Communicating with health workers about COVID-19 vaccination

Communicating with health workers about COVID-19 vaccination www.euro.who.int Photo © WHO / L. Hegested 2CORRIGENDUM Communicating with health workers about COVID-19 vaccination. WHO/EURO:2021-2927-42685-59497 The slides from page 26 to 33 were added into the electronic file on 30.09.2021 Contents 1. Introduction 2. Expectations for this training module 3. Setting the scene for health workers (HWs) 4. Learning outcomes 5. Part 1 to 3 6. COVID-19 vaccine resources for HWs 7. Post-training evaluation 8. References 3 Overview of training module Part 1: Vaccine confidence & acceptance Part 2: Strategies for communicating about COVID-19 vaccination with HWs Part 3: Fostering a work culture to promote COVID-19 vaccine uptake 4 Introduction HWs are a priority group for the COVID-19 vaccine • This training module is designed to equip HWs with knowledge and communication skills to build their confidence and support them in their ability to promote acceptance of COVID-19 vaccination among other HWs. • HWs must feel confident in their decision to get vaccinated before they can recommend the vaccine to others. As such, HWs are directed to evidence-based resources and training materials about COVID-19 vaccination to help them in their decision about getting the vaccine. • Intended audience: • Frontline HWs • National immunization managers • Senior and mid-level healthcare managers 5 6Expectations for this training module • A self-paced learning tool to be completed independently or facilitated by ToT. • ToTs can adjust content to allow for local considerations. • Participants are guided through slides focusing on a combination of theory and practical skill building scenarios. • Scenarios demonstrate strategies for effectively discussing vaccines with HWs. • Content is intended to be practical and adaptable to most healthcare settings. • Expected duration for completion is 3 hours. • Completion of the pre and post training self-reflection, and post training feedback survey is important to consolidate learning and evaluate the module. 7Pre-training self-reflection Insert link to survey 8Setting the scene for HWs Training objectives: 1. To support you in your role to ensure acceptance and trust in COVID-19 vaccination. 2. To provide you with communication strategies and tools you can use to: • Facilitate effective conversations among HWs about COVID-19 vaccination, • Inform HWs about COVID-19 vaccines, • Promote COVID-19 vaccine uptake in your work setting. © WHO / Almaz Zhumaliev 9Learning outcomes At the end of this training module, the participant will be able to: 1. Define vaccine confidence and understand HWs impact on vaccine acceptance; 2. Understand vaccine hesitancy among HWs and factors that contribute to it in the context of the COVID-19 pandemic; 3. Learn communication strategies for an effective vaccine conversation with HWs; 4. Apply communication strategies to build confidence in COVID-19 vaccination and promote vaccine uptake among HWs; 5. Foster a work culture to promote COVID-19 vaccine uptake; 6. Refer to evidence-based COVID-19 vaccination resources for HWs. Part 1: Vaccine confidence & the role of HWs © WHO / Blink Media - Ehtiram Jabi 10 11 US CDC, 2021. Essential workers COVID-19 vaccine toolkit. HWs: A top priority for COVID-19 vaccination HWs = All people serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials. • On the frontlines of the pandemic and at risk of exposure to the virus that causes COVID-19 disease. • Can potentially transmit the virus that causes COVID-19 to patients, their families, and their communities. • At risk of severe disease and outcomes from exposure to COVID-19 among patient population served. • Critical to the health care sector and essential to health system capacity. • Can positively influence vaccination decisions of peers, patients, friends, and family. • Known to play a crucial role in fostering vaccine acceptance among the vaccine-hesitant. 12 What is vaccine confidence? The trust that patients, the public and HWs have in: • Recommended vaccines; • HWs who administer vaccines; • Processes and policies that lead to vaccine development, licensure, manufacturing, and recommendations for use. MacDonald, E, N. 2015. Vaccine hesitancy: Definition, scope and determinants US CDC. 2021. Vaccinate with confidence 13 How do HWs impact vaccine confidence? HWs may underestimate their influence + don’t have much time to talk about vaccines or lack vaccine confidence A HW recommendation is a major driver of vaccine uptake • Most trusted advisors and influencers of vaccination decisions. • A HW’s strong recommendation is a strong facilitator of vaccination uptake. • A HW who leads by example is likely to increase vaccine acceptance among colleagues and other HWs. Dubé, E., et al. 2013. Vaccine hesitancy, An overview. 14 Vaccine acceptance continuum MacDonald, E, N. 2015. Vaccine hesitancy; Dubé, È. 2020. Quick and Efficient Vaccine Communication; Leask, J., et al. 2012. Communicating with parents about vaccination. The majority of people accept vaccination, several are uncertain and will have questions, few people refuse. Hesitant Accept All ACCEPT BUT UNSURE ACCEPT SOME, DELAY AND REFUSE SOME REFUSE BUT UNSURE Refuse All Goal: To increase vaccine confidence and move HW to vaccinate 2-27%30-40% 25-35% <2%20-30% 15 HW opportunity: To promote vaccine confidence I’m not so sure that it’s safe to be vaccinated. I will wait and see how things go. I have a chronic disease and I’m not sure people like me were included in the clinical trials. I was already sick with COVID so I don’t need the vaccine. I don’t like needles. I don’t believe this vaccine was sufficiently tested. These vaccines were developed way too fast. I don’t trust the health authorities. How are concerns about COVID-19 vaccines expressed among HWs? Habersaat, K.B. & Jackson, C. 2020. Understanding vaccine acceptance and demand – and ways to increase them. 3 Factors influence vaccination behaviour Understanding vaccine acceptance and demand Motivation – INDIVIDUAL • Attitudes, perceptions • Risk assessment • Intentions • Values, beliefs • Emotion, impulse, feelings • Confidence, trust “There is not enough information on this vaccine as yet. I’m going to wait and see how things develop.” “I do not trust that the COVID-19 vaccine is safe, it was developed too fast…” “I really wanted to get the COVID-19 vaccine but I can’t book an appointment because no more times are available“ VACCINATION BEHAVIOUR Opportunity – CONTEXT Physical • Access, affordability, availability of vaccination • Convenience, appropriateness of vaccination • Rights, regulation, legislation Social • Social, cultural, demands, support • Social, cultural cues, norms, values Capability – INDIVIDUAL • Knowledge • Skills, trust in own skills • Resilience, stamina, will power, surplus energy • Physical fitness, ability 16 Activity: Exploring vaccine behaviours of HWs The following 2 scenarios reflect factors that influence HWs’ vaccination behavior in the context of COVID-19 vaccination. It is important to recognize these factors and consider how they can impact vaccination decisions by acting as drivers or barriers to vaccination uptake among HWs. Read each HW scenario as a group and discuss the follow-up questions. © WHO / Blink Media - Ehtiram Jabi 17 18 Manager: “Good morning Tina, if you haven’t heard Dr. Robertson Chief of the pediatric infectious disease department will be hosting a lunch time Q and A seminar for staff about the COVID-19 vaccines, you should come if you can.” Tina: “Thanks, I will definitely join I have some questions about the development process. Did you get your vaccine?” 1. COVID-19 HW vaccination scenario – drivers to uptake Manager: “Yes, I got mine on Monday, (manager shows off her pin to say, “I got vaccinated”) they are offering routine clinics over lunch hours for all staff, and some evenings. You can find more information in the staff lounge, also an email was sent this morning to all staff. You can email all your vaccine related questions to staff health or give them a call during regular clinic hours. They respond in one day.” Tina is a pediatrician working at a children’s hospital in the city. It is Monday morning and Tina is hoping to get her COVID-19 vaccine at work this week. When she arrives to work there is a notice on the front door requesting all people to wear a mask and keep one meter distance. She applies hand sanitizer from the pump at the entrance and notices a large poster in the front foyer of the clinic reading “Vaccinating health care workers protects health care capacity”. Beside the large sign are photographs of several of her HW colleagues who recently had their COVID-19 vaccines. On her way to her office Tina greets her manager in the hallway. Physical opportunity Opportunity MotivationCapability Motivation Capability 19 Tina thanks her manager for the information and continues on her way to her office. Tina greets HW colleagues in the hallway and notices they too are wearing pins to say, “I got my COVID-19 vaccine”. She stops at the staff lounge for a cup of coffee and notices the large bulletin board with fact sheets on the COVID-19 vaccines and information on where and when the next onsite vaccine clinics are offered. Tina arrives at her office and notices another poster on her door encouraging HWs to get the COVID-19 vaccine. In her office she opens the email from staff health with the contact information for vaccination related questions and the information on vaccine clinics at the health facility for staff. Tina opens her mobile phone and updates her calendar with a time to get vaccinated at the onsite staff vaccination clinic on Wednesday. 1. COVID-19 HW vaccination scenario – drivers to uptake Motivation Physical opportunity MotivationCapability 20 Group discussion 1. Applying the COM-B model, identify the drivers to vaccine uptake affecting HWs, related to Capability, Motivation and Opportunity Capability – INDIVIDUAL • Knowledge • Skills, trust in own skills • Resilience, stamina, will power, surplus energy • Physical fitness, ability Motivation – INDIVIDUAL • Attitudes, perceptions • Risk assessment • Intentions • Values, beliefs • Emotion, impulse, feelings • Confidence, trust Opportunity – CONTEXT Physical • Access, affordability, availability of vaccination • Convenience, appropriateness of vaccination • Rights, regulation, legislation Social • Social, cultural, demands, support • Social, cultural cues, norms, values VACCINATION BEHAVIOUR Drivers COM-B Factors • Knowledge among HWs on where and how to access information Capability • Intention to vaccinate • Positive encouragement from co-workers affecting attitudes and perceptions • Trust and confidence in vaccine and health authorities Motivation • Vaccine is accessible, convenient and available Physical opportunity • Presence of role models and vaccination champions • Management support • Vaccination is a workplace norm Social opportunity 21 George is an acute care nurse working in a busy emergency department. During the pandemic he has been working 12 hour shifts 5 days a week from 8am to 8pm. He has not had the COVID-19 vaccine as yet and many of his colleagues have been sick with COVID- 19. Nurse Manager: “Sorry, nothing yet, the staff health manger is on leave. I think there is a COVID-19 vaccine clinic in the city centre at the children’s hospital over lunch hour. But I don’t know much more, look it up online. I have to run to a meeting now.” George: “Have you heard anything about COVID-19 vaccines for staff?” 2. COVID-19 HW vaccination scenario – barriers to uptake It’s Monday morning, George takes a one-hour train across town to get to work. He puts on his face mask and gets on the train. He notices some people wearing masks while others do not. There is a poster from the national health authorities reminding the public about COVID-19 precautions to prevent disease spread. George wonders if he will get the COVID-19 vaccine when it is offered to him but realizes he does not know a lot about the COVID-19 vaccines available in his country. He gets to work at 7:35 am and meets his nurse manager in the hallway who is in a rush. George greets her in passing. George changes into his nursing scrubs and takes a quick coffee in the staff lounge. He looks out the window and sees a group of loud protesters on the street holding anti-vaccination signs in front of the hospital. He asks some HW colleagues if they have heard anything about the COVID-19 vaccine for staff and they shake their heads to say no and don’t seem very interested. George takes a look at the staff information board on his way out but finds no information about vaccination for staff. Capability Opportunity Physical opportunity Motivation Opportunity 22 George approaches his colleagues who are just about to start the shift change meeting. As they wrap-up the handover notes from the evening shift, George asks a question. Another nurse: “Nope, nothing yet, and I’m not feeling very confident about it, I have heard the national authorities still have not secured enough vaccine doses.” George: “Has anyone heard about when the COVID-19 vaccine will be offered to us”? 2. COVID-19 HW vaccination scenario – barriers to uptake A staff doctor: “I don’t trust the national authorities, they say one thing and do another…” Another colleague: “Well, there is no way I’m getting the vaccine, I do not trust that the COVID-19 vaccine is safe, it was developed too fast…” Anyway, we are already short of staff. If we all get vaccinated now and experience side-effects, who will cover us?” George: “No one seems to know much about the plan for vaccines. I guess there is not enough information yet. I think it’s better we wait and see how things develop.” George turns to the nurse beside him. George is interrupted by the code blue alarm and realizes it is time to get to work. Motivation Motivation Motivation Capability 23 Group discussion 1. Applying the COM-B model, identify the barriers to vaccine uptake affecting HWs related to Capability, Motivation and Opportunity Capability – INDIVIDUAL • Knowledge • Skills, trust in own skills • Resilience, stamina, will power, surplus energy • Physical fitness, ability Motivation – INDIVIDUAL • Attitudes, perceptions • Risk assessment • Intentions • Values, beliefs • Emotion, impulse, feelings • Confidence, trust Opportunity – CONTEXT Physical • Access, affordability, availability of vaccination • Convenience, appropriateness of vaccination • Rights, regulation, legislation Social • Social, cultural, demands, support • Social, cultural cues, norms, values VACCINATION BEHAVIOUR Barriers COM-B Factors • Inadequate knowledge among HWs • Lack of resilience Capability • Lack of trust in vaccine and health authorities • Disinterest among HWs • Low intention to vaccinate among HWs • Concerns about vaccine safety and development • Negative encouragement from co-workers affecting attitudes and perceptions Motivation • Insufficient official information about vaccination • Challenges with stock and supply • Lack of convenience and access to vaccine Physical opportunity • Lack of HW support • Lack of role models, vaccination champions • Anti-vaccinator protests signaling social norms and values Social opportunity 2. Discuss possible interventions that can address the barriers and increase vaccine confidence and acceptance within George and his HW colleagues. Group discussion Barriers COM-B Factors • Inadequate knowledge among HWs • Lack of resilience Capability • Lack of trust in vaccine and health authorities • Disinterest among HWs • Low intention to vaccinate among HWs • Concerns about vaccine safety and development • Negative encouragement from co-workers affecting attitudes and perceptions Motivation • Insufficient official information about vaccination • Challenges with stock and supply • Lack of convenience and access to vaccine Physical opportunity • Lack of HW support • Lack of role models, vaccination champions • Anti-vaccinator protests signaling social norms and values Social opportunity • Education (beliefs) • Persuasion (confidence and trust) • Modelling (perceptions) • Incentives (intentions) • Training (skills, decision processes) • Education (knowledge) • Environmental restructuring (resources, access) • Modelling (role models, management support, support/interest groups) Intervention area Intervention examples • Technical HW webinars • HW communication trainings • Q and A discussion forums • Promote vaccine uptake via multiple communication channels • Communicate key messages to all staff • Engage vaccination champions • Offer small tokens of appreciation • Provide information updates from national authorities • Provide onsite vaccine clinics • Become a vaccination champion • Management support • Celebrate those who vaccinate 24 © WHO Part 2: Strategies for communicating about COVID-19 vaccination with HWs 25 26 Elements of an effective conversation with HWs expressing vaccine hesitancy CLICK ON EACH CIRCLE FOR MORE INFORMATION CLICK TO CONTINUE WITH TRAINING Announce assume vaccination Listen determine if there is hesitancy Ask permission to discuss use open-ended questions Dubé, È. 2020. Quick and efficient vaccine communication; Atwell, K., et al. 2019. Vaccine acceptance: Science, policy, and practice in a ‘post-fact’ world. Share expert knowledge provide evidence with permission Acknowledge concerns use reflective listening Secure trust leave the door open for discussion Provide your strong recommendation 27 Opel, D, J., et al. 2013. The architecture of provider-parent vaccine discussions at health supervision visits. Announce Goal: Assume vaccination • Begin conversations with a presumptive announcement that vaccination will happen. • Assumes that people are ready to vaccinate and has been shown to increase vaccine uptake. • Signals the HW’s confidence in the vaccine and helps to establish vaccination as the norm. • Use a statement, instead of a question. • Be firm avoiding a paternalistic approach. “We are eligible for our COVID-19 vaccine today” “It’s time to get our COVID-19 vaccine” “Great news, COVID-19 vaccines are being administered to all health care employees this week” CLICK HERE TO RETURN TO ELEMENTS OF AN EFFECTIVE CONVERSATION WITH HWs • Listen to the response and determine where the person is on the continuum of vaccine acceptance. • Does the response signal acceptance, hesitancy or refusal? 28 Listen Hesitancy Accept All ACCEPT BUT UNSURE ACCEPT SOME, DELAY AND REFUSE SOME REFUSE BUT UNSURE Refuse All “I’m ready.” “OK, I guess I’ll vaccinate, but...” “I’m not sure... I don’t know… I will wait for others to get theirs first ...” “No, I’m not sure this is right for me.” “I had a bad reaction to a vaccine, so I don’t get them anymore.” Goal: Determine hesitancy MORE ABOUT DETERMINING HESITANCY Adapted from Sharing Knowledge About Immunisation (SKAI). 2020; Leask J., et al. 2012. Communicating with parents about vaccination. Acceptors • Intend to vaccinate because they see the importance. • Immunization Advocates or ‘go along to get along’ groups. • Trust and know where to access expert information. • May have questions about vaccine safety and side-effects. • Report trust and confidence in vaccination and the medical system. • Supported by peers and managers. • Vaccination is a norm in their workplace. • Want information to help them answer questions from colleagues. Individuals may express one or more of the attributes in each category... Hesitators • Focused on questions or concerns about vaccine safety. • Express doubts about vaccine safety, development and necessity. • Present with a lot of questions. • Don’t intend to decline vaccination altogether, rather plan to vaccinate, delay vaccination, or select out vaccines. • Had a bad experience such as an Adverse Event Following Immunization (AEFI). • Lack trust in the medical system and/or government authorities. • Have heard or read something concerning. • Willing to rely on herd immunity. Refusers • Never vaccinated or stopped vaccinating altogether. • Hold an existing philosophical position on vaccination, or religious beliefs. • Had negative experience(s) with the medical system (i.e. AEFI). • Don’t want to discuss vaccination at all. • Believe vaccine preventable diseases (VPDs) are benign or beneficial. • Distrust pharmaceuticals and/or medical authorities. • More likely to seek complementary and alternative medicine. CLICK HERE TO RETURN TO ELEMENTS OF AN EFFECTIVE CONVERSATION WITH HWs 29 30 Gagneur, A. 2020. Motivational interviewing: A powerful tool to address vaccine hesitancy. Ask permission to discuss • Explore the reasons behind hesitancy or refusal without judgment. • Ask permission to understand the concern or decision not to vaccinate. • Use open-ended questions, which: • Facilitate dialogue • Elicit information in a neutral way • Cannot be answered with a single word • Help you understand a person’s point of view & feelings • Use questions such as: what? how? tell me? What it is that concerns you the most? Can you tell me what you heard about this vaccine? How do you think this vaccine will affect you if you get it? Goal: Understand the concern CLICK HERE TO RETURN TO ELEMENTS OF AN EFFECTIVE CONVERSATION WITH HWs 31 Acknowledge concerns • Reflect-back to the person what you have understood. • Simple reflection: directly repeating what the person says • Complex reflection: repeating what you think the person means • The aim is to show the person that you understand their concerns and how they feel about them. • Asking permission to reflect-back increases a person’s receptivity. • Once you have verified the concern through reflective listening then you may respond to their concern. Simple reflection: “If I understand you correctly, you are worried about the side-effects of the vaccine. Is this it?” Complex reflection: “If I understand correctly, you are saying that you want to make the best choice for your health, but you are nervous about experiencing an adverse reaction from the vaccine. Have I caught your concern?” Goal: Use reflective listening CLICK HERE TO RETURN TO ELEMENTS OF AN EFFECTIVE CONVERSATION WITH HWs Gagneur, A. 2020. Motivational interviewing: A powerful tool to address vaccine hesitancy. 32 Share expert knowledge • Demonstrate respect, understanding and empathy. • If the person is willing, offer expert information on COVID-19 vaccines or vaccination. • Information should be evidence-based and tailored to the person’s concern(s). • If available refer to expert information provided or supported by your healthcare facility, national health authority or WHO to help establish vaccination as the accepted norm. “Could I provide you with some information, based on what you just shared?” “The hospital has posted some information about the efficacy of this vaccine .” “Most side-effects of the COVID-19 vaccine are mild and should not last longer than 3 days, such as….” “Safety studies indicate serious allergic reactions are rare and….” Goal: Provide evidence with permission CLICK HERE TO RETURN TO ELEMENTS OF AN EFFECTIVE CONVERSATION WITH HWs 33 ECDC. 2015. Vaccine hesitancy among healthcare workers and their patients in Europe. Provide your strong recommendation “Healthcare workers are considered to be the most trusted source of vaccine-related information. They are in the best position to understand hesitancy, respond to worries and concerns and to find ways of explaining the benefits of vaccination”. (ECDC, 2015) • HWs are in a unique position to provide a strong recommendation that is critical for vaccine acceptance. • Lead by example, share your experience getting vaccinated or intention to get it with coworkers. “I strongly recommend you get the COVID-19 vaccine available to us” “I believe in this vaccine so strongly that I plan to get it when it’s offered.” “This vaccine is especially important for us because of our work in a health care environment” Goal: Leverage your unique position CLICK HERE TO RETURN TO ELEMENTS OF AN EFFECTIVE CONVERSATION WITH HWs 34 Atwell, K., et al. 2019. Vaccine acceptance: Science, policy, and practice in a ‘post-fact’ world. Secure trust Still hesitant • If the person continues to be hesitant, demonstrate respect and understanding. • Let the person know that you are open to continuing the conversation. • Direct the person to credible resources and encourage them to read expert information you provide them about COVID- 19 vaccination. Refusing • If the person declines vaccination, avoid confrontation, move to secure a trusting relationship. • Even though you disagree, demonstrate respect for their opinion and non-judgement and emphasize your mutual concern for their health. Goal: Leave the door open for discussion CLICK HERE TO RETURN TO ELEMENTS OF AN EFFECTIVE CONVERSATION WITH HWs 35 The following 3 case studies are examples of potential scenarios HWs may encounter with other HWs in the context of COVID-19 vaccination. These conversations apply the recommended conversation elements to respond to concerns regarding COVID-19 vaccine safety and effectiveness and promote vaccine acceptance among HWs. Tailoring the conversation to attitudes and beliefs 36 Example 1. Announce - assume vaccination “I heard from staff health that we are all getting the COVID-19 vaccine this week.” 2. Listen - identify on vaccine acceptance continuum The nurse expresses she has safety concerns and a chronic health condition = Hesitant 3. Ask permission to discuss - understand the concern, use open-ended questions “If it is okay with you, can we talk about your decision…? What did you read online that worries you?” 4. Acknowledge concerns - use reflective listening “If I understand correctly, the stories you read online caused you to question the vaccine’s safety and you are worried because you have a chronic disease?” 5. Share expert knowledge - provide evidence with permission “If you like, I can share with you some information from the clinical trials supported by the WHO.” 6. Provide your strong recommendation “I think getting the vaccine is the safest way to protect us and others.” 7. Secure trust - leave the door open for discussion “I know the hospital has posted some information on the vaccine. You should also have a look and remember you can always ask me questions.” Communication ElementsA nurse manager (NM) and a nurse are in a hallway discussion on a general hospital ward. The NM states that staff will be getting the COVID-19 vaccines this week. The nurse responds by saying, “I have not made up my mind about the vaccine. I have been reading some worrying things online about vaccine testing and I am not sure it is a good idea to get vaccinated because I have diabetes.” 1. Conversation challenge – the undecided nurse 37 Role play activity conversation challenge #1 3-5 minutes for role playing, 5 minutes for discussion in groups of 2 or more • In small groups, perform a role play between two members of the group. • One person act as the HW vaccine champion, who is applying the elements of an effective vaccination conversation. • The other person act as the hesitant HW described on the previous slide. • Others can be observers and provide feedback after the role play. • After completing the role play, see the following example conversation and discuss as a group the responses in the role play. Nurse Manager (NM): I heard from staff health that we are all getting the COVID-19 vaccine. (Presumptive statement) It will be offered to staff on Friday. Are you working that day? Nurse: Yes, I am working that day, but I have not made up my mind about the vaccine. I have been reading some worrying things online and I am not sure it is a good idea to get vaccinated. 38 NM listens to the response and determines the nurse is signaling Hesitancy on the continuum of vaccine acceptance. NM: If it is okay with you, can we talk about your decision, so I understand your concerns? What did you read online that worries you? (Ask permission to discuss, ask an open-ended question) Nurse: Well, stories on Facebook have made me question if it is safe for everyone. I have diabetes and it concerns me that vaccines haven’t been tested on all different groups. NM: If I understand you correctly, the stories you read online have caused you to question the vaccine’s safety and you are worried about the effects the vaccine may pose to your health given the fact you have a chronic disease? (Reflective listening, complex reflection) Nurse: Yes that’s right, I am just not convinced the vaccine is right for people like me. NM: I can understand you are concerned. (Demonstrate respect, understanding and empathy). You’re right, sometimes clinical trials focus on people without health conditions. (Acknowledge) We know that there were people in the vaccine trial who had diabetes and pulmonary diseases. In fact, large scale clinical trials have showed that vaccine efficacy was high in subgroups at higher risk of severe COVID- 19, including people with comorbidities such as diabetes. The vaccine has been rolled out in multiple countries with safety data being continuously collected by national health authorities, the WHO and the European Medicines Agency (EMA). We know that people who get this vaccine may get a sore arm and some may get chills, tiredness and/or headache. Remember that these common side-effects happen with other vaccines and they are often mild. Clinical trials show that people who got the vaccine were less likely to have more serious outcomes from COVID-19 infection compared to people who got the placebo. We also know that people with diabetes are at a higher risk of developing severe illness from COVID-19. (Share expert knowledge) Nurse: Are you planning to get the vaccine? 39 NM: Yes, I will be in on Friday and will get my 1st dose. As you know many of our colleagues have been sick with COVID-19. Given our increased risk of infection, I think getting the vaccine is the safest way to protect us and others. (Provide your strong recommendation) I know the hospital has posted some information on the vaccine. You should also have a look at that and remember you can always ask me questions. (Secure trust. Leave the door open for discussion) Nurse: Thanks, I will have a look at the information before Friday. 40 Response 1. Announce - assume vaccination “Hey, I just heard some great news, we are getting our COVID- 19 vaccines this week.” 2. Listen - identify on vaccine acceptance continuum Sara states she does not trust the vaccine = Hesitant 3. Ask permission to discuss - understand the concern, use open-ended questions “If you don’t mind me asking, what is it about the vaccine that you don’t trust?” 4. Acknowledge concerns - use reflective listening “If I understand correctly, you are concerned that this vaccine was developed too fast, is this it?” 5. Share expert knowledge - provide evidence with permission “Could I provide you with some information based on what you just shared that may help to address your concern?“ 6. Provide your strong recommendation “I really believe in this vaccine, that’s why I plan to get it this week.” 7. Secure trust - leave the door open for discussion “Let me know if you want to talk about it more. I’m happy to help.” Communication Elements A HW meets his colleague Sara on their break and announces that the COVID-19 vaccine is offered to staff at their clinic this week. Sara states, “I’m not sure I will be getting the vaccine. I just don’t trust it.” Sara shares her fear of long-term side-effects and concern over the vaccine’s development process. 2. Conversation challenge – the mistrusting HW 41 Role play activity conversation challenge #2 3-5 minutes for role playing, 5 minutes for discussion in groups of 2 or more • In small groups, perform a role play between two members of the group. • One person act as the HW vaccine champion, who is applying the elements of an effective vaccination conversation. • The other person act as the hesitant HW described on the previous slide. • Others can be observers and provide feedback after the role play. • After completing the role play, see the following example conversation and discuss as a group the responses in the role play. HW: Hey Sara, I just heard some great news, we are getting our COVID-19 vaccines this week. (Presumptive statement) Sara: Yeah, I saw the email from staff health. I’m not sure I will be getting the vaccine. I just don’t trust it. 42 HW listens to the response and determines her colleague is signaling Hesitancy on the continuum of vaccine acceptance. HW: If you don’t mind me asking, what is it about the vaccine that you don’t trust? (Open-ended question) Sara: Well, I’m worried it was developed too fast and steps in testing were skipped just so we could get a vaccine developed. For other vaccines, I don’t have the same doubts because they have been in use longer, but this one makes me nervous. It is not even clear what the long-term side effects are. I prefer to wait and see how things go. Maybe I will get it next year. HW: Okay, so if I understand correctly, you are saying that other vaccines seem safe to you, but you are concerned that this vaccine was developed too fast and this makes you worried about the possibility of unknown side-effects? Is this it? (Complex reflective listening) Sara: Yes that’s correct. HW: I can understand why you are worried, the vaccine was indeed developed quicker than previous vaccines. (Acknowledge) Could I provide you with some information based on what you just shared that may help to address your concern? (Ask permission to discuss) Sara: Sure. HW: Keep in mind, safety requirements are the same as for any other approved vaccine. Vaccines are only approved if the benefits far outweigh their risks. All vaccines must go through preclinical and three phases of clinical trials before authorization. In fact, three things made it possible for the vaccines to be developed quickly while maintaining safety: First, COVID-19 vaccines build on scientific and technological progress. The vaccine technology was already in place before the pandemic. As soon as the necessary information about the virus that causes COVID-19 was available, scientists began designing the vaccines. Second, timelines for development were accelerated by conducting trials in parallel rather than sequentially. Regulatory agencies prioritized to review each phase quickly so, if all went well, they could approve each next step soon after data from the previous step became available. Global information sharing among regulatory authorities also helped to improve and speed up the regulatory process. Third, due to the global risk of disease, massive investments were made well before the end of the clinical trials so that it was possible to have millions of doses ready to deploy. (Share expert knowledge) So, although the vaccines were developed at record speed, no compromises were made on ensuring their safety and efficacy. Sara: Okay, but what about the long-term side-effects? 43 HW: It does take time and more people getting vaccinated before we can learn about very rare or long-term side effects. That is why safety monitoring continues after vaccines are authorized for use. National health authorities, the WHO, manufacturers and the EMA review all the safety data on an ongoing basis and update recommendations based on emerging information. Any possible problems will be thoroughly investigated to find out if the issue is related to the COVID-19 vaccine and determine the best course of action. Based on the large clinical trials conducted so far, we know that the benefits of the vaccine far outweigh the risks of the vaccine. (Share expert knowledge) Sara: That’s really good to know. HW: I really believe in this vaccine, that’s why I plan to get it this week. (Strong recommendation) Sara: I’m going to think about it this evening and make a decision. 44 HW: The hospital has posted some useful information on their website about COVID-19 vaccine safety. If you’d like I could share the link with you. (Secure trust) Sara: That would be great, thanks. HW: No problem, and if you like, I can check-in with you when I’m working next week to talk about it more. I’m happy to help. (Secure trust) 45 Response 1. Announce - assume vaccination “It is time to get our COVID-19 vaccines, there is a vaccination clinic for HWs at the hospital tomorrow.” 2. Listen – identify on vaccine acceptance continuum Maria signals she does not want to get the vaccine = Refuses 3. Ask permission to discuss - understand the concern, use open-ended questions “If it is okay, do you mind if I ask what it is about the vaccine that makes you think it is not safe for you?” 4. Acknowledge concerns – use reflective listening “If I understand, you have decided to not vaccinate because you are worried about the risk it may have on pregnancy?” 5. Share expert knowledge – provide evidence with permission “If you like I can share with you some guidance from WHO and national authorities about women of fertility age..” “Given our high risk of exposure in the emergency department, I strongly recommend to get the vaccine.” 7. Secure trust - leave the door open for discussion “I respect your decision. I’m just concerned about our health. Let me know if you want to talk more about this. I am always here to listen.” Communication ElementsAn emergency doctor texts her colleague Maria to inform her about a COVID-19 vaccine clinic open to all HWs at the hospital where they both work. Maria replies to say, “I don’t want to get the vaccine - I don’t think it is safe for me right now.” Maria explains she is trying to become pregnant. 3. Conversation challenge – a refusing HW 6. Provide your strong recommendation 46 Role play activity conversation challenge #3 3-5 minutes for role playing, 5 minutes for discussion in groups of 2 or more • In small groups, perform a role play between two members of the group. • One person act as the HW vaccine champion, who is applying the elements of an effective vaccination conversation. • The other person act as the refusing HW described on the previous slide. • Others can be observers and provide feedback after the role play. • After completing the role play, see the following example conversation and discuss as a group the responses in the role play. HW: Hey Maria, it is time to get our COVID-19 vaccines, there is a vaccination clinic for HWs at the hospital tomorrow. (Presumptive statement) Are you working? Maria: Yes, I saw the email, but I won’t be going. I don’t want to get the vaccine - I don’t think it is safe for me right now. HW listens to the response and determines her colleague is signaling Refusal on the continuum of vaccine acceptance. HW: If it is okay, do you mind if I ask what it is about the vaccine that makes you think it is not safe for you? (Open-ended question) Maria: I may have mentioned, I am trying to have a baby. Getting pregnant is difficult at my age and I heard that the vaccine is not safe for pregnancy. I think it is just too risky. HW: That’s exciting news that you are trying to get pregnant. Just so I understand correctly, are you saying you have decided to not get the vaccine because you are worried about the risk it may have on pregnancy if you do get pregnant? (Reflective listening) Maria: Well yeah, I know the vaccine is not universally recommended for pregnant women as yet. Pregnant women were not included in the clinical trials and if I get the vaccine tomorrow and then get pregnant soon, I will be worried about the effects on my pregnancy. I wouldn’t want to terminate a pregnancy when it is already so difficult to get pregnant. That would be devasting. 47 HW: I can understand you are worried, if you like I can share with you some information from WHO and national authorities about women of fertility age I recently read. (Acknowledge) 48 Maria: Sure. HW: You are right, there is limited information on the coronavirus vaccine in pregnant and lactating women. However, there have been many pregnant women who were inadvertently enrolled in the vaccine trials and no specific safety concerns related to pregnancy have been identified. If you are trying to become pregnant now you may receive a COVID-19 vaccine. (Share expert knowledge) Based on how these vaccines work in the body, experts believe they are unlikely to pose a specific risk for people who are pregnant. Routine questioning about last menstrual period and/or pregnancy testing is not required before offering the vaccine, and those who are trying to become pregnant do not need to avoid pregnancy after vaccination. In fact, termination of pregnancy following immunization is not recommended. (Share expert knowledge) If a woman finds out she is pregnant after she has started a course of vaccine, she may complete vaccination during pregnancy if she is considered at high risk of exposure to COVID-19, like frontline HWs. The WHO states there is no reason to believe there will be specific risks that would outweigh the benefits of vaccination for pregnant women. Pregnant women should be vaccinated in consultation with their health care provider. (Share expert knowledge) Maria: Well maybe I need to read more about this, can you send me the information you have just shared? HW: Yes of course! Given our high risk of exposure in the emergency department, I would strongly recommend for you to get the vaccine. (Strong recommendation) Maria: I am still feeling very reluctant. HW: I can understand, vaccination is a personal choice. I’m just concerned about our health as so many of our colleagues have been sick with COVID-19. Here are some suggested links. (Share expert knowledge) I would also encourage you to talk about your concern with your health care provider. Let me know if you want to talk more about this, I am always here to listen. (Demonstrate respect for decision and secure trust) Maria: Thanks so much. 49 Conversation considerations Actively listen to understand HW’s concerns, frame vaccination in a way that matters to them. Use facts sparingly – too many can confuse. Ask permission to share information Stories can be powerful and compelling – especially if personal. Frame data clearly and positively. (e.g. better to say “99% safe” rather than “1% risk” of side- effects). Respect a person’s informed decision. Be non- judgemental and non- confrontational. Secure Trust 50 51 Keep in mind • The long-term goal of these conversations is to move the person towards a “yes” for acceptance. This may take more than one conversation. The short-term goal may be to win their confidence. • A good conversation weaves together: • Listening • The art of asking appropriate questions • The ability to craft effective messages • Conversations that guide HWs to explore their reasons for hesitancy can help increase confidence and trust in the COVID-19 vaccine. Part 3: Fostering a work culture to promote COVID-19 vaccine uptake © WHO 52 53 WHO. 2021. Healthcare workers in focus; US CDC. 2021. How to build healthcare personnel’s confidence in COVID-19 vaccines. Five strategies to make COVID-19 vaccination a workplace norm 1. Identify and leverage vaccine champions. 2. Provide information, tools and resources to HWs. 3. Promote collaborative discussions about COVID-19 vaccines. 4. Communicate key messages to all staff. 5. Acknowledge and celebrate the decision to get vaccinated! 54 WHO. 2021. Healthcare workers in focus. 1. Identify and leverage vaccine champions Identify trusted health care leaders who can serve as vaccine champions (role models) to: • Engage in campaigns directed at peers to help promote and encourage vaccination uptake. • Share experience, intentions or personal reasons for getting vaccinated and importance of vaccination. (ex, sharing videos or stories through personal and/or official social media platforms). • Answer questions and act as a channel to resources and up-to-date information for HWs. 55 WHO. 2021. Healthcare workers in focus 2. Provide information, tools and resources to HWs • Lack of knowledge can decrease HWs’ willingness to recommend vaccination. • Key areas for building HW’s knowledge: COVID-19 vaccines, efficacy, how they are developed and monitored for safety, and how HWs can talk to patients, colleagues and the public about the importance of COVID-19 vaccination. • Be transparent in sharing both the benefits and the risks related to vaccines. • Combine passive education with active engagement. • Adapt global and regional training programmes to the local context ensuring trainings and information are meaningful, culturally sensitive and tailored. • Continuously update information and make it accessible. 56 WHO. 2021. Healthcare workers in focus; US CDC. 2021. How to build healthcare personnel’s confidence in COVID-19 vaccines. 3. Promote collaborative discussions • Plan and promote forums for discussions about COVID-19 vaccines and vaccination where HWs can openly discuss their views and ask questions without judgement. • Open discussions help to address staff questions and concerns and get their input on how to best build vaccine confidence within the work setting. • Engage vaccination champions to help facilitate discussions. • Opportunity to provide tailored, effective, clear official communication and up-to-date information on vaccine and vaccination plans to enable HWs to feel informed and in control. 57 US CDC. 2021. How to build healthcare personnel’s confidence in COVID-19 vaccines. 4. Communicate key messages to all staff Use multiple communication channels to share key messages and up-to-date resources about COVID-19 precautions, vaccines, the importance of vaccination and vaccine confidence. (i.e. team meetings, posters in common spaces, email blasts, short videos, health system intranet, social media) Key messages can include: • Get the COVID-19 vaccine to protect yourself, your patients, your colleagues, and your family from infection. • Building defenses against COVID-19 is a team effort in our healthcare setting. • Getting a COVID-19 vaccine adds one more layer of protection against infection for you, your coworkers, your patients, and your families. • Vaccine confidence starts with you! HWs can promote vaccine uptake by: • Choosing to get vaccinated • Sharing reasons for getting vaccinated and encouraging others to get vaccinated • Learning how to have effective COVID-19 vaccine conversations with others to encourage them to get vaccinated. 58 US CDC. 2021. How to Build Healthcare Personnel’s Confidence in COVID-19 Vaccines 5. Acknowledge and celebrate the decision to get vaccinated Highlighting those who do vaccinate can create a positive social norm among HWs and motivate others toward vaccine acceptance. Suggestions for acknowledging vaccinated HWs: • Provide “I got my COVID-19 vaccine!” pins, lanyards, masks, bracelets, stickers, etc. • With permission, post a photo gallery in common healthcare facility areas or online as part of a social media vaccination campaign showing cheerful staff who were just vaccinated. • Offer a small, sincere token of gratitude for early adopters. • With permission, record testimonials on why HWs in your facility decided to get vaccinated and share widely with staff. • If permitted reach out to local media outlets to highlight your health facility’s leadership in COVID-19 vaccine introduction. 59 * will be made available soon Factsheets and Job Aids related to Comirnaty, Moderna, AZD1222 COVID-19 vaccines WHO Regional Office for Europe (2021) Communicating with patients about COVID-19 vaccination - training package WHO Regional Office for Europe (2021) COVID-19 vaccines and vaccination explained WHO Collaborating Centre for Vaccine Safety (2021) Explainer videos for health workers on communicating with patients about COVID-19 vaccination* WHO Collaborating Centre for Vaccine Safety (2021) Online training on COVID-19 vaccination for health workers WHO (2021) Vaccines explained: The different types of COVID-19 vaccines WHO (2021) Vaccines explained: How will there be fair and equitable allocation of limited supplies? WHO (2021) COVID-19 vaccines ; Q&A: COVID-19 vaccine research and development WHO (2020) Interim recommendations for use of the AZD1222 (ChAdOx1-S (recombinant)) vaccine against COVID-19 developed by Oxford University and AstraZeneca WHO (2021) Vaccine Safety Net WHO Interpersonal Communication for Immunization UNICEF COVID-19 Vaccination Communication Toolkit For Medical Centers, Pharmacies, and Clinicians Pre-vaccination Checklist for COVID-19 Vaccines US CDC (2021) Learn About the New mRNA COVID-19 Vaccines US CDC (2021) COVID-19 vaccination: Guide for healthcare workers Public Health England (2021) Information for Healthcare Professionals on COVID-19 Vaccine AstraZeneca Public Health England (2021) The COVID-19 Vaccine Communication Handbook Lewandowsky, S et al. (2021) Social media toolkit for healthcare professionals European Union (2020) COVID-19 vaccine resources for HWs 60 Interim recommendations for use of the inactivated COVID-19 vaccine, CoronaVac, developed by Sinovac WHO (2021) COVID-19 vaccines technical documents WHO (2021) The Sinovac COVID-19 vaccine: What you need to know WHO (2021) Evidence Assessment: Sinovac/CoronaVac COVID-19 vaccine WHO (2021) Interim public health considerations for the provision of additional COVID-19 vaccine doses ECDC (2021) COVID-19 vaccine resources for HWs 61 Post-training self-reflection and evaluation Insert link to survey 62 References 1. Dubé, È. 2020. Quick and Efficient Vaccine Communication. Vaccine Hesitancy Workshop. PPT. 2. Dubé, È., et al. 2013. Vaccine Hesitancy, An Overview. Human Vaccines & Immunotherapeutics 9(8), 1763–1773. 3. Leask, J., et al. 2012. Communicating with parents about vaccination: a framework for health professionals. BMC Pediatrics.12:154. 4. Habersaat, K.B., Jackson, C. 2020. Understanding vaccine acceptance and demand—and ways to increase them. Bundesgesundheitsbl. 63, 32–39. 5. MacDonald, E, N., & Dubé, È. 2018. Addressing vaccine hesitancy in immunization programs, clinics and practices. Paediatrics & Child Health. Vol 23(8):559. 6. MacDonald, E, N. 2015. Vaccine hesitancy: Definition, scope and determinants. Vaccine. Volume 33, Issue 34, Pages 4161-4164. 7. Gagneur, A. 2020. Motivational interviewing: A powerful tool to address vaccine hesitancy. Can Commun Dis Rep. 46(4):93–7. 8. Gagneur, A., et al. 2018. Motivational interviewing: A promising tool to address vaccine hesitancy. Vaccine. 36, 6553–6555. 9. Atwell, K., et al. 2019. Vaccine acceptance: Science, policy, and practice in a ‘post-fact’ world. Vaccine. Volume 37, Issue 5, Pages 677-682. 10. Sharing Knowledge About Immunisation (SKAI). 2020. E-Learning Module. Available from http://www.ncirs.org.au/health-professionals/skai-supporting-health-professionals. Accessed on January 06, 2021. 11. Opel D, J., et al. 2013. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 132(6):1037-46. 12. ECDC. 2015. Vaccine hesitancy among healthcare workers and their patients in Europe. Available from https://www.ecdc.europa.eu/sites/default/files/media/en/publications/Publications/vaccine-hesitancy-among-healthcare-workers.pdf Accessed on February 04, 2021. 13. US CDC. 2021. How to Build Healthcare Personnel’s Confidence in COVID-19 Vaccines. Available from https://www.cdc.gov/vaccines/covid-19/downloads/Build-Healthcare-Personnel- Confidence.pdf. Accessed on April 04, 2021. 14. US CDC, 2021. Essential Workers COVID-19 Vaccine Toolkit. Available from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/toolkits/essential-workers.html Accessed on March 05, 2021. 15. WHO. 2021. Health workers in focus: policies and practices for successful public response to COVID-19 vaccination. Strategic considerations for Member States in the WHO European Region, Copenhagen: WHO Regional Office for Europe. www.euro.who.int Thank you!