The COVID-19 pandemic has disproportionately burdened minority communities.1 Despite this, the rates of vaccine hesitancy among African-American (41.6%, 95% CI:34.4-48.9%) and Hispanic (30.2%, 95% CI:23.2 -37.7%) adults are notably higher than that of American adults overall (26.3%, 95% CI:17.3-36.4%).1 A recent study found that major predictors of vaccine hesitancy in African Americans and Hispanics included medical mistrust, history of racial discrimination, exposure to misinformation, and concerns about the vaccine’s safety.1 Though, overall, rates of COVID-19 infection are notably lower than they were at the peak of the pandemic, physicians must remain prepared to discuss COVID-19 vaccination with patients from a diverse array of backgrounds to ensure that this trend prevails in all communities, especially those historically marginalized by the medical profession.1
While public health campaigns have attempted to address these concerns through awareness campaigns and expanded collaborations with trusted community organizations, physician willingness and preparedness to discuss the vaccine in their clinical practice is needed to truly make strides on the deep roots of mistrust planted by the medical community’s injustices against minorities.2 In response, we utilized the following core principles of behavioral economics to develop a novel approach to vaccine hesitancy to offer physicians more specific recommendations on how to broach this important conversation, particularly in patients from communities that have been historically marginalized by medicine.
- Emphasize Patient Autonomy: Though behavioral economics contends that public health programs should adopt “opt-out” vaccination schemes, the discipline’s principles suggest that, at the level of the individual physician, using presumptive language to establish vaccination as the default (i.e., “At the end of this visit, I will administer your COVID-19 vaccine”) may create an apparent loss of patient autonomy in both whether to get vaccinated and where to receive the vaccination.3, 4 This regression to the paternalistic model of medicine risks reinforcing medical mistrust.5
- Prime patients to feel welcome to talk about race: Prior to providing educational counseling about the vaccine, it is critical that physicians reinforce that past injustices and racism are justified reasons for mistrust.4 In a late 2020 nationally representative survey on vaccine hesitancy in the African-American community, a participant encapsulated the importance of this by stating, “[We need to hear] ‘We understand why you’re apprehensive, we understand that these things have happened in the past to your communities and other communities. What we want to show you now is you will be able to get the vaccine for free, and in addition, you will have access to any follow-up care you might need…’ ”4
- Leverage social forces: Findings on prosocial forces and the positive framing suggest it may be beneficial to point out the reduced risk of transmitting COVID-19 to members of the patient’s support system.2, 3 However, physicians should also avoid drawing attention to how their choice to get vaccinated may be perceived by members of their support network, as patients may fear ostracization and isolation from their support network if a majority of this group is also unvaccinated.3 If this concern is raised, physicians should maintain positive messaging by identifying specific community outreach initiatives that are gradually shifting attitudes towards vaccination in the region, the overall high rates of vaccination in the country and world, and the protections vaccination would confer to the members of the patient’s support system (i.e., “There have been over 500 million doses of the vaccine given in the United States so far with minimal side effects”; “Getting vaccinated will protect both you and your loved ones”).2, 4
- Maintain a positive message frame: Positive message frames that emphasize benefits of a behavior have consistently been found to be more effective than negative ones, which highlight the negative consequences which may be avoided.2 If misperceptions are presented, physicians should avoid directly countering the misperceptions, as this deepens a patient’s conviction in misperceptions and further decreases their intent to be vaccinated.5 Instead, physicians should appeal to patient’s prosocial tendencies (see item 5), then reiterate previously discussed factual information or offer entirely novel information (i.e., “To bring an end to the pandemic, it’s important that everyone does their part by getting vaccinated.”; “COVID-19 vaccine reduces your risk of infection by 70-95% and reduce your risk of severe illness by 95%”; “There have been extensive studies to date that have verified the vaccine’s safety.”).2, 5
- Enhance active choice: Once physicians explore the benefits of vaccination with their patients and feels confident that their patients have been adequately primed to make a decision, they should present the patient with a choice to receive the vaccine or to continue discussing their concerns at a follow up appointment.3 Establishing this dichotomous choice framework validates the concerns the patient entered the appointment with, underscores patient autonomy, and encourages longitudinal reflection upon this important decision.
The COVID-19 pandemic only exacerbated the long-standing health disparities affecting Americans from minority communities. By supplementing current public health endeavors with physician level strategies to address vaccine hesitancy in minority communities, we can begin tackling this systemic issue at the grassroots level. Our application of the core tenets of behavioral economics to vaccine hesitancy in minority communities provides physicians with a more concrete framework of how to broach the topic of vaccination with their patients. This novel approach to vaccine hesitancy equips physicians with the tools not only to help mitigate the health disparities associated with COVID-19 but also, more broadly, to initiate a dialogue to repair the relationship between the medical community and the populations it has historically committed injustices against.
- Khubchandani J, Macias Y. Covid-19 vaccination hesitancy in Hispanics and African-Americans: A review and recommendations for practice. Brain Behav Immun Health. 2021 Aug;15:100277. doi: 10.1016/j.bbih.2021.100277. Epub 2021 May 21.
- Finney Rutten LJ, Zhu X, Leppin AL, et al. Evidence-based strategies for clinical organizations to address COVID-19 vaccine hesitancy. Mayo Clinic Proceedings. 2021;96(3):699-707. doi:10.1016/j.
- Jenssen BP, Buttenheim AM, Fiks AG. Using behavioral economics to encourage parent behavior change: Opportunities to improve clinical effectiveness. Acad Pediatr. 2019;19(1):4-10. doi:10.1016/j.acap.2018.08.010.
- Bogart L, Dong L, Gandi P, et al. What contributes to COVID-19 vaccine hesitancy in black communities, and how can it be addressed? Rand Corporation Res Rep. 2021. doi:10.7249/rra1110-1.
- Madad S, Jetelina K. Positive impact of COVID19 vaccines at the individual and population level. Belfer Center for Sci and Int Affairs. https://www.belfercenter.org/publication/positive-impact-covid19-vaccines-individual-and-population-level. Published May 20, 2021. Accessed August 15, 2022.
Clinical Practice, COVID-19, Health Equity, Medical Ethics, SGIM, Social Determinants of Health
Ms. Reddy (email@example.com) is a third-year medical student at New York Medical College School of Medicine. Dr. Etienne (Mill_Etienne@nymc.edu) currently serves as the vice chancellor for diversity and inclusion, associate dean for student affairs, and associate professor of neurology and medicine at New York Medical College School of Medicine.
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