COVID-19 Vaccine Distribution in the Time of Vaccine Hesitancy


Some vaccine has arrived, and more is coming.
How are we going to get everyone vaccinated who wants the vaccine?
How are we going to get everyone vaccinated who doesn’t?

As the initial COVID-19 vaccine supply comes in, the health systems, federally qualified health centers and large medical groups in our network have begun vaccinating their employees and are planning to offer vaccines to their patient population and broader community members over the coming months. Those organizations are facing a number of key challenges—challenges that require different yet interconnected responses.

Challenge 1: How do we get everyone vaccinated who wants the vaccine?

The throughput challenges are daunting. Outreach, scheduling, screening, consenting, reminders, recalls—all of these must happen in a contactless environment, with the same workforce that is already stretched due to the uptick in COVID-19 cases across the country. And then there is the problem of the second dose. Annually, only 45% of Americans get a flu vaccine, even though nearly 60% intend to get it. The difference between those who intend to get it and those who actually get it is referred to as “the intention gap.” What does it tell us? Even those who intend to get the vaccine drop off at some point if the process is not easy and convenient.

What can be done? There are known strategies for improving uptake and completion and they must be deployed consistently, at scale, to make sure those who intend to get the vaccine complete the series.

Here’s a great example. While the ease and convenience offered by a walk-in clinic sounds like it would be a great strategy to increase uptake, researchers examining flu vaccines found that having a set appointment—and even going as far as telling people there is vial with their name on it—increases the likelihood that someone who intends to get the vaccine will actually show up. Listen to Katy Milkman, Co-Director of the Behavior Change for Good Initiative at the University of Pennsylvania, talk about the intention gap here.

OK, great. We have some best practices that we can deliver that will maximize uptake among those who intend to get the vaccine.

The problem is only 41% of Americans “definitely intend” to get the COVID-19 vaccine when it is made available to them, with another 30% who “probably” intend to get the vaccine. The remaining 27% saying “they probably or definitely would not get a COVID-19 vaccine even if it were available for free and deemed safe by scientists,” according to survey results published December 15 by the Kaiser Family Foundation.

The intention percentage is even lower in vulnerable communities and communities of color that have been hit hardest by the virus. According to a study released in late November, fewer than half of Black people and 66 percent of Latinx people surveyed said they would definitely or probably take a COVID-19 vaccine if it was offered to them free of charge. That means that even if we close the intention gap, we’re still on what Heidi Larson, Director of The Vaccine Confidence Project, calls a “wobbly” path to vaccinating the 70% of the population needed for herd immunity.

Which brings us to the second challenge that healthcare organizations are facing.

Challenge 2: How do we get folks vaccinated who don’t want to get it?

Strategies to close the intention gap are not the same as strategies to engage those who are vaccine-hesitant. According to Larson, people who don’t want to get the vaccine are not a monolithic group and definitely shouldn’t be lumped together as “anti-vaxxers.” Many factors can lead people to be vaccine-hesitant.

Behavioral science has strategies to engage the vaccine-hesitant, and those strategies are very different than those used to close the “intention gap.” Intention gap strategies focus on reinforcing a decision that has already been made. Addressing vaccine hesitancy is about listening and understanding concerns of individuals and communities and resolving those concerns where possible. It requires empathy. Pummeling someone with reminder messages when they are vaccine-hesitant can be counter-productive.

Uché Blackstock, MD, an emergency medicine physician and founder and CEO of Advancing Health Equity, suggests we move away from a framework of “convincing” people and toward an approach of listening and responding to their questions so they can make informed decisions. And in a recent episode of Andy Slavitt’s podcast, In the Bubble, Larson identified different groups who are often vaccine-hesitant, including people who:

  • Have questions about COVID-19 vaccine safety, given the expedited timeline
  • Have ideas based on rumors they have heard about the vaccine
  • Believe that the government shouldn’t require any personal behavior, including masks or vaccines
  • Have a mistrust of government grounded in historic/systemic injustices in their community
  • Value an all-natural lifestyle that rejects medical and manufactured products

As healthcare professionals, we need to understand the nature of vaccine hesitancy. According to many surveys, there is a large group of people who are still on the fence about the COVID-19 vaccine. Only when and if a person makes a decision to get the vaccine can those great strategies to close the intention gap actually work.

As we embark on the nationwide effort to vaccinate the entire population, it is critical we employ the best practices of behavioral science to both close the intention gap and address vaccine hesitancy.

Hilary Hatch, PhD, Clinical Psychologist, Vice President, Clinical Engagement, Phreesia