After the COVID-19 vaccine became widely available, a group of University of New Mexico medical students and residents reached out to patients to assist them in getting vaccinated. It quickly became apparent that many were resistant to getting the new shots. Students, residents, nurses, and even experienced attendings found it challenging to talk to patients about COVID vaccines at times.

Some patients had questions or concerns about vaccine safety, effectiveness, or cost that were relatively easy to address. But others had deeply held, negative beliefs about the vaccines based on misunderstandings or misinformation. The latter group included people who felt that the COVID-19 pandemic was a hoax, the vaccines were likely to seriously harm them, or the vaccines did not have any significant benefits. Sometimes these individuals had very emotional negative reactions toward the vaccines, and those discussions were often unpleasant for the health care professionals, who felt they had failed when the patient refused to get vaccinated despite being given facts and information.

The official COVID-19 Public Health Emergency is set to expire in May, but as of February 2023, hundreds of Americans were still dying of COVID every day.¹ The Centers for Disease Control and Prevention (CDC) continues to recommend vaccination, but a recommendation from a trusted primary care physician can often have a greater effect on patients' decisions.² Still, some patients will be hesitant. Dispelling misinformation with data and facts is important, but changing beliefs also requires listening, exchanging information, and building trust.

Building on previous literature regarding other vaccines,^3,4 this article provides guidance to improve conversations with vaccine-hesitant patients, based on what we learned from our own efforts regarding COVID-19 vaccination.

TIP 1: MANAGE YOUR EXPECTATIONS

Vaccine hesitancy is sometimes rooted in strong emotions and beliefs that are difficult to change. This is especially true with the COVID-19 vaccines, which were developed at an unprecedented pace⁵ and have become fraught with political baggage.⁶

Vaccine-hesitancy is a spectrum. Some patients are eager to get the vaccine after a brief discussion, some are dug into a “never-want-to-get-the-shot” position, and many are somewhere in-between. Don't expect to change strongly held beliefs in a few minutes. Just bringing up the topic and allowing patients to share their thoughts can be an accomplishment and start them moving along the hesitancy spectrum.

TIP 2: DETERMINE WHERE YOUR PATIENT IS ON THE HESITANCY SPECTRUM

This can be done by talking about the vaccine in an open-ended, affirming manner, such as “I see you are due for your COVID vaccine/booster,” rather than “Do you want a COVID shot?” The patient's reaction will usually provide a clear indication of how hesitant they are.

In some cases, you may discover the patient is not actually vaccine-hesitant at all. For example, at our clinic, an elderly woman we had called because she hadn't received the vaccine was enthusiastic about it but did not have transportation to a vaccine center. We connected her with medical transportation services, and she got the shot.

In other cases, patient hesitancy may be strong. For example, one of our clinic's patients believed that COVID was not dangerous to him; therefore, he had little reason to get vaccinated. After we told him about a patient his age who died from COVID, he still did not immediately get the vaccine but said, “You gave me something to think about.”

By establishing where the patient is on the hesitancy spectrum, you can tailor your approach as you continue the conversation.

TIP 3: ASK PERMISSION TO DISCUSS THE VACCINE

“Ask-tell-ask” is a technique in which the clinician asks the patient a question and listens to the response, expands the conversation by telling the patient new or corrective information, and then asks what the patient thinks about the new information.³

To use this technique for COVID vaccination, begin by asking permission to talk about the vaccine, maybe by saying, “I understand you haven't had your COVID-19 shot. Can I share some information with you about it?”

If the patient is not willing to engage in a conversation at all, it's OK. At least you brought up the topic. Here's an example of how to handle this:

Clinician: “I see you declined your COVID vaccine today. Can we talk about this?”

Patient: “No.”

Clinician: “OK. I would recommend this vaccine, so if you change your mind, I am always willing to talk about it.”

Confronting strong beliefs can reinforce them. If you notice that your patient strongly disagrees with vaccination, it is OK, and probably even preferable, to end the conversation. You might say something like, “You are entitled to your opinion, but I am concerned that you may be at more risk than you think. Let's agree to disagree for now.”

TIP 4: OPEN WITH ONE POSITIVE

If the patient is willing to have a conversation, open with one positive message about the vaccine that is personalized for that patient. You may choose to focus on individual benefits, community benefits, or increased protection for family and loved ones.

For example, if a patient has asthma, you might say, “The COVID-19 vaccine helps prevent serious complications for patients with asthma, like you.”

TIP 5: ASK THE PATIENT TO LIST SPECIFIC CONCERNS

Determining the patient's concerns will help you tailor information to address them without adding additional concerns.

Imagine a physician is talking to a patient who is primarily concerned about missing work due to vaccine side effects. If the clinician does not ask about the patient's specific concerns but instead says, “Don't worry about the vaccine changing your genetics,” the patient may suddenly start worrying about genetic alteration, even if that's not something the patient considered before.

Understanding the patient's motivations and concerns and listening with empathy are key aspects of motivational interviewing. Resist the impulse to move straight to a recommendation about the vaccine based on the information you have, until you understand what information (or misinformation) is driving the patient's vaccine hesitancy.⁷

TIP 6: ACKNOWLEDGE CONCERNS AND SHARE INFORMATION

After you have elicited the patient's concerns about the vaccine, it is time to share information. You could say something like, “Thank you for sharing this with me. I can see why you would be worried about that. Although I understand your concern, my experience and research have led me to a different conclusion. Can I share what I know?”

Then listen to the patient's response carefully and observe non-verbal cues. If the patient is open to information about the shot, provide it, perhaps using trusted resources from the CDC or your state health department.⁸

The CDC's website “Myths and Facts About COVID-19 Vaccines” addresses a number of common misconceptions (e.g., mRNA technology is not a true vaccine, COVID-19 vaccines contain dangerous ingredients, and immunity from prior infection is better than immunity from vaccination).⁹

Some patients may express concerns that the vaccines are made from fetal cells.

The mRNA vaccines are not made with fetal cells, but stem cells may have been used for development or testing at some point. The Michigan Department of Health & Human Services provides in-depth information on this. (See “Useful websites for COVID-19 vaccine information.”)

Sometimes patients object to vaccination on religious grounds, based on fetal cell research or other reasons. It can be challenging to address these objections while respecting personal beliefs. But most major religions promote vaccination or at least allow it, and it may be useful to familiarize yourself with their positions.

Research has shown that storytelling paired with facts and data is often more effective than facts and data alone.¹⁰ If a patient says they don't need the COVID vaccine because they've already had COVID, you might say, “Another patient of mine refused the vaccine after having COVID because he thought he was immune after recovering. A year later, he was back in the clinic and tested positive.” You can then support this by sharing data on reinfection rates.

Certain analogies can also be useful. For instance, it's important to warn patients about routine vaccine side effects and explain that these differ from harmful adverse reactions. You might say, “When we get a vaccine, we sometimes feel sick with fever, body aches, headaches, and arm pain for a short time. This is because the body has noticed the vaccine and is getting ready to fight an invasion of virus. It is like a boxer who gets a little sore from training while preparing for a big fight.”

Acknowledge that there are rare but harmful adverse events, but add that the risk of these is outweighed by the risk of COVID-19 illness. (Serious adverse events are more common in certain age and gender groups with some specific COVID vaccines, so you may want to recommend patients in those groups receive one of the other vaccines. There are four approved for use in the U.S.)¹¹

Finally, people who have experienced bias, either as individuals or as part of a community, may be less likely to trust medical care or scientific research. Acknowledging this experience can help build relationships. Sometimes a clinician with a similar background or shared experience can help facilitate a discussion with these patients.

TIP 7: MAKE A RECOMMENDATION

If you've gotten this far in a conversation with a patient about the vaccine, it's time to make a recommendation.

First, finish the “ask-tell-ask” technique by asking, “What are your thoughts about getting a COVID shot now?” This will help you determine whether the patient has understood the information you provided and whether you have addressed all of their concerns. If so, move on to the recommendation.

A strong recommendation includes facts and personalization. A clinician might say, “We know that the COVID vaccines are safe, with only minor side effects for most people. With your asthma (or other condition or age), you are more likely to have serious complications if you get COVID-19, and I strongly recommend you take the vaccine.”

Even after all this discussion, your patient may still refuse the vaccine. If so, it's time to move to “harm reduction” mode. Warn the patient about the dangers of home remedies or medical misinformation found on social media, and emphasize the importance of taking other measures to reduce COVID risks when the transmission rate in the community is high. For example, you might say, “Whether or not you choose to get the vaccine, I strongly recommend social distancing and wearing a high-quality mask, especially in crowded indoor public spaces, because COVID is spreading a lot right now. If you do get COVID, please call the clinic before taking any home remedies or medications recommended on social media.”

You might also tell the patient about available Food and Drug Administration-approved COVID treatments, while stressing that these are not a substitute for vaccination.

TIP 8: LEAVE THE DOOR OPEN

Discussing the COVID-19 vaccine with vaccine-hesitant patients requires building a strong, trusting relationship. This takes time and often involves multiple patient encounters. If patients refuse the vaccine, make sure they know that this does not have to be the end of the discussion. To leave the door open, you might say something like, “We are here for you. If you have questions or want to talk more, let us know.”

Remember to celebrate small victories. Conversations with vaccine-hesitant patients do not always end with the patient getting the vaccine. Success is moving the patient along the vaccine hesitancy spectrum by addressing concerns and misconceptions and providing reliable information.

Success also entails maintaining a strong doctor-patient relationship by letting patients know that they are heard and that they are empowered to make their own health care decisions, with you acting as their advocate and guide. Ultimately, that relationship is what will make patients more likely to heed your advice, when it comes to the COVID vaccine or other health concerns.