Tasnime Osama

Tasnime Osama

COVID-19 vaccine hesitancy in vulnerable populations: leaving no one behind

3 November 2021

female doctor sat at desk talking to a male patient

Despite vaccinations preventing 2–3 million deaths globally every year, vaccine opposition has been growing in high-income countries.

The deployment of COVID-19 vaccines has reignited the debate around vaccine hesitancy, which was listed as a global health threat by the World Health Organization in 2019. Vaccine hesitancy is defined as the delaying of, or refusal to take, vaccines despite their availability, and is as old as vaccination itself.

The development of various effective vaccines within a year of identifying SARS-CoV-2, the virus that causes COVID-19, remains unprecedented in the history of vaccinology. The vaccines are safe and effective, but the belief that they are ineffective, unsafe and unnecessary remains pervasive among certain populations, threatening efforts to control the pandemic. Without intervention, the risk is that the hesitancy that some people feel may lead to them refusing the COVID-19 vaccines altogether.

Ethnic minorities and people with cancer have experienced an undue burden from the pandemic, being at an increased risk of serious illness and death from COVID-19. It is therefore surprising that a survey carried out by the Royal College of General Practitioners in the UK demonstrated that people from Black (53%), Asian (36%) and mixed ethnic backgrounds (67%) were less likely to receive a vaccine when compared with their White counterparts. French and American reports state that COVID-19 vaccine hesitancy is also high among people with cancer; in Mexico, 34% of people with breast cancer are hesitant to receive a COVID-19 vaccine.

Structural factors, including barriers to access, socioeconomic disadvantages and systemic racism, are known to drive low vaccine confidence and uptake.


Where does vaccine hesitancy come from?

Vaccine hesitancy is impacted by the ‘3 Cs’: confidence, convenience and complacency. Many people are taking a ‘wait and see’ approach because of doubts surrounding vaccine effectiveness and safety. Concerns include short development timelines, perception of vaccine-related risk and impact on long-term health, as well as a lack of communication and endorsement from trusted healthcare providers and community leaders. Vaccine hesitancy has been exacerbated by the COVID-19 ‘infodemic’ (the spread of inaccurate information on the pandemic and vaccines), leading to conspiracy theories and feelings of confusion and anxiety among the general public. Structural factors, including barriers to access, socioeconomic disadvantages and systemic racism, are also known to drive low vaccine confidence and uptake.

People who distrust doctors or medical and governmental institutions are more likely to be vaccine hesitant. In Black populations, a history of systemic racism, unethical healthcare research, negative healthcare experiences and biomedical abuses has led to a suspicion of institutions, amplifying feelings of mistrust. For example, a syphilis study led by the Tuskegee Institute in 1932–1972 was carried out on Black men without informed consent. A high number of participants died because penicillin, which became ‘the treatment of choice’ for syphilis in the early 1940s, was withheld from them. In 1979, the administering physician in the Depo-Provera study stated that it was his ‘moral duty’ to give a 14-year-old Black girl contraception, without her consent, while she was under general anaesthesia.

For people with breast cancer, vaccine hesitancy is reportedly driven by the fear of experiencing adverse reactions and a distrust of healthcare systems. Confidence in vaccine effectiveness has also been shaken by the fact that trials included only a small number of cancer patients.

female doctor talking to male patient who is filling out a form

Slowing the spread of COVID-19 will require proactive and empathetic listening – without prejudice and bias – to the concerns expressed by hesitant populations.


Vaccines left in vials become useless, but changing people’s minds requires empathy

Concerted efforts to restore trust among vulnerable populations are required to prevent vaccination delays. Dispelling COVID-19 misinformation through effective, tailored and culturally sensitive campaigns will increase knowledge, reduce risk perception and facilitate informed decision-making. Ways of doing this include targeted communication, health surveys, observational qualitative research and social media monitoring.

Expressing empathy may help to alleviate vaccination concerns and ensure that the needs of hesitant populations are being met. Their mistrust is not irrational; too often, genuine concerns are addressed with paternalistic and patronising messages that lack empathy. Research has shown that recommendations and advice from healthcare professionals are key predictors of vaccine acceptance. Slowing the spread of COVID-19 will require proactive and empathetic listening – without prejudice and bias – to the concerns expressed by hesitant populations, thereby encouraging voluntary cooperation.

Vaccines require balancing public health and individual choice. Having saved countless lives, vaccines remain one of humanity’s greatest achievements. To many, the COVID-19 vaccines represent the happy ending of a grim chapter in history. At a time when collective purpose should be highlighted, we must ensure that all populations are armed with the information needed to end the pandemic and prevent the widening of existing health inequalities.


The opinions expressed in this blog are those of the author and do not necessarily represent the views of The Health Policy Partnership.