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Race to vaccinate faces hesitancy hurdle in Appalachia

Race to vaccinate faces hesitancy hurdle in Appalachia


Dr. Karen Shelton watches as cases of COVID-19 begin again to rise in Virginia’s Appalachian counties.

She needs more vaccine. And she’ll need more people willing to roll up their sleeves to take it.

At the moment, Shelton, who directs public health for everyone living west of the New River Valley, doesn’t have enough doses to meet the demand. Her region was hit especially hard over the fall and winter, with the virus killing more than 800 people. The local hospital system became so overwhelmed that it had to curtail all but critical medical care, create new intensive care units and park morgue trucks outside its flagship hospitals.

After a lull, admission are swinging upward again.

Shelton knows she's in a race to vaccinate, as everyone is calling it, as a way to protect the vulnerable and slow the coronavirus's spread. But to win, Shelton will need not only more vaccine, but more people willing to take it.

She knows once the demand-supply dynamic shifts, it will be a tough sell to convince people with firm, but mistaken, ideas that the vaccine causes COVID, that it was rushed to market, that it is harming lots of people.

The Kaiser Family Foundation has been surveying Americans since December to track vaccination resistance. It has found that hesitancy has dropped over time among Black and Hispanic people but has increased among white rural Republicans who didn’t attend college — the demographic boxes checked by a plurality of people living in Shelton's districts and in much of the 13-state Appalachia region. 

To figure out why this population is so COVID vaccination-averse, a team of Virginia Tech researchers set out to determine if misinformation shared on social media fuels that resistance. They also wanted to get a sense of who would be most believable as sharers of correct information. They asked more than 1,000 people living throughout Appalachia 60 questions and found some commonalities that could help public officials.

“It is sad, unfortunately, but documented, that ... when you Google an answer for something, you tend to get what reinforces your belief,” Shelton said. “So if you’re a person who doesn’t believe in climate change, when you Google 'climate change,' you get all the affirming things on climate change. So it’s the same thing for vaccine, the misinformation. I don’t know how you combat that on a large scale, we could just hope that people will see other people being vaccinated and doing well with vaccine.”

Michelle Rockwell, a research assistant professor with the Fralin Life Sciences Institute and the lead investigator on the Tech study, said large-scale efforts might not work, as people overwhelmingly said they’d trust their own doctor the most.

“It was very loud and clear to us that people pick their primary care providers, and that was people who are young or old, people who report they’re Republican, people who report that they’re Democrats or independent,” Rockwell said. “It was really an across-the-board response. People trust their primary care providers.”

That held true, too, when they were asked where they’d prefer to get the vaccine if they were to take it. Rockwell said participants were offered eight choices, including no preference. She thought people would like the convenience of drive-through clinics. Her colleagues thought the place wouldn’t matter.

“But we very clearly see the response of primary care provider office, especially in the people who say that they’re extremely unlikely to get the vaccine,” she said. “They want to hear from the doctor that they have a relationship with.”

Battling misinformation

Much of the vaccination campaign in Virginia so far has relied on large drive-through and walk-in clinics. As of Thursday, 4.4 million doses had been given to more than 2.9 million Virginians. To move that much vaccine that quickly, public health officials looked to partners, such as Carilion Clinic in the Roanoke region, Ballad Health in Shelton’s region, and the National Guard throughout the state.

When the vaccine was approved in December, it was offered first to health care workers who were most at risk of being exposed to the virus and to long-term care residents who were most at risk of dying from it. Eligibility was then extended to other types of workers — teachers, police, firefighters — and to the elderly and any adults with medical conditions that placed them at risk of serious illnesses. Nearly half of all Virginians fell into one of these priority categories. But with only 100,000 doses coming in each week, many old folks were left frustrated by the frenzy, the mixed messages and the technological challenges of grabbing scarce appointments.

That has changed. As doses have increased, health officials have worked their way through the priority populations. Parts of Virginia have already opened up to everyone, and the others will in a week or so.

Dr. Danny Avula, who is coordinating the COVID-19 vaccination campaign for the Virginia Department of Health, thinks about two-thirds of Virginians will willingly roll up their sleeves, convinced not only that the vaccine will protect them and their families, but that it is the way out of this pandemic.

Yet the way out requires about 75% of the population to be vaccinated, Avula said. That’s when Virginia will begin to reach herd immunity, the point at which the virus has a hard time finding anyone new to infect.

Getting that next million or so people — who are healthy, young and, if infected, not likely to land in the hospital or funeral parlor — might require heavy lifting.

Avula anticipates that a big drop-off in demand will come in June.

Dr. Cynthia Morrow, director of the Roanoke City and Alleghany Health Districts, said demand is already dropping off as it is taking longer to fill the mass vaccination clinics. She said the focus will shift as they take hundreds, rather than thousands, of doses into neighborhoods and communities that have had vaccination barriers — whether registration, transportation or hesitation. Civic and church leaders have also been enlisted to help talk with people.

Vaccine supplies also are so abundant now that people can turn to neighborhood pharmacies or their doctors. That was always the plan, Morrow said.

Convincing people of the need to do this, though, might prove challenging. Avula said that marketing campaigns can go only so far, and that public health officials need to understand which populations are resistant, and why.

Avula has been paying close attention to the longitudinal survey by the Kaiser Family Foundation that began in December to track different populations' willingness to be vaccinated. It was thought early on that African Americans and Latinos would be the most resistant, but those groups have shifted to become more likely to be vaccinated.

“I think a lot of the efforts around minority populations, which were talking about history, talking about data and safety, those are still important. Even more recent surveys will show that concerns about safety are the biggest reason that people aren't getting vaccinated,” Avula said. “There clearly is still a need to find digestible ways to talk about the data and to talk about the fact that these weren't fast-tracked, per se, but that they really did follow the timeline and the extensive review that vaccines normally do.

“That work needs leads to continue, but I do think there's a whole another element of engagement around vaccine hesitancy that is targeting more rural and conservative communities and that we didn't we didn't readily prepare for that. I don't know that we anticipated that's where the resistance was,” he said.

Avula said a national focus group held in March by the de Beaumont Foundation showed the benefits of engaging people in a respectful way.

“The words that that these folks were using was 'government manipulation,' or some kind of government conspiracy, like there really were these knee-jerk reactions to just the concept of vaccination. They're putting trackers in the vaccine,” he said.

Once the participants could talk about those beliefs and then about what the data actually show from the millions of people who have been safely vaccinated, some began to see that some of what they thought wasn’t true.

“That was able to move the needle. Not in a huge way, but certainly people were more willing to consider getting vaccinated than they were before that,” Avula said. “I do think we've got to step aside from the politicization and really find respectful platforms for discourse. And that's hard work, right? Like just the effort that it takes to create those venues and platforms is very resource-intensive. And it's why there hasn't been that much of it to date, because so much of our time and energy has gone into just getting the low-hanging fruit.”

Finding trusted sources

Tech’s Rockwell said she and a team that cuts across disciplines and is backed by a grant from the Fralin Life Sciences Institute talked a lot about vaccine hesitancy and decided they wanted to look closely at misinformation and how much of that is influenced by social media.

They choose Appalachia because of its history of health disparities and because of the increase in social media presence. While the survey respondents were mostly white, a reflection of the region, they came from both rural and urban places across the 13 states and held different political viewpoints.

Rockwell said they learned so much that they plan to write several papers. And a companion project to enroll people living in the Roanoke and New River valleys in focus groups to talk about their hesitancy is underway. The team's first publication appeared last week on the website of the Annals of Family Medicine’s COVID-19 Collection.

The survey weeded out people who were vaccinated or had an appointment to get a vaccine. Some 31% of the participants said they were extremely likely to get the vaccine, but 27% said they were extremely unlikely to be vaccinated. That left 42% on the fence.

Rockwell said they wanted to know whether people trusted health and science information and how they viewed different sources of the information.

They asked about health figures such as Dr. Anthony Fauci, Dr. Mehmet Oz and Dr. Sanjay Gupta.

“We included some others that are trending on social media, and then a local nurse, your own primary care provider, a local community health worker. We tried to include a broad range of different health influencers to find out who the residents trust the most and who they trust the least,” she said.

Fauci was among both the most and least trusted sources of information. However, regardless of whether people were likely or unlikely to be vaccinated, they valued the word of their primary care provider.

“Far and away, people chose their primary care providers as who they trust the most; 40% put primary care providers. Second place was Dr. Fauci, who was only 18%,” she said. “Our results would very much suggest that the trust that patients have with their primary care providers, that personal relationship, is really meaningful and important.”

Avula said he was interested in hearing what the Tech researchers are finding. So far, he said, public health officials have learned what works with minority communities.

“What we’re finding is it’s more about trusted leaders. That when you can bring a community a vaccination event into the neighborhood, or when it’s vouched for by an elected leader or church leader, that really increases your ability to get people vaccinated,” he said. “I think in rural communities, we've got to try some of those same strategies and have not yet developed the concrete plan to do that.”

In Virginia’s coalfields, Shelton is finding that there still hasn’t been enough vaccine to meet demand and that there are many challenges getting it into rural areas, including transportation.

She said people want the one-dose Johnson & Johnson vaccine because it involves just one trip. Each of the counties has a clinic each week, but doses also are taken to people who are homebound. In a region with poor internet access, the challenges have been greater than in other parts of the state in using problematic registration and appointment systems.

Shelton said she knows that battling misinformation is the next challenge, and while she appreciates people saying that they trust their doctors, many of the young people in her region don’t have doctors. And to reach 75% vaccination rates, young people will need to take the shots.

“We could just hope that people will see other people being vaccinated and doing well with the vaccine. We know that there are some side effects and people have to be prepared. But many people have been touched, especially in Southwest Virginia, with friends, family, loved ones, neighbors, coworkers, who have gotten COVID and have had people they knew that died from COVID,” she said. “You would hope that they would see that COVID is real, the people don’t do well with COVID and ask, 'What can I do to protect myself?'”

Shelton thinks businesses could offer incentives to workers to get vaccinated, as it reduces the number of workers who would need to isolate or quarantine, ultimately increasing production.

She said the United Way of Southwest Virginia is working on a marketing campaign to use community influencers, and Emory and Henry College is dispelling myths by answering students’ questions.

“A lot of people just have simple questions they want to have answered and having those facts is helpful,” Shelton said. “Some of it is just seeing other people do well with the vaccine.”


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