Vaccine Education Strategies for the Long Haul

At the Core of Care

Published: April 17, 2023

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 with the Pennsylvania Action Coalition and the Executive Director of the National Nurse-Led Care Consortium.

We’re closing out our special series taking stock of the COVID-19 pandemic with Letha Joseph and Adeline Kline. They are members of our vaccine confidence advisory committee, and will talk about the importance of relationship-building with community members to help promote health and wellness goals.

Letha is joining us from Durham, North Carolina. She is a nurse practitioner, a program director at the Durham VA Healthcare System and consulting associate at the Duke University School of Nursing.

And Adeline is on the line with us from Honolulu, Hawaii. She is a family nurse practitioner and clinical educator for Hawai’i Keiki, which is a partnership between the University of Hawaii Mānoa School of Nursing and the Hawai‘i Department of Education.

Our producer Stephanie Marudas spoke with Adeline and Letha.

STEPHANIE: Thanks Sarah. Adeline and Letha, welcome to At the Core of Care.

ADELINE: Happy to be here.

LETHA: Thanks for having us.

STEPHANIE: We've heard that the federal government is considering lifting the COVID-19 public health emergency. And you both have been involved with the Vaccine Confidence Advisory Committee at the National Nurse-Led Care Consortium, and we'd love to hear why you both got involved. Letha, could you lead us off?

LETHA: You know, the Vaccine Confidence Advisory Committee of NNCC, I think that was one of my highly productive professional ventures. So the COVID-19 pandemic created unique needs. Of course, we knew the patient needed support, and every area was affected. However, support for the professional community, it was a significant need. And from the beginning of the pandemic, I was involved in activities including educating healthcare professionals on emerging best practices for pandemic management, as well as resilient strategies. And once the vaccine became available, improving vaccine acceptance became an additional focus. As a nurse practitioner working with all the veteran populations, a patient group that was disproportionately affected by the pandemic, vaccine acceptance, getting more and more people vaccinated, that became my primary focus. So, the Vaccine Confidence Advisory Committee, its mission and its goal, that really aligned with my interest.

STEPHANIE: Thank you Letha for sharing your perspective. And Adeline, what about for you?

ADELINE: So it's interesting, you know, thinking about the close of something, right? Because there's this implication of an end. And so what we know really is COVID-19 is here to stay. As we move into the world of endemic versus pandemic, it feels as though we're going to smooth life out a little bit, which I don't know that that's happened, but you know, we're, we're all trying the best we can. What I really appreciated about the role with the Vaccine Confidence Advisory Committee was being connected to all these people across the country and hearing the similar challenges and how they played out in different geographical areas. Like it may have been a different patient population, but you know, we still had the same conversations around trust, around safety, around efficacy. And being able to come to the table and provide high quality evidence and the latest research and the upcoming updates were just invaluable in a time where information was flying heavy from every direction. And it was really nice to have a really solid grounding source and connection that I could then bring back to my colleagues and the community we serve here in Hawaii.

STEPHANIE: What I'm hearing is having this group that can vet information, be supportive, provide resources, and something that we've heard throughout our series is the word ‘trust,’ and how to cultivate that within the health community and for people to get vaccinated. And I wonder, Letha, a lot of your interests over the course of the pandemic has been focused on how to motivate people to get vaccinated. And so, from your perspective, can you tell us some key considerations that you've studied along the way, especially since you have a journal article out on this topic now?

LETHA: Yes, Stephanie, that's an area of my interest. And I did some work on vaccine hesitancy and improving vaccine uptake. And I was able to reach a national audience using different platforms. And we all know that vaccine hesitancy is not a new phenomenon. And you know, we hear about the comeback of vaccine-preventable diseases, including the measles and the polio. And also, we see every year the resistance to get annual flu shots, and we know these vaccines are not new. They are familiar vaccines, but still there is vaccine hesitance. Then what happened with the COVID-19, there was a surge in misinformation about the disease. So, when a new vaccine, which came probably the so-called record time, the misinformation and the skepticism, everything existed. So, the COVID vaccine acceptance, we cannot expect that to be an automatic process for people to wholeheartedly get it. Now speaking of vaccine hesitance alone, we tend to label people who belong to minorities as historically vaccine resistant. We categorize people and then we forget about them because we don't want to get to the root of the problem. We just mentioned about the big word, trust. That is exactly I want to highlight here. So, as we explore the factors which are leading to vaccine hesitancy, we realized that that people's lack of trust is the central issue.

People's past healthcare experiences made them lose faith in their healthcare providers and probably the healthcare system itself. And we might think they are referring to historical experiences and mistrusting the system. No. The person in front of you, they had experiences which are not very present. They have experienced discrimination. They have experienced several shortcomings in their care, so they developed mistrust. So, restoring that trust is essential if we want to improve vaccine confidence. If we want to improve the vaccine acceptance, it's actually not just for the vaccine, for any treatment, it is not just for the COVID vaccine, just for any vaccine. So the, the trust is the basic issue.

STEPHANIE: And, you know, thinking about what Letha just shared, Adeline, in your work, how have you seen these trust issues play out in school-based settings, given that you advise school healthcare providers, staff and families on health decisions.

ADELINE: So yeah. Letha, I love that perspective ‘cause I think you're right. It does come down to trust. What's so interesting in medicine is so often it's this pre-planned visit, right? You have a doctor's appointment or a nurse practitioner. You see a P.A. You go in. It's almost a position of power as the patient, you're waiting for them in the room. They come in, they're busy. What's so different working in the community setting, which all of us that are school nurses or nurse practitioners is we're working with people at their day in and day out. So, the students go to school, the teachers come to work, the front office staff, the custodians, the cafeteria, along with the communities that surround our children.

So, here in Hawaii, often it's parents or aunties or uncles. There's a lot of intergenerational households here. And so by being that medical person in a non-sterile setting, there's a bit more of that relationship building, and it's been so interesting to me throughout the pandemic how it's played out just by having an open door. So often people are dropping in, ‘Hey, what do you think about this?’ ‘Oh, I heard there's a new vaccine.’ ‘Should I get this dose or this dose?’ Right? Lots of conversations around safety and lots of opportunities to really talk to people in an informal setting as a medical professional with a wealth of knowledge, and really bring the information I have in an equal dialogue to the table. And that's been huge because it sort of creates opportunities for conversation, discussion, and input, and really does build on that.

LETHA: Yeah. It's interesting, Adeline, that you said, because you have that open door and people are actually approaching you for input that shows the trust they have in you and their faith in your knowledge or expertise. So they take your words for granted because they have good faith in you and they know that you want the best for them. So having that confidence, developing that trust, it is applicable in any setting. And unfortunately, the setting where we are so much creative, focused or disease focused, we may not have time to address or create the trust. Have that conversation where patient feels valued, where patient feels like a partner in care.

STEPHANIE: But how do you talk about it now? Especially with the shifting climate where we don't have vaccine mandates anymore.

ADELINE: So being in the school setting, so just addressing the students, we have requirements to sort of piggyback our CDC childhood vaccinations, and you're actually required to have them in order to attend school here in the state of Hawaii. And when we changed the laws a few years ago to include seventh grade for HPV, meningococcal, and Tdap, it, of course, was a year before the pandemic. So we had this interesting change in routine childhood vaccinations that then got put on pause, and now we're getting back to a world where now we're checking those vaccinations and we're saying, you know, if your child's not compliant in HPV, meningococcal and Tdap in seventh grade, they're not going to be allowed to come to school. And I bring that up because COVID-19 is not yet required for school entry for children. And at one point, staff had mandatory either vaccination or testing, and that sort of was lifted here as well in the state of Hawaii. So now it's part of the bigger conversation of, okay, you're sick. Oh, when was your last booster? How old are you? What are your risk factors? Let's pull up the CDC calculator. Let's talk about it in the context of your regular annual physical, you know, connecting people back to that. Starting to think about health maintenance again and COVID-19 vaccination being a talking part of health maintenance, the same as all these other routine vaccinations that we do.

And Letha, I just want to touch back on your conversation around not novel. I had that conversation so many times where I was like, no, really, this technology actually was developed at University of Pennsylvania and it's been there. You know, we tried it for all these other diseases and I would describe it to people as, think about what we could accomplish if we were always allowed to cut through the red tape. There were no steps in the safety process that were sacrificed. It really was just the bureaucracy that often time gets in the way of innovation and development. And as we move forward in the world post COVID-19 pandemic, I would love to see some of that not go away completely. I mean, the fact that we're sitting here on Zoom recording a podcast, right? That wasn't really standard practice four years ago. But now I think that virtual meetings are a part of our life, allowing us to sort of have a little bit more work-life balance. And so we don't need to drop everything, drive across town in order to attend meetings in-person.

There are still some really valuable things that are important to hold dear, and I'm so happy to have opened up the world. But I'd also like to see some of that innovation that came out of the pandemic really move forward and not disappear in terms of both vaccinations, technology, you know, access to care.

We talked about that, Letha, with our seniors. You know, I think that telehealth has really exploded the market and improved the ability for people to have care. And that really did come out of this crisis that we dealt with over the last couple years.

STEPHANIE:  As you mentioned, and to hand it over to Letha, you know, what are you seeing in your work in the veteran population along these lines?

LETHA: Yeah. So I mean, COVID-19 definitely had a lot of benefits or positive outcomes as well. It was not all negative. It had some positive aspects. So the telemedicine, telehealth, my workplace, we had telehealth, but once we became the pandemic situation, the use of telehealth has expanded. So, once you expand a program, there are going to be improvements happening on the way. We don't need to have these patients getting ready and traveling long distance and then coming with the family and able to navigate all these struggles. So now, unless they really need to be seen face-to-face, we can manage their care using the telehealth. So, you know, that is one advantage. And of course, the work-life balance is there. Use of technology is there. And now Adeline is from Hawaii and I'm from North Carolina. We are collaborating on this without that effort and so lot of knowledge sharing from place to place. Even NNCC, we talk about what is new happening in our workplaces. So, people who are interested, they're adapting, and the collaborations to work together and bring that knowledge out and testing new things. So all these things are good about the COVID-19 and you know, the resilience concept got a lot of momentum with the pandemic. The burn down or burn out, whatever we call that, that distrust was not new.

It existed years ago, decades ago, everybody knew we were burning the candle from multiple ends and we are going to really burn down or burn out. But COVID brought that situation into light. So now people know that healthcare professionals experience burnout. And healthcare professionals are really not ashamed now to agree that, yes, I need help. And lot of resources came up for healthcare professionals. And then we started looking into workplace safety and workplace support. So now, rather than asking people to be resilient, we need to create the workplaces conducive for healthcare professionals, supportive for them so they won't have to think about their burnout and resilient strategies as much.

Cause here now, like the president of American Nurses Association said, we talk about resilience, we ask people to be resilient when we don't try to do something to fix the workplace issues. We can't expect people to be resilient. So, a lot of new dimensions focuses came out because of the pandemic. These are not new issues, but these issues got recognition. So, once we recognize these problems, I think we are going to do something about it.

STEPHANIE: Yeah. As you indicated, this was a time of a lot of turning points and like Adeline said too, you know, how do you keep some of these innovations going forward? What did you both learn in terms of messaging around vaccine confidence? As you both mentioned, there were previous vaccines to talk about. But, what did you find that worked?

ADELINE: You know, I wish there was like a one word answer to this, right? What we found out what worked is that it is an ongoing, I think it comes back to that root of trust. Because it's always having that ability to be open and have those conversations and try and hold that space without judgment, which can be very hard. Because when you have something that as you're training and your medical background, you go, this is amazing. Like everyone, everyone, I want to protect you. I want to protect my family. I want to protect the community at large. You know, part of you sort of wants to pick people and shake them and say, why wouldn't you get this? And that's the human part. But from the healthcare provider side, it is reasonable to have fear and mistrust, anything that's new, it's human nature. So, I think patience. I think time. I think meeting people where they're at, not trying to force opinions, because as we all know, the second you just start spouting facts and you don't hear what a person's concerns are, they shut down and they're not going to listen to you.

So, it doesn't help for me to just give you all the facts in the world if you have already made up your mind. What I need to do is create that open space where you can continue to have dialogue and discourse and conversation. And it's challenging. I think that informal messaging on the walls, I think that that formal messaging in media posts and newsletters. I was pregnant when I got my first COVID, actually, the first series, I was pregnant for both of them, and I would tell people that, right? And then after my daughter was born, I would show pictures of her. And so just to really reassure that, not, is this only something that as a healthcare professional I believe is safe and I believe all the research, but I also personally have walked the walk and talked the talk and done it with all of these other extraneous circumstances and want to encourage you to feel comfortable asking me your concerns because concerns are valid and sometimes people still say, no, I'm not getting it. And you just got to meet them where they are.

LETHA: Yes, Adeline, you're right. We have to meet them where they are. So that is my part of the messaging, also. There is no one size fits all concept here. Messaging needs to be individualized. I generally go with health belief model for crafting my message. The susceptibility of the diseases or the chances of contracting that disease, and the consequences of having that disease and the benefits of taking vaccine, all these things matters. Now again, the message needs to be individualized based on where the person is in his or her decision making process about the vaccine. Like if the person is in pre-contemplation stage where the person is not at all thinking about the vaccine, we probably should not talk about the vaccine because it's not going to work. And if the person is in contemplation stage, maybe that is the time we need to give more information on the vaccine. So, Adeline is absolutely right about telling personal stories and making people think this is the person who lived that experience and the person is doing fine. So, then maybe that is going to be good for me, too. And so this person who has done all this healthcare work and has the healthcare knowledge is trusting that vaccine. That means probably this vaccine is trustworthy. Why not me? All these things are there. So, it is difficult, as Adeline said, there is no one word answer. It's a constant process. And that effort. That dedication. It comes from healthcare professionals and I'm so proud to see how people really worked hard to improve vaccination, especially risking their life, risking their comfort and everything.

STEPHANIE: Both of you have been talking about the theme of relationship building, cultivating trust. And it's interesting to consider that you could have had moments when the patient said, I'm not ready. I'm not there yet. And when we were preparing for this interview, Letha, I think you shared about the importance of being heard, cause you want people to come back and keep engaging with their health and wellness. So, if there's anything you wanted to say to that?

LETHA: It's an important concept and it's the most important part of vaccine conversation. If we make the patient feel that we have an agenda and we are working to get it established, we will probably have more resistance because our vested interest can make the patient suspicious. So, my approach is always that of the motivational interviewing. Any vaccine refusal or any resistance to any type of treatment recommendation. I consider it as an opportunity to explore the underlying problems. If they are even mentioning a misinformation about vaccine or misinformation about COVID, it is not just that misinformation. What is making them consider that misinformation over the healthcare professional’s recommendation? That is that mistrust. Maybe they heard it from even more trustworthy sources like their friends, their family or their favorite football player or their favorite actor or actress, these people have influence on them. So, they have trust in these type of celebrities over the healthcare professionals because they don't have that much trust in healthcare professionals.

So again, we are coming to the core problem of lack of trust. So, as I mentioned earlier, their lack of trust originated from their previous experiences. So, if that patient is in that precontemplation stage, not even considering the vaccination because the person doesn't believe in vaccine, or the person doesn't believe that that vaccine is safe. Now my focus is shifting from encouraging the person to take vaccine to sitting down, talking to the person, finding out what is actually bothersome. How was his previous or her previous healthcare experiences, whether there are some unmet needs, whether there are certain hurt feelings.

So, developing that trusting relationship, that is the most important. So, vaccine conversation is not a one-time encounter, it is a process. It might take several encounters before we are successful, but if we get successful, probably this person is going to be one of the best people who can convince other people who have skepticism.

STEPHANIE: How about for you, Adeline?

ADELINE: Yeah, I mean, I think, you know, we've talked a lot about trust, right? And building those relationships. I've had many different fields in healthcare, so I've worked in ICU, I've worked in urgent care as a nurse practitioner, and now in the school setting. I just keep thinking back to patients I saw. Maybe the first time they saw, they didn't know me, they didn't trust me. They didn't know who I was. They didn't know if I knew what I was doing, and then I'd get something right. Right. I'd diagnose their gout or their shingles and then they go, ah, hey, you made that better.

And so like Letha is saying not closing the door because of one misinformation they have around the vaccines and sort of getting buy-in from them on whatever that world is. And maybe it'll be then someone they know gets sick and didn't have the vaccine, so they come back to you again and have that conversation of, oh, you know, my buddy Joe just got really sick, didn't have the vaccine. Like, do you think it's going to help if I get it?

I mean, whatever the opportunity is that presents it to have the conversation. The other approach I always took was just being consistent, regardless of your age, race, gender, what you were in for sort of asking that question. Have you had your COVID-19 vaccine? Okay. Do you want to talk about it? Allowing them to have sort of the power in leading the conversation if they were interested and if they weren't, I wouldn't necessarily poke and prod.

With our students. Where it's interesting sometimes is if you have two family members that disagree that have access, because under 18, right, you need permission from a guardian. So, we did have situations where maybe one guardian wanted to get the vaccination and the other didn't, and that was the one who won out. And so those conversations I found a bit harder to have. Both from a healthcare perspective as well as a family perspective, because one, you want to do what's right, you want to share the information and you want to protect our most vulnerable. So, to see a younger child not get coverage due to parental beliefs, those were a little bit more challenging and I don't have an easy answer for how to approach them.

But I think again, just remaining non-judgmental, open door and sort of just very factual. So, it's just like smoking. Do you smoke? Do you vape? Okay. You know, that's really bad for your health. And hopefully, that over time they hear that message enough from trusted sources of individuals that they're going to come back and go, you know, I've heard you. Like I really want to get that vaccination, or I want to talk about it, or, I really want to quit vaping. Right? All of these big picture things that play out in our health over the long term, because we are, at the end of the day, the health experts. I meant that’s  why we went to school and our onus, or we would say in Hawaii, our Kuleana is to help these people, right?

We don't do it just for a paycheck. I don't know anyone in medicine that went into medicine because they just want to get paid well. It's because we have a bigger goal, and that really is to help and serve.

LETHA: Yeah, I really like that bigger goal, the purpose approach from Adeline. The purpose makes us going. I also wanted to add what Adeline said, maybe a patient is talking to us about misinformation or even refused the COVID vaccine and next we are hearing he was really sick with COVID. So now he's back to the clinic. We need to be really compassionate and supportive. Never be trying to bring back the previous conversation and make the patient feel ashamed.

STEPHANIE: As we come to the end of the show, just would like to open up to both of you, whether you have any final thoughts to share. Adeline?

ADELINE: Thank you for listening to us, first of all. I know it can be tiring to hear about COVID-19. COVID-19 vaccination. And just really reflecting on the fact that at this point it's a picture of bigger health. So, along with your vaccination, what are you doing both as a medical professional to take care of yourself, finding that time to prevent that burnout, getting outside, exercising, spending time with family, and then staying vigilant yourself.

You know, I really have to stay vigilant on reminding myself to check the CDC booster calendar. It's really a useful tool to go on and see what the current recommendations are. We're not in this information overload all the time, but it is still part of our life. So I just encourage everyone to sort of remain vigilant. Keep an eye out for just like your annual flu vaccine, whether or not you're due for a COVID-19 vaccine, and thanks for showing up to the table.

LETHA: From my side, again, thank you for listening as well as since Adeline highlighted looking for CDC updates and following that. I would probably remind about, no, we are still living with COVID. We do have COVID. We do have the risk for contracting the disease, so masking, hand washing, physical distancing and boosting your immunity. Either by vaccination or the booster dose as it is applicable so that we can probably get a little more relaxed restrictions because we are going to slowly reaching that end of the tunnel.

STEPHANIE: Thank you Adeline and Letha for joining us on At the Core of Care.

ADELINE: Thank you.

LETHA: Thank you.

SARAH: Our special Vaccine Confidence series was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention or CDC. The CDC is an agency within the Department of Health and Human Services also known as HHS. The contents of this resource do not necessarily represent the policy of CDC or HHS, and should not be considered an endorsement by the Federal Government.

You can find our most current and past episodes of At the Core of Care wherever you get your podcasts or at

And for more information about related upcoming webinars, COVID-19 resources, and upcoming trainings for nurses to obtain continuing education credits, log on to

You can also stay up to date with us on social media by following @NurseLedCare.

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

I’m Sarah Hexem Hubbard of the Pennsylvania Action Coalition. 

Thanks for joining us.