As of mid-November 2021, the US Covid-19 death toll is about 757,000 from 47 million cases. There is broad consensus across the medical community that the most effective way for individuals to avoid the most serious consequences of Covid and for communities to stop the spread is through vaccination. With the Delta variant mostly in circulation, more than 90% of patients in ICUs are known to be unvaccinated.
Fast-track vaccines, built on top of decades of (taxpayer-funded) pharmaceutical research, have been shown to prevent death in nearly all cases and reduce the severity of symptoms and disability from Covid infection. Despite the efficacy of vaccines and their wide availability, approximately 20% of eligible adults remain unvaccinated. Those not yet vaccinated are described in medical literature as being in two categories: “hesitant” (VaxH) or “refusers” (VaxR). Strongly held personal beliefs, understandable confusion or fears, deep-seated distrust of authority (including Federal mandates), as well as industry, religious, political, and civil-liberty-group objections have all contributed to vaccine hesitancy and refusal among Americans.
In May 2021, the White House set a national goal of a 70% vaccination rate to achieve “herd immunity”, a point at which the virus was expected to fade to a lower, more manageable prevalence rate in the US population. We are now learning that this target may be too low and that booster shots may be necessary. In some countries, including New Zealand, Ireland, and Singapore, approximately 90% of eligible adults have been fully vaccinated. But as of mid-November, 29% of the US adult population are not fully vaccinated and only 19.6% of those fully vaccinated have had a booster shot. Some high-risk groups, such as those over 65 years of age and people with pre-existing chronic conditions like type 2 diabetes, cardiovascular disease, and hypertension do have a greater than 80% vaccination rate, and some subgroups of Americans have vaccination rates reaching 90-100%, including college football teams, some communities, and US physicians, while lower vaccination rates are seen among other groups, such as young adults without insurance (50%-60%). Rates of vaccination also vary widely across all 50 US states. This national pattern shows that while most Americans have some protection from the most serious effects of Covid-19, many are still at risk for severe disease, death, or experiencing “long-Covid” sickness or disability.
What are common reasons for Covid-19 vaccine hesitancy in the US?
People reporting VaxH and VaxR status may have a mix of accurate and inaccurate opinions or beliefs about the vaccines and their personal need to be vaccinated. Although those who have chosen to get vaccinated may think that vaccine hesitancy is selfish, ill-informed, or politically motivated, individuals have a wide range of reasons and justifications for their hesitancy.
The goal is to help people make informed decisions about vaccination that fit their practical needs and goals. A positive approach to addressing vaccine hesitancy is to begin by assessing the underlying reasons for an individual’s hesitancy, seeking to understand their circumstances, and then working to help interested individuals or groups explore their personal beliefs and barriers to vaccination.
Below is a list of 20 common reasons for vaccine hesitancy in the US, based on media reports and national surveys from Deloitte Health, the Kaiser Family Foundation, and others.
- I am exercising my personal freedom to make my own health decisions.
- I have had Covid-19 before, so I have natural immunity.
- I am waiting to see if my employer says I must get vaccinated.
- I worry that getting the vaccine will be painful or uncomfortable.
- I am waiting to see what happens to other people before I get vaccinated.
- I am healthy and won’t get sick from Covid-19.
- I think the vaccine was rushed out by the government and is not safe.
- I am too young to get sick from Covid-19.
- I don’t have the money to pay for Covid-19 vaccinations or doctors’ visits.
- I don’t want to give out my personal information or show an ID to get vaccinated.
- I don’t trust the media saying that everyone needs to get vaccinated.
- I don’t think Covid-19 vaccines are effective.
- I think Covid-19 vaccines could make me sick or give me health problems.
- I have medical issues and a Covid-19 vaccine is too risky.
- Vaccine clinics aren’t open at convenient times for me or are too far away.
- I think Covid-19 is a political issue not a real public health issue.
- Getting vaccines doesn’t fit with my religious or spiritual beliefs.
- I don’t trust the drug companies who make Covid-19 vaccines.
- We don’t have a problem with Covid-19 where I live.
- My family does not want me to get the vaccine.
Practical strategies to help people who are hesitant to get vaccinated make informed decisions
Giving those who are hesitant unsolicited advice, arguing with them, or judging their opinions and attitudes is unproductive. Not only does it frustrate all parties, but it also erodes trust and does not help people explore their personal beliefs or consider other options. Mutual respect, empathy, and being well informed about the personal or local values, interests, and obligations of those who are hesitant to become vaccinated will help to create a productive dialogue. That dialogue can be further supported by trusted doctors, religious leaders, close friends, family members, or members of groups to which the individual is strongly connected.
People who are vaccine hesitant are likely aware of the pros of not vaccinating and the cons of getting vaccinated, but they may not have spent much time exploring the cons of not getting vaccinated nor the pros of getting vaccinated. Helping people thoroughly consider all the pros and cons through accurate information, impactful videos, and personal experiences can help them reach fully informed decisions.
Below are some communication points on the pros of Covid-19 vaccination and the cons of not getting vaccinated.
- High personal economic cost. The cost of a Covid-19 hospital ICU stay can be $100,000-$300,000. Depending on a person’s level of insurance coverage and plan type, an individual or family could face loss of savings or assets, bankruptcy, and/or long-term credit damage.
- Help our front-line heroes. About 90% of patients in ICUs are unvaccinated. This influx of unvaccinated people is stressful for front-line workers. Clinical burnout is common among physicians, nurses, and support staff because of their heavy workloads, inability to help patients, and the emotional toll of seeing so many deaths and highly distressed family members.
- Impact on people you know with serious conditions. Right now, hospital beds and staffing resources are very much focused on helping (mostly unvaccinated) Covid-19 patients. This has diverted ICU resources from other seriously ill patients living with cancer, heart problems, strokes, etc.
- Return to travel. People with vaccination documentation will be able to travel outside the US for business or leisure. Most countries expect tourists to provide vaccine documentation.
- Workplace access and reduced hassle. Workers deciding not to vaccinate may need to undergo weekly Covid-19 testing (possibly at financial cost to the employee) and to quarantine at home in the event of a positive screen.
- Long-Covid is real. Long-Covid affects 30% of people infected and can be debilitating and economically costly. It includes poor memory and “brain fog”, fatigue, muscle pain, cough, and stomach problems, and its long-term impacts are not yet understood, so it may be wise to avoid it.
- Lower your risk and that of others you care about. While only 1.5% of cases result in death, this still translates to many people dying unnecessarily, and some groups are affected more. For example, Covid-19 is now the leading cause of death among police officers.
Depending on the specific barriers and beliefs uncovered when assessing the reasons for an individual’s hesitancy, some of the communication points above may be more or less relevant and effective. Systematic assessment of the underlying reasons for vaccine hesitancy is the first step to a successful dialogue and an effective approach with individuals and groups. Here are some approaches that can help once the relevant beliefs and barriers have been identified:
- Provide accurate, personalized, and locally relevant information in simple language.
- Build the individual’s personal motivation by helping them connect their decision to get vaccinated to issues that are important to them. Take the time to uncover and discuss these issues with them. Some will simply need time and patience to help them work through things.
- For some, the amplification of misinformation through social media has overshadowed the benefits of getting vaccinated. Providing different, fresh sources of information around Covid-19 vaccination can help put things in perspective, particularly if it is delivered by trusted sources such as doctors, friends, or family who believe in vaccination and have personally decided to get vaccinated for positive reasons. Role models and influencers are very important contributors.
Silver Fern has developed a first-of-its kind assessment to uncover the reasons behind the phenomenon of vaccine hesitancy. The Covid Vaccine Hesitancy module uses Silver Fern’s clinically proven techniques to systematically and efficiently unlock the complex underlying attitudes, beliefs, and barriers that can create hesitancy among individuals and populations.
Evaluating 20 of the most common reasons for hesitancy, the assessment module is a highly scalable and efficient way to reach people and help them make well-informed choices on Covid-19 vaccination. The module not only assesses the reasons for vaccine hesitancy, but it can provide suggested, practical actions for pathways of care that are tailored to respondent-specific barriers and beliefs unlocked by the assessment.
We must accept that not everyone will decide to become vaccinated when fully informed of the pros and cons. The best approach is one that is practical, targeted, and brings together local resources and focus to help us all move to a continually evolving “post-Covid-19” life as soon as possible. If you’re ready to address the underlying reasons for vaccine hesitancy in a targeted, effective, and efficient way, contact Silver Fern today.
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Garry Welch, PhD is an expert in the area of behavior medicine for chronic disease care. He has extensive experience leading clinical research on behavior change strategies for people with diabetes and other chronic diseases. Dr. Welch’s 30+ years of clinical research led to co-founding Silver Fern Healthcare. He leads research and development at Silver Fern.