Communicating with patients about vaccination: What works to increase uptake?

If time permits, we will give you the opportunity to speak, so our speaker today is Dr. Kimberly Fisher, associate professor of medicine in the division of pulmonary and critical medicine and the division of health system sciences at the UMass Chan School of Medicine. She graduated from the University of Pennsylvania School of Medicine and completed her residency in Internal Medicine at the Hospital of the University of Pennsylvania, as well as a fellowship in pulmonary and critical care at the University of Pennsylvania School of Medicine. from Boston. She also has a master's degree in clinical research from the University of Massachusetts Chan Graduate School. biomedical sciences and Dr.

Fisher's research centers to improve communication between providers and

patients

and includes NIH-funded research focused on increasing covid-19 vaccine

uptake

in

patients

with formal training and implementation of biomedical sciences Through the training institute and the dissemination and implementation health research program Dr. Fisher has experience with a variety of research methods and I am looking forward to hearing his discussion today about the best way to communicate with patients about the

vaccination

and with that, please join me in welcoming Dr. Fisher Dr. Fisher, the floor is yours, thank you very much. Janet and ETS, for giving us this opportunity.

I'm so happy to be here with everyone today and I'm particularly excited about the growing interest in promoting vaccine

uptake

in the ATS and I'm excited to be a part of those efforts, like Janet. I said I'm going to talk about

what

works

to

increase

vaccine acceptance through patient-provider communication. I think I can make my slides work. So this just shows my funding sources and is of particular relevance to the ATS. I feel I should mention. that I don't have any tobacco industry or other industry sponsored funding and this is an overview of

what

I'm going to cover today.

I'm going to say oh, sorry, so I'll start by introducing the incremental

vaccination

model which is a really useful way to think about vaccine acceptance. I will focus on reviewing the impact evidence supporting the impact of a healthcare provider's recommendation on vaccine acceptance. I'm going to talk a little bit about what constitutes an effective way. recommendation and I will answer the question. I'll give you a preview that there is no one size fits all, so then I'll spend some time talking about how vaccine hesitant people prefer to be contacted and then I'd like to save. A little time at the end to talk a little bit about some important levers for scaling up vaccination.

Beyond communication. I would like to start by reminding everyone of this very important distinction between vaccines and vaccinations that I believe was first made by Dr. Walt Orenstein when he said that vaccines don't save lives, vaccines do, there really hasn't been a clearer example of This distinction between vaccines and vaccinations than the covid-19 pandemic, so, on the one hand, we have the unprecedented scientific and technological achievement of having effective vaccines. less than a year into a pandemic with a new infection, and yet on the other hand, in this study we conducted in April 2020, we found that almost half of the US adult population was unsure or did not have the intention to get vaccinated when a vaccine against covid appeared.

The -19 vaccine became available, illustrating a large amount of work to incorporate the necessary vaccines into vaccinations. I think the incremental vaccination model is a really useful way to think about how to move from one vaccine to another. This was first proposed by Noel Brewer. In 2017, the World Health Organization adopted and adapted it and the version I'm showing you here is a slightly adapted form. It lays out three main categories of activities or levers that influence whether someone will get vaccinated, so the first is what people think and feel and this really focuses on the balance between disease risk assessment, so how much does someone believe who are at risk for a particular vaccine-preventable disease, balanced with their confidence in the safety and effectiveness of vaccines, also points to the importance of various social factors. processes that include a provider recommendation to promote vaccine uptake and then, more importantly, include this last category called practical strategies; in the previous version it was called direct behavior change and so it's really a recognition that there are all these levers that we have.

They can

increase

vaccine acceptance and, more importantly, they don't necessarily require changing what people think and feel, so you can sometimes get people vaccinated even if they haven't changed their ways. Thinking about the vaccine, as I said before in most of my now the conversation will really focus on the role of a provider recommendation within this model. It is well established that healthcare providers have an important role to play in promoting vaccination, which is why multiple studies have found across demographic groups that healthcare providers are consistently cited as the most trusted source of information. about vaccines.

In these two large nationally representative surveys, one looking at flu vaccine acceptance and the other looking at Covid-19 vaccine acceptance, it can be seen that respondents who reported receiving a recommendation for a supplier are shown in red. Vaccination bars were more likely to have been vaccinated against Covid or flu. Not only is it important to recommend vaccination, it turns out that what you say also matters a lot, so this is a fundamental document that is now 10 years old, although it is in the Pediatric Literature, so others may not be familiar with it in this article. Doug Opal, a pediatrician at the University of Washington, videotaped conversations between parents of children ages 1 to 19 months who were being seen for medical supervision visits, so these are visits in which vaccination is routinely recommended. routinely, described and coded the provider's initiation of a vaccine recommendation, so how did they first raise the possibility of vaccinating their children and described two distinct patterns of how providers initiated these recommendations? a presumptive recommendation, so this is a recommendation that linguistically presupposes that parents would vaccinate, so they simply say, well, we have to vaccinate today and this is the approach used in most Encounters, this is contrasted with what he called a participatory recommendation and that's when the provider starts asking more questions about what they want to do with vaccines today and in this study they found really surprising differences in the frequency of parental resistance to vaccination depending on the type of recommendation they the provider did among Parents who received a presumptive recommendation only about a quarter of them were vaccinated compared to those who received a participatory recommendation where the vast majority of them resisted.

You may astutely wonder if these differences are just because this is an observational study. and providers are more likely to make a participatory recommendation if they perceive vaccine hesitancy among parents. um, you would be right, as important as it is, the research team assessed the degree of vaccine hesitancy prior to these visits, they did not share that information with providers, so they were able to monitor the degree of parental hesitancy. about the vaccine and found exactly the same pattern even when they restricted the analysis to just parents who were vaccine hesitant, and then you can see in their adjusted odds ratio, which takes into account parents' vaccine hesitancy, that a Participatory recommendation was associated with a 17.5 increase in the odds of parental resistance.

So I think this is a really surprising finding about the importance of how we recommend vaccination to patients. This work has since been expanded to the influenza vaccine as well as the HPV vaccine and there are only two things I want to point out here, the first is to say that, similar to the previous study that I just mentioned to you, both These studies are still observational studies, so the question of causality is still an open question. I'll tell you more about this on the next slide. The other thing I want to point out really relates to terminology, so from here on out the literature on this topic gets a little inconsistent in terms of terminology, so I just wanted to provide sort of a key or definition for everyone, the People use these terms interchangeably, so a presumptive style recommendation is the same thing that other people call an indicated style or an ad style recommendation, and all of these are contrasted with a participatory or elective recommendation. or conversational style approach and that will be important in the upcoming study that will tell you which uses the ad style versus conversational style terminology to address the question of causality.

Noel Brewer and his group did a cluster randomized trial where they randomly assigned pediatric clinics to be trained to make an announcement style recommendation or training and make a conversation style recommendation and you can see that the main difference in this is which with the advertisement style as the presumptive recommendation simply says that they should receive these vaccines. give them now and if there is no resistance, they just go ahead and vaccinate and just engage in deeper conversation with parents who raise objections or concerns, while providers trained in the conversational style approach were trained to present the topic with a finding of conversation. about parents' concerns and after addressing them recommend vaccination and you can see here that both at three months after this training and at six months after this training, HPV vaccine uptake increased significantly more among patients seen in the clinics here in the dark red. bar where providers are trained in the announcement style approach compared to the conversation style approach or the control group, so I think this study really answers the question of whether it's the chicken or the egg with a presumptive recommendation or an advertisement-style recommendation and indicates that these actually increase vaccination acceptance, and not the other way around, so in the context of the Kova 19 pandemic, with, as everyone knows, an unprecedented degree of politicization and misinformation around covid-19 vaccines, in my group we were curious if the presumptive recommendation approach would be effective against kova 19 vaccine hesitancy, so to test this we conducted an experimental online survey based on vignettes using a participation panel called prolific.

We oversampled Black and Latinx members because our previous work had indicated that they were more likely to have vaccine hesitancy and we were hoping to enrich for vaccine hesitancy, um and then I also want to note that we conducted this study in January 2021, so you may remember that at this point in the pandemic vaccines were available, but they were not yet widely available to the general public. population, so at this point we were still assessing vaccine intention rather than actual acceptance, we classified participants as vaccine hesitant from the start if they answered this question do you intend to get vaccinated against Covid-19 saying no or not sure?

This shows that among the approximately 1,700 respondents in this survey, approximately 40 percent of them were classified as vaccine reluctant and people in this group were randomly assigned to receive one of five different messages from a healthcare provider, so this is where the experiment begins. vignette part of the survey comes in um we asked participants to imagine that they were seeing their doctor for a regular checkup and at the end of the appointment the doctor tells them that they have the covid-19 vaccine available and that the patient is eligible to receive it. It is very safe and very effective.

Everyone was exposed to this message and then we exposed them to one of these five varied messages that I'll talk about on the next slide. After exposure to these messages, we reassessed vaccination intention with the question. you get vaccinated on this visit, so we designed a series of form messages that were designed to address the most common concerns we heard in our previous work with vaccine-hesitant people and we also tried to work in some persuasive messaging techniques like, for example, millions. of people have already received it, use this concept of social proof that can helpto persuade people to do things.

All of these four messages were combined with an indicated style recommendation and then our fifth message was an elective style recommendation where the doctor simply said you know, after saying the vaccine is available, you are eligible to receive it, it is safe and effective , then they simply said what do you think, so this shows that after a brief simulated recommendation from a doctor, many participants became less indecisive and what I want. What's worth noting is that, as expected, the impact of a doctor's recommendation was much greater among the group that was least hesitant at first, so those who said they were unsure were asked if would get vaccinated compared to those who were more hesitant. those who said no, I do not intend to get vaccinated, the impact of a doctor's recommendation was less when looking in more detail at all the messages and I am going to start with the group that was initially not sure that they had discovered that there was no There was no significant difference between any of those four different messages that we designed so carefully or that basically didn't matter, they all had the same impact on the intention to get vaccinated.

The only one that was different was the elective style. Which do you think the message was significantly less? It is likely to reduce vaccine hesitancy than the style messages indicated. We found a slightly different pattern among the group that was more hesitant, so again these are the ones who answered our first question about vaccine hesitancy, saying no, they don't intend to get vaccinated and in this group we found that they did. which I call a prosocial message, so this is the message, it is the best way to protect the people close to you. which was most effective among the most undecided respondents, so I think these findings together indicate a need for tailored communication depending on the degree of indecision, as we saw very different patterns between those who were unsure and those who originally said no. and I think it suggests that there may be a role for prosocial messages among more hesitant people.

There were two other groups around the same time that did very similar studies but with a different set of messages, but they both also included a prosocial message and they both also found that that seemed to be the most effective message for increasing vaccine acceptance, so Just to summarize what I've said so far about what we know about healthcare provider recommendations, it is very clear that a healthcare provider recommendation is associated with increased vaccine acceptance and this has been demonstrated in vaccines against HPV influenza and covid-19. A presumptive or indicated style recommendation is more effective in increasing vaccine acceptance than a participatory recommendation and a message that emphasizes protecting others. or a prosocial message may be particularly effective among more vaccine-hesitant people, so changing gears a bit, I showed you this data earlier that illustrates the impact of a provider recommendation on vaccine acceptance so you can see that Respondents who received a recommendation from a provider were more likely to get a flu shot compared to those who did not receive a recommendation from a provider, but what I would like to focus on now is what I call the half-empty part of the glass, so what about the 50 of the population that got a recommendation from a provider and have not yet gotten the flu vaccine, this percentage is lower for covid-19, although I suspect that as things progress and we start to have taking into account the covid-19 boost, it will actually become an even bigger problem for covid-19 I know that sometimes presenters pose a question like this to Tee It Up and they are about to give you the answer to this question, like this I should warn you that I'm actually asking this question because I don't think there is a definitive answer. on how to communicate with patients who are hesitant despite a presumed vaccination recommendation.

So what I'm going to do is share some qualitative data that we collected through focus groups with patients who were hesitant about the kova 19 vaccine and a parallel set of focus groups with pcps. and I think this provides some insights into what might be an effective approach with this group, so as part of an ongoing project to promote Covid-19 vaccination by leveraging the role of PCPs, we are conducting focus groups with patients who were not vaccinated against covid-19. between August and October 2021. And we heard from them a number of topics that I think fit into two broad categories.

The first is, I think, some topics that can give us all a better understanding of what some of these unvaccinated patients are doing. they are bringing with them to the encounter in terms of their previous experiences and beliefs. So the first theme we heard from all of these participants is that they are very distrustful of the information related to the Covid-19 vaccine, which is why one participant said, “I think “They are using us like rats in a laboratory, someone else said I'm African American, it's hard for us to trust anything and someone else, having watched a video of real doctors talking about the Covid-19 vaccine, concluded that they weren't real doctors, they were actors, they were acting and they were just saying what they were told to say, many of them are struggling to navigate conflicting information and this, of course, is a product of all the misinformation that we have today, so here is a participant who says: "This is just the What I heard I'm not a doctor I don't know these are just things I've heard but how do I hear this but not hear that?

What do you understand? Some of them described feeling stigmatized for not being vaccinated. This participant said there's a lot of shame, it's all over social media, people really hate people who aren't vaccinated and someone else had experienced that through their friends and family and she said it's kind of an attitude of " I'm better than you". From people who have now received their vaccine, the other broad category of topics we heard from these participants was some ideas about how they want healthcare providers to communicate with them, so they want information that is detailed and that they perceive as unbiased, so this One participant said: "All you hear is that it's good, it will keep you safe, but what about the short and long term effects?" and many of them felt that they actually took the reports of minimal side effects as evidence of bias or lack. of transparency and that's why they said not to overpromise the lack of side effects.

Many of them indicated that they would be more receptive to information if they felt like they weren't being forced or pressured, so this person says Well, what would they listen to if we said it's not the Holy Grail, but if you're being force-fed something, a lot of people will be resistant and this is an important concept in vaccine hesitancy, among some patients who are hesitating about vaccines, the more we push the more they reject this issue of reagents or resistance um and here's someone else who says yes someone is applying a lot of pressure, you stop and say why do they want to make me do this and are wary, but if someone If they paused and said "do it if you want" then they might say yes, give it to me and lastly they really want to feel heard and understood, so this person said, you know he wants us to really address those concerns with real compassion and empathy. and someone else said don't write people off, those questions are valid, so now I want to move on to what we heard from the PCPS and the point of this slide is simply to illustrate that the PCPS described a number of different strategies that they use to communicate with their unvaccinated patients and the most important thing here is that the real strategy or what is more important than the real strategies is simply to show that their strategies fit very much into the growing vaccination models in which they try to influence what the Patients think and feel and try to take advantage of their social and relational processes to promote vaccination.

We also heard PCPs talk about a number of challenges they have encountered when

communicating

with unvaccinated patients and in case this description of challenges seems to undermine some of my previous comments about the importance of good health care. provider recommendation I just want to point out that these challenges I'm about to describe really relate to the subset of patients who are most reluctant to get vaccinated, so they don't apply broadly to all patients, but what the PCPs described is that their most hesitant patients are not open to information so they present information to their patients and then their patient says most of the time they still don't change their mind and here is another PCP who described presenting the evidence we have and then the patient still says he actually It doesn't matter that the evidence means nothing to me, this led many PCPs to wonder if they really are the most trusted Messengers among the most vaccine-hesitant patients, as one PCP described.

I've had so many people tell me you don't know what. you're talking about and someone else said it's particularly frustrating because for over 30 years I've been able to tap into that trust and I find that it

works

less for this than anything else as a result of these challenges that many PCPs adopted a strategy of truncating their communication with their most vaccine-hesitant patients, so if they perceived someone to be potentially convincing, they would try to talk to them as much as they could every time they saw them, except with those they perceived as not open. to the information, they would actually make a recommendation and then not continue the conversation and they did it because they didn't want to waste their time, so this one says: I'm not going to waste my time lecturing people who have no interest, it's a waste. of my time and it's a waste for them and they also did it because they didn't want to interrupt their relationship with the patient, so this person says: you know if you keep pushing you will lose the person and you want them to come.

Come back so you can help them in some other way and then the universal theme among all PCPs is that everyone is really frustrated with these conversations and they don't really know what to say to these patients, so they describe, um, it's frustrating and quite challenging because it adds time and that's frustrating and stressful and this one says it's frustrating because you're talking to the same people and you're wondering what else. I don't know what else I could say about some of my patients. Thinking about how to bridge this gap between what we're hearing from patients and what we're hearing from providers, I just wanted to present a communication approach that hasn't been well established particularly for adult vaccination, but that has a lot of promise for those of those.

For those unfamiliar with motivational interviewing, this is a communication approach that is based on the principles of patient-centeredness, empathetic communication, and respect for autonomy. It has been used most widely in substance use disorder counseling, although it has also begun to be considered to promote vaccination and A known feature of this approach is that it can reduce resistance which, as I described above, is a known feature of vaccine hesitancy, so there have been two studies so far that have begun to explore whether motivational interviewing has a role in promoting vaccination acceptance. one was a postpartum intervention and the other was to promote HPV vaccine uptake.

Both interventions showed a significant increase in vaccine uptake, but both had limitations, so the first is a quasi-experimental design, was not randomized, and the intervention was an educational session administered by a trained research assistant in a maternity ward. , so it leaves questions about how to bring this to the primary care setting and how you might scale it. The second study was a multi-component intervention and that's really the main one. The weakness of this is that the intervention included a number of components including communication training in motivational interviewing, so it is unknown what the active ingredient is in that intervention, but I will say that the intervention providers cited that the communication training is one of the most used and in your mind it is the most useful component, so I think both studies suggest a potential role for motivational interviewing in promoting vaccine acceptance, but there are a number of unanswered questions, including whether this approach would be effective for adult vaccination.

All of these previous studies have been performed in pediatrics. This is a different approach to a supposed recommendation that everyone could make starting tomorrow. Motivational interviewing is actually an approach that requires some formal training and then raises some questions about how to get healthcare providers tofor adults do it. I think promoting vaccination is a much more entrenched part of pediatric medicine than adult medicine, so there may be more interest in training in this in the pediatric world and, in case people are wondering how They combine presumptive recommendations with motivational interviewing, because in reality they are almost opposite approaches. one just assumes you're going to do it, let's go ahead and do it and the other is actually much kinder, let me find out more about what the patient's thinking focus is.

I agree that they really are opposites. And I think what's probably needed is to make a presumptive recommendation to all patients and then when they've expressed doubt or resistance is encountered at that point, you need to pivot to a different strategy. What is that strategy? I think it's still not clear. but I think motivational interviewing and perhaps prosocial messaging are promising potential strategies, so until now I've focused primarily on provider-patient communication, which really fits into the first two boxes of the growing vaccination model, but now I'm thinking. I would like to spend some time talking about practical strategies and how providers promote vaccination also extends to the Practical Strategies box.

This shows the results of a survey we conducted in 2021 in which we asked participants where they would prefer to get vaccinated. and what I show you here is the percentage that indicated that they would prefer to get vaccinated in a doctor's office and you can see that among the participants who were not sure if they would get vaccinated, a majority preferred to get vaccinated against covid-19 in a doctor's office, also We found that for all levels of vaccine intention, whether their intention was yes, no, or no, Black participants were significantly more likely to prefer to be vaccinated in a doctor's office than white or Latino participants, which which led us to conclude that vaccine availability in doctors' offices may be important in increasing vaccine acceptance among vaccine-hesitant individuals and members of racial minorities.

From our PCP focus group. We found from the data that PCPs actually corroborated this finding, so we had some PCPs participate. who work in clinics where they had the covid-19 vaccine on site and others where they did not and those who had the kova 19 vaccine available in their clinics described vaccineavailability in the clinic as a game changer, so this PCP He said that since we were able to offer the vaccine at our clinic, I have gotten many more people to agree and this is a quote from a PCP who works at a clinic where the Copa 19 vaccine is not available on site and they said they felt that If it was available they could take some of their most difficult patients because they found that it is available right now, but as soon as a step is taken you have to describe it.

When scheduling an appointment at CVS, the PCP acknowledged that they are starting to lose them and they can already see the deer in the headlights and have lost the opportunity to get them vaccinated. The importance of vaccine availability in the clinic has also been confirmed in the national flu survey that I showed you earlier, so earlier I showed you these first two bars that indicate that a provider recommendation is associated with greater acceptance of the flu vaccine, but what I didn't show you is even better than that is a provider. recommendation plus an offer to get vaccinated right there on site so you can see that a significantly higher percentage of patients who received a recommendation plus an offer got the flu vaccine compared to those who only received a recommendation and since we're on the topic of practical strategies to increase vaccination I also want to share some very preliminary results from a study we have been working on in which we interviewed what we describe as recently vaccinated people, so they are people who have received their first dose of covid-19. vaccine since April 2022. and we interviewed them to find out what was the main reason for getting vaccinated so far in the availability of the vaccine and we categorized these main reasons according to the increasing vaccination model.

These circles are drawn to scale according to frequency. of each main reason so you can see that some people reported reasons for getting vaccinated that are consistent with the category of what people think and feel, so maybe they know someone who was really sick with covid and that increased their evaluation of risk of disease and decided to get vaccinated. They got vaccinated or maybe they saw a lot of people get vaccinated and they seemed fine, so they became more convinced that the vaccine was safe. A smaller percentage of people reported that reasons consistent with social processes influenced their decision to get vaccinated at this time of the year. the coveted pandemic, but by far the most common primary reason for getting vaccinated among people who have been vaccinated more recently was that the vaccine was needed for something they wanted to do and that was almost exclusively for a new job or travel. things like I wanted to go on a cruise and that's why I got vaccinated, so I think this really illustrates the importance of practical strategies, particularly for vaccinating some of the more reluctant people.

There has been a lot of literature about a possible downside of vaccine requirements and I will say that out of the 51 participants there was only one who was required to get vaccinated and he was really angry about it, everyone else seemed pretty indifferent to the fact that they were required get vaccinated. I don't want to do it incorrectly. suggest that there is no role for what people think and feel or social processes in promoting vaccination, so in addition to asking about the main reason people had for getting vaccinated, we also explored secondary reasons and therefore Therefore, you can see here that, although they were infrequently cited as the main reason why social processes, including the recommendation of a health care provider, and what people think and feel, played an important secondary or supporting role. support, so I think in many cases these laid the groundwork for people to accept the practical requirement to get vaccinated, although they were not the main reason, so how do we put this all together?

I hope I have shown that a supplier recommendation is extremely influential and that exactly what you say when making a recommendation is really important. I think the supplier's recommendation, um. or I think this model is a little more complicated than all these arrows show because I think a provider recommendation probably influences what people think and feel and I think the power of a healthcare provider recommendation really can be magnified if combined with practical strategies, particularly on-site vaccination availability, so I'm looking forward to what we can expect in the future and I'll just give two disclaimers: I don't have a crystal ball and at one point I thought the Internet It was a bad idea, so I may not be the best person to make predictions, but I think we should expect that we will have more and hopefully better vaccines continuing to be developed at the same time.

I think, particularly with generative AI, we can expect misinformation and disinformation perhaps on an even larger scale than we've seen so far and I think this will make the role of a healthcare provider and promoting adoption of vaccines are simultaneously more difficult, but also increasingly important and, from a practical point of view, I think that with the coming end of the public health emergency, in particular the vaccines against covid-19, probably will not be so easily accessible and free, especially for vulnerable populations who are uninsured, and there will likely be fewer vaccine requirements for adults, I think many places are imposing vaccine requirements because of the pandemic, but when that is perceived to have finished, I'm not sure they will continue.

Although this may sound a bit negative, what I really want to highlight is the need to continue working on this. area to fully leverage the role of healthcare providers and systems in promoting vaccination and that's it, so thank you all for your attention. I want to acknowledge all the members of my research team at UMass who contributed to this work, um and me. I think we're at the question and answer part, yes Kimberly, thank you very much, we have two questions in the chat and I start with Rosemary, she asks well, she is a little worried that the initial presumptive approach may increase the hesitation of the I have many vaccine hesitancy, so do you have any recommendations and how to determine when to use the presumptive one?

Well, those couldn't work. The relational approach sounds like asking what someone thinks as a starting point, but it's actually counterproductive, yes, and I think, Rosemary, you're kind. I think the evidence from the pediatric literature, particularly the cluster randomized controlled trial of the announcement versus conversation style approach, really suggests starting. with a presumptive approach, I will say that in the experimental vignette-based survey that I described, where we exposed people to different messages, we did not find that the presumptive approach increased hesitancy or was counterproductive, so I think a simple recommendation. I recommend this vaccine, this vaccine is indicated.

I recommend that you get it, it's unlikely to increase hesitancy among those who are hesitant about the vaccine, but if you make that recommendation and then encounter resistance, I think that's when you need to pivot to a different approach. Actually, I think one of the most challenging things about the presumptive approach is that it's harder to do than you think because if I personally use some of these verbals, I'll call it a verbal tic, like saying what you think is some kind of way. of trying to show the patient that you are engaging them and that you are interested in what they think, but what we don't realize is that it has this unintended consequence or that patients interpret what we are saying as a way of building the relationship , they interpret that yeah, I don't really need this vaccine or that it's optional, it's not strongly recommended, so I think removing what you think from the initial recommendation is difficult but important, um, and I don't.

I think it increases hesitancy, it just won't be effective for someone who is really hesitant about vaccines, but I also think we don't always know, we think we know who those people are, we're often right, but not always, so the next question is He and Harold are a little surprised by the low acceptance rate of the poet's most recent vaccine. What is it? Lack of recommendation. Social reasons. Side effects. I would add what is the role of social media and if we should do something to use it. more to increase vaccine adherence, yeah, so I think there's definitely a role for social media, although I'm probably the wrong person to talk about that as someone who's not very active on social media, there's definitely data that show that among people who are open to receiving an updated Covid-19 booster, at least 50 percent of them have not received a recommendation from a provider, so I think, going back to what we know, it works, making a Presumptive recommendation to everyone at every visit is a tool that clearly has not been fully utilized to increase the absorption of Covid-19 boosters.

We've also done a survey where we're still analyzing the data, but it seems like there are a couple different patterns that people fall into that, so there are some people who, even though they received the initial series of vaccines, take the fact that they They need boosters as evidence that it doesn't work and they say things like, well, if we have to keep getting them every year, what's wrong? The point is, people are still getting Covid, so why bother getting the booster? I think that's part of it. Some people are just not aware of the recommendation for an updated booster shot, so I guess that would go along with a lack of awareness and I think there's a lot of inertia, there's a lot of people who just said, "I haven't had time." "I'm not there yet" and I think for those people that's where practical strategies and making it as easy as possible are really important.

Do you think a normal person's knowledge about vaccination is not good enough? Do we need to include that information in the school curriculum or earlier in life? Because what I heard here in Europe is that people are very uninformed about what vaccination is. can do, they don't know much about the disease, but also just a few things about preventive measures. I think increasing knowledge is always useful. We definitely found that knowledge is associated with vaccine acceptance. But I also think that sometimes we work under It's kind of an information deficit model, so if we just told them theinformation they need to know, then of course they would want to get vaccinated.

I suspect that many doctors here who have had these conversations with their patients know that many times, even after giving them all. information that doesn't really overcome your doubts, but I'm interested in the idea of ​​starting this education earlier and, a strategy I didn't talk about at all, is a very promising approach to addressing the problem of misinformation, which is certainly A A big contributor to the problem of vaccine hesitancy is this idea called pre-bunking, which is that once misinformation takes hold, it's incredibly difficult to dislodge it and change someone's mind even with information, but if you and I think What you're suggesting, Tobias, is also not to give people information about vaccination up front before they are exposed to misinformation that could be helpful and a more universal approach is to teach people how to recognize that misinformation is effective for make them more resistant to misinformation, so it's like a more generic approach that you could if you started early and I think there are some European countries, like Finland or Denmark, or recently in the news for doing a good job with this, They've incorporated it into their elementary school curriculum, where they teach kids at a young age, how to recognize misinformation and I think that really promotes resilience against well-being.

The Scandinavian countries announce it in the media, as does France. This is not the case in Germany. Do you think that type of publicly sponsored advertising is something that could be beneficial? in the US or is it something that will raise concerns. Don't know. I think, unfortunately, our media ecosystem is very fragmented and it's an echo chamber and I also think once you know that again, I think once this hits the misinformation. has been planted, we run into all these problems with similar confirmation bias and we get someone to change their mind, no matter what you tell them, they just continue to see evidence that supports what their original belief is, so I guess I don't want to I would say that there is no role for information or awareness, but I think it is less effective and harder to change people's minds if they have already been misinformed and I think the practical strategy will probably be much more value for money, for What Time's up, so I'll end with a comment from Peter here in the chat, so he said thank you Kimberly for a very clear, logical and useful presentation.

Many audiences could benefit from this presentation and I think that's what I think and I'm sure Senate. She agrees with me, so thank you very much for doing this and for highlighting the need to decide how to confront the patient and with the necessary strategy to use. Yes, convince patience what is the best strategy for the patient. future, so thank you Rosie also said she agreed, it was a great talk, it's my pleasure to thank you very much. I have to thank Janet as always and also others who organized it from the ATS side and I hope we meet from time to time and can share our experience.

Thank you Kimberly and best wishes to your son and all the best for the rest of the day. Thank you so much. I really appreciate the opportunity to share this so thank you all who helped make this happen yeah and thank you yeah buddy so maybe at the end Shannon and I will announce that we're going to continue the vaccine series here on the ATS website. I believe one of the next sessions will be a talk by Charles Feldman from South Africa, who will address the need for global strategies for vaccination. I think it is a very important topic because what we learned in hobit 19 is that it is good when there is a good vaccination rate in some countries in the world, but it is a global problem and it needs a global solution and these global health issues make it possible for low income countries be part of the program it's important so thank you all have a good day to me it's already late so I'm going out to dinner now and see you soon bye