Primary Care Docs Battle Vaccine Hesitancy

During a recent office visit with one of her medically high-risk patients, Yalda Jabbarpour, MD, revisited a routine topic: Do you have any questions I could answer for you about the COVID-19 vaccine?

The answer, she said, was an unequivocal, “Nope.”

When Jabbarpour, medical director for the Robert Graham Center and a practicing family physician at MedStar Health in Washington, D.C., tried motivational interviewing to probe further, her long-term patient shocked her with an ultimatum.

“If we can’t come to terms with the fact that I’m not getting it, and I don’t want you to talk to me about it, then I think I need to get care elsewhere,” the patient said.

“Vaccination is so foundational to what we do in primary care. We are where people get their vaccines,” said James Bigham, MD, MPH, a family medicine physician at the University of Wisconsin School of Medicine and Public Health in Madison. But increasingly, he said, this public health domain of primary care can draw a provider into the culture wars. As Bigham said he explained to his dentist recently, “Imagine if when you told your patients to floss, you were making a political statement.”

Primary care physicians and pediatricians are the most trusted source for reliable COVID-19 vaccine information. But with the recent Delta variant surge and worsening shortages of outpatient therapies such as monoclonal antibodies, many are finding their long-game approach to vaccine counseling fraught with an urgency that risks disrupting the most trusted healthcare relationship.

“It’s so hard to continue to have this conversation when it’s urgent,” said Jabbarpour. “Primary care is essential, but there really should have been a partnership between primary care and public health.” Few providers, she noted, have the time for outreach to large populations while also seeing patients in 15-minute increments.

Matthew Hornsey, PhD, a social psychologist at the University of Queensland Business School in Australia, has studied how the psychology of mistrust and threat can lead people to reject reasonable messages, even from trusted sources.

Explication, or sharing information, is the best teaching method for those who have little foreknowledge of treatments, Hornsey said. But in the setting of vaccine debates, where the well had already been tainted with misinformation long before COVID, explication only backfires. “The standard method of just repeating data, of repeating evidence and mashing facts in peoples’ faces, can actually seem quite superior and confrontational,” he said.

Trying to understand the underlying driver of resistance and just listening might be all a provider can do. Hornsey said that if there is little time for that, he recommends keeping the message simple: “It’s safer to take the vaccine than to not take the vaccine.”

While the early COVID-19 campaigns at mass vaccination sites, hospitals, and pharmacies reached those who implicitly trusted the vaccine, once the availability expanded into primary care clinics, providers faced a largely vaccine-hesitant population.

“I think the hard thing about this vaccine is that it’s become so politicized,” said Jabbarpour. She, like most primary care providers, sees mostly female patients. And women, as the main healthcare decision makers for their families, are under enormous pressure to get things right, all the while managing confusing and conflicting information.

“There’s no straight, clear messaging. We might think there is, but we’re not getting the same messaging that they’re getting,” said Jabbarpour.

Even among the vaccine hesitant, the demographics vary. Hornsey has found features of both the far left and the far right, the highly and the poorly educated, the science-avoidant and the science-curious. They are united, however, in “their suspicion of the system and elites.”

“Because COVID involved a massive government response, it was susceptible to this conspiracist worldview,” he said.

When there are countless potential risks, people tend to pick what they worry about, said Hornsey. “And what we choose to worry about are the things that align with our ideologies, communities, and sensibilities. That’s why people can be so patchy about what they’re anxious about and what information they choose to mistrust,” he said. “The day there are people coaching communities to be suspicious of cardiac medicine, for example, you may find they’ll resist your advice on that too.”

At the end of an office visit with one of his medically high-risk patients, Bigham brought up the COVID-19 vaccine — the most life-saving intervention he believes primary care clinicians can offer right now. “We’d just had a discussion about all other sorts of therapies that they had no reservations about … blood pressure medication, anti-coagulation for their atrial fibrillation. The second I talked about this thing that I perceived as a really easy discussion-point: free, safe, effective, and actually life-saving treatment … [they] said no.”

He was surprised by the sudden deadlock as the patient cited misinformation about the vaccine coupled with deeply held beliefs about the importance of not vaccinating.

The Delta surge has exposed the vulnerability of large swaths of the nation, where a full one-third of the eligible population are not fully vaccinated. The question now in primary care clinics is what can be done to improve vaccination rates for adults and children alike.

According to Jabbarpour, thinking ahead to setting up electronic health records for faster population health management and establishing primary care partnerships with schools would be a good first step.

“There’s not necessarily going to be an end to pandemics, and so — note to self — we need to really work on our infrastructure here,” she said. “We really need to work on strengthening teams in the clinic, we need to work on the primary care-public health interface and invest more in both of those systems, because we know it depends on public health and primary care to get the population vaccinated.”

In addition, said Hornsey, in a world where the institutional memory of pandemics has been lost, only the perception of vaccine risk remains. With adverse effects making headlines daily, even in mainstream outlets, it’s hard to promote a message of safety.

David M. Oshinsky, PhD, a Pulitzer Prize-winning author and professor of medicine at NYU Grossman School of Medicine in New York City, noted the sense of euphoria with the polio vaccine, dubbed at the time as “the peoples’ vaccine.”

During the Salk vaccine trials of 1954, the largest public health experiment in American history, more than a million parents lined up their children for the vaccine campaign that was framed as a “privilege bestowed.” Vaccine recipients were called “polio pioneers” and consent forms stated: “I hereby request…”

“There was not only very little resistance to the polio vaccine in the public, it was just the opposite,” said Oshinsky. “Parents were pushing their kids into lines so they could be the first to get this vaccine even though it was experimental.”

Bigham said that while in his office, he typically peppers his conversation about the COVID-19 vaccine with the words “safe, healthy, and effective” and spends time “forecasting” with patients about the likely FDA approval of boosters for the general public, or the impending emergency use authorization for kids under 12.

He understands, though, he said, that decisions take time. “The most important therapeutic asset we have is the trust we build with our patients, and when it comes down to helping folks with barriers with any treatment, but especially with vaccine hesitancy, in many ways it comes down to — can people trust the treatment?”

And while there is much contested real estate in primary care as other voices crowd out the advice that was once the sole provenance of the physician, one uncontested domain for Bigham is compassion.

“I tell patients that I am encouraging you to get the COVID vaccine and that comes from the exact same place that I’m encouraging you to take your blood pressure medication,” he said. “Know it comes from caring about you and wanting you to live a healthy and fulfilling life … this is not a separate thing — but is part of what we do every day in primary care.”