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Thousands of Americans are dying each day because they did not get a free COVID-19 vaccine, and the arrival of the highly transmissible Omicron variant is poised to drive the number of vaccine-preventable deaths even higher and slow the return to normal economic and social activity. Some — including outgoing NIH Director Francis Collins — are surprised so many people have turned down the life-saving COVID-19 vaccine. But our yearly experience with low rates of flu vaccination points to widespread and persistent vaccine hesitancy even prior to the pandemic. To be sure, COVID-19 vaccination is politicized, but many people decline the vaccine — even in high-risk settings like nursing homes — for the same reasons they skip annual flu shots.
Some still face barriers to accessing the COVID-19 vaccine, but the experience of nursing homes shows that neither access nor politicization is the only problem. The initial rollout of the vaccine to nursing homes hit some snags, and the staff in many nursing homes are currently stretched thin. Still, the COVID-19 vaccine has largely been freely available to nursing home residents and staff for months, yet many have chosen to skip the shot. Only 77% of nursing home staff have completed the primary COVID-19 vaccination series, up from just 58% before the Delta wave, suggesting vaccine hesitancy is common even among health care workers who witnessed the devastation of COVID-19 firsthand.
Nursing home residents face extremely high risk of severe outcomes from COVID-19 — at least 30% of COVID-19 deaths in 2020 were among nursing home residents — so the fact that 87% of residents have completed the primary series is not that impressive. Only an estimated 1% to 4% of residents have medical contraindications to vaccination. Under-vaccination despite early and ongoing access points to hesitancy among nursing home staff and residents or their proxies.
The role of political identity in vaccine hesitancy has been widely discussed, but does not appear to be the main driver of uptake among nursing home residents and is not the only factor outside nursing homes either. Most conservative states have done an outstanding job vaccinating nursing home residents for COVID-19. West Virginia, for example, achieved the quickest vaccine roll-out without participating in the federal pharmacy partnership for long-term care, and Trump won four out of the five states with the highest rate of nursing home residents who have received a booster dose.
Vaccine hesitancy is not a COVID-specific phenomenon and is not unique to Republicans or vocal anti-vaxxers. Seasonal flu kills tens of thousands annually, and nursing home residents are especially at risk, yet less than three-quarters of nursing home residents are vaccinated for flu in a typical year; flu vaccination rates in the general population are even lower, with only about a third of adults 18–49 getting a shot. The societal benefits of increasing flu vaccination are substantial: according to one recent study, one life is saved for every 4,000 flu shots given, and just two additional flu shots averts one lost day of work. The same study suggests the benefit of increasing flu vaccination among health care workers yields 10 times the benefit of the typical flu vaccination for individuals who are not health care workers.
Despite these substantial benefits, we haven’t invested enough in programs or research to improve vaccination rates, for COVID-19 or flu. Research shows that younger and lower-risk individuals, those who perceive vaccines to be less effective, the less educated, the uninsured, and racial/ethnic minorities are consistently less likely to get vaccinated for both COVID-19 and the flu, and that trust in the medical system and institutions more broadly is key to vaccine uptake.
A number of studies have shown that making access to the flu vaccine convenient or reminding people to vaccinate can improve uptake, but these approaches do not move the needle much. Few studies focus on reaching the vaccine hesitant, who are unlikely to respond to standard approaches. One recent randomized controlled trial that does focus on this group finds that nudges and financial incentives did not increase COVID-19 vaccination among the hesitant and may even backfire.
We need to invest much more in research on vaccine hesitancy, not just to learn who is hesitant, but to identify strategies that work to reduce hesitancy and improve messaging. But high-quality studies using “gold-standard” random assignment methods to evaluate specific interventions, programs, or approaches are rare. We could not find any random-assignment study of an intervention to increase flu vaccination among nursing home residents, even though flu is often lethal in this population. Between 2000 and 2019, we estimate that the National Institutes of Health (NIH) spent roughly $80 million on research testing interventions related to vaccine hesitancy; that has grown to $240 million since the pandemic began, a positive development that also underscores a lack of previous investment.
Making vaccination convenient and free is critical, but effective strategies to address vaccine hesitancy in the long run will need to build trust in ways that are tailored to particular communities, especially among certain communities of color that have faced historical and ongoing racism in the medical system and beyond. For example, despite a long history of racism against American Indian and Alaska Native (AIAN) people, high levels of economic disadvantage, and relatively low flu vaccination rates, AIAN people have the highest COVID-19 vaccination rate of any group. AIAN people were devastated by the pandemic, and the campaign to vaccinate this population against COVID-19, which centered on trusted Tribal leaders and was tailored to the community, is a success story that should be studied more. One random-assignment study found that Black men were more likely to take a flu vaccine when treated by a Black doctor, perhaps because they trust a same-race doctor more.
Political conservatives are now an identifiable vaccine-hesitant group, so finding trusted messengers and strategies to reach them is critical. Scare tactics such as the White House’s statement that unvaccinated individuals are “looking at a winter of severe illness and death for yourselves, your families, and the hospitals you may soon overwhelm” is unlikely to build the trust necessary to reach the vaccine hesitant.
Increasingly, it looks like frequent or variant-specific COVID-19 vaccination will be required, and the value of increasing vaccine uptake is bigger than ever. Serious investment in research on how to reach the vaccine-hesitant is long overdue. In the absence of a strong research base on interventions to address vaccine hesitancy, state and local policymakers can chip away at the undervaccination problem by expanding efforts to make the vaccine easy to access in familiar locations and from trusted providers, and make sure that people understand the vaccine is free and safe. Since the benefits of vaccination are so large, policymakers should not shy away from experimenting with new or more expensive approaches to reaching the unvaccinated.
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