Vaccine Hesitancy—A Case Study
A study was published in December 2020 of 991 adults, who were participating in the National Opinion Research Center AmeriSpeak Omnibus Survey, were asked about their willingness to take a then-theoretical vaccine to protect against COVID-19 infection. They found 10% were unwilling to consider vaccination at all, and another 30% were unsure if they would take a vaccination. “Factors independently associated with vaccine hesitancy included younger age, Black race, lower educational attainment, and not having received influenza vaccine in the prior year. Such surveys have been repeated and reported in the press now that vaccinations have begun, and the precent unsure has declined from the 30% in this study to more like 20%, but the “no” category has remained at about 10%. Dr. Anthony Fauci, who has been the medical “face” of the official pandemic response was quoted as saying something to the effect we have more education to do. But is that really the issue?
Clinicians face this sort of issue every day when recommending actions to patients designed to reduce the risk of future complications. We discussed the challenges of standard health advice like losing weight and exercising more in a previous article, so this article will focus on medical advice such as taking a medication to control blood pressure. Patients with hypertension rarely feel anything attributable to hypertension, but may experience side-effects, and certainly expense, related to taking medications, not to mention the hassle factor and the psychological import of having a disease. Studies frequently show “good” blood pressure control in hypertensive patients is somewhere between 60% and 70% —even without considering the challenge of defining good. I am struck by the parallel of the numbers with the vaccine hesitancy numbers.
Given this parallel, I would argue vaccine hesitancy is a specific instance of a general issue—how willing are people to follow medical advice? Of course, there is a difference. If I choose to endanger my health by not taking my medication, society is impacted only in terms of medical costs, which are diffuse and difficult to estimate. If I choose to endanger my health by not taking the vaccine, then I may not get sick, but my neighbor may catch the infection from me and die, which is a measurable risk. Nonetheless, I think it is important to look at this issue as a case study.
I think there are three basic issues involved: fear, attitudes toward risk conditioned by that fear, and trust. I realize these issues are interconnected, but want to look at specific aspects of each. First, fear is the dominant emotion underlying vaccine hesitancy. While some of this may be a fear of getting sick and/or dying, I think the more general issue is a threat to the notion that “I am in control of my life.” The illusion of control is one many people hold to rigorously, and is worth extended discussion at a different time, but the pandemic creates fear, in part, because an “invisible” disease might sneak up on me at any time. When told to wear a mask and socially distance, some people’s fear causes them to become angry and defiant, even when that position is really increasing the likelihood the fearful event will come to pass.
Given that the world is full of threats to us, we all develop an internal calculus toward risk, which I have discussed in an earlier article dealing with the pandemic. While there are actuarial data on risks, we usually make our decisions about what we are comfortable doing based on perceptions of control—getting to the airport is more dangerous than the flight, but I control my automobile, while in the airplane the pilot, whom I do not know, is in control. But when it comes to vaccine hesitancy, a better understanding is risk now versus risk deferred. If I take the shot, I know I will have some soreness/sickness, time out of my day, etc. In other words, the risk of taking the shot is immediate. The benefit is delayed and uncertain—yes, it reduces my risk of getting sick from the infection, but I might not get infected anyway, and even if I do, the risk of being hospitalized is below my risk threshold.
Which brings me to the third issue: trust. Whether I believe the vaccine is effective, or that the risk-benefit analysis favors taking it, reflect my attitudes toward the source of those statements. We talk about “data,” but most people don’t have the chance to examine the data, nor the time and understanding to interpret the data, so, to some extent, almost everyone is dependent upon experts summarizing it for us. Consider the question this way. Do you trust experts? The honest answer, of course, is “No.” I trust some experts, based on personal knowledge of their track record and opinions of others I trust, but I don’t trust an anonymous class of people labeled experts—by whom and of what?
I think a majority of citizens are willing to give “medical experts” the benefit of the doubt, but some, for various reasons, are not. This does not mean these doubters are ignorant, stupid, or unreasonable—just that they are not trusting. There has been a lot of talk about why minority populations in the U. S. are not trusting, based on historical examples, but I think the problem is a human one, not just a racial one. Bad experiences can sour anyone. On the other hand, the percentage of patients who trust their personal physician is much higher, but the number of people with such a relationship has declined as a result of shifts in medical practice.
With all due respect to Dr. Fauci, whose papers and writings I have been following for forty plus years, I don’t think the answer is “education.” Nor do I think the answer is more effective “messaging,” although that can’t hurt. I saw a news clip the other evening where a Native American counselor was discussing the issue of vaccine hesitancy among his tribal members. The clip featured a discussion with one of his relatives, who announced she was taking a trip to visit kin in another state. When he asked her if she was going to take the vaccine, she said “no.” He then demonstrated his skill as a counselor by opening a conversation by asking her why, rather than lecturing her about her risky behavior. By the end of the conversation, they had progressed to the point where she was willing to think about it, but still hadn’t gotten to a “yes.” This story makes an important point—success requires conversation with trusted advisers and takes a lot of time. Does our current medical model of an office visit lasting 10 minutes set a good working base for such a conversation? Of course not. Furthermore, as physicians, are we tolerant of “I’ll think about” it as an answer? Can we continue the conversation in the near future?
Vaccine hesitancy has implications for our current industrial, production-oriented approach to medical care for population health. The natural result of routine care is “success,” by whatever metric is being studied, of about 60%. Applying trust-building measures and more conversations may get us to 70%. If we want to get to 90%, though, we are going to have to think about totally different approaches. What do you think?
21 February 2021
 Fisher KA, Bloomstone SJ, Walder J, Crawford S, Fouayzi H, Mazor KM. Attitudes Toward a Potential SARS-CoV-2 Vaccine: A Survey of U. S. Adults. Ann Intern Med 2020;173-964-973. doi: 10.7326/M20-3569.
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