Vaccine Confidence: Building Trust

At the Core of Care

Published: April 19, 2021


Sarah: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families and communities. I'm Sarah Hexem Hubbard, Executive Director of the Pennsylvania Action Coalition and the National Nurse-Led Care Consortium.

As part of our special COVID-19 vaccine confidence efforts, we're creating a series of podcast episodes that can be helpful to nurses at this time and the communities they serve. During these episodes, we'll be hearing from nurses across the country. We know that depending where you are, your experience with vaccines, vaccine deployment, even with COVID-19 is going to vary. And that's to say nothing of the personal, social, and cultural histories that we all bring to this facet of public health.

On this episode, we're going to explore the concept of vaccine confidence, discuss some of the behavioral techniques that nurses are adopting at this time to build vaccine confidence, and how trust and empathy are crucial to the process. Joining us today are Stephen Perez and Jasmine Nakayama from the Centers for Disease Control and Prevention.

Stephen is a lieutenant in the US Public Health Service. He's also a nurse epidemiologist with the Transmission and Molecular Epidemiology Team in the Division of HIV Prevention at the CDC. Up until recently, he served as the clinical lead for the CDC Vaccine Confidence Team. And now Jasmine is the clinical lead. She's an Epidemic Intelligence Officer at the CDC National Center for Chronic Disease Prevention and Health Promotion in the Division of Nutrition, Physical Activity and Obesity.

Our conversation with Jasmine and Stephen reflects their opinions and does not necessarily reflect the official position of CDC. And at the end of the episode, we're going to hear from Dr. Gloria Jones, a Maryland-based family nurse practitioner about how she's building vaccine confidence in the community where she provides care for individuals with intellectual and developmental disabilities.

But first, let's turn to Jasmine Nakayama and Stephen Perez, thank you so much for joining us on At the Core of Care.

Jasmine: Thank you for having us. We're very excited to be here.

Stephen: Yeah, thank you so much.

Sarah: So to get started, we always love to hear from our guests a bit about how they got to this point in their career, how they became a nurse. Can you share what drew you to nursing, you know, how each of you got into your current role?

Jasmine: I was initially drawn to nursing so that I could use science and data to care for people and communities. After I worked as a nurse in various clinical settings, I went back to school for a PhD in nursing. And then I started a training fellowship at CDC to apply my experience and education to public health. And the major part of this fellowship is to learn new skills and get varied experiences. So when Stephen told me about this clinical lead role in the vaccine confidence team as he was stepping out of it, it sounded like a really wonderful opportunity to contribute to the public health response to this pandemic.

Sarah: And Stephen, how about you? What drew you to nursing?

Stephen: I've always really been interested in public health and communicable disease, and I saw nursing as an opportunity to explore those interests. But also it allowed me to sort of be able to work directly with individuals with their families and their communities. And I spent time working clinically as a nurse and a nurse practitioner, and I got some policy experience in Washington DC as well. And that experience really helped me realize that I wanted to get some additional training in science and inquiry, because I think that would really help me affect some real change. So after my PhD, I did the same fellowship program as Jasmine and I took a permanent position with CDC. And working with the vaccine confidence team was a great opportunity to use a lot of the skills that I've gained during my career to help serve on the COVID-19 response.

Sarah: And besides the current pandemic, have you ever worked as a nurse during another public health crisis?

Jasmine: I worked in an emergency department when there were cases of Ebola in the US. And we weren't one of the hospitals that saw that. But I do remember that preparation and apprehension. This feeling that the next patient coming through the door could be the one carrying that pathogen. I also worked at a clinic during the opioid overdose epidemic, which is still ongoing, and I saw how that was dramatically affecting individuals, families and communities. And of course, this current pandemic that we're living in is unprecedented, but I do see some similarities. These public health crises require preparation, can evoke a lot of emotions, and have far-ranging effects.

Stephen: And I've spent most of my career working as a nurse or nurse practitioner caring for people living with HIV. And I think even now, I see a lot of parallels, particularly in the way that nurses were called to lead early on in both pandemics, the work of nurses in both pandemics can be really isolating and stigmatizing. And there were a lot of unknowns, especially in the early days. At the same time, though, nurses really rose to the occasion. And they continue to do so every day. And I think we're still learning lessons from both crises and will continue to be for a long time.

Sarah: And I'm wondering if we could explore, you know, Stephen, and what you were talking about in terms of nurses leading in a public health crisis. Can you tell me a little bit more about how you see nurses taking lead in this pandemic?

Stephen: Nurses are, certainly, as we've seen, come to light in this pandemic, but have always been really at the frontline of healthcare. They're often the ones that are at the bedside in the clinic day in and day out and working hands on directly with patients. And I think, in that space, nurses are natural leaders, and they have the ability to become leaders, because they are so close to the patient, they are doing the work that's in and out of the patient's lives every day. And so I think, as we've seen, nurses sort of be elevated to the front line, we know that they've been on the front line this entire time, both in this latest public health crisis, but in many others as well. And nurses, as they always do have just risen to the occasion, time and time again. And we've seen that over and over and over again with this pandemic.

Sarah: So at this point, millions of Americans have been vaccinated, but there's also some hesitancy. And we've talked on a couple recent At the Core of Care episodes about how nurses are navigating that on multiple fronts. Can you break down for us how vaccine hesitancy has played out historically?

Jasmine: I think that's a really interesting and very important question. And I want to reframe it a little bit and talk more about vaccine confidence rather than focusing on vaccine hesitancy. At its core vaccine confidence is the trust that individuals, their families, their communities, and also healthcare professionals have in vaccines development, implementation, use and effectiveness. And we do know that some communities who have experienced mistreatment and traumas from the health care system may have mistrust in those institutions. And this mistrust can contribute to issues with vaccine confidence in these groups. So we're seeing this in racial and ethnic minority groups and others who have experienced mistreatment. And there's this idea that we're using the word hesitancy as an excuse to explain low vaccination rates among communities of color, rather than confronting long held equity and access issues. And as a result, we're seeing that structural issues are often being met with individual level intervention than solutions.

Sarah: So I loved the reframing of, you know, this isn't about hesitancy, it's about confidence. And I think it would be great to get into those examples, I'd love to talk a little bit more about vaccine confidence, and I know that you defined it. But if one or both of you could speak more to you know, how you define confidence, how you see that playing out the origin of vaccine confidence?

Stephen: The key to vaccine confidence and confidence in lots of different interventions, and in the medical system as a whole. And there's been a lot of discussion about this is really the foundation of trust. You know, we talk about those two concepts together, because they really do go together. And I think, in our framework, and when we think of confidence in general, we really focus on trust and trust in the messenger, trust in the processes, trust in the delivery system. So all of these components, they have to have trust behind them in order to instill confidence, again, both in the vaccine itself and also the confidence in the messenger that's delivering education and information about the vaccine. And trust is really key. And it's critical. And if we can't build trust among the people who are vaccinating and among the people who are receiving the vaccine, then we have difficulty in building confidence.

Sarah: Misinformation is another topic that we've been exploring through this series. And we know nurses are pulling information from CDC, directing patients to CDC. That's certainly where we direct folks to go. Can you walk us through what the process is for vetting information at CDC? You know, what are the measures that you take to ensure that you're providing credible information to the public?

Stephen: As you can imagine, vetting of scientific information that yields national guidelines is really critical to this response. And I can assure you at CDC we pride scientific integrity and professional excellence in all that we do and every day CDC functions off of a set of core values around accountability. You know, we're stewards of public trust and public funds. And we have to act decisively and compassionately to serve the country, and really to serve the world. We have a core value of respect within our agency and around the world. And then again, we follow a core value of integrity to be honest and ethical in all that we do. And since January 21, of 2020, CDC has mounted an agency wide response to this pandemic, and we've been preparing healthcare workers, learning more every day about how the disease spreads, and providing support to state, local, tribal and territorial governments on the frontlines of public health. And we do this, pledging every day our highest quality scientific data that's derived openly and objectively. And so all of these data are evaluated by experts, by scientists, within our agency and sometimes outside of our agency. Just to give you an example, when we look at putting out vaccination guidelines, we have an Advisory Committee on Immunization Practices, or ACIP, as most people have heard, and this is an independent Federal Advisory Committee of medical and public health experts that provide advice and guidance to our CDC director. And this guidance is about the most effective means to prevent vaccine preventable diseases in the United States. So this model has been in place for vaccine guidance for a very long time. And it's one that we use to develop COVID-19 vaccine guidance as well. And so ACIP develops written recommendations, you know, subject to our directors approval for routine administration of vaccines. So we have established practices that we've used for other responses, other public health issues in emergencies. And we continue to adhere to those core values and processes to make sure that we're getting out the best information that we have to the American public so that they can make decisions to protect themselves and their families.

Sarah: And I don't know that all public agencies have that trust really that CDC has earned. What do you think the source of that is?

Stephen: I think it's established trust from years of service to the country. You know, I think one of the things that we are realizing is how critical public health is a lot of times public health stands in the background. You know, there's an old saying that public health is working well, when you don't know that it's there, because it's doing everything that it's supposed to be doing to protect communities to prevent disease and to promote health and wellness. But public health is a large infrastructure and CDC time and time again, has responded sometimes in the headlines, and sometimes not, but always working diligently to respond to public health crises and emergencies, but also everyday public health issues that affect the country.

Sarah: And you spoke earlier about the role of nursing and your role as a nurse. We've seen nurses throughout the pandemic, in the frontline, and then part of the vaccination efforts. So how are nurses supporting the vaccine efforts?

Jasmine: Nurses have so many roles in this pandemic. Nurses especially are trained and experienced, and having these conversations with patients with colleagues with family members and communities. These conversations that are rooted in empathy and understanding when we're communicating important health information. And data indicate that people are most likely going to turn to health care professionals when they're deciding whether to get the COVID-19 vaccine. And we know that nursing has been ranked the most trusted profession for 19 years in a row now, we have a critical role to play in communicating these key points with our patients and communities. Things like the COVID-19 vaccines are safe and effective, that people might experience side effects after vaccination, but they're normal indicates that the body is mounting an immune response. And as healthcare professionals, our impact is often centered around helping patients trust in us as the people who give the vaccines. But I think it's also important to recognize that we can have a role in building trust that people have in the system, trust in the policies, trust in the processes, and helping our patients to understand the new vaccine technologies, what to expect in terms of possible side effects, how these vaccines are being continuously monitored for safety. Another important part to note is that being honest about what we don't know is equally important to build this trust.

Sarah: Yeah, absolutely. And I think we've definitely been hearing that from our other guests and yeah, trust starts with honesty, you know, given that trust in nurses and that experience, we're really thinking about that behavioral science approach to building vaccine confidence. So we'd love to hear from you, what skill set can nurses bring to help build this vaccine confidence?

Stephen: So nurses are trained to think across the healthcare spectrum. And that means thinking holistically about their patients and the individuals and the communities that they're working in. And so that really means that nurses bring a very unique training and skill set to the discussion of trust and confidence, especially when it comes to COVID-19 vaccines. And there are a lot of behavioral science models out there. The stages of change model is one and CDC uses a World Health Organization model to think about some of the social and behavioral factors that drive COVID-19 vaccine uptake. And this includes factors that are like what people think and feel, social processes, motivation, and practical issues. And each of these domains is really important because they can each be measured to understand enablers and barriers to COVID-19 vaccine uptake. So things like what people are feeling confidence in vaccine benefits, confidence in vaccine safety, perceived risk for self and others. Some of the social processes might be influencing others to support vaccination, workplace norms, vaccination norms, and the community trust in the providers. And then motivation is what's a person's intent to get a vaccine, what's driving them towards vaccination? And then thinking through practical issues. Like, as we talked already about access, has there been previous uptake of vaccination? And what are some of the preferred areas or places that people can go to access a vaccine, maybe it's in a non traditional site, maybe it's outside of our healthcare setting. So there's a lot of practical issues. And what this all boils down to is that there's a lot of factors, individual factors, community factors, societal factors, and then policy or political factors as well, that can impact someone's decisions to get vaccinated. And some of these factors may be in the individual's control, and some are outside of their control. So we hope that we can better design communication and community engagement strategies, if we have the data, and we can measure some of these responses and attitudes. And we've shown that we can, and so we were able to sort of use this information to craft better interventions around trust and confidence. And we think about confidence, you know, we think about how to model confidence, we know that it falls along this continuum. And we talk a lot about this continuum at CDC. This idea on one side of the continuum is refusal. And on the other side of the continuum is demand. And then right in the middle, there is this sort of idea of passive acceptance or this wait and see approach. And we really focus a lot of our efforts on that wait and see group because those are the groups that are often concerned about side effects or concerned about other issues around the vaccine. And so those are the ones that we really try to target and communicate with to try to get them out of that movable middle.

Sarah: And so how would a strategy like motivational interviewing work with that wait and see group.

Jasmine: Motivational interviewing is a great technique. It's a collaborative, conversational style to strengthen a person's own motivation. It's collaborative. It's very complementary to what we recommend in terms of having conversations from a place of empathy and understanding. It's all about partnering with your patient, or your family member or someone you're talking with in the community to focus on a conversation a nurse and a patient may have. But it's really partnering with this patient and understanding their intrinsic motivation to change behaviors. It's exploring their thoughts and their decision making and helping patients resolve possibly contradictory feelings or ideas. And ultimately, it's nurses, recognizing patients’ thoughts of changing behavior, and nurturing these thoughts into commitments toward a particular health goal. And so some core principles of motivational interviewing include, emphasizing and supporting that the patient has a central and critical role in managing their own health, honoring the patient's preferences for involvement in their care and decision making, respecting the patient, respecting their thoughts, their decisions without judgment, communicating with compassion and really seeking the patient's health and well being. And also seeking to understand where the patient is coming from, understanding their motivation, asking open ended questions to elicit them telling you more rather than assuming that they know certain things or believe certain things or even want to hear certain things.

Sarah: So what are some concrete steps for nurses who are listening who want to practice these skills?

Jasmine: First, ask permission to discuss a topic, basically asking to be invited to a certain space because some of these conversations can be very personal. And second, explore the patient's understanding, beliefs, experiences, what they have seen and heard, what they're thinking, and then affirm and support where they are, especially the positive things, things that the patient is already doing to mitigate the risk of getting COVID-19, or spreading it to others, confirm their past successes. And then once again, ask permission to share more information specifically about COVID-19 vaccines and check for understanding. And then finally, you want to confirm the next steps and plans and possibly schedule a follow-up for further conversation.

Sarah: There's so much value definitely that nursing is bringing in terms of skills, background, approach. Another best practice seems to be involving a diverse, broadly representative group of nurses in vaccination, vaccine deployment that are designing these campaigns. So how have you seen the diversity of nursing in the vaccine rollout?

Stephen: Diversity of nursing is just really critical. When you have diversity in nursing, you bring a richness to the profession and the communities that they serve, because it brings in different life experiences, different viewpoints, all of which are important to bring to the table and share with communities and patients. And it's critical because in general, nurses and all healthcare professionals should be representative of the diversity of the communities that they're working with. And we talk a lot about in confidence how trusted messengers are extremely effective when they represent the communities who are receiving their messages. And so this is really key across all communities affected by health disparities and inequity. And highlighting and increasing the diversity in the nursing community is really only going to benefit communities and benefit the COVID-19 response and vaccine rollout.

Sarah: So how have we been seeing the vaccine effort differ in communities of color in terms of access to the vaccine or uptake of the vaccine

Jasmine: We’re hearing more reports about the idea that hesitancy is being used as an excuse to explain low vaccination rates among communities of color, rather than confronting long-held equity and access issues. And so we're seeing that these structural issues are being met with individual-level interventions and solutions.

Sarah: And so can you give a couple examples of that?

Jasmine: We've seen that even though these COVID-19 vaccine supplies have increased and states have dramatically expanded eligibility criteria, our data indicating that vaccination rates for Black people have not caught up to those of white people. And in some states, white people are vaccinated at two to three times the rate of Black people. And we do see that early polling data reported that Black people were more likely to be vaccine-hesitant. But one year later, it seems like vaccine access may be a greater threat to vaccine uptake, or at least a very considerable threat. And we're seeing issues such as vaccination sites are less common in Black communities, Black Americans face longer driving distances to these vaccination sites than their white counterparts. And appointment access codes have been misused by some people for whom they were not intended. Lack of Internet access and technology is also a threat to vaccination coverage. Nearly half of all people in the United States who don't have home internet access are people of color. We know that the majority of appointment booking systems are online. So that's one significant barrier. And also Black people are overrepresented in frontline and essential jobs which makes it more difficult for them to take time off work and further compounding those issues. And we're seeing similar challenges in different groups including adults over the age of 65, non-US born people, and people living in rural areas.

Sarah: What are some solutions to address the inequity in transportation, Internet, other access issues? So what are some ideas to try to make it easier for people to make and get to appointments? As an example, you know, we've heard from nurses and office staff in Massachusetts who are essentially just cold calling people every day to make appointments, which takes a lot of resources. So what are the best practices to address that access issue?

Jasmine: I think part of it is having these innovative, creative solutions. And Stephen mentioned one about offering vaccination at non-traditional sites, this may be particularly useful for people who have mistrust of the traditional health care institutions. Another idea that I've heard is using existing programs and systems to really bring vaccines to where the people are. So like Meals on Wheels programs, I think a big part of it is connecting with the communities and capitalizing on current relationships and strengths.

Stephen: That's what we spend a lot of our time doing is really working across relationships and community groups and national groups, you know, and leveraging those relationships to create interventions. And I think the other thing that we really have to make sure that we do is understand what those barriers are, you know, I think, as Jasmine mentioned earlier, there's a lot of assumptions about hesitancy and different groups. And we really have to understand and do the work to understand what's going on in communities so that we're creating effective interventions first.

Sarah: Thinking back on this past year, and your roles as nurses and in your role as clinical leads with the vaccine confidence effort, how do you see these experiences impacting your approach and practice? And then more broadly, how do you see the experience as a pandemic impacting the future of health care?

Jasmine: This pandemic has been a very unique threat to our country and the world. And we've all taken unprecedented action to meet the challenges of this time. And I think that we can take a lot of the lessons learned moving forward, to improve our response to future public health issues. And so specifically, what Stephen and I have been doing is just contributing to our agency's response. And we have core capabilities of using world-class data and analytics, state-of-the-art laboratory capacity, and public health expertise, in order to really respond to outbreaks at their source, and build global capacity and domestic preparedness. And I think that we can take all of the lessons that we have learned this past year and just make those better.

Stephen: Yeah, I agree. I think for me, this pandemic has taught me a lot about communication. You know, as nurses, I think we're trained on how to communicate mostly to patients, you know, one on one, which is really critical and important. We've talked a lot about how to talk to patients and communities. But I think even in our training programs, and certainly, you know, at CDC and elsewhere, we're taught about crisis communications and things like that. And, but I think this was different. And when I was in a state health department, we were writing guidance for healthcare facilities or contributing to a policy document. And then you have to turn around and develop or contribute something that's much more public-facing that's meant to impact and reach communities. And I think now I sort of keep that in the back of my mind, I kind of asked myself how we're going to get these key messages across to different audiences who really need to hear them. And how do we do that effectively and accurately, particularly in a situation that literally is changing day to day. And I think we're going to be learning lessons from this pandemic for a long time, as I had said before. And for people who are in healthcare and in public health, I think this will be a career-defining response and a career-defining moment. And, you know, we have to keep equity at the forefront. And I think this teaches us that public health and health care can't exist without each other. They're different concepts, I think, community health and public health and health care. These are all different concepts and how we're taught and how we're trained, but they're really all connected. And nurses work across all of these different continuums and structures. And you can't have hospitals or long-term care settings without primary care. And you can't have primary care without community health engagement. And you can't have any of that without public health infrastructure. So what's amazing is that nurses work throughout all these domains. And my hope is that whatever changes come from this, that nurses have a central role in leading those changes.

Sarah: So thank you again so much for making time to talk with us today. I'm glad that the two of you are working on this effort and to see nurses doing this work is just so important. So thank you for the work that you're doing, and also for joining us today.

Jasmine: Thank you so much for having us. It's been a pleasure. And thank you so much for all the work that you're doing to encourage and support nurses across our nation.

Stephen: Yes, thank you so much. It was great to be here.

Sarah: And finally, we're going to hear from a family nurse practitioner about how she's building vaccine confidence in the Maryland community where she provides care for individuals with intellectual and developmental disabilities.

Gloria: I'm Dr. Gloria Jones, family nurse practitioner. I'm based here in Silver Spring, Maryland. I work with individuals with intellectual and developmental disabilities.

With this population, the rollout for the COVID vaccine was a little bit slow in terms of this population was not necessarily at the forefront of the rollout, if I could say so. So what happened with us in terms of as healthcare providers, there was a lot of education that we had to provide, not only to the individuals that we serve, but also to the families, to the providers that provide in-home support services, as well as to the POAs and the guardians. There was a lot of hesitancy, a lot of questions being asked a lot of times from individuals, those that are high functioning. And they would ask a lot of questions. A lot of times it was because they felt it was not safe. They would verbalize this, they would say that it seems like it's rushed. And in some cases, because of their experience with some health care providers, they felt that they were being used as guinea pigs. And because of the fact that unfortunately, in some cases, the population that we serve don't always have the best experiences with the health care providers, that is sometimes not as sensitive as they need to be to this population. Those all the obstacles and hurdles that we had to overcome, to be able to get them comfortable with just the idea of receiving the vaccine, and just providing that additional support and education in that regard.

I kind of step back for a moment, and ask them the question, What do you know about COVID-19? What do you know about the vaccination? What have you heard? What are you talking about with others? Because what I find that does is that opens the conversation, as opposed to me saying to them, Why haven't you received your vaccine yet? What are you waiting for? What happens in that regard, they tend to get more defensive. And now you shut down your communication. So by me asking them the question, then I can actually help to answer any of their concerns. Because if they say to me that the vaccine is not safe, and this is one of their concerns, then I can actually speak to them on the efficacy, evidence-based, of course, of the vaccine, and also talk about the safety profile.

So these are the conversations that I tend to have. And I can do this, if I allow them to speak first, if I go in and explain to them initially why they need to get the vaccine, why this is important. I haven't allowed them to explain to me why they haven't gotten the vaccine or why they're hesitant in getting the vaccine. So this approach from me helps. And then I can now explain all the different types of vaccines, scheduling the vaccine, what they can expect, we can have those types of conversations now.

I got vaccinated, fully vaccinated, because I have to also explain that to my population as well, because a lot of times they tend to think after they receive the second vaccine, they're fully vaccinated. But it's not until at least two weeks after that you're considered fully vaccinated.

So I think it's very important that you share your experiences, as well as your challenges as well as your hesitancies. I think you should be fully transparent when speaking with these individuals. So just in general, because it's something that they can benefit from and learn from if you talk about and say, Well, you know, initially I was hesitant to receive the vaccination and share some of your concerns as to why it's different for each of us. That I'm sure and that way, they sit and they listen, and they pay attention to what it is that you say. And they say, Well, you know what, I didn't know that you would have felt that way. You know, so then it seems like they would get a little bit relieved to some degree when they hear that someone else also is willing to share that someone that they trust is willing to share that they too had hesitancy initially and may still have hesitancy but again, you tried to overcome those obstacles or whatever those barriers are for them not getting vaccinated.

I think that needs to be something to do more public announcements about. I know you hear it from politicians and others and you hear it from celebrities, but I think if we can actually have others, I’m talking about from my community, specifically, others that look like them and have some of the same, I guess intellectual developmental disabilities also sharing their experiences, it goes a long way. They identify with what they see, and who they see and who they interact with. And they also trust them as well, because they feel like hey, they just like me, they're going to tell me the truth, and that also helps to overcome some of their fears. 


Sarah: Funding for our special vaccine confidence series comes from the Centers for Disease Control and Prevention. Stay tuned for more episodes coming up. We'll be exploring how nurses can become trusted messengers, build confidence, partner with community-based organizations, and share their vaccine experiences. And for more information about related upcoming webinars and where to find COVID-19 resources, log on to You could also stay up to date with us on social media @NurseLedCare.

At the Core Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.

I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.

This project was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention (grant number NU50CK000580). The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services (HHS). The contents of this resource center do not necessarily represent the policy of CDC or HHS, and should not be considered an endorsement by the Federal Government.