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Coronavirus Disease 2019 Vaccine Barriers: Educating Patients to Alleviate Fear of Receiving the Vaccine

Vaccination is an important step to avoid coronavirus disease 2019 infection and alleviate the disruption caused by the pandemic. Health care providers can improve outcomes by educating themselves and subsequently encouraging patients to vaccinate against the virus. This can be accomplished by understanding how the coronavirus disease 2019 vaccine works and what causes barriers and fear of vaccination.


a b s t r a c t
Vaccination is an important step to avoid coronavirus disease 2019 infection and alleviate the disruption caused by the pandemic. Health care providers can improve outcomes by educating themselves and subsequently encouraging patients to vaccinate against the virus. This can be accomplished by understanding how the coronavirus disease 2019 vaccine works and what causes barriers and fear of vaccination.
Healthcare providers armed with informed decisions about the coronavirus disease 2109 (COVID-19) vaccine can carry a unified message to overcome mistrust and decrease loss of life to this virus. As providers, we benefit from vaccine protection and can encourage others to follow our example and become vaccinated. As COVID-19 mutations evolve, it has become increasingly evident that we need to vaccinate as many people as possible in a short time. 1 Nurse practitioners can improve vaccination efforts and compliance by building trust with patients, being sensitive to different beliefs surrounding vaccination fears, and ultimately decreasing severe illness from COVID-19. This can be accomplished by "meeting people where they are" in their knowledge and providing information that is credible and specific to their fears. 2

Operation Warp Speed and COVID-19 Response Vaccine Development
The United States invested over 10 billion dollars to fast-track the COVID-19 vaccine. 3 Eleven pharmaceutical companies reached the final stage of Federal Drug Administration (FDA) testing, with 3 approved to distribute the vaccine by March 2021. 3,4 Skepticism due to the rapid development of the new technology has affected public confidence in the vaccine. 5 Under the new administration, President Biden changed the name from Operation Warp Speed to COVID Response in an effort to focus on dispensing the vaccine and curb fears of shortcuts in development. 6 The Centers for Disease Control and Prevention (CDC) and the FDA worked together to demonstrate efficacy and safety in the phase 3 trials, as well as beginning a safety monitoring system to report adverse effects postvaccination. 7

Vaccine Efficacy and Ongoing Study
The vaccines are approved for individuals 18 years and older. Studies with Moderna and Pfizer in this age group show 93% to 94% efficacy and initial reports of a strong immune response in adolescents 12 to 15 years old. 4,7 The Johnson & Johnson (J&J) Janssen vaccine was found to be 85% effective against severe disease after 28 days and 65% effective against symptomatic moderate to severe infection. 4 The World Health Organization has been monitoring variants and mutations since the outbreak of COVID-19. The current data suggest that the vaccines give protection against most variants that are spreading in the United States. 7 The J&J vaccine was paused because of a rare risk of blood clot with low platelets in women younger than 50 years old. Approval resumed as of April 23, 2021. 4 The Pfizer and Moderna vaccines have been recommended for people ages 12 and older. Although there have been reports of myocarditis and pericarditis in adolescents and young adults, it is still felt that the benefits outweigh the risk. 4 The research continues to develop, and currently Pfizer has Emergency Use Authorization for individuals 12 years old and up. 2

Barriers to Vaccine Compliance
Despite the incredible achievement of the COVID-19 vaccine development, studies initially showed only 46% may consider vaccination once others have begun. 8 Recently, the Pew Research Center found that 69% of Americans were likely to receive the vaccine (up from 60% in December), with lower-income people less inclined to get vaccinated. 8 Personal fear, distrust in vaccines, and partisanship all play a part in overall public health immunity. 9 Unfortunately, the greatest fears are noted in high-risk populations. 10,11 Barriers can be overcome by understanding why patients are declining vaccination and who is likely to decline. Hesitant

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The Journal for Nurse Practitioners populations include childbearing years, ethnicity, age, education as well as social media sources and politicized misinformation. 12 Similarly, hesitancy occurs because of misconceptions in how the vaccine works in the body. 10,13 Many younger people plan to wait and see how the vaccines affect others before considering. 14

Strategies to Improve Compliance
Providers can listen to patient concerns and find common ground, such as increased freedom or economic improvement. Other strategies are targeting specific fears with information 11 ; suggesting that all of us want to return to normal and open businesses, houses of worship, and restaurants; and informing patients as to how the vaccine works. 15 Information in handouts and CDC educational pamphlets, providing vaccination locations, and informing the public that there is no cost are also helpful strategies. 9,15,16 How the Vaccine Works The messenger RNA (mRNA) in the Moderna and Pfizer vaccine is carried into the cell by fatty lipids. This lipid protective coating must be kept at low temperatures to keep it from dissolving. Potassium chloride and sodium chloride in the vaccine keep the acidity similar in the body. Sucrose stops the nanoparticles from adhering together when frozen. 17 Once in the cell, the mRNA vaccine uses cell ribosomes to make coronavirus spike proteins, and T-helper cells release cytokines, which, in turn, stimulate lymphocytes to make antibodies that recognize COVID-19. 17 These vaccines do not enter the nucleus and do not alter DNA or cause genetic changes. 14 The J&J vaccine is based on a recombinant adenovirus vector that does not replicate after administration and clears from tissues after injection. The vaccine is not a live or attenuated vaccine. 14

Racial and Ethnic Populations
Communities of color have been disproportionately affected by the pandemic. The CDC states COVID-19 affects nearly 3 times as many Black, Hispanic, and Native Americans compared with White populations. These communities are more likely to suffer severe illness because of economic disparities, systemic racism, and inequities in the health care system. The American Medical Association's video series "Prioritizing Equity" found that although 60% of Americans will take the vaccine, only 42% of Black Americans are willing to get vaccinated. 14 Distrust stems from harmful research done in the past. For example, the Tuskegee Study from 1932 to 1972 allowed Black men free health care, who, in turn, were used to study untreated syphilis without consent. 18 Marcell Nunez Smith, MD, MHS, the current chair of President Biden's COVID-19 Advisory Board, suggests reminding communities that there is another history of Black pioneers in the field of public health. She emphasizes the "important role of health care providers as trusted messengers" in overcoming vaccine hesitancy and the disproportionate loss of life. 14 She suggests that White communities need to strategize to increase commonalities between providers administering the vaccine and the patient. 14 Recent studies show significant improvements in the Black communities, whereas Hispanic and Indigenous populations still fall behind despite eagerness to obtain the immunization. Many in these communities are concerned about missing work, the cost, and immigration status. 12,14 Similarly, the history of genocide and sterilization of women without consent in the 1960s to 1970s has traumatized Indigenous communities, causing fear of vaccination. 16 "To earn trust in the new vaccines, public health leaders will need to seek out 'sources of authority' within those communities," stated Zackary Berger, a bioethicist and associate professor of medicine at Johns Hopkins School of Medicine. "You can't say it's time for the vaccine now; believe in us." 15

Childbearing Years
The American College of Gynecology recommends that COVID-19 vaccines should not be withheld from pregnant individuals. Although the safety data on use are not complete, there are no data to indicate the vaccine is contraindicated. 19 The Elderly Access can be improved by having a vaccine dose waiting for the elderly population at scheduled appointments. A 2010 study at Rutgers University showed that informing people that a dose of flu vaccine was waiting for them at a specified time and place boosted their vaccination rate by 36%. 9

Social Media Misinformation
There is a significant amount of discussion on social media. Much of the information feeds into fears of government control, conspiracies, and distrust of vaccination. Unfortunately, the majority of people on these sites have dispersed misinformation that leads to the refusal of vaccination. 15,20 Suggestions by the CDC may be useful in online information. 21 Research by Rupali Limaye, a health communication scientist at Johns Hopkins Bloomberg School of Public Health, reveals resistance from people ambivalent or wary. "One thing that we've learned very clearly is not to correct misperceptions because people feel as though we are being dismissive." 22 It seems advisable to direct the conversation to mask wearing because the discussion of vaccination is met with such resistance. Many people may decide to vaccinate once they feel reassured, and concerns (such as long-term side effects) are not dismissed. 22 Politization An unusual aspect of the COVID-19 vaccine hesitancy stems from political alliances, which does not occur with other vaccines, such as influenza or shingles. Studies show that 84% of Democrats see the outbreak as a public threat compared with 43% of Republicans. 15,23 Rural Republican men are currently the most resistant population to vaccination. 24 It is recommended that providers listen but do not try to engage in a political conversation with patients who are adamantly against vaccination. While education in how the vaccine works is helpful, the important message to discuss is mask wearing for safety of self and others in this situation.

Summary
Vaccination can reduce the incidence of COVID-19 infection in the population. 9 The benefit outweighs the risk, and encouraging patients to take the vaccine will achieve an immunity for the majority of the population and decrease the risk of variants. Unfortunately, there are still many people who fear the vaccine. 22 Reaching "herd immunity" of 80% of the population is a goal, and currently the United States is at 30% vaccination. 23 Health care practitioners are in a position to strongly recommend vaccination against COVID-19. Understanding fears and having empathy for patients' point of view will allow practitioners to educate in a manner that breaks down barriers and encourages confidence in the vaccine. 22