A family poses for a photo after their child received a dose of the COVID-19 vaccine in November 2021 at a community clinic at Henderson-Hopkins.

Image caption: A family poses for a photo after their child received a dose of the COVID-19 vaccine in November 2021 at a community clinic at Henderson-Hopkins.

Credit: Larry Canner for Johns Hopkins University


Training ambassadors to talk to vaccine-hesitant parents

Rupali Limaye of the Bloomberg School of Public Health discusses the creation of a free virtual course for parents, teachers, and school staff to help them encourage other caregivers to make evidence-based decisions about vaccinating their children

Public health experts believe that vaccinating young children against COVID-19 is critical to getting the pandemic under control, both for their health and the well-being of others around them. Contrary to the widespread belief that COVID-19 is mild in children, they can become very ill, especially if they are immunocompromised or have other medical conditions. Pediatric cases spiked with the emergence of the highly transmissible omicron variant, according to the American Academy of Pediatrics and the Children's Hospital Association. During the week ending Jan. 2, an average of 672 children younger than 17 were hospitalized every day with COVID-19, the highest since the pandemic began, according to the Centers for Disease Control and Prevention.

Despite this urgency, COVID-19 immunizations among children aged 5 to 11 have stalled since the CDC approved the Pfizer vaccine for this age group in October. A recent analysis by the Kaiser Family Foundation reported that the number of first doses given to 5 to 11 year olds is still far below its initial peak, despite a slight temporary jump for a period in December. The percentage of 5- to 11-year-old children who are fully vaccinated has hovered at just above 20% since early January, according to analysis by Emily Pond, a research data analyst for the Johns Hopkins Coronavirus Resource Center and the Center for Health Security. And only 55% of older children from 12 to 15 are fully vaccinated.

Image caption: Rupali Limaye helped produce this kid-friendly explainer about how COVID-19 vaccines work.

The latest complication in the child vaccination effort came in early February, when the Food and Drug Administration announced it was postponing its evaluation of Pfizer's vaccine for children 6 months through 4 years until it can look at trial data for a three-dose series.

Understandably concerned by the ongoing developments, the public health community has sought various ways to jumpstart vaccinations among eligible children. One such effort is a free, two-hour online course, "COVID Vaccine Ambassador Training: How to Talk to Parents," launched in January by the Johns Hopkins Bloomberg School of Public Health with the Johns Hopkins Consortium for School-Based Health Solutions and support from Bloomberg Philanthropies. The idea is to train parents of school-age children, teachers, school staff, and others to promote vaccine acceptance in their communities, encouraging parents to make evidence-based decisions about vaccinating their children. By mid-February, more than 17,000 people had enrolled.

The course is available on Coursera.org and is the latest offering from the Johns Hopkins University COVID-19 Training Initiative, which offers expertise and practical guidance from Johns Hopkins and other experts to help address the pandemic response.

To learn more about the course, the Hub spoke to Rupali Limaye, director of behavioral and implementation science and deputy director of the Bloomberg School's International Vaccine Access Center, who initiated and designed it.

What sparked the idea for this course?

I've been working on vaccine communication for about 10 years, and I have two children under the age of 12. During the pandemic, I began to have many conversations with other parents about the COVID vaccine, especially during the summer when we took our kids to our outdoor neighborhood pool and people would come up and ask questions. It became a way to have conversations with people in my community. I've also been to speak at about 50 African Methodist Episcopalian churches as a vaccine resource person. Many pastors have asked me to come and field questions related to COVID and the vaccines from their congregations.

Since the pandemic started, we have observed an erosion in trust toward the government in general, as well as in health care providers, and—because of my own experience—it got me thinking about how we could leverage peer-to-peer conversations, friend-to-friend, especially among parents. That led me down this path: Can we develop a peer-to-peer evidence-based resource that would counteract misinformation that is causing parents to become reluctant to vaccinate their children?

How did you develop it?

We had a parent advisory group that helped us inform the course, which was critical. They helped us in many ways, including the content we should cover, the delivery, and the format. We met with them three times over three months, starting in the early fall of last year. For our part, we wanted to make sure it was a resource parents and others would want. And the timing really worked because we knew approval of the vaccine for children 5 and older was coming.

In addition to our parent advisers, we also studied adult learning methodologies to understand what would help adults learn best. As a result, we sought to ensure that our training included exercises that focus on cognitive, affective, and behavioral learning.

We ended up using a combination of slides, animated videos and white board videos, where someone draws something while it is being explained. The course should take less than two hours. Most people finish in little over an hour.

Who are the most credible ambassadors?

Because of the erosion in trust in the government and the health care system, we have learned the importance of relying on non-health sources to serve as ambassadors. For example, we know that community leaders, teachers, and religious leaders are seen as trusted sources in communities. This is because each of these groups play a unique role in their communities and hold the trust of different segments of the population.

Can you provide some details on the content of the course, and describe the audience you hope to reach through these ambassadors?

The one thing that was most important was that we wanted parents to have evidenced-based information in order to make a decision. And the idea was to be able navigate conversations with people you might not see eye-to-eye with.

We start by going through all the concerns, and why people might be hesitant, then move into the science—how the immune system works, information about the virus, and how the vaccines work.

Then we focus on communication techniques, such as presumptive communication. For example, you could say, "Are you going to get your child the vaccine?" Instead, you could use a presumptive approach and say, "Your child is 10, right? When are you going to get her the vaccine?" By being presumptive, you make the assumption they will get their child vaccinated.

We also highlight and answer the main concerns we hear from parents, such as the concern that the vaccine was developed too quickly, and that they have heard that COVID is mild for kids, and as such, there is no need for them to vaccinate their child. We go through the primary concerns and explain what they need to know to help alleviate the concern.

We also identify and respond to misinformation. The biggest one is that people think there is a microchip in the vaccine and that the government is going to track them. It's really important not to dismiss concerns when you are speaking with someone trying to make a decision. One of the things we teach is empathy as the basis of all conversations—trying to understand where these concerns are coming from. A lot is based on the idea that people are trying to reduce uncertainty, so they might be more likely to latch onto a conspiracy theory to make sense of the world and reduce the uncertainty in their lives.

The point of the course is to help people navigate these difficult conversations. All of the communication techniques are also applicable outside the vaccine context, meaning you can use it with individuals you disagree with on other issues, like politics, for example, and apply them.

Why has this issue become so political? Many of the states with the lowest vaccination rates among children are red states, while those with the highest are blue states.

A lot of it has to do with group identity. People who are traditionally more conservative tend to believe more in science denialism compared to those who are more progressive. This is how you essentially show you are part of this group—by supporting their agenda and views.

These parents don't hesitate to comply with state laws that require childhood immunizations to attend school, yet they oppose COVID-19 vaccine mandates and won't get their kids the COVID-19 vaccine—what's going on here?

I think there is a disconnect. Vaccines have become representative of the way in which to show your support to the science denialism cause. So, parents may not be necessarily opposed to vaccines. They are opposed to science, and vaccines, at the moment, represent science.

Are the same parents who are reluctant to vaccinate their kids vaccinated themselves?

It really depends. In the past, parent behavior related to vaccines was predictive of childhood vaccination behavior. But the COVID vaccine is newer, and so the decision-making process is quite different when thinking about accepting a new vaccine compared to one that has been around for a long time.

Why is it so critical to reach these unvaccinated children?

We know COVID is not mild for all children. We have seen an increase of cases in pediatric hospitals over the last several months, and this is another way to protect your child from a severe outcome. Also, parents everywhere know—from having had countless colds and other viral illnesses—that children are exposed to many pathogens, including viruses, and can bring them home. There is a real urgency for parents to vaccinate their children if they live in multigenerational households with other people who may be vulnerable. Also, the more children who are protected, the quicker society can return them to a "normal school" experience and something that more closely resembles a normal childhood from a holistic perspective—emotional, social, and cognitive.