How Healthcare Leaders Can Combat Vaccine Hesitancy

“It’s about meeting people where they are. There are many barriers we could remove to getting vaccinated, but we don’t do a good enough job of it.”

Dr. Emily Smith, Epidemiologist and Assistant Professor at The George Washington University Milken Institute School of Public Health

Vaccination rates in the US have lagged behind other rich countries. The reasons for that lag are multivariate, but sometimes grouped under the generic label of vaccine hesitancy: the refusal or reluctance to have oneself or one’s children vaccinated against an infectious disease or diseases.

Vaccine hesitancy is dangerous. Unvaccinated people are more likely to contract, and thus spread, disease. In May of 2021, a Gallup poll found that 32 percent of adults were unwilling to take a free Covid-19 vaccine. If extrapolated globally, that amounts to 1.3 billion people.

Today, the number of Americans who have taken at least one dose of the Covid-19 vaccine has risen to be more in line with other wealthy nations. But vaccination rates remain unequal across the US, and major pockets of vaccine hesitancy remain, even in those who chose to get vaccinated against Covid-19.

Sometimes vaccine hesitancy originates from toxic political debate, and carries little basis in fact. But at other times, it’s rooted in the historical mistreatment of certain communities and demographics, particularly people of color. In all cases, more can be done in outreach, education, and cultural competency.

Read on to learn more about the realities of vaccine hesitancy and what can be done to address it.

Meet the Expert: Emily R. Smith, ScD, MPH

Emily Smith

Dr. Emily Smith is an epidemiologist and an assistant professor at The George Washington University Milken Institute School of Public Health in Washington, DC. She is a graduate of the population and reproductive health doctoral program in the Department of Global Health and Population at the Harvard T. H. Chan School of Public Health. She completed her MPH at the Rollins School of Public Health at Emory University.

Dr. Smith’s research focuses on infection and nutrition across the life course, to generate, analyze, and translate epidemiological data to improve maternal, newborn, and child health in low- and middle-income countries. She worked closely with the World Health Organization (WHO) to synthesize and translate evidence for use in global policy contexts on topics, including the risk of SARS-CoV-2 in pregnancy; mother-to-child transmission of SARS-CoV-2; efficacy and safety of neonatal vitamin A supplementation, and interventions for care and feeding of low birthweight infants.

Assessing & Addressing Vaccine Hesitancy in the US

“There are many reasons for low vaccination rates,” Dr. Smith says. “One of the less-discussed reasons is this idea of the infodemic. While not misinformation or disinformation, per se—though those both contribute to low vaccination rates, too—the infodemic refers to there being too much information. It makes it hard for people to sort through. This is a real issue across all demographics.”

The Covid-19 pandemic was a particularly fraught information environment. Some members of the public had difficulty grappling with the fluctuation of official information and guidelines, as scientists and public health officials adjusted their models to accommodate new data. What was actually science in action appeared, to a few, as uncertainty.

“In science communication, we need transparency on the things we do and don’t know, both at the individual level and at a higher level,” Dr. Smith says. “I think a lot of times there’s an attempt to overcompensate. It’s difficult to correctly communicate what we do and don’t know in a way that still instills confidence.”

While the politicization of science does contribute to an increase in vaccine hesitancy, there are core public health levers that can be used to bring it back down. Currently, barriers to vaccination persist, and persist unequally, across the nation. Some state public health organizations are better funded than others; some are more strategic. The difference between employer-provided insurance and low-cost insurance (or no insurance at all) is significant. Active outreach that makes getting vaccinated convenient and understandable, as opposed to inconvenient and confusing, can make all the difference.

“It’s about meeting people where they are,” Dr. Smith says. “There are many barriers we could remove to getting vaccinated, but we don’t do a good enough job of it.”

Medical Mistrust in Historically Mistreated Communities

A 2021 poll conducted by the African American Research Collaborative (AARC) found that past and present discrimination from medical professionals deterred unvaccinated Black and American Indian/Alaska Native respondents from getting a Covid-19 vaccine. The findings were consistent with previous research showing that people who say they mistrust healthcare organizations because of discrimination are less likely to take medical advice and keep follow-up appointments.

But even those who do get vaccinated can exhibit skepticism; vaccine hesitancy and vaccination status are sometimes incorrectly conflated. A March 2023 study found that nearly half of vaccinated American adults reported some level of hesitancy in getting the Covid-19 vaccine, with younger respondents, women, and Black and American Indian or Alaska Native participants having greater adjusted odds of being more hesitant.

“There’s a well-deserved mistrust of the healthcare system among Black and Native communities,” Dr. Smith says. “Step one is healthcare providers acknowledging the historical lens and current landscape of racism in America as an issue, and as a legitimate reason for people to feel undecided, hesitant, or mistrustful.”

This lack of trust, sometimes called medical mistrust—though that term could carry its own footnotes—goes well beyond vaccinations. Healthy behaviors, prescription adherence, and preventative testing all go up when patients trust their healthcare providers. Studies are now looking at how health systems can better understand and address the impact of racism on patient safety.

How Healthcare Leaders Can Build Back Trust

Trust, once revoked, is not given back easily. Health leaders face a significant challenge in finding methods of re-engaging their communities, and it must go beyond lip service. Research suggests that the health systems most likely to find success are the ones with integrated care models that are tailored to the cultural and linguistic needs and preferences of their local community.

Provider-side education and a person-to-person approach could reap benefits. Patients typically already have more trust in their providers than in “healthcare” as a whole (Journal of General Internal Medicine 2006). Initiatives like 3rd Conversation carve out time away from the exam room where patients and providers can have frank conversations about their experiences (and their frustrations) with healthcare.

Money talks. Geisinger Health System has been testing a program called Proven Experience, where patients who have had a poor experience can apply for a no-questions-asked refund of copayment, deductible, or other cost as a way of building trust.

On the provider side, Geisinger gives its new physicians and advanced practice providers extra training on communication, including the importance of making eye contact, introducing yourself, explaining procedures, asking permission, and being personable. Providers who continue to have problems are given individual coaching sessions.

These are meaningful efforts towards rebuilding trust. More should follow. But the healthcare workforce itself also needs an overhaul.

“We need more diversity in the healthcare workforce,” Dr. Smith says. “That’s important. We see benefits in health outcomes when people are able to work with providers who look like them, or talk like them, or live like them. It’s a big systemic issue that no one has a good solution for, but for which there are many small solutions and ways to improve.”

The future is unlikely to be less information-dense than the present. But it can be more healthy and more equitable. Healthcare administrators and other health leaders who focus on rebuilding trust, and making health systems more trustworthy, can help bring that future about.

Matt Zbrog
Matt Zbrog

Matt Zbrog is a writer and researcher from Southern California. Since 2018, he’s written extensively about emerging issues in healthcare administration and public health, with a particular focus on progressive policies that empower communities and reduce health disparities. His work centers around detailed interviews with researchers, professors, and practitioners, as well as with subject matter experts from professional associations such as the American Health Care Association / National Center for Assisted Living (AHCA/NCAL) and the American College of Health Care Executives (ACHCA).

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