Expanding Vaccine Access and Overcoming Hesitancy

(Photo courtesy of GOTVax)

With more than half of the US population having received at least one dose of a COVID-19 vaccine, the shape of our vaccine rollout is changing. And while the unvaccinated people who remain are often lumped together and generalized as “hesitant” or “anti-vaccine,” many unvaccinated individuals have significant trouble accessing health care, or reliable information about the vaccine. Community leaders must understand the specific barriers and concerns that are preventing different groups from accessing the vaccines, and they must deploy targeted strategies to address them.

Get Out the Vaccine (GOTVax) is a Boston-based initiative working to reach this heterogeneous group of unvaccinated Americans by engaging with disenfranchised populations and adapting political campaign strategies to aid the vaccine rollout. By involving community leaders, health care providers, electoral campaign staff, and a local supply chain company, GOTVax bridges the gap between community engagement and health care accessibility through our pop-up vaccine clinics, which reached up to seven clinics per week in mid-May. Although our clinics initially served hundreds of patients per clinic from March through May, the number of patients at our clinics is now dwindling, despite the fact that communities of color in Boston still have disproportionately low vaccination rates.

In response, GOTVax revamped its operations to better reach unvaccinated residents. Our approach applied the Surgo Ventures framework, built from their analysis of nationally representative survey data on American attitudes toward the vaccine. Along with “the Enthusiasts,” they identified four distinct groups of vaccine hesitators:

• the Watchful,
• the Cost-Anxious,
• the System Distrusters, and
• the COVID Skeptics.

The Watchful are not completely opposed to getting vaccinated but are characterized as waiting to see how their vaccinated peers fare (e.g., with longer-term side effects). For this reason, community and social norms, as well as explanations of the vaccines’ efficacy and safety, are generally compelling to this group. According to the Kaiser Family Foundation, full FDA approval would encourage one-third of unvaccinated adults to get vaccinated (presumably many from this category). And for this group, maintaining follow-up touchpoints and giving them a chance to easily receive the vaccine once they feel comfortable is crucial. Some states are even employing financial incentives, like Ohio’s Vax-a-Million lottery, which may draw those who have been procrastinating.

GOTVax has strategically targeted the Watchful through various means. During our initial outreach, we text identified individuals using language proven to increase inoculation rates for the flu and COVID-19 vaccines (e.g., a vaccine is “available for you”). Our door-to-door canvassing employs health care professionals, from medical students to retired physicians, who provide residents with up-to-date, evidence-based guidance. “The individual attention was magnificent,” one person who received their COVID-19 vaccine through GOTVax said, “They listened to all my concerns and took the time out to care.” Our use of campaign-like deliverables, including flyers and handouts with QR codes to vaccine clinic schedules in multiple languages, also provides the Watchful with multiple opportunities to get vaccinated. On this topic, one of our clinic participants remarked, “I got a phone call reaching out to ME to set up an appointment; it made everything so easy and there was no wait.” Our strategies not only supply the Watchful with comprehensive information about vaccination but also give them the opportunity to engage with trusted community leaders to help ease their concerns.

The Cost-Anxious are primarily concerned about the price of the COVID-19 vaccines. The vaccine itself is free, of course, but some people are still wary. And in a medical system full of surprise medical bills and price hikes, it’s understandable that people are worried about there being a catch. For this population, frequent and repeated messaging on the zero-dollar price tag of the COVID-19 vaccines is paramount.

Beyond finances, there is also an opportunity cost that precludes certain individuals from receiving the vaccine such as people who may have to take time off of work to get the shot (or for side effects), and those who may need transportation or childcare. GOTVax walk-in clinics are the cornerstone to our approach, reaching individuals with demanding and inflexible schedules. Given the opportunity cost of getting vaccinated, the Cost-Anxious may prefer appointments booked together as a family, have issues using an online booking system, or be homebound with a disability.

For this reason, bringing the vaccine to their communities—supermarkets, places of worship, local clinics, restaurants—is vital. For example, GOTVax built a partnership with the Boston Housing Authority to hold clinics in apartment common spaces, and we also partnered with community leaders to do the same in churches and other accessible sites. More recently, we began setting up a GOTVax tent at local community gatherings, such as farmers markets, where volunteers engage with community members to inform them about our free upcoming COVID-19 clinics. Proximity and word of mouth have been integral in our turnout.

The System Distrusters have little faith in the health system and the government as a whole. According to Surgo Ventures’ survey data, many members of this subgroup are people of color who have been unfairly and poorly treated by health care workers or have witnessed and lived the consequences of numerous public policy failures. One of our Spanish-speaking vaccine recipients recounted her experience with GOTVax, shifting from initial hesitation to unreserved acceptance. She said, "When I was first called by you guys, I told the lady I did not want the vaccine. I even told my own doctor no. But when the doctor from your team knocked on my door, he didn't make me feel bad about being scared. He listened." Offering Bostonians the opportunity to have a health care worker genuinely listen to and address concerns nonjudgmentally is a meaningful part of our community engagement.

For this group, hearing from their friends, family, and neighbors can also make a huge difference. GOTVax leverages relational organizing in its outreach to marginalized communities. If a person responds to our outreach text message stating that they have been vaccinated, we follow up by asking if anyone in their network would like the vaccine. We employ the same strategy during our door-knocking, ensuring that every eligible member in the household is vaccinated. During the 15-minute post-vaccination waiting period at our clinics, we use a vaccine tripling intervention to prompt individuals to text three friends or family members about getting the vaccine. As a result of this patient-centered outreach, 80 percent of those vaccinated through GOTVax identify as a person of color.

The COVID Skeptics are the toughest population to reach. They have specific, tightly held beliefs surrounding COVID-19, as a result of widespread misinformation. An important point to remember for this group is that the messaging of “going back to normal life” is not compelling, because many of them did not physically distance or change their lifestyles in the first place. Emphasizing the individual freedom to get vaccinated and explaining that the rapid development of vaccines is a result of unprecedented collaboration between the public and private sectors may be more meaningful, a tactic that has been implemented by GOP doctors, for instance. The key is to not talk down to members of this subgroup or dismiss them entirely. They can change their minds, and former anti-vaxxers are particularly well-equipped to reach out to current anti-vaxxers.

However, COVID Skeptics do pose the greatest challenge for vaccine outreach initiatives. While canvassing and direct community engagement have proven impactful for access, it is important to recognize that our tactics and strategies may appear invasive to COVID Skeptics, and require well-trained staff to handle what can be, at times, difficult encounters. Validating their concerns, while also providing factual evidence, is key in juggling autonomy, access, and hesitancy. As compared to 17.3 percent of GOTVax participants who attributed their decision to get vaccinated to a conversation with a health care provider, a whopping 50.6 percent of individuals who received a vaccine attributed their decision to friends or family members. Utilizing the social networks of those we’ve already vaccinated is one of the greatest avenues for persuading COVID Skeptics. So far, GOTVax has partnered with over 40 community partners that reach a diverse population in the Greater Boston area, including COVID Skeptics.

Ultimately, our priorities are to ensure equitable access to the COVID-19 vaccines and to engage sincerely and openly with those who aren’t yet sure about getting their shot. To date, GOTVax has delivered nearly 7,000 COVID-19 vaccines, aiming to reach 10,000. This pandemic demonstrated in myriad ways how our communities, cities, states, and nation as a whole are paradoxically interconnected and fractionated. This remains true when it comes to vaccination. We must continue to inform, engage, and reimagine vaccination outreach for everyone’s sake.

Read more stories by Anson Tong, Cade Herman, David Velasquez & Alister Martin.