, the polarized sociopolitical environment, and the inherent complexities of large-scale vaccination efforts may undermine vaccination confidence and increase complacency about COVID-19 vaccination. While the experience of recent lethal surges of COVID-19 infections have underscored the value of COVID-19 vaccines, ensuring population uptake of COVID-19 vaccination will require application of multi-level, evidence-based strategies to influence behavior change and address vaccine hesitancy. Recent survey research evaluating public attitudes in the U.S. toward the COVID-19 vaccine reveals substantial vaccine hesitancy. Building upon efforts at the policy and community level to ensure population access to COVID-19 vaccination, a strong healthcare system response is critical to address vaccine hesitancy. Drawing on the evidence base in social, behavioral, communication, and implementation science, we review, summarize and encourage use of interpersonal, individual-level, and organizational interventions within clinical organizations to address this critical gap and improve population adoption of COVID-19 vaccination. Successful immunization programs require high rates of acceptance and population coverage. 1, 2 Thus, the availability of safe and effective vaccines is insufficient; vaccines have to be widely accepted by the public and by the health community to confer population benefit. 2, 3 Mounting evidence teaches that segments of the U.S. public experience some degree of hesitancy about accepting vaccination. 3 Indeed, vaccination hesitancy, lack of confidence in vaccination and/or complacency about vaccination that may lead to delay in acceptance or refusal to vaccinate despite access to vaccination services, 4, 5 was deemed a top ten threat to global health by the World Health Organization in 2019. 6 Indeed, vaccine hesitancy was deemed a top ten threat to global health by the World Health Organization in 2019. 6 Although this designation preceded the coronavirus (COVID-19) pandemic, the sociopolitical response to the pandemic in the U.S. and other countries provides a timely example of this threat. Vaccination confidence is influenced by trust in the safety and effectiveness of vaccines, trust in healthcare professionals and public health and healthcare delivery systems, and trust in the policy makers who develop vaccination requirements. 5 Experts have noted a decline in public confidence in vaccination. 7 Vaccination complacency is influenced by individuals' health beliefs (e.g. perceived risk of vaccination, perceived risk and severity of disease, perceived need for the vaccine, and self-efficacy to vaccinate) and their assessment of the risks and benefits of vaccination. 5 Ironically, the success of vaccination has contributed to such complacency by reducing perceived risk and severity of disease. 7 J o u r n a l P r e -p r o o f A convergence of critical uncertainties and social trends will likely exacerbate vaccine hesitancy specific to COVID-19. 3, [8] [9] [10] [11] [12] [13] [14] [15] The COVID-19 vaccine is offered to a public suffering from pandemic fatigue, 3 while misinformation in popular and social media, and conspiracy beliefs about COVID-19 pandemic and COVID-19 vaccination are perpetuated. 18, 19 Research conducted during the COVID-19 pandemic to ascertain public willingness to accept COVID-19 vaccination and to assess vaccination confidence and complacency reveal a general decline in public acceptance of a potential vaccine coupled with increasing vaccine hesitancy. [16] [17] [18] [19] [20] Factors associated with COVID-19 vaccine hesitancy generally mirror factors known to influence vaccine hesitancy for other vaccines. These include vaccine-related attributes, political factors, and vaccine-related attitudes and beliefs. 4 Vaccine Attributes. Survey data reveal public hesitancy about COVID-19 vaccine effectiveness, uncertainty around the protection duration, and apprehension about safety or side effects. 17, 19 Critical information about vaccine attributes, such as duration of immunity and immunogenicity, is gradually accumulating and will vary by vaccine manufacturer and/or among populations. 11, 12 This emerging understanding of COVID-19 immunology and virology, [8] [9] [10] coupled with the unprecedented speed of vaccine development threaten to undermine public confidence. Political Factors. Efforts to rapidly develop with aggressive federal funding and deploy vaccines with emergency use authorization from the US Food and Drug Administration (FDA) may J o u r n a l P r e -p r o o f worsen concerns about vaccine safety and effectiveness. 21, 22 Data from public surveys in the U.S. also reveal the influence of political factors on hesitancy wherein lack of trust in those endorsing vaccination, country of vaccine origin, and concerns about profit or political motives increase public mistrust. 13, 17, 19 Individual Attitudes and Characteristics. General mistrust of vaccination, misperceptions about the severity of COVID-19 infection, and a preference for natural immunity were also found to be associated with greater hesitancy. 13, 23 Survey data also revealed greater hesitancy among those with lower education, unemployed, younger populations, and among certain ethnic and racial minority groups including Hispanics and African Americans who have been disproportionally affected by COVID-19. 17, 18, 20, 23, 24 The present review is offered to summarize effective strategies to address vaccine hesitancy for use by healthcare providers and clinical organizations in the care of their patients and employees. To improve population adoption of COVID-19 vaccination, it is imperative to draw on implementation of multi-level, evidenced based strategies to increase vaccine uptake and address vaccine hesitancy. Equally critical is the widespread adoption of evidence-based best practices that have been developed and refined with previous vaccines. These include evidence-base efforts from social, behavioral, communication, and implementation science that can inform clinical efforts at the interpersonal, individual, and organization levels to address COVID-19 vaccine hesitancy and support public health efforts (Figure) . Policy-level interventions, such as reducing out of pocket expense for patients and requiring vaccination for child care, school and college attendance, and community-level interventions that address access barriers by offering vaccination programs in schools and child care centers, and providing vaccination in Women-Infant-and Children programs are very effective strategies for increasing vaccination rates. 25 While interventions at the policy and community-level do not specifically address vaccine hesitancy, they do set the stage for interventions to address vaccine hesitancy within clinical organizations. Adoption of best practices in clinical organizations at the interpersonal, individual, and organizational levels from the evidence-base in social, behavioral, communication, and implementation science can improve clinical efforts to address COVID-19 vaccine hesitancy and support public health efforts to increase vaccination rates (Figure) . Interpersonal-level interventions address the interactions between healthcare professionals and patients (or parents of patients, as is most often the case with pediatric populations). Healthcare provider recommendations have been consistently demonstrated to result in higher vaccination rates across a variety of preventive behaviors including vaccines. [26] [27] [28] Healthcare professionals remain the most trusted source of information, in general 29 and specifically in regard to COVID-19. 30 The quality and strength of healthcare provider recommendations has also been shown to influence vaccination rates. 28, [31] [32] [33] Indeed, in a recently conducted survey, respondents indicate a greater likelihood of accepting the COVID-19 vaccine if recommended by their healthcare provider. 20 Observational studies 33, 34 and clinical trials 35, 36 with childhood J o u r n a l P r e -p r o o f vaccines indicate that use of presumptive, announcement-style language ("Today you'll be getting your vaccine") rather than conversational, participatory-style language ("How would you feel about getting a vaccine today?") results in higher vaccination uptake. 34 Table 1 . Individual-level interventions, in this context, target members of the healthcare team and patients. While research teaches that education of healthcare providers and patients offered in the absence of other strategies is largely ineffective, 32 when offered in combination with interventions at the organization and interpersonal level, individual-level educational interventions can empower healthcare teams to promote vaccination and optimize efforts to address hesitancy among patients (See Table 1 for examples). 2528, 32, 33, 41 Healthcare Providers. To ensure readiness to offer strong recommendations to their patients, (Table 2) should also be offered to healthcare providers to address the vaccine-related attributes, political factors, and attitudes and beliefs that contribute to vaccine hesitancy. 28, 32, 33, [36] [37] [38] The emergence of several vaccines with varying dosing schedules and storing requirements will intensify logistical and communication challenges, which may, in turn, render addressing vaccine hesitancy more challenging. 13 The healthcare provider should be provided with resources ( Table 2 ) and training in making strong recommendations and addressing vaccine hesitancy. 28, 32, 33, [36] [37] [38] Capacity building strategies, including training, technical assistance, and other support have been demonstrated to increase healthcare providers' adoption and implementation of evidence-based interventions. 39, 40 Training and education in addressing patient concerns should be offered to healthcare providers in an easy format so that they, in turn, can make their strongest recommendations to patients. The training must also foster communication that is honest, culturally appropriate, and consistent. Furthermore, training and education is necessary to empower all healthcare staff, and not just healthcare providers, who interact with patients. These include nurses, receptionists, scheduling and appointment staff, and other administrative assistants. 2 Patients. Developing and offering patient education materials in combination with other evidence-based strategies can improve vaccination rates. 25 This approach can be strengthened J o u r n a l P r e -p r o o f by drawing upon behavior and communication science evidence which has consistently shown that positive framing or gain-framing of messages is effective for promoting prevention. 41 Specifically, a positive frame involves emphasizing the benefits gained by participating in vaccination (e.g. Getting the COVID-19 vaccine will protect you and your family) versus a negative frame, which would emphasize the risks of failing to vaccinate (e.g. If you choose not to get the COVID-19 vaccine, you are putting yourself and your family at risk). Appeals to altruism and prosocial behavior (e.g. protecting one's family) have also been shown to be effective communication strategies for promotion of vaccination. 42 Tailoring patient reminders to vaccinate to address common patient barriers and concerns may improve uptake. 25 This may additionally involve the offer of novel information about the disease rather than an explicit attempt to counter common misperceptions about the vaccine to be optimally effective. 43 Research has shown that direct efforts to counter misperceptions may backfire resulting in an increase in misperceptions or a decrease in intention to vaccinate. 44-46 32 If correcting misperceptions about the vaccine is needed, it is important to 1) frame the messages in ways that affirm the audience's worldview or personal values (e.g., Drawing upon implementation science, a variety of organization-level interventions have been shown to increase vaccination rates by supporting the work of healthcare professionals or removing barriers to vaccination for patients. These include availability of standing orders for nurse visits, audit and feedback, reminder/recall systems, point of care prompts, and home visits. 25, 32, 48 As with other routine and at-risk vaccinations, healthcare providers should seek to approach every patient visit as an opportunity to assess vaccination status and deliver needed vaccinations; organization level interventions support this approach. 49 Standing orders support nurse visits without clinical exams and allow nurses to vaccinate patients without individual, patient-specific orders written by the healthcare providers. These are sometimes referred to as nurse protocols rather than standing orders. These increase vaccination, in general, and improve access for patients. 25, 32, 48 Standing orders expand access to vaccination and streamline the vaccination process for patients. 25, 32 Audit-and-feedback interventions, that involve regular presentation of vaccination performance metrics to healthcare providers, have also shown effectiveness for vaccination, in general. 25, 32, 48 Regular healthcare provider appraisal of vaccination rates in their patient panel has been shown to improve coverage rates. 49 Inclusion of peer performance or benchmark performance metrics in audit-and-feedback interventions J o u r n a l P r e -p r o o f can also promote a sense of normative behavior among healthcare providers. Reminders and recalls, which involve directly contacting patients to inform them that a vaccine is due, coming due, or past due, have consistently shown effectiveness in improving vaccination rates. 48, 50 Point-of-care prompts, which flag recommended vaccines during clinical encounters either through review of current vaccine records or through electronic clinical decision support, are effective for increasing vaccination rates. 25, 32, 48 Home visits can also improve vaccination rates, and may be particularly useful in reaching underserved populations. 25 Lastly, organization-level interventions implemented in combination involving the use of two or more coordinated interventions to increase vaccination rates have also been shown effective. 25 In general, bundled approaches that target multiple levels of influence (e.g. organizational, interpersonal, individual) and engage stakeholders (e.g. patients, healthcare providers) are most effective. Practical constraints require organizations to select from among available evidence-based strategies to identify approaches that are feasible and acceptable within their specific contexts. Strategies to increase uptake of evidence-based interventions, such as COVID-19 vaccination, must be selected and tailored to conform to the unique needs and resources of clinical settings and to address known barriers to adoption. 39 It is therefore, critical to conduct local context assessments to understand relevant barriers and resources. 51 Furthermore, couching efforts within iterative evaluation approaches can assist with efficiently finding and adapting the right Ensuring adequate population adoption of COVID-19 vaccination will entail addressing increasing vaccine hesitancy among a pandemic-weary public. Fortunately, the use of evidencebased strategies to increase vaccination uptake provides healthcare systems with a roadmap to navigate vaccine hesitancy. Implementation of evidence-based strategies at the organizational, interpersonal, and individual levels in clinical organizations to increase uptake of COVID-19 vaccination is the crucial last leg of the arduous race to end the COVID-19 pandemic. Use presumptive-style language. After this visit, the nurse will give you your COVID-19 vaccine. Frame messages in terms of gain Getting the COVID-19 vaccine will protect you and your family. Offer novel information about the disease We are learning that COVID-19 infections can result in longer-lasting and debilitating health problems such as fatigue, headaches, joint pain, and sleep difficulty. Getting the COVID-19 vaccine not only protects you it will protect the people you care about including your family and friends. Address patient barriers and use effective approaches to countering misperceptions. 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