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Targeting COVID Vaccine Hesitancy: What are the ‘5Cs’?

coronavirus vaccine

June 8, 2021 -- Counseling the vaccine-hesitant on the benefits of COVID-19 immunization can at times be uncomfortable or even combative.

Even with an estimated 52% of American adults now fully vaccinated against the coronavirus, some people remain reluctant to join the vaccinated majority – even as states and companies offer creative incentives for getting the shot, such as millions of dollars in lotteries, shotgun giveaways and, yes, even free beer.

Experts in the United Kingdom are taking a different approach to combat vaccine hesitancy, proposing clinicians and public health officials keep the so-called '5 Cs' in mind to increase the likelihood of a fruitful discussion.

"The take-home message for discussing vaccination and engaging with patients is to conduct it in an open, honest, non-judgmental manner," lead author of a new commentary Mohammad Razai, MD, says.

The 'Elicit-Share-Elicit' approach can be useful, for example, he says.

"This is where the health care worker asks open-ended questions to identify concerns, then offers to share their expertise about this concern,"Razai, a general practitioner and researcher at St. George's University in London, adds.


Start by addressing the first 'C' -- confidence -- suggests Razai, senior author Melinda Mills, and colleagues in a commentary published online June 2 in the Journal of the Royal Society of Medicine.

Getting people to believe in the safety, efficacy and importance of vaccines is "crucial," Razai and colleagues wrote. . Recent attention to rare but serious blood clot events potentially associated with AstraZeneca and Johnson & Johnson COVID-19 vaccines could have a detrimental effect on such confidence, they added.


Razai and colleagues define vaccine hesitancy as a delay in acceptance or a refusal to get immunized despite vaccine availability.

Some researchers point to a perception of low risk of COVID-19 coupled with perception of low risk for severe disease — particularly among young people and individuals of lower socioeconomic status — for fueling complacency.

Now that vaccine emergency use authorization has extended to lower age groups, "addressing complacency through repeated risk communication is crucial to facilitate informed decision-making," the authors wrote.


If you offer vaccines in a convenient way, the vaccine hesitant may be more inclined to receive the shot— that's the gist of the third C. Providing COVID-19 immunizations in an easy-to-reach location can boost access and acceptance, the researchers wrote.. Removing financial barriers can also help get more people vaccinated.

Evidence of convenience helping vaccine efforts already exists for other immunizations. Offering flu vaccines at schools in the United States, for instance, can boost vaccination rates. Another study showed immunization rates increased in the U.K. when vaccines were offered at doctors’ offices and pharmacies.


For this reason, Razai and colleagues propose that vaccines be distributed to pharmacies, primary care offices, and trusted health care professionals to increase acceptance. The fourth C in their strategy involves effective communication and dispelling misinformation.

"It will go wrong if doctors assume that all people need is more facts and evidence," Razai says "One-way communication of science without engaging in dialogue will be very unlikely to establish trust or build confidence in vaccines' safety, importance, or efficacy."

"The key is to have a dialogue and listen to concerns," he adds.

Addressing any misinformation remains essential. "Misinformation feeds on people's fears and anxieties about the pandemic to promote anti-vaccination conspiracy theories," the authors noted.

"An excessive amount of information, rapid changes in COVID-19 information and guidance, and lack of certainty has caused misinformation to spread faster than the infection," they added, "thus creating general distrust and confusion."

To counter misinformation, a genuine transparent dialogue could alleviate concerns and build confidence in vaccines, the authors note. Razai addressed these tactics and more in a BMJ paper published on May 20.

"I'd love to see more control regarding dissemination of misinformation through social media," says Ludmila De Faria, MD. "On the other hand, the paper's suggestion that 'the government makes it illegal to share misinformation' is a slippery slope."

"In order for public health policies to work, the general population needs to trust those creating policies. Censorship does not breed trust," De Faria, chair of the American Psychiatric Association's Committee on Women's Mental Health and associate clinical professor of psychiatry at the University of Florida, says.


Putting it all in context is the fifth C. Razai and colleagues believe factors such as ethnicity, occupation, and socioeconomic status are often overlooked in vaccine initiatives.

"The problem starts with the term vaccine hesitancy itself," the authors wrote . "That wording emphasizes individual behavior and assigns some blame to each reluctant person. This approach does not consider "powerful structural factors such as systemic racism and access barriers,” they noted.

Most research on vaccine acceptance is conducted in high-income countries, they added, and as a result few effective strategies have been identified for people in low- and middle-income settings.

’Very Helpful’ Guidance

"The framework suggested is very helpful," says De Fari.. "It is like motivational interviewing, in the sense of identifying possible barriers to compliance with treatment and addressing them, only expanding it to public health."

Providing clear information that addresses specific concerns, answering questions, delivering a clear and consistent message that is disseminated through different platforms, and making the process to get the vaccine easy "are really key issues in a successful vaccination campaign," she says.

Even so, "there will be a small percentage of the population that will not get vaccinated no matter what strategies are used to convince them, as has been the case for other vaccines in the past, she warns.

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