22. Trust Erosion & Vaccine Skepticism in the Post-COVID World

Download Transcript

Trust Erosion & Vaccine Skepticism in the Post-COVID World

Carl Earl Lambert, Jr., MD, FAAFPAnnouncement00:04

Welcome back to season two of Beyond the Needle a physician’s guide to increasing COVID-19 vaccination rates. I’m Carl Lambert, a family physician and a member of IAFP, and I’m an assistant professor of family medicine at Rush University Medical College. This podcast series is brought to you from the Illinois Academy of Family Physicians, IAFP, through the Illinois Vaccinates or IVAC project. Joining for this podcast series is provided by the Office of Disease Control through the Illinois Department of Public Health. For more information on the IVAC project and receiving free CME credit for these podcasts, visit illinoisvaccinates.com/podcasts. Thank you for joining us as we come together to vaccinate against COVID-19.

Christina Wells, MD, MPH, DipABLM, FAAFPCo-host00:54

Hello and welcome to another episode of Beyond the Needle. I’m Dr. Christina Wells and I’m here with Dr. Marian Sassetti, and today we’re going to be talking about trust erosion and vaccine skepticism post-COVID. Again, I’m Dr. Christina Wells, I’m a family medicine physician and a faculty member at the University of Illinois, and Dr. Sassetti, can you introduce yourself today?

Marian R. Sassetti, MD, FAAFPCo-host01:19

Sure, I’m Marian Sassetti. I’m a family doc with over 30 years of experience in a private practice just west of the city called Lake Street Family Physicians, and I’m also an assistant professor at Rush Medical School.

Christina Wells, MD, MPH, DipABLM, FAAFPCo-host01:32

Thank you, Dr. Sassetti, and we welcome all of our listeners today, as we talk about another topic that we know is impacting all of us as healthcare providers, some statistics that we want to point out that are startling is that there have been declines in routine vaccination worldwide since 2021, with 25 million children missing out on DTAP vaccinations, and this is 2 million more than in 2020 and 6 million more than in 2019. And so what we have seen is that during COVID, there has been a decline in the uptake of vaccinations. A survey by the American Academy of Family Physicians found that 20.8% of respondents reported decreased vaccine confidence, and so today again, we’re going to talk about what has caused this decline in vaccine uptake and what are things that we can do as healthcare providers to help to improve vaccine uptake in our patients. So, Dr. Sassetti, what have you seen in terms of hesitancy that has come about since we’ve been in COVID, and how that hesitancy has not only impacted the uptake of COVID vaccine, but how that has spilled over to the uptake of other vaccinations.

Marian R. Sassetti, MD, FAAFPCo-host03:06

Sure. So, just speaking personally from our practice, we were really blindsided. We understood that there was this hue and cry for the vaccine. We were delighted, we were in it, we were providing the vaccine and then what seemed like out of the blue, there was an enormous amount of information pouring in about some rabbit holes that our patients were going through on the internet. It was all internet-based and coming up with often rabid concerns and belief systems about what was happening with the vaccine and why they shouldn’t trust the medical community, why they should stop trusting science, why they should stop trusting me. So enormous amounts of shocking kind of mistrust. In trying to get to the bottom of it was almost impossible because our patients were quoting things we had never heard, people we had never heard about, but the sources. That seemed to just be extraordinarily impactful. So it blindsided us and then we started to read about it in the literature and we began to see it as a real phenomenon In my own patients. What continues to surprise me to today is the fact that they will trust me.

04:16

Actually, I have a young mother who was insistent, didn’t give her kid MMR vaccine. Her child was born during COVID. Refused all vaccines for herself COVID vaccines flu vaccines refused to vaccinate. This child, who’s now two years old, feared that she had a DVT and called immediately and came to my practice immediately. We got her care. I had to find a gentle way of expressing to her this misalignment, where she trusted me implicitly and immediately. It was the first place she went to when she was afraid she had a blood clot, but continues to insist that anything I put in her baby and what she talks about it is all those chemicals and that they can hurt the baby, it can cause autism and just quoting ancient tropes and things like that. So I was astonished that on one level she still had this implicit trust in me and I was able to have a conversation that started with. You know, I’m reading the same information, I’m relying on the same experts, I read the same journals. All of the things that make you trust me to take care of your potential blood clot are the same things I’m reading that make me want to take care of your baby and want to keep your baby safe from illnesses.

05:21

Still not buying it, I’m still chipping away gently as I can, but those kind of things are very surprising to me. So what has ever happened in our patient’s life has allowed them to be entrenched in this belief system that those of us who are talking about vaccines really are part of some conspiracy ourselves. And one of the more gentle patients who I was trying to talk to, who said you don’t know that you’re being manipulated, Dr. Sassetti, and I said really? And she said yes, I know your heart’s in the right place, I know that you read and you’re up to date, but you are being manipulated by pharmaceutical companies, by the government, by people making money off of all of these vaccines that you’re putting in. My child Could not chip away at it. I couldn’t talk about polio, I couldn’t talk about all of the armamentarium I’ve used.

06:07

Some of my patients are simply entrenched and I personally need help on a neurologic level. I haven’t looked at the literature. I’m kind of entrenched in it because of my interest in mental health. I’m not seeing what is happening in our patient’s brains. That just seem to be hijacked by this very fierce, very aggressive, often very hostile section that’s coming from somewhere in our society that is leading them to believe that there is so much to be mistrusted in these vaccines. So this child is not protected against anything, so very much at risk, for all of the vaccines that we’ve had triumph over. I mean all the illnesses that we’ve had triumph over measles, mumps, rubella, polio all of those things that we thought were a thing of the past are now springing back into reality because of this misinformation campaign that is very, very pernicious.

Christina Wells, MD, MPH, DipABLM, FAAFPCo-host07:01

And I think part of it, Dr. Sassetti, may be streaming from that place of fear. I’ve seen a lot of different things in my practice. I’ve seen less people coming into the clinic because of fear of getting COVID or some other illness. I’ve seen people not coming in until they’re really, really sick. I’ve also seen less children coming in for things like well, child checks.

07:27

And so I think that there is this place of fear and when there’s a place of fear, you may be more willing to be susceptible to that misinformation, that sort of feeds that fear and leads to mistrust that is misplaced.

07:47

And so I think that it’s startling and we need to be talking about ways of how do we get beyond that fear, ways of how do we instill trust with our patients.

07:59

How do we have messaging that’s going to be more patient-centered, how do we increase the health literacy of our patients so they can be better educated about vaccines, what they do and their risk and their benefits, and that those benefits outweigh any risks that may happen. But being also honest with our patients about risks that may come from being vaccinated in similar ways, risks that come from taking a medication or any other risks that we may encounter in our lives, but helping patients to really understand and be more health literate in these areas, which may help to decrease some of those fears and take away the misinformation, or the gravitation to that misinformation, that may be prevalent. So what have you seen in terms of how this is impacted? Have you seen less well child checks? Have you seen less people coming in to get their routine immunizations? Or in what practices have your particular health care center put in place to be able to increase uptake of routine vaccinations as well as to provide better messaging to patients about the COVID vaccines and other vaccines?

Marian R. Sassetti, MD, FAAFPCo-host09:25

So several answers In general. Early in the pandemic, of course, when we reopened and then began to have the hybrid practice, we did see a decrease in all comers and then began to see specifically a decrease in well child visits. I’m happy to say we seem to be up back to our regular statistics, maybe a little bit less of the well child. We seem to be getting those people in. As far as what we’ve done about vaccine, we have a lot of the literature from the AAFP that we have hanging in our practice. We have a lot of literature in each of the rooms. We have some nurses who are really well trained. Our triage nurses are really well trained in information and in understanding how to confront misinformation, sometimes over the phone, but most of the time the people who are confronting the misinformation are providers, the physicians and the physician assistants in the practice, and what we’ve done is the same kind of language I think we talked about it before which is to acknowledge it and we all have begun to say it makes sense that you’re afraid. This is a really scary time on our planet. Tell me what your worst fears are. I’m really getting at it and I agree 100%. Dr. Wells, I like that you use the phrase. Why are they gravitating to misinformation? I think we really have to get our arms around that, because we have to use that in the same way. What is it that makes somebody listen to somebody other than us? What sources do they go to that they are ascribing much more trust and truth to? Why is it that some anonymous source is more available to them? Why do they trust it more? Why do they engage with that rather than their health care providers that, theoretically, they’ve trusted for years? So I think we really do need to get our arms around it and to honor it.

11:02

So the first thing I’ll do is just say it makes sense and you’re a great mom. Usually it’s a mom in my office. I do enjoy when the dads show up, but you’ve been a great mom and we’ve been a great team. Tell me about this. Help me understand one of my favorite phrases. Or I have other patients who don’t want the vaccine, so I want to understand from you. You tell me in your own words, because I want to understand it. And then I wonder if and I ask permission again I’m wondering if we could talk about it again. I’m wondering if we could bring this up again because it’s really important and it’s a real concern of mine. I haven’t had a mother say no, she doesn’t want to talk about it.

11:36

We are moving the needle a little bit when I bring up the issue of neurodevelopmental delays. Long COVID in children is beginning to show us the impact and show up as behavioral or neurocognitive issues and that’s beginning to stop a lot of parents in their tracks. And I say there’s a lot of autism, there’s a lot of problems that we wish we weren’t facing. The one I don’t want to face is a COVID related outcome with your child. Can we partner on that? Inevitably they say yes. Then I say well, then let’s talk about something that we can prevent that. Can we talk about ways that you can trust me again around this topic? What would you need to trust me again? So I really want them to teach me what it is that they are hesitant about, instead of me just reminding them why it’s so valuable and why it works so well. I want to understand what would move the needle for them and how we can talk about it.

Christina Wells, MD, MPH, DipABLM, FAAFPCo-host12:32

I think that’s an excellent approach. I think that one trying to understand your patient’s beliefs that may be leading to their hesitancy or how their beliefs have been shaped by misinformation, is really important, because that helps to open the door for conversations, that helps to open the door for being able to provide education and also being able to build trust and, hopefully, confidence. The other day I was talking with a person and they were saying that, well, doctors get paid to get these vaccines, and so that’s why they’re promoting them. And I said well, if doctors getting paid, I’m still waiting on my check. Yeah right, because I haven’t gotten one yet to be able to, and so that has nothing to do with why I may be promoting the vaccine. It’s purely about my concern about your health and I feel like it’s one tool in our toolbox that we can utilize to help in terms of prevention. But I also tell that there are many other ways that I also want to incorporate a holistic approach to adDress your health. So they don’t feel like I’m just focusing on one thing, but I think as we ask our patients what they believe, then we may be able to dispel some of those myths or their beliefs of why they think that certain things like the COVID vaccines, are being promoted and really it’s something that is absolutely not true in most instances. So I think that’s really important to understand what our patients believe and try to really get at the root of that. So another question is we’ve been looking at I was looking at the CDC’s Lets’ rise campaign and their strategies of how to increase vaccination and I wanted you to comment on these.

14:35

But I wanted to throw out a couple of these strategies that they have. Some are to try to reinforce, with our patients, confidence in routine vaccines. Other things are to make vaccination a sustainable practice and also to support a culture of vaccination within your practice. One of those things is offering vaccines at every visit, even when it’s not a well-child visit, as long as the child isn’t coming in and having a moderate or severe illness. How do we promote uptake for vaccinations at all visits for children and adults? How do we make access to routine health care services and vaccinations accessible to all people in terms of time, transportation and other factors that may be barriers to them? So are there ways that your office has put in specific strategies to make vaccines more accessible and to make not only COVID vaccines a part of your routine practice, but to get more of those routine vaccines delivered to patients at all visits.

Marian R. Sassetti, MD, FAAFPCo-host15:50

Yes, absolutely. And you know what, Dr. Wells, I want to reinforce for our audience this wonderful program that they can access. It’s called Let’s Rise L-E-T, apostrophe S Rise, wonderful resource that I hope everybody’s listening can access and that really does help you walk through these conversations. So I’m happy that we are well resourced in our office with really good RNs and MAs. One of the priorities is going through each chart before we see anybody and seeing what vaccines are due. So my staff will actually do that and highlight what vaccines are due if they’re coming in for a cough, a fever, something like that, so I’ll know. Walking into the room at the end of the visit, typically I say by the way, did you know they’re due for the X, y or Z? And then we have in place standing nurse visits. So I’ll have a clipboard, despite electronic records, where we use a clipboard and I circle a nurse visit and I say to the patient bring this up to the front. And the patients I think like it because they see the communication that I’m giving to the front desk and sometimes I think that was a little bit intimidating, wondering what I was communicating to the front desk. They’d go up to the front desk and not be so sure. But there it is, it’s circled in my handwriting and it says your baby needs this vaccine. Let’s bring you back If they don’t want to give it that day. And typically I ally with them if the baby has a fever or something, the baby is feeling lousy or child. I keep saying baby. That’s my Italian culture. Babies go up to 31, by the way, but a lot of visits. I’ll actually say you know why don’t we go ahead and give them this vaccine? They’re due for it. And just like you said, Dr. Wells, in this, in your medical home, this is what we do. We see what vaccines are due, we see what else needs to happen to keep you and your child safe.

17:32

I’m a big family systems person so I use the whole family system. Who else needs their vaccine? You know you’re going to come in, maybe mom, dad. I have little young families that come in and make their flu shots together. I love that. We encourage that. You know family flu visits, that kind of thing.

17:50

So, to answer your questions succinctly, we have a flag system where we know what vaccines are due. Whatever the visit is, we will bring up the vaccine that’s due. Much more often than not. If it’s, if the child is not ill, we will go ahead and get severely, you know, a fever, really feeling lousy. We’ll go ahead, give the vaccine. And we also have the leeway because we’re well, we’re happy to have enough resources to ask the parents to if I haven’t seen a dad in a while, the day I was bringing a child, and are you up to date on your dbt, that kind of thing. So the flag system works and the little system where I write, go up to the front, make a nurse visit.

18:28

A lot of people, a lot of my adults, want the shingles vaccine on a Friday because they’ve heard they get sick from the shingles vaccine. We’ve really accommodated that. We love that. We love communicating your patients. Great, we’ll do it your way. That’s perfect.

18:42

Let’s get this vaccine in you in a way that works for you and for transportation. We’re very conscious of transportation issues and when it works for our patients. So we have patients who sometimes are in our waiting room an hour early because that’s the transportation that worked for them. So we accommodate that. I’ll say you know. However, you’re getting here, how are you going to get here to get this vaccine? Do you want to make it part of the next visit. So sometimes I’ll say, let’s, let’s do your hypertension visit and your dpt on the next visit if you don’t want to do it right now. So we’ve gotten really, really creative and we’ve just embedded every vaccine that’s due. My patients are used to walking in and knowing that we’re going to talk about a vaccine that’s due. So we’re really lucky to have our nurse force working for us that way.

Christina Wells, MD, MPH, DipABLM, FAAFPCo-host19:24

That’s great. One of the things that we do and I think we’re also a work in progress is we will print out the vaccination records visit and then that way we can see what the patient may be, especially for our children. We do this mostly see what they’re looking for. So, like the earlier this week I saw a patient for an issue that was not a well child and I saw that this patient did not have a code with booster. It was a 17 year old and also didn’t have a flu shot. So we’re talking about something else and I asked the mom why don’t we go ahead and update the code with booster and the flu shot? And we were able to do that the same day.

20:08

So something else we’re starting to implement our reminder calls and I think that’s important.

20:13

I know that sometimes staffing issues might not allow for that, but it’s possible having implementing reminder calls where you can see and go through and look, you can do an audit to see what the children and even adults are maybe missing vaccinations and then calling them and scheduling them for a visit or, if they were seen recently, depending on the policies in your clinic, to be able to come in for a nurse visit to update those vaccines. So I think that we’re starting to implement some things. We still have some steps to go into how we solidify our processes, but I’m hoping that we’ll move towards more of these strategies that are going to help break down barriers to access so that patients can have the vaccines that they need. So, as we wind down here, I just wanted to get some of your final thoughts about what other improvements do you think that we can make in messaging and how we deliver the vaccines, so that we can help to build more trust and more confidence in health care and in the vaccinations massive topic.

Marian R. Sassetti, MD, FAAFPCo-host21:30

Let me start with something I think I’ve alluded to in another podcast, and again it’s trying to build trust in a lying I like the word lying with our patients, being in solidarity with our patients when a family is undecided, or you’re actually telling me no, I don’t believe in it. I’ll say I think we’ve not done a great job in public health and I think where we failed is reminding people why we give vaccines. And I say you know, remember when I gave your baby the chickenpox vaccine, it wasn’t because I wanted to prevent chickenpox, it was because I wanted to prevent the awful things that happen if they get chickenpox. I think it’s good for our patients to see that we acknowledge mistakes that we made. And I said you know, and I think it was a mistake that we didn’t package that the right way. And now patients come in and they say my brother-in-law got the vaccine and then he got COVID. And I’ll say how did he do? Did he go in the hospital? Did he go in the ICU? No, and I say, well, great.

22:22

That reminds me to tell you something I think we haven’t done well. The reason we want you to get the COVID vaccine is because we don’t want you to be in the hospital and we don’t want you to end up in the ICU or certainly dead. So it is true, the vaccine that I want you to get might not prevent you from getting the illness. What I know it will happen is that it will prevent you from getting severely ill and suffering, and I really don’t want anybody I care about to be suffering on my watch. So I embed that in that whole. Let’s remind each other why we’re giving vaccines and to acknowledge the reality that makes them skeptics, which is hey, so-and-so got the vaccine and they got sick, so I’m not getting it and they are missing the message. I think that it’s really important that the vaccine was designed to prevent very significant illness, hospitalization, certainly death and it’s working extraordinarily well.

Christina Wells, MD, MPH, DipABLM, FAAFPCo-host23:12

I think that’s really great, because I think that that led to some misinformation in the beginning, when patients were thinking that, well, if I get the vaccine, then I shouldn’t get sick at all, and I had to remind people that the purpose of vaccinations is to reduce hospitalizations and to keep you from dying from COVID and other illnesses that the other vaccines that we give protect against.

23:37

So it’s important that we’re clear, as healthcare providers as well, about our own messaging, so that patients understand what really is the effectiveness of this tool and how vaccines really work and what they can and what they cannot do. Also, because we’ve had decreased uptake of vaccinations, we’re seeing the rise of other diseases that we thought were eradicated things like polio and measles, and what we don’t understand is that the reason that children and adults weren’t getting this is because they were vaccinated, and we forget about the devastating impact that these diseases brought upon us, and so reminding our patients that these things can help us, these vaccinations, will really help us to be able to prevent the devastating impact that these diseases represent, and so I think it’s going to be reeducation and continuing ongoing education and reminding our patients of where we come. We don’t see some diseases now, like smallpox and other things because of vaccinations, and so reminding our patients of the importance and what vaccines can do and what they cannot do. Any other thoughts on that?

Marian R. Sassetti, MD, FAAFPCo-host25:02

No, I think that’s excellent. Certainly, what I’m beginning to do is to use a language, a new language for me and where I talk about, we have triumphed over diseases that we didn’t think we could A generation ago. Mothers were weeping over their children getting polio and they were clamoring for a vaccine. Now we have children who are suffering and parents aren’t clamoring for a vaccine. That makes me pause and wonder what I and you can do about that situation. And then I said you know, I want to honor the fact of what you’re reading. You know, you bet you are a great mom and clearly you want the best for your child. I’ve seen that from day one. Let’s just talk about just you and me, and I’m experimenting with this. It’s not finished yet and I say you know, there’s people out there that you’re listening to and I honor that, and you are trusting that body of literature or whoever that is.

25:58

I want to paint a picture for you. I want to paint a picture of the measles epidemic that’s happening in Ohio, where, I think it was, 37 children died. I have to look it up, but I’ll give that number. And then I say so it’s just, it’s just a matter of time until we see measles in Illinois. I want to help you and you don’t have to tell me now, but what is your position going to be if your child gets measles? I want you to think about that. I don’t want you to be scared about it, but you and I have been great partners and I just want to bring this up. It’s just a matter of time until measles is on our doorstep.

26:32

What is your position going to be if your child gets measles? Because I have to tell you we don’t have anything to treat it. I wish we did. We don’t. At least with chickenpox we can give a.acyclovirWe don’t have anything to treat measles. I want you to think about that. And then I don’t say anything else and I’m not a doctor that scares people, but I do say we have to remind each other. This is your medical home. I’m responsible for helping you understand what might be coming to our doorstep. So that’s a new language I’m experimenting with. It’s beginning to get some traction. I don’t know, but this measles epidemic next door is a big deal.

Christina Wells, MD, MPH, DipABLM, FAAFPCo-host27:07

Right. So I think that we have to be thinking about how this overarching mistrust and decrease confidence in vaccines that are coming from a lot of different avenues and a lot of different outlets and thinking about how we really target our messaging so that we can make sure that patients, their families, parents are getting correct information and not perpetuating the issue where we’re getting to a point where we start to see the resurgence of all of these diseases that we thought that we had eradicated, because we know that more and more illnesses are going to be on the rise. We’re never going to be without some sort of illness that we’re faced with. So any other thoughts for our audience today in terms of messaging vaccine hesitancy that you would like to leave them with?

Marian R. Sassetti, MD, FAAFPCo-host28:03

Oh, just my usual Thanks for tuning in. You could do this. What came to my mind is how cognizant I am that, how tired I am of the whole topic and how that translates into what happens in my practice. I do encourage us to be very aware of our fatigue and our desire to really just another one. Are you really going to refuse? Today, I noticed by the end of the day I have a different demeanor that I have to be really careful of.

28:29

So a lot of this is self care. So, for all of those who are listening, first of all, thank you. Thank you for continuing to do this important work. And, number two, let’s make sure we take care of ourselves and each other, because on a day where I’m worn out, the conversations are far less compassionate and empathic, and I’m very aware that I’m very fatigued. So if you feel that bubbling up in you, I would just encourage you to recognize it and do whatever self care you need to do.

28:57

In the old days, I would never allow myself to get behind because I was doing something, you know, either going into my office and doing some mindfulness, or taking some deep breaths, or doing some box breathing or whatever. Now I really do that. If I’m aware of how fatigued I am at the end of the day and I’ve got a parent that is a vaccine refuser I recognize I better take care of myself before I walk into that room. So just another reminder we’re grateful for the work you do. I’m sure your patients are grateful, and let’s take care of each other and ourselves.

Christina Wells, MD, MPH, DipABLM, FAAFPCo-host29:26

Yes, you know just a reminder that vaccines are an effective way to reduce severe illness, and I’ve done several mission trips to Africa. I’ve seen people over there who don’t get vaccinated. I’ve seen adults who have polio actually crawling on the ground and other things that are happening because they don’t have vaccinations like we have over here and so they’re susceptible to those diseases that we don’t see here. But we’ve got to stop making it seem as if it’s the vaccine and that’s all that there is. I think we have to make it a part of everything else that we’re doing, because when we make it seem like all of there is, it makes it seem like there is something suspicious about that or there’s something special about that that concerns me or that gives me fear. But if I put it in the context of this is one of the tools that I’m going to use to help you prevent illness, help you prevent disease, along with these other tools that I’m going to use, then I think it may be more palatable for patients, because they don’t feel as if there’s this one thing that we’re pushing and that’s the only thing we’re pushing. You know, it’s like the only thing I can do to fix cholesterol is to take a statin. No, that isn’t the only thing, but it can be helpful.

30:43

And so I think we got to get out of the way of thinking of how we promote and our messaging again. So thinking about ways that we can target our messaging, build trust and confidence in vaccines, and it is not really our job to reduce hesitancy, but it’s more of our job to help our patients that have confidence and trust in the information that we provide to them, and that will help to reduce vaccine hesitancy. And then also, we should have the approach that vaccines are great tools, but also helping our patients to understand that there are other ways that we are also thinking about in terms of prevention. Vaccines are not the only way, but it’s one way that we can help to prevent severe illness and disease. And so let us continue thinking about how we partner with our patients, how we have patient-centered approaches in our messaging, and so that we can help to really really decrease the uptake of misinformation and help to rebuild confidence in our healthcare system. So thank you for joining us for another episode of Beyond the Needle.

Carl Earl Lambert, Jr., MD, FAAFPAnnouncement32:06

Thank you to our expert faculty and to you, our listener, for tuning into this episode. For more episodes of Beyond the Needle, please visit illinoisvaccinates.com. Here you’ll also find links to an online toolkit, how to join learning collaboratives in bootcamps, podcast transcripts, speaker disclosures and instructions to claim CME credit. Subscribe to Beyond the Needle on your favorite streaming platform.