Ms. Clark comes for her annual visit. You notice on her medical record that she has not yet been vaccinated against COVID-19. Near the end of the visit, you ask her why she hasn’t been vaccinated yet. She replies that she has heard conflicting information from her friends and family about the vaccine and is not sure she trusts it.
Convincing patients like Ms. Clark to consider the vaccine may be more important than ever, as COVID-19 cases are increasing in nearly 90% of the U.S. states and territories with the rise of the more infectious Delta variant. Only half of the U.S. population is fully vaccinated and the latest surge is highlighting the disparities in outcomes between the vaccinated and the unvaccinated. The COVID-19 vaccine is increasingly available in outpatient clinics, pharmacies, and other readily available locations, so clinicians may be facing conversations with patients like Ms. Clark more often and wondering how best to guide their patients.
Communicating effectively with vaccine-hesitant patients is critically important to increase the number of vaccinated individuals in all countries. Research on communicating with vaccine-hesitant patients in other contexts (e.g., HPV) has demonstrated that good communication can make a difference in patients’ vaccine choices.
The CDC published five techniques to guide healthcare professionals and pharmacies in discussing the COVID-19 vaccine with patients. The techniques include:
- Actively listen
- Use patient-centered communication techniques (e.g., open-ended questions)
- Empathically respond to questions and concerns
- Give a strong recommendation
- Close the conversation ensuring they know you are open to talk again if desired
Although these techniques are useful, they could be improved in two important ways. First, the timing of empathy matters. When a clinician uses empathy in response to a patient’s concerns, it is better received if the clinician expresses empathy before answering the patient’s questions. This timing allows the patient to feel that their particular concerns are taken seriously and have been considered by the clinician. Second, it is important to both begin and end the conversation with a strong recommendation.
Thus, as healthcare researchers and educators, we developed the C-LEAR approach — Counsel, Listen, Empathize, Answer, Recommend — an easy to remember, evidence- and theory-based mnemonic to guide clinicians through the process of introducing and discussing vaccines with patients. The mnemonic is based on the counseling and communication principles of motivational interviewing, facework theories, and patient-centered communication. Below we outline each letter of the C-LEAR approach and how it could be used by a clinician to give a strong COVID-19 vaccine recommendation.
Counsel. The first step in discussing the COVID-19 vaccine is to introduce the vaccine with a strong statement of its evidence base and a clear recommendation of the vaccine. You might want to say: “Scientists have developed a safe vaccine that will prevent you from becoming seriously ill or dying from COVID-19. Receiving the COVID-19 vaccine may also protect your friends and family from catching COVID-19 when interacting with you. I recommend you get this vaccine today.”
Following the introduction to the vaccine, you can pause to see if the patient has any comments or questions. After counseling, if there are no questions or concerns, the visit can proceed with the vaccine being administered. However, if there are questions you can continue to progress through the C-LEAR mnemonic. The dash after the “C” illustrates the intentional pause for this decision point.
Listen. If the patient asks a question or makes a comment, you should actively listen to the patient. It is important to remember that even if patients have questions or concerns about the vaccine, it does not mean they will refuse it. In fact, studies have shown that vaccine hesitancy can be overcome with good communication. Engaging with the patient about the question or concern is key to overcoming hesitancy.
Empathize. Demonstrating clinical empathy toward the patient after the question or concern is critical. Skills that can be used to demonstrate clinical empathy include: exploring (“Tell me more about …”), restating (“Your main concern is …”), acknowledging (“I understand why that would concern you”), normalizing (“A lot of patients have that question”), and validating (“It is really great you read online about …”). Likely only one or two empathic communication skills will be needed for each concern. The important thing here is to use some empathic communication skills before moving to the next step of responding to the concern.
Answer. After communicating empathically, give a brief and accurate answer to the patient about their concern. Sample questions and answers to the most common concerns about the COVID-19 vaccine can be found here and here.
Recommend. Immediately after giving the answer, reinforce the importance of the vaccine by recommending the vaccine. Finishing with a strong recommendation is important. If at this point the patient raises another concern or question, you can cycle back through the model, starting with the L for Listen.
We understand that it can be difficult to understand hesitancy for COVID-19 vaccination, and it may feel uncomfortable to engage patients in discussion. But getting the conversation started is key to fighting the pandemic. We hope that relying on the C-LEAR model can help all clinicians as they talk with their patients about COVID-19 vaccination.
Carma L. Bylund, PhD, is a professor in the College of Journalism and Communications at the University of Florida. Lindsay A. Thompson, MD, is a professor and Vice Chair for Health Outcomes and Translational Research of Pediatrics in the College of Medicine at the University of Florida. Stephanie A. S. Staras, PhD, is an associate professor and Division Director of Health Outcomes and Implementation Science in the College of Medicine at the University of Florida.
Last Updated July 30, 2021
Bylund has received honorariums from Amgen for consultation on cancer communication.