UCI Podcast: Why are people hesitant to get the COVID-19 vaccine?

Even before the COVID-19 pandemic, some people shunned vaccines because of concerns about their safety, or the inconvenience of inoculation, or other reasons. But in order for the pandemic to fully end and for normal social life to resume, we need almost everyone to get vaccinated.

What are the five most common reasons for vaccine hesitancy? And how can we convince everyone that they should get the shot?

From the University of California, Irvine, I’m Aaron Orlowski. And you’re listening to the UCI Podcast. Today, I’m speaking with Suellen Hopfer, who is an assistant professor in the Program in Public Health at UCI.

Professor Hopfer, thank you for joining me today on the UCI Podcast.

Great to be here. Thanks.

So the COVID-19 pandemic will be over when we reach herd immunity, and we’re going to be able to reach herd immunity by successfully vaccinating a significant majority of people. But at the same time, a lot of folks have expressed some hesitancy about getting the vaccine. So I wanted to ask you: How many people need to be vaccinated for us to get to that herd immunity level? And then from the surveys that you’ve read and seen how many people are actually expressing hesitancy about the vaccine?

Good Aaron to reach herd immunity, we need at least 70 to 90 percent of our population vaccinated. So we still have quite a bit, a ways to go. As far as vaccine hesitancy, there have been national and local surveys that have waxed and waned. So we have national surveys back in a year ago (that) estimated about 60 percent willing to vaccinate. Then in the fall it went down. Then in the past winter, it’s gone back up. It’s increasing, with at least 70 percent of the population willing to vaccinate or, saying they are, although it differs depending on parts of the country or different populations. I think it’s growing, as more and more people vaccinate and witness their friends and networks vaccinating. They’re okay, and they’re in good health. So I think the vaccine confidence is growing. But there’s still a substantial group of people — there’s about 18 to 20 percent of people who are unsure. And another 10 to 15 percent who are really not willing to vaccinate.

It seems like people believe that they have a choice between either getting the vaccine or not getting the vaccine, but the choice is a lot more complicated than that. And it’s not binary like that.

Right, so when we talk to people about considering vaccinating, we hear people often making a false choice. There’s this hyper-awareness about the possible side effects of the vaccine, which should be considered. People should be educated and consider this. But the comparison to just status quo or not vaccinating is really a false choice. It should really be compared to the possibility of acquiring COVID-19 and getting sick, which can lead to serious illness.

And people tend to assume that it’s not going to happen to me. I’m not going to be the person who gets COVID-19.

Exactly the status quo or going about business as usual, it led us into quite a disastrous pandemic where the entire economy shut down. And that’s why we need to be proactive and do everything we can to stop the transmission and spread of the virus so that we can get out of this pandemic and resume the social activities that we love and get back to work.

Experts have been studying vaccine hesitancy for years now, including yourself. And there are some certain reasons that people tend to give for expressing hesitancy. So what are those reasons?

So we know from communication and psychology research, that there are five universal reasons of why people tend to be unsure — hesitate — to vaccinate, across all vaccines, across all countries. And there may be a constellation of reasons. It’s also called the 5C Model. It was put together sort of more formally beginning in 2012, working with the World Health Organization. These are about vaccine confidence, which relates to trust and concerns about safety and the process of vaccine development. There’s vaccine confidence. There’s vaccine complacency, which relates to perceiving yourself at low risk, or that you don’t need to vaccinate. Then there are constraints, which relate to practical barriers, concerns about cost, time, I’m too busy, I’ve got a stressful life, or I work all day, I have two jobs. So cost and time, or access. This is the third C. Collective responsibility is the fourth C, which is about either vaccinating for others or actually believing well, if everybody else vaccinates, then I’ll basically be a vaccine free rider, that I don’t need to because everybody is. And the last one is calculation, is where you over — you’re an information seeker, and you’re really weighing the benefits and risks to the extent that your personality — that you’re risk averse, and you’re just hesitant to vaccinate.

I want to come back to those five reasons in a little bit, but I want to ask, first of all, about some work that you’re doing here locally in Orange County, where you’re interviewing parents and students about their attitudes towards the COVID-19 vaccine. So what are you finding with that research right now?

It’s very interesting. We’ve been able to talk to families and parents, as well as high school and middle schoolers in Orange County. We’ve interviewed 46 families so far and sampled families across race, ethnicity, occupation, multi-generational households, kids with chronic conditions. And we talked to them about four areas, their past experiences vaccinating, their thoughts and concerns and questions as well as motivators for considering vaccinating their kids come this summer. And then their trusted information sources they turn to. And what would they like to know. We also asked them, was their intent to vaccinate. And so we have really a split. We have 45 percent of parents willing to vaccinate their children, 11 percent responded no, and 43 percent responded they’re unsure about vaccinating their kids. We have, currently, the Pfizer vaccine is available and included, 16 year olds and older. And currently Pfizer and Moderna had clinical trials of 11 to 17 year olds. Up to 3,000 kids enrolled. And they’ll be coming out with those results in June. They’re very promising. And so probably this summer they’ll be offering these vaccines to adolescents and possibly preteens.

So we talked to families whose children were between sixth grade and 12th grade. And from the parents, so we had of these five Cs that we know, three of the five really emerged in conversations with parents and kids. The number one was vaccine confidence, which involves, again, trust about the process, safety of the vaccines, ingredients, long-term effects. These are questions that parents and kids have. And they’re being increasingly — at least the high school students — were increasingly confident as they witnessed their parents and their teachers vaccinating, and began to have their questions answered about the vaccine through school webinars with experts. This really helps — these community educational webinars that are being offered to the community, almost every week. In Orange County, there are a lot of different entities working hard — UCI as well as community groups — trying to reach families and communities with education. So this was vaccine confidence. Then there was also complacency that a lot of families felt that their children were not at risk, or that the risk was manageable. And then calculation was this risk-benefit consideration for children given that they’re less likely to become very sick. But that doesn’t mean it’s not possible. There have been, actually, at least 2 million reported cases of COVID-19 among children, with at least 200 or more — that was already a few months ago — who have actually died from COVID-19. So it’s not negligible. It’s not that it can’t happen, especially with new variants emerging where young people do get seriously ill.

So those were some of the concerns that emerged among families when we talked to them. Motivators to vaccinate was also interesting. It really included — they wanted to hear strong recommendations from their clinicians, from their pediatricians. I think that goes a long way, and we need to prepare our pediatricians to be able to confidently talk about this with families. As well as, some parents said school requiring vaccination. I actually don’t think that will — I don’t anticipate that happening. Some parents are worried about that. Others shared that that would motivate them to vaccinate their children. But most importantly, being able to return to social activities and travel — family travel — without worrying that they might put vulnerable others at risk. And improving mental health of their kids and the whole family was a big compelling reason also to vaccinate.

Well and this is your area of expertise about how to communicate effectively around these public health issues. And specifically, you looked at one point at communication campaigns related to adolescents who were taking the HPV vaccine. So a younger age cohort, just like with this Orange County study. So from your experience there, what are the key ingredients in developing and implementing an effective public health messaging strategy?

Very good question. There’s a number of points. I would say tailoring the message and normalizing the message. The way I have approached reaching families with adolescents with voluntary vaccines, like the HPV vaccine, is actually interviewing families and adolescents and capturing decision stories about vaccinating. I actually began with young adults, at the time. Capturing these vaccine decision stories from people and translating that into scripts and short films that — where it really resonates, sort of authentic storytelling integrated with factual, some factual, information that’s and medical information that’s relevant to know. But capturing this within decision stories that resonate as authentic, in relatable ways. So I try to listen to the people we’re trying to reach and then take what they tell us into consideration to tailor these messages.

Well, so when you look at how public health officials are currently messaging around the COVID-19 vaccine, how are they doing?

I think they’re doing, I mean, it’s a moving target. Things change every — there are different issues that can seem to come up every week. And so adapting to that rapidly, responding to that to avoid information gaps, which can then easily be filled with misinformation. So responding to the changing information and answering people’s questions and using many different channels. Some people call it an integrative marketing approach, but to use a coordinated effort through many different platforms, to try to reach as many people as possible.

Reaching people and convincing them to get the vaccine and sharing that information with them — it’s not, it’s not a one and done thing.

It’s very dynamic.

And it’s not just a single effort. It’s a dialogue and it’s a constant effort to reach people wherever they’re at, if that’s on social media or advertising or wherever else.

Yes. And emphasizing that it is a dialogue. And we want to share information that’s understandable and that they can process to make informed decisions about vaccinating.

Well, let’s get back to those five reasons, the five Cs that you mentioned a little bit ago. So this is a lightning round of questions. I’ll say a reason why someone might not want to get the vaccine, and then you tell me why I should still get it. Does that sound good?

Okay. Sounds good.

All right. So what if I’m just not confident that I trust the safety of the vaccine?

So we’ve had 140 million people in the United States receive the vaccine already without serious side effects. It can be checked also at the Centers for Disease Control and Prevention with updated information. The vaccines that are available in the United States are very safe. And you can also consider maximizing a positive experience with vaccinating by getting good sleep and getting up and vaccinating early in the morning and resting. The available evidence is on the CDC website. And so far, the evidence is that these vaccines are very safe.

What if I feel complacent? You know, I’m healthy, I’m young, and I just don’t feel like I’m at risk.

This is where I can only say (that) many people have underestimated the risks of COVID-19. And the status quo has led us into a disastrous pandemic, where we had to shut down everything, which has the economic consequences, as well as lots of people losing their lives and lots of tragedies. So that’s why it’s important to prioritize and be reminded of being proactive and vaccinating to help prevent the continued transmission of this virus.

What if I’m just so busy, I don’t have time to get an appointment, there are just too many constraints?

And this is where I would say the vaccine is free. There’s no cost of vaccinating. You can get it at a local pharmacy when it works for you. I would go to myturn.ca.gov in California to look up — you enter your information, it’s available to everyone now. Make it happen. It’s available in different places, different offices, pharmacies, sites. And it’s really important for everybody to chip in and prioritize this. They’re making it available and it doesn’t cost anything. So that’s where the government and everyone has done a great job trying to lower those barriers.

And I should mention, too, that if you’re a member of the UCI community, a student staff or faculty member, the coronavirus team is helping those members of the UCI community to schedule appointments. So if you just go to the UCI Forward website, you can call the phone number and they’ll help you find an appointment, because I know it is challenging to get those appointments.

Yes, UCI and Public Health have — and lots of schools across the university — have been putting in a lot of time and effort to try to reach out and make the information and vaccinating accessible.

The next reason. So what if I feel like everyone else is doing it? The sense of collective responsibility just isn’t there because, you know, I don’t need to.

Well, this is again where I would say, for social reasons, if you want to resume social activities and travel without putting vulnerable others at risk, this would be a great reason. Not only just to protect yourself, but also if you have vulnerable others in your family or network.

And then what if I have just done all the research, I’ve read a thousand articles and I’ve done all the calculations and I’m just not sure?

This is where I would say, again, the benefits outweigh the risks. The available vaccines are actually a rare case of a vaccine immunity being much more robust than natural immunity, without the lingering long term-effects of if you actually get COVID-19. We have friends who are still using inhalers to be able to walk upstairs six to nine months later, or not regaining their sense of smell, ever, having long neurological cardiovascular, depression, lingering effects. This virus really has some nasty long-term effects. The vaccines are available. They’re free. They’re amazingly effective. And they have very little side effects. They’re safe. This is a much better alternative than the possible risks when acquiring COVID-19.

So we’ve talked a lot about all the information that people can access as they’re weighing this vaccine decision. But what do you think will be the ultimate reason that people will get it or not?

I think that we need to normalize vaccination and have clinicians and public health folks reminding us about prioritizing this and the importance of vaccinating. The social reasons that we all want to resume social activities and see our friends and family and feel safe. We want to resume travel —  also for our mental health — and we want to get out of this pandemic and not be fearful or regretful. And so this is one very important tool — vaccinating — that will help us get there.

Professor Hopfer, thank you for joining me today on the UCI Podcast.

Thank you so much.