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Upping the anti: How health workers can engage anti-vaxxers and the vaccine hesitant with grace and patience

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Dr Remy Daroowala is a medical doctor from the UK. He worked in rural hospitals in the Eastern Cape and KwaZulu-Natal before moving to Cape Town to work in Infectious Disease Research at the University of Cape Town. He founded www.mindful-medic.com, an online community to improve wellbeing and destigmatise mental health issues among healthcare workers.

The anti-science, anti-vaccine movement is a relatively new phenomenon, one that, far from demonstrating ignorance, is seen by its followers as aspirational, with voices speaking against the medical-industrial complex. Public health messaging is going to have to evolve quickly to meet this new age of misinformation.

On 30 August in Daily Maverick, I wrote about how healthcare workers could bridge the gap between science and anti-vaxxers. Online, someone wrote back: “This is their hill and they’re willing to die on it – and I’m willing to let them at this point.” While I understand and empathise with the depth of frustration behind this statement, it is you, my friends and colleagues holding the hands of the people on that hill. We aren’t smiling and saying, ‘I told you so”. We are taking on yet more vicarious trauma and mental anguish.⁠⁠

It feels like compassionate conversation between those with opposing ideas has been a challenge for more than a few years. Brexit, followed by Donald Trump’s election in 2016, seemed to mark the advent of a weaponised internet landscape. Lockdowns have pushed people apart not only in the intended, physical sense, but in an emotional one, too. As a result, we spend increasing amounts of time online in this depersonalised environment of clapbacks and takedowns. While some of these meme- and retweet-worthy responses may be satisfying or cathartic, they often fail to reach someone else.

Offline, I have had several difficult encounters with vaccine-hesitant or opposed people and left many of these feeling like a failure, as if I were unable to adequately fight for the corner of knowledge and reason. It was after reflecting on these conversations that I realised that the scientific content is only part of the story. In the words of Professor Heidi Larson, founding director of the Vaccine Confidence Project, “there’s all this focus on the public understanding the science. I think we’re not focusing enough on scientists understanding the public.”

Communication is traditionally classed as a “soft” skill in healthcare, but this term diminishes its importance and perhaps instils a sense that it is an optional one. Now more than ever, these conversations are vital and potentially lifesaving. A kinder, more compassionate way of dealing with this issue doesn’t only benefit them, but us as a profession and a community, too.

I wrote the following not to change someone’s mind but to help in approaching them with a kindness and compassion that fosters open communication, understanding and exchange of ideas. Then, and only then will we have a hope of getting through.

1. Consent

As healthcare professionals at the thick end of this pandemic, we often feel duty bound to share our opinions with others. Checking whether someone is willing to have a conversation about vaccination is an all-important first step. Whether you are medical or not, imposing an opinion onto someone is a fruitless exercise that is likely to do at least two things: build resentment and chip away at your crumbling reserves of morale.

2. Check in with yourself

It is important to remember that we don’t always initiate these conversations. I speak for many in stating that we would rather not spend our downtime engaged in public health messaging. However, hearing a half-truth stated with infuriatingly misplaced confidence you may find it hard to bite your tongue. Pause here.

How are you, really? Are you tired and stressed from a taxing shift? Have you had to hold the hand of another unvaccinated patient breathlessly pleading for a jab before you put them on a ventilator? In these moments, balance and reason leave the best of us.

If you can’t guarantee that you are able to give your side of the story in a way that is fair, balanced and without condescension, walk away. It is not a failure on your part. We are all human and have emotional biases and there is great strength in recognising that fact. If it is likely that you are going to do more damage than good, then walking away is a net win, no matter how many trials and studies you have ready to quote.

3. Practise active listening

Seek first to understand, then to be understood. Stephen Covey placed this skill as the central pillar of successful communication in his book, The 7 Habits of Highly Effective People. In it, he notes that we often respond to others in one of four ways: evaluating, probing, advising or interpreting. As healthcare professionals, we tend to see the issue of vaccination preference as a problem that we are uniquely placed and qualified to solve. To an extent, this is true, but in actively listening we can uncover a narrative, a fear, an unmet need, or expectation. In our eagerness to fix, we deny the other an opportunity to share their truth and miss an opportunity to see where we can be most effective.

4. Know your audience

It is important to tailor the information to the person that you are speaking to, and you will only be able to do this properly if you have followed the step above. You will now know if you are speaking to someone who is vaccine hesitant or a fervent anti-vaxxer. You will also have an idea if this is a worried, vulnerable person who has suffered trauma in the medical system, or a full-blown conspiracy theorist.

If it is the former, effective communication could steer this person towards vaccination, while a traumatic or forceful interaction with a healthcare professional could deter them. If it is the latter, perhaps the realisation that you will not be able to convince this person no matter how hard you try is the best result. If you can defuse the conversation, walking away with grace and equanimity, you may be doing more for your cause and your mental health than you realise.

5. Guide, don’t direct

Motivational interviewing is an effective technique that has significantly outperformed traditional advice-giving. Instead of outmoded, prescriptive advice that generates resistance, motivational interviewing elicits the desire for change from the patient, placing us as well-informed guides collaborating with a fully autonomous individual.

Importantly, motivational interviewing employs active listening, with reflective statements such as, “it seems like you are worried about the side-effects of the vaccines?” Such statements demonstrate empathy and encourage the interviewee to elaborate further. You will understand where the other person is mentally, physically and emotionally and can guide the conversation in line with their concerns.

6. Recognise your limitations

This anti-science, anti-vaccine movement is a relatively new phenomenon, one that far from demonstrating ignorance, is seen by its followers as aspirational, with voices speaking against the establishment, to independence and naturalism. These are people who view themselves as making a positive health choice by stepping away from the medical-industrial complex. This is not something we have been adequately prepared to address and we do not yet have all the tools. Public health messaging is going to have to evolve quickly to meet this new age of misinformation.

7. Play the long game

It is more than likely that this will not be the last pandemic in our lifetime. While Covid-19 is unprecedented in modern times, the World Health Organization has declared five other public health emergencies of international concern since 2009, with swine flu, the Zika virus, Ebola and a resurgence of polio. Fate seems to be knocking on our door and when the next pandemic comes along, we may rue having burnt any bridges. DM

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