Overcoming COVID-19 Vaccine Hesitancy

Contagious Conversations  /  Episode 21: Overcoming Vaccine Hesitancy




Dr. Judy Monroe: Hello, and welcome to Contagious Conversations. I'm Dr. Judy Monroe, the president and CEO of the CDC Foundation and the host of today’s conversation. Every episode we hear from inspiring leaders and innovators who make the world healthier and safer for us all. Contagious Conversations is brought to you by the CDC Foundation, an independent nonprofit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives. Joining me today is Dr. Atul Nakhasi and Dr. Elizabeth Homan Sandoval, frontline doctors working on the COVID-19 response. Dr. Nakhasi serves as an advisor to the office of government affairs and policy for the LA County Department of Health Services. He is also the co-founder of #ThisIsOurShot, the country's leading vaccine trust movement by frontline healthcare workers.

Dr. Homan Sandoval is a psychiatrist working with children and teens. She is also focused on educating and empowering the Latinx community to get vaccinated and highlighting ways to combat healthcare disparities. In this episode, we'll discuss how vaccine hesitancy continues to be a challenge in fighting the pandemic and the power of spreading culturally competent information using trusted voices in our communities. Welcome Dr. Nakhasi and Dr. Homan Sandoval.

Dr. Atul Nakhasi: Thank you, Judy. A pleasure to be here.

Dr. Elizabeth Homan Sandoval: Thank you. It's so nice to be invited. Thank you.

Dr. Judy Monroe: Well, it's really terrific to have you. So Atul, I'm going to start with you. As a doctor, how has COVID-19 changed the work that you do?

Dr. Atul Nakhasi: Great question, Judy. In so so many ways, one of the most evident ways I would say is just, it's shown us how fragile our societal support structures are, our safety net systems are. One quick example I’ll give, I trained at UCLA on the west side here of Los Angeles, UCLA Westwood, and Judy, the zip code there is 90095. I now practice in South Los Angeles and Watts Compton as a primary care doctor. And, believe it or not, the zip code’s actually the same five numbers with one difference. Instead of 90095, it's 90059. And that one switch, five for nine, instead of nine for five, Judy, is 10 years of life expectancy, 10 years across the city of Los Angeles. And so I think, this pandemic, how did it change our work? It made us realize the longstanding and pre-existing inequities that have become very raw and real.

And we saw those firsthand here in Los Angeles, which became the epicenter of the epicenter of this last December in January. In so many ways, this pandemic has affected the work we do, but I think that's a very real way that has made us all realize we really have to double down in the safety net structures we are providing our patients and our communities.

Dr. Judy Monroe: It's stark, a 10-year life expectancy. Unbelievable. Elizabeth, in your work with children and teens, how has your job changed with the emergence of COVID-19 and the Delta variant?

Dr. Elizabeth Homan Sandoval: Yes. So child and adolescent psychiatry in the United States is one of the fields that is in the most demand. The American Academy of Child and Adolescent Psychiatry actually has a workforce map that highlights the areas where it's an urgent situation. And most of the country is highlighted red because there's not enough resources and not enough child analysis psychiatrists. So unfortunately, the pandemic has made what was already a pretty precarious situation, much more challenging for kids and teenagers to access mental health care. What has changed a bit is, we've shifted quite a bit more to telemedicine. Whereas, in the past certain types of evaluations would really not have been standard of care to do from somebody's home, that did become acceptable to do because the alternative was no evaluation. Also, earlier on in the pandemic, a lot of the therapy offices closed and there wasn't access to inpatient hospitalization.

And so, I know myself and a lot of other child analysis psychiatrists really felt that there was even more responsibility for us in seeing our patients and providing support for our patients' families. With the Delta variant, unfortunately, what I'm seeing, and again, I'm very involved nationally with the American Academy of Child and Adolescent Psychiatry. And we just had an advocacy meeting earlier this week because what has already for several years been a huge issue with children and adolescents having to often spend the night in emergency rooms for one to three days, waiting for a bed to open up has now gotten even more severe. And so, as we're hearing with ICU beds and other hospitalization beds with child and adolescent psychiatry, it was already a huge problem. And then, with all the change with school and routines, I'm definitely seeing an increase in mood issues. And so, increased issues with self-harm and suicidal thoughts, unfortunately.

Dr. Judy Monroe: Wow. Well, thank you for the work you're doing. It's quite sobering to hear the situation right now and all the shortages. So, we also know that vaccine hesitancy continues to be a challenge in combating the pandemic, especially as the Delta variant has emerged. Atul, let me come back to you. What are some of the reasons that you're hearing from patients about why they may be hesitant to get the COVID-19 vaccine?

Dr. Atul Nakhasi: Yeah, that's a great question, Judy. And actually just to build off of Elizabeth's point here too, I will say one silver lining to this previous question has been the telehealth aspect here in South Los Angeles. Judy, our no-show rate is about 25 percent typically, because it's that tough to get in for many of our patients who have multiple jobs, multiple caregiving responsibilities, have to take multiple bus routes to get to south LA and Compton and Watts. Our no-show rates have dropped by half because of telehealth and it's access it provides. So, in some ways it has ushered in and accelerated the impact at telehealth to really be a lifeline for healthcare for patients who otherwise may not have access or not be able to make it in. Now at the same time, going to the hesitancy issue here, I'll give a very clear example.

I had three patients this week I saw, and discussed and brought up the vaccine. I had a young woman in her twenties with chronic conditions. I had another woman in her forties with two auto-immune conditions, including lupus on immunosuppression, strong medications that bring down her immune system. And then, I had a third patient with metastatic cancer. And one thing was common with all of them. They all had declined the vaccine, Judy. And this was all this week. And the common reason, all three were afraid. They were afraid of what the vaccine might do to them. And understandably so, because they each had chronic conditions that had really shaped their experience of healthcare and how they felt. And they didn't want to take that risk for their fears of what might happen with the vaccine. And we are seeing that from the unvaccinated. If you look at the data, more than 50 percent of those who are unvaccinated, say they fear the vaccine more than the virus, whereas it should be fearing the virus more than the vaccine.

Dr. Judy Monroe: That's just remarkable hearing that fear of the vaccine is the driver there. Elizabeth, tell us more about what you're seeing, and how are you experiencing issues around vaccine hesitancy?

Dr. Elizabeth Homan Sandoval: I would agree that many of the parents and families and guardians that I speak to, that and my own family members that are not getting the vaccine, or have not, or waited, have a lot of fear. And it's exactly what Atul was just saying. It's kind of like, they've become hyper-focused on potential small statistical risks of the vaccine and don't seem to be very, as knowledgeable about the statistical dangers and risks of COVID.

Dr. Judy Monroe: Wow. And, I will say for myself, watching some of the stories of regret from those that were not vaccinated, that then have experienced really severe illness, and pregnant women is another area that we know. There's hesitancy and concern about the vaccine, but then seeing the devastating stories of still births or mothers losing their lives, it just ... the fear, Atul, as you said, it should be quite the opposite. The fear should be of this virus.

So, for both of you, you're serving on the frontlines of the COVID-19 pandemic. You've done this over the last year, 18 months. I mean, we've been at this now a long time. Can you tell us a little bit more about your experience? For you personally, what's it been like? That's a question for both of you.

Dr. Atul Nakhasi: Thank you, Judy. I appreciate that question. And because it has been personally tough in so many ways, emotionally, I think for all of us, Elizabeth, I'm sure yourself too, and family members, myself as well. And Judy, I will say, I think we'll all remember, especially those serving on the frontlines across this nation. I still vividly remember in April of 2020, when our clinic director at Martin Luther King outpatient center summoned all the healthcare staff, our nurses, front desk staff, doctors, providers, NPs to come together in the hallway inside the clinic to share the news of the first positive case of a staff member in our clinic. And the fear that reverberated across all of us, none of us slept easy that that night. And it was very early in the pandemic where we didn't know that much about this virus.

We certainly didn't have a vaccine at that point. And, I remember going to sleep multiple times throughout this pandemic with that little itch in my throat, that little scratch in my throat, and just thinking, maybe I'll wake up and it'll be COVID. And I think, we've all felt that on the frontlines, as we are taking care of these patients. I had the grateful opportunity to serve in our LA surge hospital here that was stood up by the governor of the state as well. And I think, those early times were very impressionable to how many of us felt. And the prolonged nature of this has been such a struggle, too. We are seeing such burnout, exhaustion, fatigue amongst our own and no fault to their own. This has been an unprecedented challenge. But I think, there is hope. We see it through our patients each week, even in these conversations, Judy, slowly, we're building trust and we're moving people to yes. And I think, that's giving us hope that our work is not without impact, but it is slow. It is meticulous. And one conversation at a time, we have the hope to save individuals lives, but the pandemic personally has been very tough to grapple. Even visiting family, friends, the holidays, everything has been on standstill for so many of us for so long. So, better times ahead. We certainly hope.

Dr. Judy Monroe: Yes, indeed. Elizabeth, I’ll turn to you. Both personally, how this has impacted you, and also what you're seeing the impact on children and teens?

Dr. Elizabeth Homan Sandoval: Sure. Well, personally, I mean, I am a mother and I have been talking, of course, with a lot of my other female physician friends across the country. And so, I don't think my experience is majorly different than a lot of other female physicians. It's been very, very challenging, especially in the early start of the pandemic, to continue practicing without any childcare support and to figure that out. And so, for about a month and a half, I was lucky that I was able to do telemedicine, very lucky, and that I was able to do it from home, so I had my son basically watching a lot of television and I would in between visits run and check on him. And, that was very stressful, but I felt very strongly that I needed to continue to be there for my patients, especially in light of what I said earlier, that most of the schools had closed down. The therapists weren't seeing patients. They couldn't get into hospitals.

So, I just felt like it was that much more important that I was still there. And one of the things that was really neat is that, a lot of the medical students around the country organized and started providing childcare for physicians. So, I was able to take advantage of that from the University of Iowa, two medical students started coming in and watching my son since they were not able to be in the hospital on rotations. The other thing I think that really personally impacted me towards the beginning was of course, I'm a psychiatrist. I'm not a hospitalist. I'm not in the ICU. I'm not in the emergency room. And so I think, again, I don't think this is particular just to me. I've heard this expressed by other psychiatrists, but a little bit of how can we help support everybody? And, maybe a little bit of guilt too, that we weren't the ones right there being exposed first. But, something that the psychiatrist did is they created a call line for physicians across the country to call in if they were struggling with stress or mood. And so, while there's crisis lines, suicide hotlines already, this one was focused specifically on physicians and it still exists today. It's called the Physician Support Line. And so, I hear a lot of confusion among my colleagues when they talk to their patients who they've known for a while, who trust them on other health issues, how it can be that they don't seem to be able to find the trust about that it's okay and safe to get this vaccine.

And, I've had that thought myself a little bit. I mean, I work with children and teenagers, and guardians are trusting me with the lives of their most precious loved ones. And while they trust me on other recommendations and other medications, some of which can have a lot more potential side effects, there's been some families that it's still been hard to reach in helping them overcome the fear of the vaccine.

Dr. Judy Monroe: Wow. So, that's a really good segue into my next questions I had for you all. We're all seeing tensions between those who are vaccinated and those who remain unvaccinated. And as you said, Elizabeth, I mean, this is different with the relationship with physicians and the trust. And yet, as you said, physicians make recommendations that have much greater impact on more serious health. And yet, that trust is there. So, we've got this tension. So, Atul, let me turn to you. What messages do those who are vaccinated and unvaccinated need to hear as we deal with this tension in our country?

Dr. Atul Nakhasi: Yeah. Thank you, Judy. And, thank you, Elizabeth, for sharing that beautiful perspective too, of the challenges you all have faced in psychiatry and the mental health of supporting our patients, our children, our community members as well. And Judy, that's a great question. I think for the vaccinated, the message is stay compassionate. Stay empathetic. Don't give up. You could be that one conversation that reaches an unvaccinated uncle, or aunt, or grandchild, or sibling, or friend or neighbor. You could be that one conversation away from getting them to yes to believing in the vaccination and moving forward. So I think for the vaccinated, it's really, like you said, Judy, it's been so politicized, unfortunately. And, it is just the most fundamental of public health interventions that we know can save individuals lives. And so, I think for the vaccinated, it's really about staying compassionate and empathetic to the concerns of those who are still unvaccinated.

We know 75 percent of the country now almost has received at least one dose of those who are 18 and up now. And for the unvaccinated, I really would say, we hear you. We hear your concerns. We understand your worries, your hesitancies, the questions you have, and you deserve to have those questions answered. And so, to the unvaccinated, I would say, turn to a loved one who's been vaccinated that you trust. Ask them about their experience. Ask them why they chose to get vaccinated. Ask them how they're feeling after vaccination and have that conversation with someone you trust. And then, have that conversation with your doctor. We know eight out of ten individuals, Judy, say they will turn to their trusted personal healthcare provider when making this decision, eight out of ten. We have a special responsibility and duty and obligation in my opinion as providers to reach our unvaccinated individuals. And so, having that conversation is so important. And I think, family and friends, and neighbors, and community members all play a role as trusted messengers to bridge that gap. So, to both the vaccinated and unvaccinated, there are important messages here.

Dr. Judy Monroe: Yeah. That is so well stated. Everyone can use their influence. And, I completely agree. I mean, hearing you talk about the compassion, the understanding that's needed. We're just going to drive a greater wedge if there's shaming of those that are unvaccinated and the other things that we've seen play out in many places. We know that leveraging digital and social media in unique ways has an important, or is an important way for us to share information. Atul, you are the co-founder of #ThisIsOurShot, a digital campaign that promotes positive messaging about the coronavirus vaccines through a network of more than 25,000 healthcare workers. Tell us more about this campaign.

Dr. Atul Nakhasi: Thank you, Judy. We are very fortunate and grateful to have a coalition of frontline healthcare providers, pharmacists, nurse practitioners, physicians coming together here and really to build this trust. And Judy, it really started about back in December when the first EUA was authorized by the FDA for the vaccine around mid-December. And, it started because of the anecdotes and stories and struggles of us providers in our clinics, in our communities. And I'll be very specific here. I remember having a young man in my community in Compton call me during a typical routine visit. And he said, "Dr. Nakhasi, I think I'm going to be just fine. I heard that sunlight can eliminate this virus and that the sunlight outside can take care of this virus." And he asked that question, Judy, though, in a way that he was looking for a trusted voice to help him find the right answer.

And he said, "Dr. Nakhasi, but I'm so confused because I see one thing on Twitter. I hear another thing on news media. I'm hearing another thing from my family and friends." And he was looking to me to help guide where that source of truth is of about the virus and eventually about the vaccine. And, that was just one of many anecdotes. We even had, even in our health system, healthcare workers are not immune from misinformation. Judy, here in our health system at the LA County Department of Health Services, we still have 25 percent of our own healthcare staff and workers unvaccinated. We have a lot of work to do in our own house, in our own home, within healthcare to reach folks and to build that trust. And many of my colleagues that I work with day in and day out, some of the best nurses I could have ever worked with, they have their own valid concerns.

Many of which have been underlying historical, rightful mistrust. And others are concerns with the side effects, the efficacy, the safety. So, what we realized with this campaign is that there is a tremendous need for trusted, accurate information. That's a public health, a vital public health measure. And so, what we ended up doing was mobilizing healthcare providers across the United States to provide that information digitally, but also on the ground. And Judy, the reason why that's so important is if you look at, take my clinic, for example. My most complex patient with end stage kidney disease, end stage heart disease, end stage lung disease, COPD, I may see them every three months, every two, three, four months. So let's say, four visits a year on average, that's 20 minutes a visit, four visits a year. That's one hour of time with their doctor in a year. The average person, Judy, spends 2.5 hours a day on social media, 2.5 hours a day on social media. That is more than 900 hours a year. So, where are we reaching our patients? One hour in the clinic visits a year, or the 916 a year on social media? And, that is where we're also seeing the proliferation of misinformation.

Dr. Judy Monroe: Wow. It is staggering to hear those statistics, two and a half hours per day. You're right. We're up against…this is daunting. What we're up against with the misinformation, it's such a major challenge. Certainly, a lot of folks are talking about with this misinformation and receiving information about the pandemic, that how important it is to come from trusted voices within their communities. So, Atul, as you've worked on #ThisIsOurShot, do you have more that you can tell us about how that has been demonstrated with the trusted voices in your network?

Dr. Atul Nakhasi: Thank you, Judy. That's a great question. So, what we've done to measure the impact with ThisIsOurShot campaign and for folks out there, if you're are interested in getting engaged, please…we're always looking for more healthcare heroes at www.thisisourshot.info And Judy, maybe we can include that information to folks as well to get engaged. But, what we've done so far, Judy, is we've looked across Twitter, Instagram, TikTok, Facebook, and we've analyzed the number of digital impressions, trusted healthcare hero voices have reached. And so, we know there's about 25,000 healthcare heroes that have engaged social media with the the hashtag #ThisIsOurShot to help promote accurate information. And that has measured, we've measured that through social media analytical software. And Judy, believe it or not, we are now at over 1 billion digital media impressions. We're actually at 1.1 billion digital impressions, that's views that have appeared of this trusted information across our digital platform channels.

And so, that's been a tremendous milestone, but I'll also say the other impact we've measured is we've done specialized trainings on how to have effective vaccine conversations to help move individuals to yes, and to combat misinformation. So, we've trained about 1700 healthcare providers and workers on those effective vaccine conversations. Much of that work has been in partnership with the California Department of Public Health, a great allied partner to this work. And, we've also measured increases in vaccine confidence in having those conversations about the vaccine from those who attended, and we just have new results. They showed, just last week, that there was a 40 percentage point increase in confidence of those who attended our trainings in terms of how to have effective conversations and combat misinformation. So, we're measuring the number of people getting trained, the number of healthcare workers getting trained. They're increasing confidence to having these tough conversations and then their digital reach and impression. So, it's been really marvelous to see how we've been able to have impact on digital channels, and the work goes on.

Dr. Judy Monroe: That's impressive. Thank you so much for leaning in and creating #ThisIsOurShot. That is remarkable. Elizabeth, this campaign also has a focus on health equity and inclusivity. A sister campaign is focused on sharing important public health information with the Latinx community. Can you tell us more about that work?

Dr. Elizabeth Homan Sandoval: Yes. So, I'm not one of the founders of #VacunateYa, or one of the founding organizations that kind of got brought in, but my understanding is that there was grassroots efforts around the country and some major efforts in California and out of LA with the #ThisIsOurShot group. And, I'm very active nationally in organized medicine, focusing on decreasing health disparities in the Latinx community. And so, I am friends with many people through other organizations like the National Hispanic Medical Association and the Latino Medical Student Association.

And so, many of us saw this pandemic and saw the need to help with education about vaccines and also signed up to start volunteering and being part of #VacunateYa when the different grassroot groups started to come together. And as I said earlier, we have just really been hearing from our patients and our families and seeing the results too, that it helps when someone who speaks the same language or has the same cultural history or journey, same background, in some ways is able to talk about the safety of the vaccine and the pros and cons. And so, we have been really working hard to help our community feel safe. And then, like I said earlier too, it's really helped bring us together and helped with our morale as clinicians.

Dr. Judy Monroe: Thank you for that. So, Atul, coming back to you, what are some of the key lessons from you to help other medical and public health leaders share trusted information?

Dr. Atul Nakhasi: Thank you, Judy. I'd say there's three steps that we've kind of learned through this process in our work as trusted messengers. So, I'd say the first step, Judy, honestly, is deep listening. We have a tendency, Judy, Elizabeth, and myself, we all know this, as a provider, we have information we want to convey to our patients. And, within the first 10 or 15 seconds, all of us are jumping as providers to help offer that information to our patients right off the bat. And we don't always take the time, partly because of all the time pressure, the clinic environment, the demand for services. We don't always take the time for that deep listening. So, the very first step, to be honest here Judy, is just that deep listening, to understand the emotions behind those concerns and reasons, and then validating those emotions through the verbal expression.

So, even a simple phrase like, "I understand why you feel that way," or "I could see why you are afraid given the information you heard," or "I would feel the same exact way, had I heard that," for example, that side effect or that myth, whether the microchip, infertility. So, validating that emotion is so important, regardless of the concern, because then you are an ally. You're on their team. And once you're on their team, so step one, deep listening. Step two, validate the emotion. Step three, find their personally compelling reason to get motivated.

Judy, they may have nine reasons why they don't want the vaccine, but all you need to find is one, one reason they do want the vaccine. And for each person, that reason is a little different. One quick tip that I often use in my clinic is I'll ask a patient. So, on a scale of one to 10, where are you on your likelihood of getting the vaccine here? Where are you on your chance of getting the vaccine? And, my patient who's currently unvaccinated might say, "Dr. Nakhasi, I'm a three out of ten right now." And I'll say, "Well, how come you aren't one out of ten?"

And, that oftentimes will unlock the reason of, "Oh, well. I do want to see my grandma for Thanksgiving, or I do want to go to the concert of my favorite artist, or I do want to have dinner again with my friends at my favorite restaurant in Los Angeles." And so, finding that personally compelling reason, no matter how many reasons they might not want to get the vaccine for, can be that key. So, deep listening, validation of emotions, and find that compelling reason.

Dr. Judy Monroe: That is brilliant. Thank you for sharing that. That is really valuable advice to all of us and of course to the clinicians. The journey of trust is one that we all need to be on every day. And I just want to thank both of you for everything that you're doing and for joining us today and sharing your wisdom and experience with our listeners.

Dr. Atul Nakhasi: Thank you, Judy. Thank you, Elizabeth.

Dr. Elizabeth Homan Sandoval: Gracias. It was a pleasure. Thank you.

Dr. Judy Monroe: Thanks for listening to Contagious Conversations produced by the CDC Foundation and available wherever you get podcasts. Be sure to visit cdcfoundation.org/conversations for show notes and bonus content. And if you like what you just heard, please pass it along to your colleagues and friends, rate the show, leave a review, and tell others. It helps us to get the word out. Thanks again for tuning in and join us next time for another episode of Contagious Conversations.