Vaccine hesitancy – the reluctance or refusal to receive a vaccine despite its availability – is nothing new. Hesitation and even opposition to vaccines began shortly after the introduction of the smallpox vaccination in the 1800s and have continued ever since. In fact, the World Health Organization (WHO) listed vaccine hesitancy as one of the top 10 threats to global health back in 2019.

The reasons for vaccine hesitancy are varied. For some, a fear of needles, concerns about missing work, or anxiety regarding side effects are behind decisions to delay or avoid a vaccine. For others, the reasons can be more complex and tied to deep-seated spiritual, religious, philosophical and/or political beliefs of individuals, thus making conversations about vaccines all the more difficult.

While the debate over vaccines hasn't waned over the last two centuries, the COVID-19 pandemic has definitely brought it to the forefront as death tolls from the virus continue to rise and countries around the world continue to roll out the vaccine. According to Our World in Data, only about 44% of the world population had received at least one dose of a COVID-19 vaccine as of September, with the vast majority of vaccinated individuals living in higher-income countries. Only 2% of people living in low-income countries have had at least one dose of the vaccine. Meanwhile, the global death toll has reached more than 4.5 million and counting.

Outside of access to the vaccine – which is clearly one of the top reasons for low vaccination numbers, particularly in low-income countries – vaccine hesitancy is another major contributor. Concerns about the safety of the vaccine, given the lack of long-term data and the speed of development and authorization for use, are often cited. For example, more than one-third of unvaccinated individuals in the U.S. believe risks from the vaccine are greater than the risk of COVID-19, according to data from the Kaiser Family Foundation. Similarly, a recent poll conducted by the de Beaumont Foundation found that one-third of nearly a thousand unvaccinated adults said full approval by the U.S. Food and Drug Administration (FDA) would address all or most of their concerns about the vaccines' safety, while another 20% said it would address some of their concerns.

Religious beliefs, concerns about government mandates on health care decisions and civil liberties, and lack of public trust in government and research, especially among certain racial and ethnic groups, are also playing a role in the vaccine debate. Layer on complacency with the status quo and all the misinformation and disinformation (i.e., alteration of DNA myths and microchip and 5G conspiracy theories) that are easily propagated and spread through social media platforms and the internet, and there's a powerful vortex that continues to keep too many individuals on the sidelines, not getting vaccinated.

Understanding the "3 Cs" Model of Vaccine Hesitancy

The "3 Cs" model outlines how complacency, confidence and convenience play into vaccine hesitancy. Addressing concerns within these domains can help with moving patients along the spectrum from resistance or hesitancy to accepting a vaccine.

Who Do You Trust?

How do we solve for this dilemma, given the very real scientific evidence showing the ability of the vaccine to save lives, reduce hospitalizations and slow the spread of the virus? Enter the role of health care providers, who are viewed as trusted sources of information when it comes to decisions about vaccines, disease management and overall health.

"The government and the media have tried to encourage people to get a vaccine. Yet, many times patients want to hear directly from their own caregivers about the risks and benefits of having a vaccine," says Ami Bhatt, MD, FACC, director of the Massachusetts General Hospital's Adult Congenital Heart Disease Program in Boston. "Having the discussion with somebody in the medical field who knows them and who recommends the shot was more than enough to convince many of my patients to get a vaccine," she says.

This trust in health care providers hasn't been lost on groups like the WHO, which have made it a priority to help increase public trust in health care clinicians and health systems to combat misinformation and improve patient outcomes – whether it's combatting COVID-19 or dramatically reducing noncommunicable diseases like cardiovascular disease and cancer, which account for 71% of all deaths globally.

"At times it can seem like a daunting task to even ask a patient if they have been vaccinated or to test the waters about their willingness to discuss why not and engage them in a conversation that may help them make a different choice," says Bhatt, "but with the uptake of COVID-19 vaccines stalling, and the numbers of people infected and dying, it's falling to individual conversations between clinicians and patients to move the needle, one at a time."

Gladys Velarde, MD, FACC, professor and medical director of the Women's Cardiovascular Heart Program at the University of Florida in Jacksonville, agrees. "It's critical that cardiologists talk with their patients about vaccine hesitancy," says Velarde, noting the need to treat the whole patient, not just one condition. "When I speak with patients, I make it very clear their chronic conditions could lead to a worse outcome if they get infected."

Diverse Populations, Diverse Concerns

In both the Latinx and Black communities, the rates of risk factors, comorbidities and cardiovascular disease are higher compared with Whites. "While COVID-19 didn't cause these underlying disparities, it unmasked and revealed them because it placed these patient populations at higher risk," says Keith C. Ferdinand, MD, FACC. Death rates from COVID-19 were ninefold higher in Blacks than Whites in March 2021, while they were fourfold higher for American Indians and Alaska Natives and threefold higher for Latinx Americans.¹

Meanwhile, vaccination uptake for COVID-19 in these communities continues to be lower, compared with Whites. While there are some signs of a recent uptick in vaccination rates across all racial and ethnic groups, the rates of vaccination still fall far short in relation to the share of COVID-19 infection in most of these communities.

What are some of the reasons behind these trends? Within the African American/Black community, a long-standing mistrust of orthodox medicine is a major barrier to accepting vaccinations, says Ferdinand. The Tuskegee syphilis study, where Black men were deliberately not treated for syphilis for research purposes, and the infamous case of Henrietta Lacks, whose cancer cells were used by scientists without her knowledge, are two prominent drivers of this mistrust.

Velarde notes a similar widespread mistrust of the government and the medical system within the Latinx community, in addition to frequent language barriers and often limited access to regular care. "The Latinx community uses a lot of social media, which has been inundated with misinformation that creates mistrust and fear," she says. For example, misinformation about proof of citizenship requirements has held undocumented workers back from vaccination, while rumors about fertility impacts, DNA alteration and microchips are also adding to vaccine hesitancy in this patient population.

Language barriers and lack of information about the vaccine, rather than misinformation, is a common problem in Asian communities that are also disproportionately impacted by COVID-19, says Eugene Yang, MD, FACC, professor of medicine and Carl and Renée Behnke Endowed Professor for Asian Health at the University of Washington School of Medicine in Seattle. More recently, concerns about hate-related violence have also meant many Asian Americans are afraid of leaving their homes or communities out of fear of being attacked. Research from the Pew Research Center published this past March said 26% of Asian Americans surveyed feared being threatened or attacked in the last year.

Personalizing Solutions

When Ferdinand met recently with a younger, Black immunocompromised patient the first question to the patient was whether he'd been vaccinated for COVID-19. Because the patient was at high risk, addressing an immediate barrier to his ongoing health came before the usual cardiac evaluation, Ferdinand says.

As with all his vaccine-hesitant patients, Ferdinand, a cardiologist and professor of clinical medicine at the Tulane University Heart and Vascular Institute in New Orleans, listened without judgment to the man's fears and then was able to engage in a conversation and provide important resources on the vaccine's safety, as well as the very real risks of death should the patient remain unvaccinated and be diagnosed with COVID-19. "I think understanding the potential impacts on his life and his family helped him to recognize the need to protect himself and get vaccinated," he says.

Ferdinand, who is also a member of the National Institutes of Health's Community Engagement Alliance (CEAL) Against COVID-19 Disparities and the Louisiana COVID-19 Health Equity Task Force, also shares with patients the South African concept of Ubuntu, which recognizes that everyone within a community is connected. "Although there seems to be a concept afloat that whether or not to get vaccinated is one's personal choice, in reality, with infectious diseases, it's everyone's business. This is especially true for coronavirus infections that are spread through droplets and aerosols and prolonged contact." According to Ferdinand, when individuals are able to recognize that the disproportionate rate of hospitalization and death are real, not imagined, they are more willing to see the value and the role they can play in helping themselves, their families and their community.

Health care providers working in tandem with community leaders and organizations have also proven to be successful tactics in reaching Black, Latinx and Asian communities. Yang notes that community events to book appointments have been successful in overcoming technology and language barriers and reaching specific Asian communities across the country, such as Hmong communities in Minnesota or Korean communities in Seattle.

Community partnerships can also help provide translating services and/or distribute information where people live, work, worship and play. Yang notes that when he sees vaccine-hesitant patients who don't speak fluent English, he makes sure to rely on translators and to hand out information sheets in their native language.

Velarde uses similar tactics with her Latinx patients. She was one of the first in Florida in line for the COVID-19 vaccine and shares that photo of herself in the newspaper with her patients and during Spanish-speaking community vaccination events where she's a volunteer. She takes the time to listen to and address the concerns of those who are hesitant about vaccination and has handouts ready to give them to take home.

If a patient agrees to get a COVID-19 vaccine, Velarde arranges for a medical assistant to take the patient to the hospital's vaccination clinic directly after the visit. Encouraging patients to get vaccinated is a team effort, she says, and she reminds staff that accompanying someone to the clinic is just as important as taking the patient's vitals.

"Education, education, education, verbal and written, is needed to reach specific populations about the benefit of COVID-19 vaccination," says Velarde. She also urges clinicians not to underestimate the value of community volunteering. "Volunteering shouldn't stop in medical school," she says. "It's important for clinicians to have a wider breadth of knowledge of what it means to take care of our citizens."

Reference

1. Quinn SC, Andrasik MP. N Engl J Med 2021;385:97-100.