The '5 Cs': How to Target COVID-19 Vaccine Hesitancy

Damian McNamara

June 07, 2021

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Counseling the vaccine-hesitant on the benefits of COVID-19 immunization can at times be uncomfortable or even combative. Experts in the United Kingdom propose clinicians and public health officials keep '5 Cs' in mind to increase the likelihood of a fruitful discussion.

Even with an estimated 52% of American adults now fully vaccinated — and states and companies offering creative incentives like $1 million lotteries, shotgun giveaways and, yes, free beer — some people remain reluctant to join the vaccinated majority.

"The take-home message for discussing vaccination and engaging with patients is to conduct it in an open, honest, nonjudgmental manner," lead author of a new commentary Mohammad Razai, MD, told Medscape Medical News.

Dr Mohammad Razai

The 'Elicit-Share-Elicit' approach can be useful, for example, he said. "This is where the healthcare worker asks open-ended questions to identify concerns, then offers to share his or her expertise about this concern," added Razai, a general practitioner and researcher at St. George's University in London.


Start by addressing the first 'C', confidence, suggests Razai, senior author Melinda Mills, MBE, and colleagues in a Commentary published online June 2 in the Journal of the Royal Society of Medicine.

People believing in the safety, efficacy and importance of vaccines is "crucial," Razai and colleagues note. Recent attention to rare but serious blood clot events potentially associated with AstraZeneca and Johnson and Johnson COVID-19 vaccines could have a detrimental effect on such confidence, they add.


Razai and colleagues define vaccine hesitancy as a delay in acceptance or a refusal to get immunized despite vaccine availability.

Some researchers point to a perception of low risk of COVID-19 coupled with perception of low risk for severe disease — particularly among young people and individuals of lower socioeconomic status — for fueling complacency.

Now that vaccine emergency use authorization has extended to lower age groups, "addressing complacency through repeated risk communication is crucial to facilitate informed decision-making," the authors note.


If you offer vaccines in a convenient way, they will come — that's the gist of the third C. Providing COVID-19 immunizations in an easy-to-reach location can boost access and acceptance, Razai and colleagues note. Furthermore, removing financial barriers can also facilitate vaccinations.

Evidence suggests that offering flu vaccines at schools in the United States can boost vaccination rates, for example. Another study showed immunization rates increased in the UK when vaccines were offered at general practices and pharmacies.


For this reason, Razai and colleagues propose that vaccines be distributed to pharmacies, primary care offices, and trusted healthcare professionals to increase acceptance. The fourth C in their strategy involves effective communication and dispelling misinformation. 

"It will go wrong if doctors assume that all people need is more facts and evidence," Razai said. "One-way communication of science without engaging in dialogue will be very unlikely to establish trust or build confidence in vaccines' safety, importance, or efficacy."

"The key is to have a dialogue and listen to concerns," he added.

Addressing any misinformation remains essential. "Misinformation feeds on people's fears and anxieties about the pandemic to promote anti-vaccination conspiracy theories," the authors note.

"An excessive amount of information, rapid changes in COVID-19 information and guidance, and lack of certainty has caused misinformation to spread faster than the infection," they add, "thus creating general distrust and confusion."

To counter misinformation, a genuine transparent dialogue supported by community engagement could alleviate concerns and build confidence in vaccines, the authors note. Razai addressed these tactics and more in a BMJ paper published on May 20.  

"I'd love to see more control regarding dissemination of misinformation through social media," Ludmila De Faria, MD, told Medscape Medical News when asked to comment. "On the other hand, the paper's suggestion that 'the government makes it illegal to share misinformation' is a slippery slope."

"In order for public health policies to work, the general population needs to trust those creating policies. Censorship does not breed trust," added De Faria, chair of the American Psychiatric Association's Committee on Women's Mental Health and associate clinical professor of psychiatry at the University of Florida, Gainesville.

Instead, she suggested using well-known and respected 'ambassadors' who can disseminate factual information about the COVID-19 vaccine and answer specific concerns. "Hopefully, that would generate the word-of-mouth amplification that is needed to convince other people to get vaccinated as well."


Putting it all in context is the fifth C. Razai and colleagues believe factors like ethnicity, occupation, and socioeconomic status are often overlooked in vaccine uptake initiatives.

"The problem starts with the term vaccine hesitancy itself," the authors note. Such wording emphasizes individual behavior and assigns some blame to each reluctant person. This approach does not consider "powerful structural factors such as systemic racism and access barriers."

Most research on vaccine acceptance is conducted in high-income countries, they add, and as a result few effective strategies have been identified for people in low- and middle-income settings.

"It is therefore essential that along with COVID-19 Vaccines Global Access [COVAX], a mechanism to fairly distribute COVID-19 vaccine doses around the world," they add, "there is a concerted international effort to understand, analyze, and overcome vaccine hesitancy."

"Very Helpful" Guidance

"The framework suggested is very helpful," De Faria said. "It is like motivational interviewing, in the sense of identifying possible barriers to compliance with treatment and addressing them, only expanding it to public health."

Providing clear information that addresses specific concerns, answering questions, delivering a clear and consistent message that is disseminated through different platforms, and making the process to get the vaccine easy "are really key issues in a successful vaccination campaign," she added.

Even so, she acknowledged that "there will be a small percentage of the population that will not get vaccinated no matter what strategies are used to convince them, as has been the case for other vaccines in the past."

Razai and De Faria have disclosed no relevant financial relationships.

J R Soc Med. Published online June 2, 2021. Full text

Damian McNamara is a staff journalist based in Miami. He covers a wide range of medical specialties, including infectious diseases, gastroenterology and critical care. Follow Damian on Twitter:  @MedReporter.


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