As vaccines began to roll out weeks ago, some hospitals around the country reported that 40 percent or more of their health care workers who could have gotten a Covid-19 vaccine by January had not immediately signed up for it. Other health facilities have had so many extra doses from employees who declined the vaccine that people outside that first priority group — including a sheriff’s deputy and a Disney employee — ended up getting shots.
And a new report by a consortium of universities, released Friday, shows that Covid-19 vaccine uptake and enthusiasm in the health care workforce has also been incredibly uneven. For example, those earning less than $50,000 a year were almost three times less likely to have been vaccinated by mid-January than someone earning more than $200,000 — 8 percent vs 23 percent. Those making lower wages were also much more likely to say they would not get the vaccine at all (27 percent versus 11 percent).
These are troubling developments, especially since health care workers are at higher risk of contracting the virus and are essential in our efforts to treat Covid-19 patients. Some public health experts hoped this group would be relatively easy to vaccinate — and could help pave the way for broader vaccine acceptance. But they also represent a revealing cross-section of America.
A December survey by the Kaiser Family Foundation found health care workers overall were about as likely to be hesitant about getting the vaccine as the general population (29 percent and 27 percent, respectively), with these respondents saying they would probably not or definitely not get the vaccine.
And even those who say they plan to get the vaccine might not actually do so right away. Another December survey, of workers in the Yale Medicine and Yale New Haven Health systems, described in a commentary in NEJM Catalyst found that of the 3,500-plus respondents, 85 percent said they would be “extremely likely” or “somewhat likely” to get a Covid-19 vaccine. So far about 68 percent of their workers have gotten the vaccine when it was offered to them (which is, however, a sizable increase from early January, when the rate was 53 percent).
Understanding what’s holding many health care workers back could help us improve vaccine uptake in the wider population. What’s clear is that we will need the vast majority of people in the US to get vaccinated against Covid-19 in order to stop the pandemic.
But we also have to be careful. Using the wrong approach or language to encourage vaccination could backfire, increasing hesitancy overall, says Alison Buttenheim, a faculty member at Penn Nursing and the Perelman School of Medicine, and scientific director for the Center for Health Incentives and Behavioral Economics. “If we go about it in the wrong way, we could miss the window and blow it,” she says.
Here’s what we know about vaccine hesitancy among health care workers — and what we can learn from it.
3 big reasons health care workers are putting off the vaccines
In addition to preventing infections, serious illness, and even death, vaccinating health care workers first provides an opportunity to gather a wealth of information we won’t be able to get from the general public. That’s because health care systems have the data not only on how many people were offered and got the vaccine, but also on their demographics.
It’s a diverse group: People working in health systems include not just nurses and doctors, but also those who move patients, work in food service, serve in administrative roles, and keep facilities clean and operational. And the people in these many roles span ages, races and ethnicities, educational attainment, income levels, and many other categories.
“In the United States, it’s our best shot at really understanding vaccine hesitancy and the populations we need to be considering for getting the most vaccine coverage,” says Whitney Robinson, an epidemiologist at the Gillings School of Public Health at the University of North Carolina.
From early trends, some key lessons about why some health care workers are putting off the vaccine are emerging.
1) Covid-19 vaccine hesitancy may not be the same as other vaccine hesitancy
The experts we spoke with noted that most of the health care workers who are reluctant to get the Covid-19 vaccine immediately are not necessarily refusing it indefinitely. Many nurses, Buttenheim said in early January, “are in a wait-and-see mode: ‘I wouldn’t mind if a few more million people got it before I did.’” Despite robust safety and efficacy data, they want to see more real-world proof first.
That’s a very different stance from people who refuse — or refuse for their children — vaccines that have been around and proven safe for decades. This means “you can’t necessarily just apply what we know about vaccine hesitancy for childhood vaccines and other vaccines,” Robinson says.
As the Yale study found, among those 15 percent of workers who said they were less likely to get a Covid-19 vaccine now, many wanted a year — or at least six months — of follow-up data on recipients. Only about 11 percent of these reluctant people said that nothing would make them comfortable getting it; and fewer than 1 percent of them said they were “anti-vaccine” overall. Still, as Vice reported, health care workers are vulnerable to both believing and disseminating the Covid-19 vaccine misinformation circulating via social media.
“Accounts with names like The Holistic Nurse are proclaiming that they won’t get vaccinated, and strongly implying their followers should do the same,” Vice’s Shayla Love and Anna Merlan write. “It’s a uniquely risky situation, where people claiming medical expertise are working to undermine trust in a vaccine, just as it becomes clear that a majority of the population worldwide will need to get it in order to keep us all safe.”
2) Covid-19 hesitancy among health care workers tends to follow education
The new February report found that, of workers in the health care field who had not received education beyond high school, 29 percent said they would not get the Covid-19 vaccine (and 22 percent said they would wait until most people they knew had been vaccinated) — compared to 9 percent (and 10 percent, respectively) of people who hold a graduate degree.
Similarly, of the 15 percent of adults in the Kaiser survey who said they would “definitely not” get a Covid-19 vaccine, more than half of those (53 percent) had a high school degree or less. On the flip side, those who reported they would get the vaccine “as soon as possible” were most likely to have at least a college degree.
These patterns track with reports from health systems so far. For example, groups getting the vaccine at higher rates also are those most likely to have among the highest education. Brita Roy, of the Yale School of Medicine, where she is also director of population health and co-author of the Yale NEJM Catalyst study, notes that by early January, about 90 percent of medical residents had chosen to get the vaccine right away, compared with about 20 to 25 percent for those working in environmental services, food service, and transportation (who are likely to have lower overall education attainment). These latter groups have since started signing up for the vaccine in larger numbers, with 45 percent of people in environmental services choosing to get the shot and 35 percent of those in food service. But a striking gap between uptake with those in higher-credentialed jobs remains.
3) There are historical reasons for health care workers of color to be skeptical about getting an early health intervention
About 40 percent of health care workers in the US are people of color. A deep history of institutionalized medical racism means that people of color have frequently been subjects of unethical experiments in the US, often sowing justified mistrust in the medical establishment. Unfortunately, due also to centuries of systemic racism, many of these groups have also been among those hardest hit by the pandemic.
“I want these populations that have been burdened so badly with Covid-19 to be prioritized” for the vaccine, Robinson says. But, she acknowledges that even that ethos could make people suspect. “That’s so unusual with how health care usually operates in the United States, people might have pause,” she says.
And while some workers who haven’t gotten a vaccine yet might be prompted to sign up through simple reminders or other behavioral nudges, overcoming mistrust due to systemic racism, “this is not a nudgeable problem,” Buttenheim says. “That set of concerns and history isn’t going to be solved by a ‘mythbusters’ fact sheet or another study. It’s about really frank conversations about what you need to feel comfortable about this vaccine.”
Another step in addressing this, she says, would also be for health and medical institutions to clearly communicate and own up to past wrongdoings and indicate their goals for equitable medical treatment now and in the future.
How to address vaccine hesitancy
The rate at which health care workers are declining or delaying Covid-19 vaccines is, to many experts, unfortunately not a surprise. “I’m on record banging my head against the wall for several months that we need to be prepared for this, to have a vaccine acceptance strategy,” says Saad Omer, an infectious disease professor at the Yale School of Medicine and director of the Yale Institute for Global Health.
Although some were optimistic that health care workers would have a particularly high uptake of the vaccine, Robinson was also skeptical. “Everybody saw this coming who works in this field,” she says. “This is one of my frustrations: We know things that we haven’t been acting on.”
And there is a vast amount of research on the best ways to help people feel more comfortable getting a vaccine in general, which we can borrow from to some extent for the new Covid-19 vaccines.
For starters, we know what not to do when approaching people who are reluctant to get a vaccine. “‘You’re wrong’ — that doesn’t tend to work,” Robinson notes. “It’s a delicate thing.” She has found that among the most effective techniques is understanding where people are coming from and what their hesitations are. Acknowledging the vaccines’ newness will likely be important in addressing people’s concerns — both in this first priority group and likely later ones, as well.
How to talk with vaccine-hesitant people: a thread for epidemiologists & humans in general, on what the research suggests, and what has worked for me in the past.— Maria Sundaram, PhD (@mariasundaram) December 7, 2020
Also, giving people incentives — financial or otherwise — can actually discourage them from getting vaccinated, especially if they already have concerns about side effects.
Many health systems are already working hard to ramp up communications strategies with workers, provide peer-to-peer discussion opportunities, and even talking to their employees outside of work.
“Health care workers are also community members, so reaching them through social media and our local media outlets, as well as internal communications, has been key,” Mike Dacey, president and chief operations officer at Riverside Health System in Virginia (where they have now had about 66 percent uptake among workers), wrote to Vox in an email. “We are encouraging team members who are eligible to receive the vaccine to do so within their designated phase to best support the safety and health of our team and community.”
In a December JAMA op-ed, Buttenheim and her co-authors also suggested five behavior-based strategies for getting more people to get the Covid-19 vaccine:
- Have community and public leaders endorse the vaccine
- Frame vaccination as a “public act” that benefits others; maybe even hand out stickers
- Make getting the vaccine free and easy
- Give people early access to the vaccine — if they sign up early
- Eventually make vaccination a requirement for entry, such as to schools, workplaces, and even restaurants, gyms, or airplanes
Other experts note that being transparent about any potential side effects, small and large, will help engender trust. For example, some people balked at a January 6 report from the CDC that noted several severe allergic reactions — anaphylaxis — following Covid-19 vaccinations, at a rate of about 11 per 1 million doses or about 0.001 percent of people who get the vaccine, and haven’t caused any deaths (unlike the virus itself). But these events would have been unlikely to surface in the trials of tens of thousands of people, which is why the government keeps careful record of all vaccines after they go to market.
Lesser side effects are also important to communicate clearly to improve trust and transparency now and in the future. “Planning to survey the population on mild side effects experience and share those data with our health care workers will also be useful for the community and [larger] population,” Brita Roy wrote to Vox in an email.
Grateful to get the second Pfizer COVID vaccine yesterday. I just had some mild left arm pain and a low grade fever overnight, but feeling well today. Looking forward to seeing seniors and the general population getting vaccinated this spring! #ThisIsOurShot #DocsforVax #vaccine pic.twitter.com/rW3PIuaShI— Sion Roy (@SionRoy) January 7, 2021
“The sooner we can get more people vaccinated, the sooner we can get back to some semblance of normal,” Buttenheim says. And we have to get a whole lot of people vaccinated. Director of the National Institute of Allergy and Infectious Diseases Anthony Fauci (after revising his public immunity estimations upward) says we’ll need 70 to 90 percent of people immune to the virus to squelch the pandemic.
For health care workers who refuse their first chance at a vaccine, getting back in line could be tricky. There’s no guarantee of when people will be able to get a vaccine if they wait past their designated phase — until more doses are available to the general public. And even more immediately, some states, including Connecticut, have been resupplying facilities based on the number of doses they were able to give the week before. So if uptake is chronically low, availability could dip, too.
That many health care workers are not refusing the vaccine outright and, instead, planning to wait and see provides some small glimmer of hope. Acceptance of the vaccine “is likely to grow as the social norm is established,” Omer says, with the result of more people getting it when they can.
For now, many advocate using the science and information we already have to meet people where they are, and help them feel comfortable getting the shot. “We just need to get ahead of it,” Robinson says. “So much of the response has been reactionary when it comes to Covid-19. I just hope we can break that cycle.”