Impacts on practice

  • Pharmacists are well positioned to improve people’s understanding of the COVID19 vaccine and influence on decision-making among those who are vaccine-hesitant.

  • While educating the public, pharmacists can use motivational interviewing techniques to explore people’s ambivalence regarding the COVID-19 vaccine.

Background

Vaccination programs have contributed substantially to the decline in mortality and morbidity of infectious diseases [1]. The coronavirus disease pandemic that emerged in 2019 (COVID-19) continues to impact all aspects of life worldwide from countless lives being lost to the cause of unprecedented social distress. Although several strategies have been implemented to tackle the spread of this infection, vaccination as opposed to natural infection offers the most viable and optimistic option in achieving herd immunity [2, 3].

Vaccine hesitancy, defined by the World Health Organization (WHO) as the “delay in acceptance or refusal of vaccines, despite availability of vaccine services”, is within the top ten global health threats of 2019 [4,5,6]. Despite the promising efficacy and safety of COVID-19 vaccines, many continue to remain opposed to getting vaccinated [7]. Educational strategies that focus not only on increasing the public’s knowledge and awareness, but also that evoke health behaviour change, have been recommended to decrease vaccine hesitancy [4, 5, 8, 9]. Motivational interviewing (MI) is a patient-centered communication style used to enhance a person’s internal motivation for attitudinal change by exploring and solving inherent ambivalences [10]. Evidence suggests that pharmacists are well positioned to utilize the MI approach to help people overcome ambivalence towards immunizations [11,12,13].

The underlying framework, often referred to as the “spirit” of MI, is based on partnership, acceptance, compassion, and autonomy [14]. The goal is to engage the person in a collaborative working relationship, allowing the individual to feel involved in the decision to change within a respectful and non-judgmental atmosphere, and to resist the urge to dictate the problem and the solution. As outlined in Table 1, the core communication skills consistent with the spirit of MI that are used by practitioners to build rapport and establish a therapeutic relationship with patients are represented by the acronym OARS: Open questioning, Affirming, Reflective listening, and Summarizing [10]

Table 1 Interviewing techniques used in motivational interviewing
Full size table

MI has traditionally been employed with people who are experiencing ambivalence or resistance toward behavioral change and are disengaging from treatment services. Thus, eliciting “change talk” is an important aspect of MI, as it is a consciously directive strategy used for resolving ambivalence. This guiding style is preferred over the authoritative, practitioner-led strategy of educating, advising, or convincing, which can have the opposite effect resulting in further resistance and defiance from the individual [10]. As outlined in Table 1, change talk involves 4 steps: Displaying empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy. Changing attitudes and behaviours or adopting new ones depend on how important the change is to the individual as well as how confident and prepared they are in adopting change. Using the “importance/confidence ruler” also facilitates change talk and allows practitioners to learn about facilitators and barriers to guide the individual towards change and make it easier to tailor an appropriate action plan. In this article a case vignette is used to illustrate a common scenario and how the pharmacist can use MI to increase knowledge, reduce perceived misconceptions, change attitudes, and enable informed decision-making with regards to the COVID-19 vaccines.

Case vignette

A pharmacist working in a community pharmacy is approached by Mrs. VD, a 54 year-old teacher working at a local international school. She asks the pharmacist for vitamin D, zinc, vitamin C, and ivermectin. When asked the reason for requesting these products, Mrs. VD states she is using them to prevent COVID-19.

Pharmacist (Rx): “Hi Ms. VD …How are you doing today?” [OARS: Open questioning]

Mrs. VD: “Barely managing with this pandemic!”

Rx: “You seem to be handling it well; I can see you wearing your mask, you’re pretty conscious about the distance... Well done!” [OARS: Affirmation]

Mrs. VD: “Yeah, but it seems endless...”

Rx: “Indeed. Everyone suffered in one way or another but there seems to be optimism and hope to get our lives back now that the COVID vaccines are available. Have you been vaccinated yet?” [OARS: Affirmation; Change Talk: Displaying empathy]

Mrs. VD: “No! Not me! I’m not going to get vaccinated. It’s not safe, plus I have allergies. These vaccines are still undergoing trials. They were made so quickly! No one knows what side effects they can cause! I’m good with my natural supplements.”

Rx: “I can definitely relate to your concerns, there is a lot of conflicting information out there. I heard you mentioning some concerns about the COVID vaccine because of your allergies. Can you tell me more about your allergies?” [OARS: Affirmation, Reflective Listening; Open questioning; Change Talk: Rolling with resistance]

Mrs. VD: “Well, since early childhood I have been allergic to peanuts. Apparently, my mom got scared because I developed a skin rash and my lips started swelling after eating chocolate with peanuts.”

Rx: “Did you have a similar reaction in adulthood? How have you managed this allergy before?” [OARS: Open questioning; Change Talk: Developing discrepancy]

Mrs. VD: “Not in adulthood, as I was taught to read food labels and always identify myself as allergic to nuts. Sometimes, I take an antihistamine if I suspect something I took had nuts. I also carry an epinephrine injection with me, just in case! I also have seasonal allergies every Spring, with mostly nasal congestion that I treat with loratadine.

Rx: “I imagine you are up-to-date on your immunizations. Did you experience any reactions to any of the vaccines you had in the past?” [OARS: Affirmation; Change Talk: Developing discrepancy]

Mrs. VD: “I (and my kids) had all recommended childhood immunizations. We did not experience any reactions. But this COVID vaccine, I read it is not safe for people with allergies. I rather take vitamins to boost my immune system.”

Rx: “Your concerns are valid. If I had experienced an allergic reaction to peanuts as you had in the past, I would be worried myself of experiencing an allergic reaction to the vaccine. So, because of that fear you prefer to boost your immunity against COVID with vitamins. Can you tell me more about what you know about vitamin D, zinc, vitamin C, and ivermectin protecting you against COVID19?” [OARS: Affirmation, Reflective listening, Summarizing; Open questioning; Change Talk: Developing discrepancy]

Mrs. VD: “I always used vitamin C when I had a cold to help me recover. I also heard that people with low levels of vitamin D are more likely to die if they are infected with COVID-19. I understand that zinc is an antioxidant and thus protects against some toxins released by the virus, and that ivermectin prevents you from getting infected.”

Rx: “I agree that these vitamins have properties that can boost the immune system. The World Health Organization states that only the vaccine will be able to protect us from getting seriously ill with COVID-19. What do you think?” [OARS: Open questioning; Change Talk: Rolling with resistance, Developing discrepancy]

Mrs. VD: “Well, on one hand I feel I should get vaccinated and get back to a normal life, and on the other hand, I’m worried if it is safe.”

Rx: “You sound like you don’t know what to do. What would be the worst scenario if you get vaccinated?” [OARS: Affirming, Open questioning; Change Talk: Rolling with resistance, Developing discrepancy]

Mrs. VD: “I fear experiencing a severe allergic reaction. But, I have also heard that people won’t be able to travel if they don’t get vaccinated! That would be really hard for me!”

Rx: “I have heard that too! So, on a scale from 1 to 10, 1 being not important at all and 10 being extremely important, how important is it to you to travel and go back to life how it was before COVID19.” [OARS: Affirming, Open questioning; Change Talk: Importance ruler]

Mrs. VD: “I guess a 7. It is not just the traveling. Being able to socialize, having a meal with friends, going to the gym, or even go to work…I really don’t like online teaching.”

Rx: “It seems rather important to you to get your life back! And sounds like the vaccine may facilitate this… but your history of allergies is coming in the way of you taking the vaccine. ?

Tell me what you know about the allergic reactions caused by COVID vaccine.” [OARS: Affirming, Summarizing, Open questioning; Change Talk: Rolling with resistance, Developing discrepancy]

Mrs. VD: “I just heard that people with allergies like me have died when taking the vaccine.”

Rx: “What I have learned is that the probability of dying as a consequence of the COVID19 infection is significantly more likely than experiencing a life-threatening reaction to the vaccine. Did you know that people are monitored for 15-30 minutes after receiving the vaccine? Severe allergic reactions mostly occur within this timeframe. If you agree, I can provide you with a printout of the ingredients found in all currently available vaccines. You mentioned that you read food labels and carry around an epinephrine pen to protect yourself against any allergic reactions. How do you feel about using these approaches for the vaccine?” [OARS: Affirming, Summarizing, Open questioning; Change Talk: Supporting self-efficacy]

Mrs. VD: “I like the idea about carrying the epinephrine pen with me if I decide on getting vaccinated.”

Rx: “I have other patients with allergies similar to yours who have taken the vaccine without any reactions. He told me he was able to get on a plane to Dubai to see his grandkids, he was so happy!” [OARS: Summarizing; Change Talk: Supporting self-efficacy]

Mrs. VD: “Really? That gives me hope! I will consult my doctor before I make an appointment at the primary care clinic, so that all are aware of my allergies at the time of the vaccination.”

Rx: “Do you have anyone who can further support you in this process?”[OARS: Open questioning, Summarizing; Change Talk: Supporting self-efficacy]

Mrs. VD: “I will ask my husband to accompany me to the appointment.”

Rx: “Sounds like a good plan! Please let me know when you get an appointment. I would like to follow up with you after your first vaccine dose. I also must mention that after being fully vaccinated it is important that you continue to wear your mask in public places and engage in proper hand hygiene.” [OARS: Summarizing; Change Talk: Supporting self-efficacy]

Mrs. VD: “Really? But, what is the point of getting vaccinated then?”

Rx: “We are learning new things about the virus every day. Therefore, it is vital that we continue to protect ourselves and others whether or not we are vaccinated. It is important to continue with the preventative measures until we are able to get everyone vaccinated to stop the spread of the virus.” [OARS: Affirming, Summarizing; Change Talk: Rolling with resistance, Supporting self-efficacy]

Mrs. VD: “Thank you for relieving my safety concerns over the COVID vaccine.”

Rx: “Thank you for sharing your concerns about the COVID19 vaccine and for allowing me to discuss with you what I know”

Tips for providers

The case vignette presented illustrates how pharmacists may use the MI approach to communicate with those who are hesitant to take the COVID-19 vaccine. The focus should revolve around collaboration, drawing on their personal beliefs by listening to their fears, thoughts, and opinions. Time constraints has been reported as a main barrier to using MI in community practice [13, 15]. Brief interventions based on MI may be a simpler alternative, where the aim is starting a conversation by using mostly open questions and empathic listening statements. A question as simple as “What are your personal health and safety goals around COVID-19 and this pandemic?” is a good starting point [9, 16]

Staying current with the myths surrounding the COVID-19 vaccine is almost as important as staying up to date on the evidence on vaccine efficacy and safety [2, 7, 9, 16,17,18,19]. Current conspiracy theories over-emphasize on the risks associated with the vaccine itself rather than on those related the COVID-19 illness. Studies exploring attitudes towards COVID‐19 vaccines undertaken in several countries report the safety of the vaccine as the most prominent reason for vaccine hesitancy [20,21,22,23]. Table 2 provides evidence-based information to respond to the most common myths and concerns about the COVID-19 vaccines.

Table 2 Common myths about the COVID-19 vaccines
Full size table