As COVID-19 rates have surged again, many people blame unvaccinated Americans for increasing cases and deaths. They are consequently being pressured from all angles to get vaccinated. While this approach channels our frustration, it is unlikely to make people get vaccinated, which is what is needed to curb the pandemic. We need a better approach.
Choosing to get the COVID-19 vaccine is a medical decision like any other medical decision. Therefore, to increase vaccination rates, it is necessary to understand how people think about those decisions.
To do so, we offer a concept called “lay epidemiology.” Epidemiology seeks to understand cause and effect in health from observations of groups of people. Lay epidemiology is the idea that every person has their own sense of epidemiology, how they understand risks and benefits, and make conclusions about health decisions based on the world around them. People collect data from their family and friends, doctors, social media and the news media to make medical decisions for themselves.
Take, for example, smoking. Surveys show that nearly everyone who smokes knows that it’s bad for them, but they choose to smoke anyway. Perhaps their father smoked and didn’t die of lung cancer, or their friends smoke and don’t have lung problems; moreover, they smoke and feel fine. Based on the information they have from the world around them, they keep smoking. So, to help change their decision, simply providing more information about smoking’s side effects won’t work. We must understand and address the thinking behind their decision.
By looking at COVID-19 vaccinations through the lens of lay epidemiology, decreased vaccine uptake makes more sense. A new report from the federal government shows that among the 30 percent of Americans who are unvaccinated, many are willing to get the shot but they want to “wait and see,” particularly about vaccine safety. Like an epidemiologist, they are taking time to collect more data — such as seeing more people get vaccinated without serious side effects or waiting for Food and Drug Administration approval — before deciding.
Moreover, the report suggests that demographic groups with the highest rate of unvaccinated but willing adults are young people, Blacks, Hispanics, the uninsured, and those who haven’t graduated college. Along geographic lines, many counties in the South, Midwest and West, especially rural areas, have low vaccination rates but residents who are willing to be vaccinated. To understand this data, we must recognize that many of these groups have generations of experience being neglected by the health care system, with well-documented health disparities. They have reason to expect that their experiences with health care interventions, like a vaccination, will not be the same as what others experience. Simply telling them to get vaccinated isn’t enough to overcome evidence they have of worse treatment and outcomes.
Lay epidemiology offers some concrete steps to increase vaccination rates among the unvaccinated.
It starts by listening to people’s questions and concerns without passing judgment or pressing an agenda. Doing so not only makes people feel heard, but also provides insights into how they are thinking about the vaccine and the information they need to decide, which informs more tailored messaging and outreach.
After identifying what information people need, data must be provided in a personalized manner. Research suggests that tailored messaging works. It’s not enough to say the vaccine is effective; information needs to be shared about the vaccine experience of people in their community, on their street, or people who look like them. Data should be provided through different forms — numbers, infographics, videos, and stories from peers — to ensure that folks can understand and process the data in a way that works for them.
Finally, there needs to be a national investment in making the health care system more equitable, so that people’s experiences — their lay epidemiology — match the data we have from medical trials and other studies about the benefits of COVID-19 vaccination and other medical interventions, regardless of who you are or where you live.
This work is hard and slow, and it is natural to feel impatient. But it takes time and effort to understand and address concerns for someone who may have good reasons to be hesitant. A lay epidemiology approach is not a one-off effort, but a change in the way we engage with people about decisions around their health. This will prove beneficial as we must continue having conversations about vaccines, boosters or otherwise, in the months and years to come.
Lay epidemiology shows us that people are smarter and more nuanced in their medical decision-making than we often give them credit for. Let’s work with them to increase vaccine confidence and help end the pandemic.
Sudhakar V. Nuti, MD, MSc, is an internal medicine/primary care resident at Massachusetts General Hospital who has worked on increasing vaccine confidence during the pandemic. He is a public voices fellow with the Op-Ed Project. Follow him on Twitter @SudhakarNuti.
Katrina Armstrong, MD, MSCE, is the chair of the Department of Medicine and physician-in-chief of Massachusetts General Hospital, where she is considered an expert on medical decision-making. Follow her on Twitter @katrinarmstrong.