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It is easy to assume that most people who get the COVID-19 vaccine do so without a shred of trepidation, while those who are hesitant about it choose never to get vaccinated. But a recent set of findings blows up this binary and provides insights that could make vaccination campaigns more successful.

The studies cut through toxic public discourse about the vaccine and focus on a significant group that is often overlooked by researchers, policy makers and the media: so-called hesitant adopters. Such people get vaccinated and report afterward that they felt some degree of hesitation about doing so.

To look into this group, scientists at the University of Arkansas for Medical Sciences Northwest (UAMS Northwest) and their colleagues surveyed 1,475 adults at more than 30 COVID-19 vaccination sites in the state as they sat out their 15-minute wait time after receiving the shot. This sample, collected between late April and early July 2021, is regionally limited but diverse in other ways: The survey was available in English, Spanish or Marshallese. Northwest Arkansas is home to one of the largest populations of Marshallese speakers outside of the Marshall Islands, and this community was hard hit by COVID-19, the researchers say.

The team’s standout finding is that the majority of those who had just been vaccinated—60 percent of the respondents—reported that they had felt hesitant about getting the shot. This result, published on January 15 in the Journal of Behavioral Medicine, initially surprised medical sociologist Don E. Willis and his co-authors. But then team members reflected on their own path to the COVID-19 vaccine—and it was not a straight line for some of them.

The same scientists also conducted a preliminary analysis of national data collected in September and October 2021 that include questions about vaccination status and hesitancy. The investigation reveals similar trends in the prevalence of hesitancy among people who got the COVID-19 vaccine, says team leader and community health researcher Pearl A. McElfish of UAMS Northwest.

One hope behind these studies is that insights into how people come to set aside their vaccination anxieties or concerns could lead to more effective campaigns to increase uptake of the COVID-19 vaccine and other vaccines. And the results call into question the idea that people’s vaccination-related thoughts and behavior are in perfect harmony and fall into mutually exclusive categories—either embracing the COVID-19 vaccine or refusing it.

“It’s not that ‘if you’re not vaccinated, then you are vaccine-hesitant’ or ‘if you’re vaccinated, then you are vaccine-confident,’” says medical anthropologist Eve Dubé of Laval University in Quebec. “You could be nonvaccinated and highly confident but face important barriers to access. Or you could be vaccinated and still be vaccine-hesitant.” In 2013 Dubé and her colleagues published an influential review of research on vaccine hesitancy, revealing that people’s feelings and behaviors surrounding vaccines are complex, influenced by many different factors and part of a continuum.

In recent years Dubé and others who study vaccination behavior have advocated for more nuanced discussions of and responses to people who are hesitant about vaccination. A failure to see the complexity underlying this hesitation can be counterproductive. “Many media reports were blaming nonvaccinated people for the ongoing pandemic, and this stigmatization often results in stronger attitudes against vaccines,” Dubé says.

To dig into hesitancy surrounding COVID-19 vaccination, community health researcher Rachel S. Purvis, also at UAMS Northwest, looked at data on the sources of information deemed trustworthy among nearly 870 hesitant adopters in the same Arkansas sample used for the January study. These respondents most frequently reported that they trusted health care providers, academic medical experts, and state and federal public health organizations, including the U.S. Centers for Disease Control and Prevention. The results were published on December 1, 2021, in Vaccines.

The replies to a question about trusted sources of information included these quotes:

“I trusted the scientists that they would not have put it on the market if it wasn’t safe.”

“My personal doctor … confirmed that it was a safe and best way to go about the virus.”

“I talked to my doctor and he highly recommended it.”

“Dr. Fauci. I trust him more than any other public figure and value his years of experience and service to our country.”

Hesitant adopters most frequently reported relatives, friends and other members of their social network as helping them overcome their concerns along the way to the COVID-19 vaccine, according to an analysis of the same Arkansas data by medical sociologist and January study co-author Emily Hallgren, also at UAMS Northwest. In some cases, family members influenced hesitant people’s decision to receive the vaccine. In others, getting access to the shot became a family affair. “My family providing the funds to help me go and get the shot gave [me] the support I needed,” said one respondent, according to Hallgren’s study.

Most of the people reporting vaccine hesitancy in the full Arkansas sample rated themselves as “a little hesitant.” These respondents amounted to 31 percent of the full sample, the UAMS Northwest researchers found. About 10 percent of all respondents stated they had been “very hesitant” to get the COVID-19 vaccine, however.

Some people who had been firmly opposed to getting vaccinated recently chose to do so, says public health researcher Sandra Crouse Quinn of the University of Maryland School of Public Health’s department of family science. Quinn has been co-leading a local component of a multi-state study of COVID-19 pandemic experiences and health equity, including barriers and facilitators to vaccination against the disease. To explore COVID-19 vaccine hesitancy and aid greater vaccine equity in Black and Latino communities in Prince George’s County, Maryland, she and her colleagues worked with a network of local partners, including area barbershops and hair salons, to listen to and learn from community members and conduct interviews, among numerous additional outreach activities. The interviews and other field research revealed that some community members voiced strong concerns about COVID-19 vaccination in conversations with barbers and stylists, many of whom serve as local influencers and trusted sources of health information, Quinn says.

“One of our barbers refers to those folks as they’re at the ‘Hell No Wall’: ‘No way am I going to do this,’” she says. “But what we also saw happening with this: number one, our community partners are barbers and stylists. They’re vaccinated. They’re boosted. They’re talking to people all the time.” Hesitancy started to decline as community members explored their legitimate questions with barbers, stylists and others about subjects such as emergency use authorizations and how mRNA-based and other vaccines are made, Quinn adds.

The large number of people infected with the Omicron variant of SARS-CoV-2, the virus that causes COVID, this winter also had an impact on some participants in the Prince George’s County study, Quinn says. “Even if they hadn’t been touched before, people were getting sick,” she says. “And there was one particular case where several of them knew a 51-year-old—unvaccinated—[who] was at the Hell No Wall, got sick [and] two weeks later was dead. And that spurred this great ‘Well, I may still be reluctant, but where do I get it?’”

No universal strategy is likely to help all people resolve their COVID-19 vaccine hesitancy because hesitant adopters’ motives and social influences often vary among constellations of demographics and life experiences, McElfish and other researchers have found.

So strategies to help people think through their hesitancy should be “attentive to the actual questions that people have—not an imagined set of questions or an imagined homogenous group of people who all share the same ideas,” says medical anthropologist Ramey A. Moore of UAMS Northwest, who published an analysis of factors that motivated people in the Arkansas sample to get the COVID-19 vaccine. The results appeared on October 23, 2021, in the Journal of Community Health.

The recommendation for more open-ended conversations is aimed in part at health care providers, some of whom have grown weary of repeating the same COVID-19 vaccine safety and effectiveness information to hesitant patients, Moore says. The new findings suggest these chats should be tailored to the diverse issues that are relevant to vaccine-hesitant individuals and to specific communities, he adds.

Dubé says effective solutions to hesitancy should make sure vaccination campaigns address local concerns, while also addressing access issues and barriers to vaccination where they exist.

These days persistent hesitancy around COVID-19 vaccination is not linked to a lack of information, education or communication, Dubé says. “I would say that it’s due to … no space to have open discussion and maybe ask your question to a trusted health care provider—and maybe get some support to make sense of everything that’s happening to make an informed decision.”

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