Why do some people hesitate to get a COVID-19 vaccine and what to do about it?

Understanding vaccine hesitancy


By Candela Iglesias Chiesa, MPH, PhD. Founder and Director, Alanda Health

In the midst of the COVID-19 pandemic, vaccine hesitancy has become a key concern in countries with high access to COVID-19 vaccines. While many low and middle income countries have not yet received the needed amount of vaccines to cover their populations due to inequities in access, in high income countries it is now vaccine hesitancy which is preventing the achievement of complete vaccination coverage. In these countries we are seeing two very different trends today: vaccinated people have mainly avoided severe outcomes from COVID-19, while unvaccinated people represent the majority of those who are being hospitalized and dying from COVID-19. How is this possible? Why would someone who has access to these precious, life-saving vaccines to protect themselves, their loved ones and their communities, refuse to get vaccinated?


Let’s break it down. We’ll first look at what is vaccine hesitancy and how we can visualize the different groups refusing vaccines, and finally we’ll discuss what each of us can do to help nudge our friends and family towards accepting vaccines.


What is vaccine hesitancy?


The WHO’s Strategic Advisory Group of Experts (SAGE) on Immunization has defined vaccine hesitancy as “the delay in acceptance or refusal of vaccines despite availability of vaccine services".

"Vaccine hesitancy is complex and context specific, varying across time, place and vaccines."

It is influenced by factors such as complacency, convenience and confidence. This definition encompasses those who flatly refuse the vaccine, those who refuse it for the time being, as well as those who will accept some vaccines but not others.


Complacency refers to a feeling that “this will not happen to me” and can be also influenced by other life or health issues that a person considers more important. Convenience is about how easy it is to get a vaccine, for example, whether you can get it for free while shopping for groceries, as opposed to waiting in line for hours in a hospital. Confidence reflects how much a person trusts the safety and efficacy of a particular vaccine, as well as the system delivering the vaccines (e.g. in many cases the public healthcare system).


Who are the people who refuse or are hesitant about vaccines?


People refusing vaccines are a heterogeneous group, they inhabit a continuum from vaccine refusal to vaccine confidence. Every step we can take to nudge people respectfully towards vaccine confidence is a good thing. But talking to people who adamantly refuse vaccines and share misinformation can be frustrating. Thus I find it helpful to think of a pyramid to distinguish different groups along the hesitancy—trust continuum.


1. At the top of the pyramid, we find a tiny group that is actually benefiting from the hesitancy/refusal messages. These people have an agenda. It can include people who seek to increase their followers, those selling books, “alternative” treatments or speaking engagements related to their vaccine refusal positions. While small, this group can be loud. A study by the Center for Countering Digital Hate found that almost two thirds of all vaccine misinformation on social media could be traced back to only 12 people, and several of them had clear gains to be made from spreading these messages.


2. In the middle of the pyramid, I place a larger group who is very attuned to vaccine refusal messages. They don’t necessarily benefit from spreading vaccine misinformation but these messages feed into deeply held beliefs or lifestyles. They can belong to several overlapping communities: refusing some or most vaccines and other mainstream medical treatments, preferring “natural” treatments or diets, and potentially believing in other claims that lack scientific proof.


3. Finally, there is the largest group at the base of the pyramid. I see this group as being simply vaccine hesitant. They may receive messages from public health authorities but also from some of the other two pyramid groups - mostly on social media - and they are confused and concerned by this information. They have questions about side effects and/or valid reasons (personal or historical) to distrust the medical establishment. They might refuse one particular vaccine and not others.


While the two first pyramid groups are much harder to reach, I believe each of us can reach people at the base of the pyramid and help lessen their concerns over vaccines. We can find some of these people among our friends, family and co-workers. The key is knowing HOW to reach out effectively.

Source: CDC on Unsplash


What can you do to help others overcome vaccine hesitancy?


If you are a health worker or simply concerned about a family member or friend who refuses to get vaccinated, here are some useful tips.


  • Talk less and listen more. When talking to a friend who has doubts about getting vaccinated, we tend to want to share advice about the safety and effectiveness of vaccines. However, research has shown that a more effective approach is to listen actively and ask questions to probe deeper into people’s concerns. For example, if someone says, “I’m not sure about getting a COVID-19 vaccine, have you gotten vaccinated?” Instead of citing vaccine efficacy numbers, you may ask “Oh, I had some concerns too before getting vaccinated. What makes you unsure about getting the shot?” The New York Times published a fun interactive test where you can try your hand at talking about vaccine doubts with your friend, and learn good tips.


  • Show empathy. When we are feeling worried, the last thing we want is for others to brush away our concerns. Showing empathy even if you don’t agree with the person's current stand on vaccination can make a difference. You can empathize with their feelings (worries, concerns, hesitation), while disagreeing with their thoughts on vaccines. Phrases such as “I understand how that could feel threatening” can show you empathize.


  • Normalize having questions around vaccination. Normalization is an easy technique that coaches and mentors use, and so can you. Saying “many people are asking themselves the same question” can help the person see that others have walked this path and eventually decided to get the shot. Similarly, acknowledging the small known risks and the side effects associated with vaccines instead of diminishing them can also make the person feel validated, and open the door to discussing the much bigger risk represented by a COVID-19 infection.


  • Answer specific questions. We sometimes fall prey to providing too much information to try to assuage people’s concerns. This can create resistance or confusion. It’s better to focus on the specific questions that your friend is asking, and always ask for permission to share information from a trusted source before answering.


  • Go the extra mile. Showing you care and are willing to help can also be a game-changer. Some people’s hesitation around vaccination can stem from practical issues. If the person is afraid of needles or has had bad experiences with the medical establishment, propose to accompany them to get their shot. Or go get it together if you are still missing a dose. Offer to be there to help with grocery shopping or looking after kids should your friend experience side effects.

"Vaccine hesitancy is a complex issue, but we can all do our small part to counter vaccine hesitancy and misinformation by focusing on the people close to us, being respectful and empathetic, and sharing facts as needed. "

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Thank you Candela Iglesias Chiesa,for your valuable perspective. For any inquiries related to the GHMe Blog, please contact our team at globalhealthmentorships@gmail.com



Disclaimer: This blog was prepared by the author, in her/his/their personal capacity. The opinions, views, and thoughts expressed in the blog belong solely to the author and do not reflect the views of Global Health Mentorships.

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