COVID Vaccine Hesitancy in Frontline Nursing Home Staff

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And, Alex, I see three faces on the podcast with us today.

Alex: Yes, three wonderful guests today. We have Sarah Berry, who’s a geriatrician and associate professor at Harvard Medical School. Welcome to the GeriPal podcast, Sarah.

Sarah: Thanks, Alex.

Alex: And finally we have on Kimberly Johnson, who I think I’ve tried to get before. She’s a geriatrician and palliative care doc and professor of medicine at Duke. Welcome to the GeriPal podcast, Kimberly.

Kimberly: Thanks for having me. You wore me down. [laughter]

Eric: Yeah, we finally tricked her. We said we weren’t going to be on YouTube. [laughter]

Alex: That’s right.

Kimberly: You withheld information that would’ve been important in my decision making. [laughter]

Alex: That’s the key to good decision making. And then, finally we have David Gifford, who goes by Giff, who’s the CMO of the American Healthcare Association. Welcome to the GeriPal podcast, Giff.

David: Thanks for having me on, Alex. This is going to be a lot of fun.

Eric: Yeah. We got Giff by just adding this to his schedule without even asking. [laughter]

David: Yeah. It just showed up on my Outlook and I just clicked on Zoom and all of a sudden I see all of you.

Eric: We’re getting good at this, Alex.

Alex: It’s pretty good. I like these techniques. We’re learning.

Eric: We are learning. If anybody wants to start a podcast, these are the prime techniques to get guests.

Alex: You’re right. Our guide to podcast guest decision making. Leave out valuable information surreptitiously inserted into their calendar.

Eric: So we’re going to be talking about a JAGS article just published, Lessons Learned from Frontline Skilled Nursing Facility Staff Regarding COVID-19 Vaccine Hesitancy. We’re going to be talking a lot about vaccines on long-term care today. But before we do, Kim, I heard you have a song request for Alex.

Kimberly: I do have a song request and I came up with this request with a little help from my 12-year-old who’s a huge Hamilton fan. And so, I have asked Alex to play “I’m Not Throwing Away My Shot”, which is an adaptation from Hamilton that was created by physicians at a practice in California.

Alex: That’s great. All right. We’ll give this a shot, but the likelihood that I will get all the lyrics correct? Low.

Alex: (singing)

Eric: I want to thank all three of you for joining us today. I just realized today is my three-month anniversary from getting the first Moderna shot in my arm. So, I’m three months into it, I think a lot of us are around that time who’ve been getting these vaccinations. Can you just give us a broad overview? Where are we right now with vaccinations in longterm care facilities?

Sarah: Giff, I’m guessing you have the most up-to-date information on that.

David: Yeah. Actually, I was just talking to CDC about it. It looks like close to two million residents have gotten it and about two million staff have gotten it. I’m rounding the numbers. So, equal numbers have gotten it.

David: The residents are more likely to get vaccinated than staff. And just eyeballing the data and talking to them, it’s around a little over 80% residents and a little over 50% staff have gotten at least one shot, if not both.

Eric: So, a fair amount lower as far as the number of staff getting it. When I actually look at the CDC data as far as cases, both for staff and for residents, it looks like cases have dramatically plummeted from highs of close to I think, was it 40,000 or something, to really, in the US, I think, currently it’s about 1,000 for longterm care staff? Does that sound about right?

David: Yeah.

Sarah: Yeah. You can feel the difference between January, December with the cases and around facility, talking with others, it’s good. They’re coming down.

Kimberly: You also feel that exhaling that people have done as the … This time, the data actually supports, I think, the feelings of relief among long-term care residents and staff.

Eric: Mm-hmm (affirmative). So I guess the big question here, so you’ve got this paper coming out in JAGS about vaccine hesitancy. The numbers are dropping, it looks like people are getting vaccinated. Half of staff, though … is this a big deal right now? Are we out of the woods? Should we not have to worry about it? Where are we as far as vaccines in long-term care?

Sarah: Yeah. I don’t think we’re out of the woods, for sure. 50% is a great start, but I think a goal of 75% … I think, Giff, you mentioned the AHCA had set a goal of 75% by June would probably achieve better herd immunity.

Sarah: The trouble with long-term care is there is a lot of turnover, both of patients and of staff. And so, even with achieving 80% of residents, we can’t sit back. We’ve got to worry about new admissions than an ongoing plan for vaccination.

David: The vaccination rate amongst healthcare workers has been remarkably similar to the vaccination rate amongst influenza. About a little over half of long-term care healthcare workers get the influenza vaccine each year. I think we’re going to see higher for COVID-19.

David: Sarah, Kim, what do you guys see in the hospital? Because I’m hearing the hospital staff is also not as high as patients and the elderly.

Kimberly: Yeah, we’re seeing the same thing. I’m part of a vaccine equity committee at our health system, and it’s highly variable across disciplines and jobs. And so, you find that physicians and nurses have higher rates of vaccinations than those in more supporting roles but often frontline roles like CNAs or hospital transporters or environmental services workers. Rates of hesitancy are higher and rates of vaccination are lower in those groups.

Eric: And Kim, is that just because of vaccine hesitancy, or are there access issues or other issues that may be playing a role there? Do you know, or you have an idea?

Kimberly: We’ve been trying to figure it out, and I suspect that it’s some combination. So if you think about some of the ways that the vaccine rollout happens within hospitals initially, the way I learned about the vaccine was an email. “Dear Dr. Johnson, you are now eligible. Do this and you will be able to get your vaccine.”

Kimberly: Well, I think what many health systems didn’t realize upfront is that nurses and doctors like me, particularly nurse managers, live on their email, but a lot of our frontline healthcare workers don’t know that they have access to our health system email, have never used our health system email, and have no reason to check it every five minutes.

Kimberly: And so, I think that some of the hesitancy has been learning about it. We’ve employed some other techniques, but there certainly seems to be more concern and misinformation. And then there are access issues even within our health system. I have the opportunity to go and be vaccinated upon making an appointment, and those appointments initially had limited hours. So there were concerns that people couldn’t leave the floor if you’re a frontline healthcare worker and be able to just go and get a vaccine, or that being vaccinated after hours wasn’t possible if people had to get home right away.

Kimberly: Something that actually has worked is providing a particular time for managers, for instance, environmental services managers, to walk groups of people over for vaccines at a particular time and even to have them registered at that time. We all know that it’s not just showing up; you have to complete some information prior to the vaccination itself.

Eric: Mm-hmm (affirmative). That’s great.

David: Well, the nursing home, Eric, it was all different. The federal government sent in Walgreens or CVS. We knew when the schedules were and do it. I mean, evening and weekend shift individuals or people working two jobs might have trouble accessing it. But, generally, the access issues were a lot less.

David: But, Kimberly, you did remind me, or Sarah, you remember we were talking about the trouble we have with Zoom? We did all these town hall meetings with staff and dietary and housekeeping. We were trying to email in the schedule of the meetings and they didn’t have emails. We tried to use a different platform, not a Zoom, and people were used to using Zoom. I felt like I was talking to my parents, “Click on this button here for the sound and mute.”

Alex: Yeah. So certainly technological barriers to getting the vaccine, major component. One year ago, we did one of our first COVID podcasts with Jim Wright and David Grabowski. That was early in the pandemic, and Jim’s nursing home was just slammed in horrible ways and Dave was talking about systematic issues with poorly paid staff, inadequate PPE. I wonder if there’s also a sense of betrayal and loss of trust in the system to support them that’s occurred over this past year, and if that plays into vaccine hesitancy at all.

Sarah: Yeah, absolutely. We certainly felt that on the town hall meetings, some of them more than others. It definitely varied. But some of the workers were, as you say, still angry, still upset, still didn’t feel valued. I think it’s really important to go into those conversations. One of the things that we tried to do is our goal isn’t to convince you, to twist your arm to get vaccinated. Our goal is just to give you good information for you to decide whether or not you want to get vaccinated.

Eric: So, Sarah, maybe we can take a step back. Going back to the JAGS paper, which describes these town hall meetings, why did you decide to set this up? What was the reasoning and your thinking behind it?

Sarah: This was part of a randomized controlled trial within four large nursing home chains. When we started out, the question was testing and how do you best test people. But by October, November, it was clear that really the salient question for nursing homes were how do you get people vaccinated?

Sarah: So the randomized controlled trial, again, we said, “Probably one intervention wasn’t going to do it.” But these town hall meetings were a piece of it, where we set out to identify opinion leaders. Giff, you were the one that suggested that we don’t just recruit people that want to get the vaccine, we recruit really anybody that’s outspoken, whether they’d be pro-vaccine or not. But just the staff that are frontline staff that people listen to, that talk a lot.

David: We said we had four categories: nurses, CNAs, housekeeping, dietary. And then a bunch of the nursing homes said we want to add activities. Then we had this great idea that we would do town hall meetings where it’s just nurses, just aides, just dietary and just housekeepers. Within the third town hall, we threw that out and we just had anyone we could get.

Eric: And these were all done via Zoom?

David: Yeah.

Sarah: That’s right. That’s right.

Kimberly: They were. What was really exciting was I was on one of these town halls and there was a guy on there who said that he was from the Mississippi Delta, which was not far from my home town. I was so excited I had to call my mom and see if she knew anybody who may have joined a town hall. I think he was in activities or maintenance. Actually, he was in maintenance. I mean, we had people from a range of different regions, which was really exciting.

Eric: Yeah. I guess when you’re setting up these town hall meetings, what were you hoping to accomplish or do?

Sarah: We were hoping to give people good information about the vaccine. It was pretty clear back in December from surveys going out that there was a lot of hesitancy and that there was some misinformation. I don’t think we realized until we got started how widespread the misinformation was. For instance, we ended up doing 30 of these, right, Giff? I think the first 26 or so are what’s published in JAGS. And I think we talked about it, I think on every call, either a staff member had the concern or had talked to somebody who had the concerns about infertility and sterilization. I mean, we heard that loud and clear, that that was the concern across disciplines, across regions.

David: I mean, after the fourth one, there was maybe one or two new questions. The priority of where they came and the number of head-noddings changed a bit. The infertility started, I would say, probably fourth or fifth in the priority list. But within a week or two, it was the number two reason we are hearing people didn’t want the vaccine.

David: We got down to all three of us had the same answer. We borrowed each other’s answers and refined our answers over time. And we knew who had the better answer. So Sarah will go, “Giff, I think you have a good answer on that,” or I go, “Sarah, you have a great answer,” or Kim would have a good answer.

Alex: Kind of like a podcast.

Kimberly: Exactly.

Alex: You should start your own podcast. [laughter]

Eric: Where do you think that infertility came up? I’m trying to remember, I think there was a movie five or six years ago, a sci-fi movie, where human beings stopped being fertile except for this one person. And I think it was after a massive outbreak. Where do you think some of this misinformation is coming from?

David: It was hard to track it down and sort it out. Rather than try to figure it out, we do what Sarah said, it was we acknowledge that if you thought and heard from a trusted source that the vaccine caused infertility, we understand why you wouldn’t want the vaccine.

Sarah: Who would want it?

David: Who would? Yeah. But then we would then try to talk about what the evidence was and we said, “Look, you have to make your own decision. Here is what the facts are. You make your decision.” I think that was a key theme to our messaging overall. And that’s the way we addressed the microchip, the mark of the beast, all of these …

Eric: Mark of the beast?

David: Yeah. Sarah, Kimberly, you guys had that one. I never understood it.

Sarah: Yeah. On a few calls, it was, I mean, a really concerned staff who had heard that it’s marked and it’s a reference to the Book of Revelation, that if you get the vaccine, that you’re not going to go to heaven. And I mean, if you heard that from a trusted source, I mean, you wouldn’t want to get the vaccine either. And as Giff said, I mean, no matter what concerns we heard, our goal was to offer reassurance that they were valid concerns and, “Here’s what evidence we have to help you make a decision about whether or not they’re true.”

Kimberly: Yeah. I think something else that was helpful, and I had not heard the mark of the beast thing at all. So I’m glad I wasn’t on the call when that one was brought up because I would’ve said, “Giff?” We did hear a lot, and I hear a lot now, people say that they’ve gotten information from social media or from their family members, and something I often encouraged questions when there was silence was our skilled facilitators would say, “Well, what are you hearing from others?” Because I think people are much more comfortable saying what others are saying than what they’ve heard.

Eric: “I heard from a friend.”

Kimberly: Yeah, exactly. A friend said or around the dinner table … And we certainly would share things that we heard from our own family members. I had plenty of those stories to share about what my family members were saying about the vaccine…

David: You guys both started sharing family stories and then I started sharing some of my family stories. I think it was helpful.

Alex: It’s a way of relating to them. Yeah.

Kimberly: It was.

Alex: And normalizing that there are concerns.

Kimberly: Absolutely. And I think the thing the infertility and thing we had not anticipated, but really spoke to something that I guess we all knew that certainly if you look at the healthcare worker population within skilled nursing facilities, based on our own experience, these are young women of childbearing age who are still interested in having kids, which is interesting. Since we’re geriatricians, that one initially took us by surprise.

David: Sarah kept saying, “Giff, your wife’s an OBGYN. Can you try and answer the question?” Like I had magical knowledge because she’s an OBGYN so I had to answer a lot of the infertility questions.

Eric: Osmosis right there. One question, especially early on, a lot of people were downplaying uncertainty and risks of vaccine, especially given that the mRNA vaccines were brand new, it’s a brand new technology, and there was a lot of focus just on appealing to safety. Like, “These are safe, the trials that we have, and these are the benefits of it.” And really downplaying any uncertainty that there may be some risks with new stuff. It sounds like maybe you took a little bit of a different approach. Is that right?

Sarah: I think that’s right. For an example, Bell’s palsy…

David: That was Sarah’s question.

David: If Sarah wasn’t on the town hall meeting, we were doomed on the Bell’s palsy question.

Eric: Two years ago, I had Bell’s palsy, so I can tell you, that was on my mind. That sucked. I had it for like three months, I never want to have it again. It was on the top of my mind. So I’d love to hear what you said, Sarah.

Sarah: Eric, I also had Bell’s palsy. And so when I heard these case reports in December, I was like, “I got to go to the data and look.” And at the end of the day, there were, I think it was between the Moderna and the Pfizer, I think there was maybe seven cases in the treated in one in the placebo. It wasn’t statistically significant in either, but I’m not sure that we can really definitively say that it didn’t cause Bell’s palsy.

Sarah: And we were, I think, upfront about that, but also told people that if it did, the risk was really low. It was probably increasing your risk in the order of one in 10,000. And if you got COVID, let’s be honest, you can also get Bell’s palsy, because there are cases with that. And so, it was a ray in this small uncertain risk with, again, the benefits of getting the vaccine. These guys must have gotten tired of that story.

David: No. I loved it because I had read all the same stuff. And so I knew intellectually exactly what Sarah just said, but then Sarah would say, “But I had Bell’s palsy. And so I was worried about it, and I got the shot.” And I’m like, “Okay. She had Bell’s palsy and she got the shot.” The data didn’t matter at that point. It was like, “I know Sarah, Sarah has it.” I started telling family members and everyone about it, Sarah. I can now say with confidence that … because before I was like, “Well, I don’t really know.”

David: I knew intellectually it made sense, but there’s always that little bit of worry, but as soon as Sarah said it, and I think that’s, Kimberly, what you were talking about, is they were talking to each other and trusted information sources. And so Sarah is a trusted information source to me.

Kimberly: Exactly. And Sarah, when you weren’t on the call, we would say, “Well, we have a colleague, and she’s had Bell’s palsy and she took the vaccine.”

Kimberly: So I do think that that was really important. And people did ask about, “Have you gotten the vaccine and what were your experiences with the vaccine?” I mean, I think regarding the uncertainty piece, I think we had anything people say we immediately acknowledged that that was a concern. And if we had it as a similar concern or knew someone who had, we went there.

Kimberly: We did focus a lot on the safety and effectiveness of the vaccine and the likelihood as far as we knew of side effects, serious ones being pretty minimal. We talked some about, because one of the things people say, “Well this has been tested in lots of people, but what about long-term side effects?” And so we actually talked about how vaccines work a lot, so how messenger RNA vaccines work, that either you create this protein, the messenger RNA itself is then gone and then your body actually creates this normal response that they would create in response to a virus anyway. And we remind that people about other kinds of vaccines and the extent to which we were not worried about long-term side effects based on the way that they work, but emphasize that people had to make the decision.

Kimberly: I even remember once reminding people, my husband talks about what the decision is and he said he doesn’t think the decision is to get a vaccine or not, it’s do I risk getting this vaccine or getting COVID? And then what happens? And so I even shared that I actually lost two of my uncles from COVID. And so for us, the vaccine, even though there may have been some concern, having that real, tangible knowledge of what could happen if you didn’t have some protection was important. And other people share that too, they share their own experiences with COVID or experiences with family members or friends that they had lost as a result.

Eric: Yeah, it’s interesting around risk assessment and how we judge risk. Because I was just talking to somebody, and just thinking about risk is that we’ve given over 120 million doses in the US. Maybe, let’s say worst case scenario, we’re missing a one in a million symptom or a side effect that we didn’t see in the clinical trial, so there’s that risk one in a million, versus if this 75-year-old gets it, and if they’re in a nursing home, that’s a one in three chance that they’ll get seriously ill and maybe die. For younger people, much smaller risk, but certainly not one in a million. How do you weigh risk? There’s this discrepancy.

Kimberly: Yeah. That’s why I was like, “They’re forgetting about the COVID risk.” Just saying vaccine or not, that’s not the risk that you want to be worried about. You did mention something, Eric, that I think was important. People often, they really felt positive about the extent to which they could protect the people in the nursing homes. And so, even as Alex mentioned early on people had not always had great experiences with PPE or other things, but they were still there and they were still there because of the residents. And so they often brought in questions where the residents wanted to know if everybody gets this vaccine, can we get back to communal dining or seeing our families?

Kimberly: And so that was a huge motivation for people, even when they had concerns, because they’re still there in jobs that aren’t the best jobs, or might be low paid or high risk with respect to protection. And they were still there to take care of the residents. So they were really moved, I think, in the direction of vaccine often by that desire to do what was right for the people they were caring for.

David: Yeah. We started out talking about individual safety, and I think it was Kim describing it. I think, Sarah, you picked up on it. I remember it was one or two aides, they brought it up, or it was a housekeeper that brought it up. It was about getting back to normal and going and visiting there family … I think, Kimberly, it was the person from down where your mom is, who said, “I want to go back and see my family.” And you talked about going back to your family. And it was a aha moment that when we started to incorporate into the messaging about the value of getting a vaccine for protecting your residents, getting back to normal and doing everything else. And it was clear, people were willing to take the perceived risk for that benefit, but if it was just about their own health, that one in a million, Eric, they weren’t willing to take that risk, but if there was a benefit to it. And so we pivoted and de-emphasized … Well, I shouldn’t say we de-emphasized it. We spent more time talking about that benefit.

Sarah: One of the benefits of having an open town hall meeting that I didn’t anticipate was exactly that. It lended itself, not just to us talking, but to them talking. I can remember a care aide talking about how sick she got with COVID and how she was sick for months and felt terrible and fatigued and short of breath. And she talked about how scared she was to get the vaccine, but she did it. And that was way more powerful than anything that I could say to talk to other people.

David: I remember that. I remember the housekeeper talking about seeing family visiting the residents through the window and the patients with dementia, they didn’t understand what was going on and they were like, “I can’t let this happen any more to my residents. I may get the vaccine because I want family to be able to come in.” That was just like, wow.

Alex: So powerful. Yeah. Everyone listening to his podcasts should go read the JAGS article. There’s a couple of terrific tables in there. The first lists concerns with specific phrases of what this nursing home staff said, for example, the infertility concern, and then the second table lists responses to those categories of concerns. And I’d love to hear what your response is to this infertility concern that you said was quite common.

David: That was Sarah. Sarah put that table together in the paper. She added the column. I’m like, “I don’t think we should have that column in here.” She says, “No, I think we should have the column in this article.”

Sarah: Well, I do think because as you say, when you heard some of these questions for the first time, they did take you aback. But I think like Kimberly and Giff said, by the end, we weren’t hearing new questions at all. And so, we’d picked up on what worked and a good response. So if we can help share it with others …

Sarah: I think for the concern about infertility, a lot of it stems from a misconception that this vaccine actually gets into your DNA and alters your DNA. And, I mean, as a physician, as a mom, if I was wanting to get pregnant and I thought something was going to alter my DNA, I mean, I wouldn’t want it either. I loved, loved the way that Kimberly described this vaccine. And I think that was helpful. Kimberly, do you want to share that?

Kimberly: Oh, that might be a little bit rough. Uh-oh. I haven’t done this for many months, but it was an explanation that I heard. People were often concerned about getting the virus, of course, with any vaccine, are you actually injecting us with virus? And people know very little about messenger RNA technology. So I often explain it as a blueprint. So, thinking of a blueprint to your home. And so what you’re getting is a blueprint, and that blueprint is used by your body to create the spike protein of the coronavirus or the COVID virus. And as a result, your body recognizes that protein that was just created as abnormal, and as a result builds antibodies.

Kimberly: And so if you were exposed to it, your body is ready to go, but reminding them, like most blueprints, so they get degraded and we throw them away. I can’t tell you where the blueprint is to my house right now because it’s not needed any more.

Kimberly: Also, as Sarah said, I always wanted to work in that our DNA is protected within our nucleus. This messenger RNA never crosses into it and so it can’t possibly touch our DNA. I think that made people more comfortable. I would say that I think something Sarah did, and I think it was important because this infertility thing became really important. And we did often call on Giff because his wife is an OBGYN and at the time, OBGYNs and others were putting out statements about what was believed to be the safety of the vaccine for women who later wanted to bear children or were pregnant or were nursing.

Kimberly: And so we reminded people of those recommendations, but Sarah often said, “But talk to your OBGYN about it if you have concerns.” But we did quote what the recommendations were currently based on what we knew, but to your point, Eric, people are always worried about uncertainty and there’s probably nothing more important to us than a baby and having a child. And so, we could certainly identify that. We also reminded people that pregnant women were at high risk and they had had poor health outcomes. And so thinking again about that risk benefit.

Eric: And Kimberly, one of the things you mentioned earlier was the importance of having a trusted provider talk to you about this. And, with current disparities that we see with both cases and vaccinations. And I also see on the table, you guys also give recommendations on how to talk when the issue is the historical abuse of blacks. Were you seeing a lot of that in these town halls? And if people want to do similar town halls, any suggestions on how to have those discussions moving forward?

Kimberly: Yeah. When we started out doing this, we were quite aware of that, and quite concerned about the likely disproportionate uptake of the vaccine as well as the disproportionate effect on COVID for residents and minorities in nursing homes. Recently in fact, there was an article, maybe you guys will do that when there was in JAMA Network open that show that if you were in a nursing home where the proportion of whites was lower, so the proportion of racial and ethnic minority is higher, those nursing homes had higher death rates from COVID.

Kimberly: And so, in talking about that, I do think it was important that we … I mean, we were intentionally diverse in our inclusiveness of the panel to say that, yes, I did get the vaccine as a black woman physician and why I thought that was safe, why I was encouraging my mom and all of my other family members to do so I think was important. And certainly I could acknowledge what concerns might exist around that.

Kimberly: And so concerns about people being experimented on or how they might’ve been previously treated, or, I always like to remind people, even as we go back to what would have happened, watching what we’ve watched over the past year with respect to social injustice and watching the disparities in COVID-19 play out on the TV screen has been more than heartbreaking for me even as a disparities researcher. And so acknowledging that our communities have been disproportionately affected and that my bigger concerns were about us having access to appropriate treatment and prevention like the vaccine.

Kimberly: I do think that that was really helpful and to be upfront about that. Often people ask about whether or not the vaccine in trials was given to people like me, and often that was about older adults or chronic illness. But during one call, there was a specific question about the extent to which racial and ethnic minorities have participated in COVID vaccine trials. And I remember I had a little sheet of paper that actually I had written down those numbers, 10% for blacks, about 25% for Hispanics, and could quote that and that there was no difference in safety profile. And I think that was important. I don’t know, Giff or Sarah, if you guys remember some particular calls where that came up.

David: Yeah. I think if I remember right, we heard Tuskegee mentioned at least twice, if not more than that. What was really striking was how open and thoughtful all the participants were. It was clear that they came, even if they were very hesitant or they were on the fence, they were really thinking very hard and had really wanted to hear the answers that we had out there. And they were very thoughtful.

David: I was really impressed by … I was almost, frankly, more impressed by the housekeepers and dietary staff with the way they ask the questions and what they went, there were two types of responses. I don’t know if you guys remember this. You had to read their body language. questions would come up, and there’d be a group of people on the call who just roll their eyes, like, “I can’t believe someone was asking that question,” or they would refer to their colleagues and semi derogatory manners, like they don’t really know what they’re talking about because they think of infertility or something.

David: And then others were much more open about it. And that idea that you’re talking about, Eric, of that trusting relationship, I think really it came through. And it’s something we’re hearing outside of this trial and outside of these focus groups, that that trusting relationship is really critical. And I think the distrust that some of the minorities have because of Tuskegee and I think with the government, the distrust they have with management, the distrust they have with whoever, really came through, but it doesn’t manifest it with, like, they just say, “I distrust them.” You have to read their body language, have to read the questions. It was hidden behind the questions that were there.

Sarah: One of our moderators in particular, I think, was really good at empowering people, sort of like, “What do you do when you hear misinformation?” We had this slogan … when you hear something, say something. That was Kimberly’s.

David: That was Kimberly, yeah.

Kimberly: Yes, that was me. Please note that, and I’d like to receive royalties.

Sarah: All royalties to Kimberly. It was a great slogan, but we would remind people, “Hey, when you hear something, say something. Speak up.” One of our moderators in particular did I think a good job of suggesting language, and you want to avoid, “Why don’t you think it causes infertility?” Instead of, “Oh, I used to think that,” or, “I heard that too, and that was scary. But I did my research, or I went and looked at the data and this is what it is,” turning it to “I” statements instead of “you” statements.

Eric: Right. Yeah. And not downplaying their concern. It’s scary to think it may cause infertility or that we don’t have long-term follow-up or that … and I love the tables. I was just going through the tables in this article, really encourage all of our listeners to download the article and look at the tables, both what did these staff actually bring up as far as sample statements, and then how to respond to it in an empathic way, also acknowledge their concerns. But also, how do you share some of the data that you have?

Alex: Yes, exactly. Because what you’re doing is you’re not just giving the response with data, you’re personalizing your responses with, “I have that concern,” or, “I had Bell’s palsy,” or, “People in my family were concerned about that,” or, “I had relatives who died of COVID.” And that’s the old saying that stories trump data. And so data only takes you so far. When you can personalize it with those stories, it means so much more.

Alex: I wanted to ask about what do you think our listeners should do? Our listeners, many of them work in long-term care facilities or care for people in the hospital or the outpatient setting who are older or work with staff in the hospital or in the outpatient clinic, or in long-term care who may experience vaccine hesitancy, is this town hall an approach that you’d encourage them to take, getting the leaders of the nursing home staff to come join you for a town hall? What do you think a next step should be for our listeners?

David: Hear something, say something. That was our answer.

Sarah: I do think that a conversational format as opposed to a predetermined lecture is going to be more effective. So whether it’s one-on-one or whether it’s these town halls again, without an agenda, just, “Tell me what you’re hearing about the COVID-19 vaccine,” are likely to be effective. And I do think physicians should be involved. I think they really appreciated having physicians and multiple physicians on the call. I remember one home said, “People should stop listening to the news. They should listen to you guys.”

David: I mean, it was intensive. I mean, there was three of us. You’re seeing three physicians. There were a few times we had more of us than there were participants. There’d be two people or three people, but often we capped it. We tried to cap it at 10 people so that they could all get their questions. No PowerPoint slides, we immediately went right into introductions and right into questions.

David: And I remember early on, you guys remember that one individual, he said, “We all have just one or two questions we want answered. We’ve already done our research, everyone wants one or two questions.” And then what would happen is during the hour we’d usually cover about 15 to 18 questions, and they would be the same question just in different order, slightly different stories behind them and everything, but it was the same questions over and over again.

Eric: Okay, Giff. I got a question. This is my last question, then I want to be mindful of the time. That sounds like a lot of work. Can we just mandate everybody gets a vaccine and call it a day?

David: That goes to distrust. It’s coercive. If trust is the problem and you mandate, you immediately play into that distrust and it’s a coercive activity. Now, that said, there have been some providers who’ve made mandated as part of an employer, and it works because they have a trusting relationship. If there’s a trusting relationship already, and it’s part of a comprehensive plan it’s okay. If it’s by itself, I think it backfires.

Eric: One nursing home did it and there was a high amount of people who said they weren’t taking it for health reasons, so there was the health exemption. I guess the question is, can you mandate a vaccine that’s under emergency authorization use?

David: The federal government can’t, states and providers can. But you can’t mandate anything. Only the government can mandate that someone take something. It’s really is, can you make it a condition of employment? So, a lot of places made it a condition of employment, but as you say, there’s all sorts of EOC rules about it and I can exempt out of it.

David: And so, the polls show that healthcare workers between long-term care, about two thirds are willing to take a condition of employment issue. But I think it backfires. I think it doesn’t play to the trust issue. I wouldn’t dismiss it summarily, but I would be very cautious about adding it to my portfolio of strategies that I’d be trying to do to get vaccine uptake.

Alex: And I assume you feel the same way about incentives like bonus if you get … same way, there was a JAMA article about that recently, it was talking about all the reasons that incentives might actually cause more distrust.

Sarah: Another part of our intervention was t-shirts with a positive message: “Vaccinated for you,” and masks as well. And those are not coercive. And then the staff would take pictures of themselves getting vaccinated wearing the t-shirt and posted on social media. And then you’ve got really a trusted source reaching out to others. I think that’s it.

David: I mean, Sarah and I were involved in a separate project where we surveyed facilities with high staff uptake and low self uptake and asked them what they used, and using t-shirts and masks and those incentives was one of the strongest predictors of having high staff uptake. Financial incentives and bonuses were not. They were equal across there. If anything, they actually looked they may have backfired, though paying for time off. And as Kimberly said, access paying for time off and time off if you were sick or time to go get the vaccine or get scheduled, that worked. Those go to trust and a respect of the individual. Paying cash is a coercive move.

Eric: What about Alex Smith singing songs about not missing his shot?

Kimberly: That would definitely make me get it. I mean, if I had been hesitant, Alex could’ve moved me. [laughter]

David: We’d have people getting three shots if we did that. [laughter]

Eric: I want to thank all of you for joining us. This was a fabulous discussion. Special thanks to Sarah for sharing the Bell’s palsy story because I remember after getting the shot, for three days, I was just looking at my face. “Anything changing?” Because, man, I certainly never wanted that again.

Sarah: Same. They were going to have to get another moderator. I was worried.

Kimberly: You wouldn’t have told them, Sarah, why you were away. [laughter]

Eric: Why is half of Sarah’s face not moving? Alex, you want to give us a little bit more of that song?

Alex: A bit more.

Alex: (singing)

Eric: Okay, Kim, last question, who did it better, Alex or Miranda? You can ask your 13-year-old.

Kimberly: I mean, it was close. I’ll leave it at that. It was close.

Alex: Thank you, Kim.

Eric: Again, a very big thank you for joining us today. Great lessons learned, I really encourage all our listeners to download that JAGS article and have some town halls. And do spread the word, acknowledge concerns, and clear up some misinformation.

Eric: And a very big thank you to Archstone Foundation for your continued support and to all of our listeners, thank you.

Eric: Good night, everybody.