If you were watching a movie about a deadly infectious disease that impacts the entire world, you might expect it to go a little something like this: Deadly disease is discovered. People panic. Deadly disease spreads and causes death and disruption. Scientists race against the clock to stop it. Challenges and setbacks occur along the way. Finally, scientists craft a weapon capable of defeating the disease: a vaccine. People rejoice and line up to receive it. Credits roll, triumphant ending.
In real life, it turns out, the story is not so simple. In the United States, the COVID-19 vaccine is free, widely available, effective against the disease, and safe. But not everyone is lining up to receive it. As of September 30, 2021, the Mayo Clinic estimates that 64.7% of Americans have received at least one dose of the COVID-19 vaccine. That means almost one-third of the U.S. population has yet to get the shot. The question is why? Why are people waiting, or, in some cases, refusing to get the vaccine? What’s the hold-up?
This issue is often labeled “vaccine hesitancy.” Vaccine hesitancy is defined as the reluctance of people to get safe and recommended available vaccines. For example, in Franklin County, the Centers for Disease Control and Prevention (CDC) estimates that 7.41% of population members are strongly hesitant, 12.67% are hesitant, and 18.5% are hesitant or unsure. People who are labeled “vaccine hesitant” are usually people who have expressed some degree of uncertainty about getting the vaccine; however, the term is also sometimes applied to people who have expressed that they are certain they will not get the vaccine.
Vaccine hesitancy is not new—people have been cautious about vaccines since vaccines were introduced. In the 1920’s, for example, opposition to vaccines arose from “perceived health dangers and threats to personal liberty.” Sound familiar?
That’s not to say, though, that the story of COVID-19 vaccine hesitancy is the same old story. In fact, the nuances of what drive COVID-19 vaccine hesitancy in different populations are largely what make it so difficult to address. Now, with the highly-infectious Delta variant of SARS-CoV-2 circulating in the population and COVID-19 vaccines sitting on the shelves, the need to overcome vaccine hesitancy is greater than ever.
Even the label “vaccine hesitancy” may be too simple for the complicated story behind why more than one third of eligible Americans have yet to receive the shot. In a report published in July by the Johns Hopkins Center for Health Security, the authors argue that the term “glosses over diverse concerns about vaccines, COVID-19, and health authorities. Rather than a perceived moral failure of being ‘hesitant’ or ‘noncompliant,’ a lack of vaccination is often an external reality related to lack of access to vaccines.” Medical anthropologists Elisa J. Sobo, Diana Schow, and Stephanie McClure argue that the label “overlooks persistent barriers to access and lumps together the varied reasons people have for refraining from vaccination. It also places all the responsibility for getting vaccinated on individuals.”
Placing the responsibility solely on individuals leads to framing the vaccine hesitant as the current villains of the COVID-19 story. But this framing obscures the complex reasons people are waiting to get the vaccine and takes the focus away from the real enemy we are collectively fighting: COVID-19. The authors of the Johns Hopkins report state that “[v]accine decision making is ongoing, dynamic, and interpersonal, rather than a straightforward process of an individual, alone, digesting educational materials and then moving to action.”
In order to begin re-framing the story, this decision-making process needs to be unpacked and explored. At the outset, though, it is important to disclaim that the following is intended to be a general discussion of the reasons individuals and communities across the nation are waiting to get vaccinated based on available data. It would be improper to assume that any of the following reasons are reasons driving vaccine hesitancy in a specific community without speaking to members of that community and listening to their experiences and concerns.
The reasons people report for not getting the vaccine can be divided into three broad categories: (1) lack of access; (2) fear; and (3) political forces.
Lack of Access
First, people are waiting to get the vaccine, because they lack access not only to the vaccine but also to critical resources necessary to access the vaccine such as time, transportation, technology, and job security. The authors of the Johns Hopkins report state that “[the] same socioeconomic and structural barriers that have contributed to the disparate impacts of COVID-19 by socioeconomic status and by race/ethnicity have also created barriers to accessing vaccines.”
The authors of the Johns Hopkins report conducted local, ethnographic research within Black and Hispanic/Latino communities in Alabama, California, Idaho, Maryland, and Virginia.
This research identified access issues in the following areas:
- Lack of transportation to vaccination sites (especially in rural areas);
- Lack of funds to pay for transportation to vaccination sites;
- Limited operating hours at vaccination sites;
- The inability to take time off work for vaccination appointments or to take time off if vaccination resulted in sickness;
- Lack of childcare and/or eldercare;
- Lack of access to computers and/or smart phones (to access online appointment registration portals or even information about when and where vaccines were available);
- Limited or no internet access (another common problem in rural areas); and
- Lack of online literacy.
For many individuals and communities, the pandemic only exacerbated the conditions that produced these barriers, such as lack of childcare/eldercare or job instability.
People have reported a number of fears about risks associated with the COVID-19 vaccine itself as well as the process of receiving the vaccine that play into their decision to wait on receiving the vaccine.
Concerns about the COVID-19 vaccine stem from several sources such as the safety of the vaccine, distrust in the intent of the vaccine, and potential side effects. An analysis of data from the Kaiser Family Foundation vaccine monitor in June found that 12% of adults indicated they wanted to “wait until [the vaccine] has been available for a while to see how it is working for other people.” Of this wait and see group, 78% indicated they were concerned that COVID-19 vaccines were not as safe as they are said to be, and 37% indicated they were concerned they would not be able to get the vaccine from a place they trust.
In addition, nearly half of the wait and see group (44%) said they would be “more likely” to get a vaccine if one of the vaccines currently authorized for emergency use received full approval from the FDA. Public health officials are hopeful that the recent FDA approval of the Pfizer vaccine will convince people in the wait and see category to schedule a vaccine appointment. After Pfizer’s vaccine gained full FDA approval, Dr. Anthony Fauci estimated in an interview with NPR that the approval would likely convince “about 20 or more percent of people” in the eligible-but-unvaccinated category to step forward and get vaccinated.
Survey data also suggest that people are waiting, because they are afraid the vaccine will have side effects. The U.S. Census Bureau created a COVID-19 vaccine tracker that tracks vaccination status and vaccine hesitancy using data from the Census Bureau’s Household Pulse Survey.
As of September 13, 2021, 13.3% of adults in the U.S. reported that they were unsure about getting the vaccine, would probably not get the vaccine, or would definitely not get the vaccine. Respondents were also asked to select a reason, or multiple reasons, for why they were hesitant. 56.7% said they were hesitant, because they were concerned about side effects.
A report released in March 2021 by the Delphi Group at Facebook and Carnegie Mellon University also found that concerns about side effects played a large role in vaccine hesitancy. The report was based on survey responses collected between January 10 and February 27, 2021 from more than 1.9 million Americans regarding COVID-19 behaviors and attitudes. The study found that “the percentage of individuals who are concerned about experiencing a side effect is high and has remained stable over time.” Based on the most recent week of data collected for the report, “the percentage of vaccine hesitant adults who are concerned about a side effect [was] 70%.”
Fears about getting the vaccine also stem from distrust of the government and healthcare providers. The Household Pulse survey data also indicated that 49% of people in the waiting category were hesitant because they do not trust COVID-19 vaccines and 41.3% said they don’t trust the government.
A report issued by the Science, Technology and Public Policy Program at the University of Michigan identified two main causes of public mistrust:
- limitations and failures in scientific and technical institutions, and
- institutionalized mistreatment of marginalized communities.
According to the report, the first cause is composed of high-profile technological failures, disregard of community knowledge and expertise, and visible failures in how the scientific community polices itself and communicates uncertainties. The second cause stems from the high-profile historical examples where public health and medical care organizations devalued the medical concerns of people of color, practiced eugenics, and championed initiatives purportedly for the public good that disproportionately harmed people of color.
The authors note that these causes of citizen mistrust have the consequence of driving people to rely on their immediate networks of friends and family and media outlets for knowledge about the vaccine. According to the authors, when people feel they cannot trust what the government or public health officials are saying about the vaccine, people turn towards sources they feel they can trust: “themselves, their friends and family, and media outlets that seem to share their perspectives and concerns.” This results in people not only tuning out government officials, but also tuning into sources where false information proliferates and potentially further entrenches the fears that people harbor about the vaccine.
According to a 2017 Pew Center Research study cited in the Michigan report, social media is the main source of news for two-thirds of US adults. Social media is subject to even less moderation and professional journalistic scrutiny than news institutions which makes it a ripe breeding ground for the spread of misleading or manipulative forms of information such as misinformation, disinformation, and propaganda. Conspiracy theories, a subcategory of misinformation, “provide cohesive and streamlined explanations for a particular event or phenomenon, falsely attributing agency to public or private institutions, individuals, groups of private citizens, or governments.” Conspiracy theories are particularly pernicious because they are mutually reinforcing, meaning believing in one usually leads to believing in others, and people who believe in them “often think they have discovered the truth and are motivated by revealing these truths to others.” These theories also often operate to unite their audiences against an imagined “Other.” In conditions where trust in government and public health institutions are low, conspiracy theories about the COVID-19 vaccine can spread rampantly as people turn to their virtual networks for information.
Some fears are less about the government’s intent with the vaccine and more about the consequences of interacting with the health care system. An article by Leo Lopez et al. on racial and ethnic disparities related to COVID-19 reported that immigrants, whether undocumented or legally in the U.S., are likely to avoid the health care system altogether due to concerns about deportation or that use of publicly supported services would be used as a reason for denying future immigration.
A contentious, but critical, factor in vaccine hesitancy is political partisanship. The proportion of Americans who have expressed reluctance or outright refusal to get a vaccine is not evenly distributed across Americans, rather, studies have indicated a significant partisan gap exists between Republican-leaning and Democratic-leaning individuals.
Prior to the rollout of the vaccine, surveys of Americans conducted in late 2020 indicated a stark partisan divide in willingness to get the vaccine. Gallup recorded “a 25-point difference between Democrats and Republicans” with Democrats being more positive, Pew Research showed a 19-point difference in willingness to get a vaccine between Democrats and Republicans, and the Kaiser Family Foundation found a 30-point partisan difference in those who said they would "definitely" or "probably" get the vaccine.
This divide persisted throughout the rollout of the vaccine. The Kaiser Family Foundation analyzed survey data from late May 2021 and found strong partisan differences in vaccine intentions with almost half (49%) of unvaccinated adults identifying as Republicans or Republican-leaning independents, compared to three in ten (31%) vaccinated adults. On the other hand, Democrats and Democratic-leaning independents make up a majority of the vaccinated population (about six in ten), while about three in ten in the unvaccinated population identify as Democrats or Democratic-leaning independents.
Interestingly, though, the wait and see group is split politically. The Kaiser Family Foundation found that about four in ten in the wait and see group identify as Republicans or Republican-leaning independents and another four in ten as Democrats or Democratic-leaning. The more vaccine-resistant definitely not group is overwhelmingly Republican-leaning, with two-thirds (67%) in the group identifying as either Republican or Republican-leaning independents.
The reasons driving this divide are not easy to pinpoint. People are complex, and so are their reasons for making decisions. Sociologists studying vaccine refusal and partisanship prior to COVID-19 hypothesized that political identity functions as a proxy for trust in institutions and other personal characteristics; however, a recent study by sociologists Sarah K. Cowan et al. analyzing COVID-19 survey data found that by early February “differences in demographics, concern about the pandemic, and institutional trust no longer explained the partisan gap.” The authors pointed to recent evidence that political party affiliation “has become a source of identity,” such that getting a “COVID-19 vaccine may have become ‘what Democrats do’ whereas it is not ‘what Republicans do.’”
Complicating the term “vaccine hesitancy,” unfortunately, does not yield simple solutions. However, understanding the reasons people are waiting, even if those reasons are complex, has helped public health professionals develop meaningful interventions that meet people’s real needs and address their real concerns. The key recommendations for individuals and institutions seeking to convince vaccine-hesitant members of their communities to take the plunge include:
Partner with local communities:
In order to build, or rebuild, the trust of marginalized communities, research suggests public health officials need to “develop vaccination initiatives in partnership with local institutions and leaders, particularly to serve marginalized communities.” This means working with institutions that community members already trust, such as schools, houses of worship, community centers, and sports leagues. This means taking the time to develop deep relationships with these groups and facilitating a “two-way flow of knowledge.” Finally, this means investing in local-level public engagement as well as research that engages with community priorities.
For more recommendations on this point, read the full report: In Communities We Trust: Institutional Failures and Sustained Solutions for Vaccine Hesitancy.
Listen to understand:
People who are still waiting to get the vaccine have very different reasons for holding back. In a one-on-one conversation with someone who is waiting, public health experts recommend not assuming that you know why they are waiting. Instead, give them a space where they can voice their concerns and try to understand what is causing them. Answer their questions honestly, and simply.
For more recommendations on how to have the COVID-19 vaccine conversation, read: A user’s guide: How to talk to those hesitant about the COVID-19 vaccine.
Don’t shame, inspire:
Shame is an ineffective tool to get people to do things. Research suggests that it did not work earlier in the pandemic, and public health experts do not think it will work now. People are more likely to tune out messaging that evokes negative emotions. A corollary to listening to understand is to not mock or admonish people for their choices and beliefs about the vaccine. Instead, communications experts recommend calling people to action by appealing to positive emotions like hope, parental love, and pride. They suggest taking an aspirational approach focusing on how getting vaccinated protects others and helps move toward future outcomes that are personally relevant to the individual who is considering vaccination. This approach encourages people to behave altruistically and motivates them to take actions that will help attain outcomes they view as desirable.
For more recommendations on how to engage in messaging that stays away from the blame game, read: Evoke the Right Emotions.
The COVID-19 pandemic has continually forced us to examine and rewrite the narratives we tell about ourselves and how we ought to engage with each other. In order to shape a narrative where humanity comes together to overcome COVID-19, we need to take a hard look at the story we are telling about people waiting to get the vaccine and craft language that encourages them to join the fight against the disease.