Beyond “vax-hesitance”: The social determinants of COVID-19 vaccination

COVID-19 vaccines are powerful tools in the fight against COVID-19 and have been crucial in combatting the latest wave. Vaccination reduces the likelihood of spread and also reduces the likelihood of serious illness with COVID-19 if a person gets infected.

Despite Canada’s relatively large supply of COVID-19 vaccines, we have still a long way to go to ensure everyone is fully protected against COVID-19. Much media attention has focused on “anti-vaxxers” – people who are ideologically opposed to vaccination in general. Though vocal, they represent a small proportion of the unvaccinated. Many of the factors hindering COVID-19 vaccination are more complex, and reflect access barriers, a lack of tailored and targeted information, and longstanding inequities and injustices that require deep and meaningful change to address.

These challenges are more pronounced in the communities also affected by HIV and hepatitis C, and this is no coincidence. Having faced similar challenges before, people affected by HIV and hepatitis C and their service providers have raced to bridge gaps in vaccine uptake among our communities, advocating for access and to ensure the most vulnerable among us are protected.

Gaps in COVID-19 vaccine uptake

Broadly, gaps in vaccine uptake exist for three reasons: access to, comfort with and information about COVID-19 vaccination. Underlying these reasons are complex factors related to people’s social, geographic, political and economic realities. There is no singular reason for not getting vaccinated, and similarly, there is no one solution either.

Gaps in vaccine access continue to prevent people from getting vaccinated. These gaps are often related to socio-structural barriers to acquiring vaccines, such as access to and ease with technology, geographic barriers, employment that allows for paid sick leave and time off for vaccination appointments, and concern about short-term and temporary side effects.

Across the country, many appointment bookings occur online, which poses a challenge for people who have low computer literacy or those who lack Internet access or devices. Alternatives to online bookings have been fraught with difficulties. Vaccine access also has required that some people travel far away from their homes or places of employment and wait in long lines. This can be a challenge for many, but may be disproportionately felt by racialized and Indigenous people who live in areas with poorer transportation infrastructure or nearby healthcare services. Adequate paid leave is still not consistently available for all, especially for those in underpaid essential services disproportionately staffed by Black, Indigenous and people of colour (BIPOC). People with precarious housing also face barriers, such as revisiting vaccination clinics for their second dose.

Gaps exist with respect to both understanding and disseminating vaccine information. People find it difficult to keep pace with rapidly evolving science regarding vaccine efficacy and safety. While the majority of COVID-19 cases, hospitalizations and deaths occur among the unvaccinated, some people still remain concerned about getting vaccinated. Correctly weighing the perceived risk of rare vaccination-related side effects against the actual risk of COVID-19 is not easy, especially when media reporting focuses more on rare incidents than the most common ones. Vaccine information, such as outlining benefits, or addressing myths, needs to be communicated in a way that is relatable, meaningful, and responds to people’s real concerns.

Gaps in vaccine comfort, particularly among BIPOC communities, can be rooted in long-standing legacies and contemporary experiences of medical and institutional negligence, abuse and malpractice. A history of disenfranchisement experienced by BIPOC communities in general has also produced deep discomfort with directives and messaging from government authorities, including health authorities.

Increasing vaccine comfort remains a key avenue to encourage vaccine uptake across Canada, but this requires serious investment in relationship- and trust-building with communities. We must remember that people have good reason to mistrust governmental actions about their health and well-being over the span of centuries. The work taken to rebuild trust will take time.

Communities are responding to address these gaps

Across Canada, we have seen incredible innovation to address these gaps. Communities and community organizations have rallied to support people through advocacy, redesigned programs and direct service, all while facing limited resources and significant public health restrictions.

Throughout the pandemic, HIV, hepatitis C and harm reduction programs have leveraged their existing capacity to ensure access to COVID-19 vaccines. One-stop-shop models, for example, where service providers combine COVID-19 vaccination with hepatitis C testing, housing support, settlement and other services, have helped to engage marginalized communities who may naturally prioritize basic needs over vaccination. Some organizations that previously offered mobile clinical health services alongside harm reduction quickly integrated COVID-19 vaccination, including tailored information and approaches to ensure transient clients could get both doses. Others created new partnerships with medical professionals and health centres to bring vaccines to their service users. Many advocated for structural and systemic change in vaccine distribution to improve access for among communities hardest hit.

For many communities affected by HIV and hepatitis C, standard messaging from public health authorities did not adequately address their concerns or reach them, especially with rapidly changing scientific information. To fill this gap, community organizations took the lead in developing and delivering COVID-19 messaging relevant and meaningful to the people they serve. This involved contextualizing conversations about infection, disease, medicine and vaccination into existing community understandings of protecting oneself and one another.

Improving comfort with vaccination among communities historically disenfranchised by healthcare systems can be a long and slow process, which has dire consequences in the face of a rapidly-moving pandemic like COVID-19. But as some have said, healthcare only moves at the speed of trust. Improving vaccine comfort – and therefore acceptance – necessitates broader actions to improve health equity. Engaging community leaders who can speak effectively and easily about vaccination, as well as advise healthcare and public health institutions on strategies to engage certain communities, is crucial to building trust. So, too, is providing space and resources for communities to create programs that they themselves lead.

What next?

Vaccine roll-out continues across the country and new strategies are being implemented to implore people to get vaccinated, such as vaccine mandates.

COVID-19 revealed to the mainstream the deep injustices experienced by marginalized communities. It revealed what we know from our constant efforts to address HIV, hepatitis C and overdoses ─ that racialized, Indigenous and other marginalized communities are often left out of mainstream approaches to addressing health crises.

Many are perturbed, and there is a growing sense of anger, especially with the lack of systemic supports to address widening inequities. Vaccination roll-out, like all pandemic responses, must be planned and executed with explicit attention to promoting health equity.

This is a lesson we can’t afford to sidestep: the role of health equity can no longer be an afterthought in policy, allocation or distribution, because COVID-19 is not the last pandemic we will face. Looming in the shadows, as epidemiologists and virologists have warned, is the potential threat of future pandemics. As we respond to COVID-19, the ongoing crises of HIV, hepatitis C and the overdose epidemic, we are coldly reminded that the status quo must change. We can no longer tolerate the inequities that currently permeate every strata of society, and which define health outcomes for the most vulnerable.

Shriya Hari is based in Toronto, Ontario, where she works as a health educator and as the COVID-19 information specialist at CATIE. Shriya has a deep appreciation for community-led research, and her primary areas of interest include sexual health, HIV/AIDS, hepatitis C, communicable diseases and chronic illness. In her spare time, she writes poetry and is starting up a public health podcast, as well as sketching and writing a fantasy novel.