You have probably heard it hundreds of times, “Vaccines save lives!”. It is true. Diseases that killed millions of Americans in the early 20th century dropped 90% in incidence between the 1930s and 2017 with the uptake of important vaccines.
We also know that vaccines are safe and effective, as they all go through rigorous pre- and post-market testing to ensure the public’s health and safety are of paramount importance. Even from an economic standpoint, vaccines are great. It is estimated that for every dollar spent on a childhood vaccination, the United States saves about $11.
While all of this information is encouraging, the United States, and even the world, tends to find itself in a juxtaposition with vaccine hesitancy circulating. Vaccines cannot counteract pandemics if people do not receive them. Right now, rebuilding trust in the science—in this case vaccines, is critical. Who better to address vaccine hesitancy and reestablish that confidence than the friendly, neighborhood pharmacist?
What is vaccine hesitancy? Essentially, it is a reluctance to vaccination despite access.
A more formal definition can be found on the World Health Organization’s webpage. It is a very complex subject, and it can be different depending on time, place, and even the specific vaccine.
However, it is important to know that three factors play into vaccine hesitancy: (1) Confidence: low trust in the system, manufacturers, safety, healthcare providers, etc. (2) Convenience: low access to or appeal in vaccines (cultural contexts, language gaps, etc. (3) Complacency: belief that there is a low risk in catching a vaccine preventable disease.
Knowing these factors, how can pharmacists or other healthcare providers address vaccine hesitancy? Maybe you guessed it—motivational interviewing!
Motivational interviewing is a concept that was introduced in the 1980s that focuses on a guiding communication style to “move the needle” on a patient’s decision making and strengthen their motivation to change. Motivational interviewing can also be used outside of a healthcare provider-to-patient conversation – anybody can use the technique.
The main principles of motivational interviewing are: expressing empathy, avoiding argument (the “righting reflex”), rolling with resistance, developing discrepancy, and supporting self-efficacy.
While the first three may be self-descriptive, let’s quickly address the last two. Developing discrepancy encompasses digging into someone’s motivation and goals and then noting a conflict with what they want and what they are doing. It is our job as healthcare professionals to help patients see these discrepancies if they exist. In supporting self-efficacy, patients should be empowered to make these decisions themselves (once given proper information) rather than having us fix problems for them.
Before giving an example of what this process would look like in a conversation between a healthcare provider and a patient, let’s talk about the acronym “OARS”. OARS is essentially an outline for motivational interviewing.
Table 1. OARS Acronym
| Open-ended questions | Allows the patient to expand on their thoughts or opinions |
| Affirmation | Allows the healthcare provider to deliver a positive statement and develop rapport |
| Reflection | Allows the healthcare provider to clarify/confirm statements and allows the patient to hear back and consider their response |
| Summary | Allows the healthcare provider to tie everything together and allows the patient to reflect on everything they have stated |
OARS can be used by healthcare providers when speaking to patients. However, it can also be utilized by motivated individuals when speaking to friends, family members, and other members of the community when discussing the issue of vaccine hesitancy.
Throughout the motivational interviewing session, there may come a time where you can give the patient health information that can aid in their decision-making. This process is broken down into three easy steps:
- Elicit: Seek out and ask about the patient’s knowledge on the subject before asking permission to give them more information
- Provide: Prioritize important information and deliver it concisely without introducing personal biases
- Elicit: Check for understanding of the information
An example conversation:
Pharmacist: Good afternoon, Mrs. Smith! Thanks for stopping by today to pick up your prescription. I also see that, based on your patient profile, you are eligible to receive the second shingles vaccine. I can have that ready in no time if you would like!
Mrs. Smith: Oh no, I won’t be getting that today or ever.
Pharmacist: What makes you say that Mrs. Smith? What questions or concerns can I help with? (O in OARS)
Mrs. Smith: Well last time when I got that shot, I got shingles. I am not going through that again.
Pharmacist: I hear you; it seems like last time when you tried to do the right thing for your health, you ended up having a negative experience. That must have been frustrating. (A in OARS)
Mrs. Smith: Definitely. I felt terrible. I was super tired, and my arm ached for what seemed like days!
Pharmacist: That does sound rough. Do you mind if I share some information on the vaccine and we can go a little deeper into your experience? (Elicit)
Mrs. Smith: Sure, go ahead.
Pharmacist: Great. So, I agree with you that the symptoms you experienced were not ideal. When we give the shingles vaccine, we’re giving you an “inactivated” vaccine, so there isn’t a live virus in it. Because it’s inactivated, it can’t cause illness like the typical shingles virus. What the vaccine does do, though, is cause your body to have an immune response. Essentially your body is learning the virus’s game plan from the vaccine so that it’s prepared if the real thing ever comes around. Imagine getting your hands on the opposing football team’s entire playbook. When your body is reacting to the vaccine and making an immune response, you can have mild symptoms such as fatigue, headache, or arm soreness. (Provide) You mentioned that you were experiencing some symptoms after you got the vaccine. How does what I just shared compare to what you experienced? (Elicit/R in OARS)
Mrs. Smith: Yeah, I guess that’s pretty similar. So, you’re saying those are side effects I might experience AGAIN?
Pharmacist: You may experience them again, but only for a few days at most. It may not be pleasant, but I can assure you that these mild symptoms are a better and safer alternative than getting shingles which can land you in the hospital in some cases. When you had those symptoms last time, what did you do to control them?
Mrs. Smith: Well, I just waited it out at home and took some Tylenol. Eventually they went away.
Pharmacist: That’s good to hear that they went away. It seems that you may have been experiencing some of the symptoms from the immune response that we talked about. However, I want you to feel comfortable with that idea, so may I give you some patient education handouts on shingles and the vaccine?
Mrs. Smith: That would be great. I can read them later today once I get home.
Pharmacist: Great. So just to make sure I heard it all, you were concerned about getting the second shingles vaccine because you believe the first one gave you shingles. You experienced tiredness and some arm pain and treated it at home with Tylenol (acetaminophen) for a few days. We discussed how it could have been a result of your body’s immune response to the vaccine rather than shingles. Did I get everything? (S in OARS)
Mrs. Smith: Yes, exactly.
Pharmacist: Okay. Feel free to read through those hand outs and when you come back next time, we can review them together. What questions do you have for me?
This example is just one of many that you can encounter in practice. It’s important to note that while the conversation topic may change, the principles of “OARS” and “Elicit, Provide, Elicit” can be flexed for any topic. It isn’t always about changing a person’s mind instantly but giving them the ability to find information for themselves and help them “move the needle” toward a positive decision.
Below you will also find a list of helpful resources for addressing vaccine hesitancy. Encourage your patients to visit some of these sites and to come to you with questions. Some of them even provide patient handouts that you can use in practice!
When in doubt, tell friends, family members, or anybody else to always stop by their easy-to-reach, ready to help pharmacist for information on medicine AND vaccines.
Table 2. Resources to Utilize
| Resource | Comments |
| The American Pharmacists Association (APhA) Immunization Center | Features downloadable, handy vaccination guides and is consistently updated to reflect new pharmacy-specific information (may require membership) |
| Johns Hopkins Bloomberg School of Public Health | Gives resources on vaccine safety, vaccine ingredients, state exemption laws, etc. |
| Substance Abuse and Mental Health Service Administration (SAMHSA) | Details motivational interviewing as a counseling style |
| Immunization Action Coalition (IAC) | Contains a specific section on vaccine confidence |
| The Vaccine Education Center at Children’s Hospital of Philadelphia (CHOP) | Features sections on evaluating sources of information for the general public as well as up-to-date videos on vaccines (like COVID-19) |
References:
- Rouch SW, Murphy TV. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA. 2007 Nov 14;298(18):2155-63. doi: 10.1001/jama.298.18.2155.
- Vaccine Safety. Vaccines.gov. Accessible via: https://www.vaccines.gov/basics/safety. Last reviewed February 2020. Accessed 23 December 2020.
- Vaccines Are Cost Saving. Vaccinate Your Family. Accessible via: https://vaccinateyourfamily.org/why-vaccinate/vaccine-benefits/costs-of-disease-outbreaks/#:~:text=For%20every%20%241%20spent%20on,trillion%20in%20total%20society%20costs. Last updated 19 October 2020. Accessed 23 December 2020.
- Shen S, Dubey V. Addressing vaccine hesitancy – clinical guidance for primary care physicians working with parents. Can Fam Physician. 2019 Mar; 65(3): 175–181. PMC6515949.
- Miller WR, Rollnick S. Motivational Interviewing. 3rd ed. New York, NY: The Guilford Press; 2013.
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