COVID vaccine hesitancy is linked to educational level, study says
INDIANAPOLIS — No one thought persuading everyone in the United States to embrace a new, not fully approved vaccine was going to be easy.
The last eight months, though, have proven the task is even more difficult than once thought. Initially public health officials worried about communities of color being resistant to the vaccine. Reality has borne out that concern to a certain extent but other links have arisen as well, from politics to past medical history.
Early on as vaccinations began this year, though, one factor emerged as significant that few had predicted would have as great an impact on shaping vaccine hesitancy as it did — educational level.
Essentially, Americans are weighing the perceived costs and benefits associated with taking the vaccine versus those associated with getting sick from COVID-19. And on average Americans with higher education levels are choosing the vaccine.
Deaths associated with the vaccine have been rare and in many cases there has been no causal link between the vaccine and the death, according to the Centers for Disease Control and Prevention. At the same time COVID-19 has killed more than 630,000 people in the United States.
U.S. adults with at least a bachelor’s degree view the vaccine as much safer and more effective than those with less education.
“One would think that people who have lower levels of education, it may be harder for some of those people to sift out the misinformation from verified facts,” said Colin Planalp, a senior research fellow at the State Health Access Data Assistance Center, which is based at the University of Minnesota. His center has studied annual uptake of flu shots and seen similar dynamics at play.
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A national Surgo Ventures survey conducted in March found that with the COVID-19 vaccine as education status increased, so did vaccination rates. The survey found that just under 23% of people who had not graduated high school had been vaccinated.
Vaccination rates increased with educational attainment, down the line. The high school graduate vaccination rate was just over 30%, rising to 36% for those with some college education, to just over 46% for those with a bachelor’s degree, to 68% with post-graduate education.
Initially, public health experts focused on persuading vulnerable populations hardest hit by the pandemic to take the vaccine, not rural populations and those with lower educational status, said Dr. Peter Embí, president and CEO of the Regenstrief Institute.
More recently the field has started focusing on attention on how to pitch the right messages to different groups. But Embí said the signs were there that lack of education could also pose a barrier to vaccination.
“I think we could have anticipated this to some degree,” Embí said. “I think we have in this particular case a fair bit of that general trend that we see more broadly with previous vaccination efforts as well as with general health preventive measures.”
There are no easy solutions and anti-vaccination sentiments transcend some traditional battle lines. Consider that former President Trump was booed at his own rally in Alabama Sunday after encouraging folks to get vaccinated.
Public health did not anticipate all of the pushback that has occurred against COVID-19 vaccination, said Kyla Thomas, a sociologist at the Dornsife Center for Economic and Social Research at the University of Southern California.
When vaccines first became available, Thomas said, she was hopeful they would curb the virus. Now, she wonders how to persuade vaccine holdouts. It’s not just about any one demographic group, but an overall lack of trust, she said.
“I think in February, I myself was more hopeful about our ability to really intervene in and change people’s attitudes,” she said. “That said, we do see some change over time in people’s attitudes.”
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Fears about the vaccine
That vaccine hesitancy would correlate with less education should not be surprising, some say.
Education level affects poorer health status in general, due to other factors such as socioeconomic status and access to health insurance and care. Whether someone lives in an urban or rural setting also appears to lead to differences in vaccine uptake, Embí said.
Access to care plays a large role as well. Many people may turn to their health care provider for advice; in many instances one’s family doctor or other health care provider may prod patients into vaccination, discussing the benefits with them.
Without a family practitioner, people often turn to family and friends for health advice, says Jagdish Khubchandani, a professor of public health at New Mexico State University, who has written about vaccine hesitancy. Or, they look online.
“And that is dangerous,” he said. “Social media is easily accessible and you only need a first-grade education to read on social media. Plus it gives a false sense of confidence.”
Surgo surveys have found that beliefs and perceptions about COVID-19 and vaccine safety are far stronger predictors of willingness to be vaccinated than education. Those attitudes were more or less prevalent, depending on a person’s educational levels.
Just under 20% of people who had less than a bachelor’s degree feared the vaccine was unsafe, compared with just under 8% of those with a college degree. Just over half of people with less than a bachelor’s degree worried that they might catch COVID while more than 60% of those with a college degree voiced that fear.
Flu vaccine hesitancy
None of this is new to anyone who has studied vaccine hesitancy in the past. Before COVID was a household word, Planalp and colleagues did a study that revealed that found the more education a person had, the more likely he or she was to get a flu shot.
While only 34% of adults over 18 who lacked a high school diploma had a flu shot, almost 48% of those with a bachelor’s degree or higher had.
“A lot of focus lately has treated COVID vaccination as a kind of special case, but really it isn’t unique at all,” Planalp said. “The patterns we’re seeing with COVID vaccination are similar to the same challenges that we have seen in the United States with vaccination campaigns in the past.”
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Just as with COVID-19 vaccination, other factors may play a role in why those with less education are more likely not to be protected against the flu. They are more likely to lack health insurance and therefore less likely to have an annual doctor’s visit where they hear about the benefits of vaccination, Planalp said. Studies on flu vaccine have shown that the flu vaccine hesitant have concerns about the safety and side effects associated with vaccines, a dynamic that may also be seen with COVID-19 vaccines.
Some think full approval will win over many of the hesitant, but the experience with the fully approved flu vaccine suggests the opposite, Planalp said.
In general, the uptake of childhood vaccinations, mandatory for school in most instances, does not reveal as many disparities based on parental education. While a gap used to exist, that has narrowed over time. Nor is it clear that this is due to the requirement, he said; children also tend to have health insurance and more regular doctor visits, two factors that could also play a role in the pediatric vaccination rate, he added.
Other researchers have done work that suggests that the COVID-19 vaccine may be different from other vaccines. One Carnegie Mellon study found that most of those who have yet to get the COVID-19 vaccine do not necessarily feel the same about other vaccines. About half of people they surveyed who are hesitant to get the COVID-19 vaccine fear its side effects while one third said they do not trust the government and are waiting to make sure this vaccine is safe.
Carrier recently hosted the first of two on-site mobile vaccine clinics at its Indianapolis facility.
Attitudes towards vaccination among members of the United Steelworkers Local 1999, which represents Carrier workers, are mixed, said Robert James, local president.
“Some are for it and some are just not ready to take it at this point,” said James, who falls among those who have taken the vaccine.
Union meetings have been virtual since the pandemic began and vaccination has not come up in any formal discussions but James said that he has heard some who are unvaccinated say they were waiting on full governmental approval for the vaccine.
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FDA approval for Pfizer vaccine
Earlier this week the Food and Drug Administration granted that full approval to the Biotech-Pfizer two-dose vaccine. Only time will tell if that approval leads many holdouts to accept the vaccine.
Researchers have seen changes in some people’s willingness to be vaccinated. In February, the divide in vaccine hesitancy between people without a college degree and with one exceeded the divide between Black and white Americans, said USC's Thomas.
Her center conducted a biweekly survey of attitudes towards vaccination through May. While distinctions between races diminished, those between less and more educated people have only increased.
But other researchers have done surveys that suggest that those with lower education levels may be open to shifting their attitudes towards vaccination over time, a promising conclusion for vaccine advocates.
One study that looked from January to May found that while those with a high school degree or less were the most likely to be vaccine hesitant at first, this group showed the greatest decline in vaccine hesitancy over time.
The percentage of vaccine hesitant people with a PhD, however, did not change from the start of the survey to the end, said Wendy King, associate professor of epidemiology at the University of Pittsburgh, who conducted the study along with colleagues from Carnegie Mellon University.
“The story is it’s getting smaller over time,” she said, “and when you adjust for other factors, it’s even smaller.”
The most vaccine hesitant are not budging
Those who remain vaccine hesitant months after the vaccine arrived may be particularly stubborn, studies suggest.
In January, 12.7% of people that King’s group surveyed said they would definitely not be vaccinated. In May, 11.1% still felt that way. Those will less hardened views, though, did change their minds. In January, 13% had said they probably would not get a vaccine, a figure that fell to 6% by May.
“Hesitancy is decreasing but this hold-out definitely-not group isn’t budging much and they are going to be tricky to persuade,” King said.
While vaccine hesitancy has decreased as vaccines have become more available and more accepted, educational divides still exist, Thomas said. In February, her survey found that 76% of college-educated people were vaccinated or likely to be so. By July that rose to 85%.
That survey offered some hope for vaccines, too. In that same time period, the numbers for non college-educated vaccinated people rose from 53% to 66%.
But at the end of the day, public health officials and experts recognize that no easy answers exist for how to persuade more people to get vaccinated. Each vaccine holdout may have specific reasons and often the factors that researchers identify are interwoven with one another.
“This speaks to how complex it is,” King said. “There’s not one factor that’s going to explain it all.”
Follow on Shari Rudavsky Twitter: @srudavsky.