Why won't some health care workers get vaccinated?

Many Americans cannot wait to get the COVID-19 vaccine. They call hotline numbers. They search online for vaccine clinics. They wait for hours in line. Yet, others with ready access to the vaccine have declined it in large numbers. Staff in long-term care facilities were prioritized to receive the vaccine, but many are choosing not to get vaccinated. Why?

Nobody is more familiar with the impact of COVID-19 than staff at nursing homes and assisted living facilities that have been ground zero for the pandemic. Large numbers of residents and staff have contracted the virus. Nearly 40% of the COVID deaths in the US have occurred among residents of these facilities. Over 1,500 nursing home staff have also died from COVID, making nursing home caregiver the most dangerous job in America.

Nonetheless, many long-term care staff continue to refuse the COVID-19 vaccine. In a recent CDC report, nursing homes had a median vaccination rate of 37.5% for staff during the first month of the federal vaccination effort; by comparison, a median of 77.8% of nursing home residents received the vaccine. This has surprised some policymakers. Recently, Maryland's acting health secretary told state lawmakers that about one-third to one-half of staff offered the vaccine chose to have it –– nowhere near an expectation of 80% to 90%. In a bit of positive news earlier this month, a large national nursing home chain reported 61% of staff and 84% of residents had been vaccinated as of early February, still far short of many policymakers' expectations.

An information problem or a trust problem?

Many experts attribute low vaccination rates among staff to an information problem. Indeed, a recent survey of nursing home caregivers suggests many staff worry about vaccine safety and side effects. Yet, major information campaigns including well-crafted toolkits and fact sheets have not been sufficient. The problem isn't just a lack of information, but also who delivers this information. Direct caregivers in long-term care may lack information about the vaccine, but they also lack trust in facility leadership.

We have historically undervalued the work of caregivers in long-term care facilities. They perform a difficult job for pay at or near minimum wage, with few benefits like health insurance or paid sick leave. They often work at multiple facilities in order to earn a living wage. Many facilities are understaffed with high turnover. The vast majority of caregivers are women, and many are people of color and recent immigrants. They may be treated poorly while being asked to work long hours at low pay.

Since the start of the pandemic, this workforce has been further exploited. They have often had to work in facilities that were severely short-staffed, without adequate personal protective equipment or rapid COVID testing. Many staff did not receive hazard or hero pay despite working in the most dangerous of conditions. Not surprisingly, many staff do not trust management at the facilities where they work.

The role of trust, vaccine mandates, and cash incentives

Given the lack of trust among caregivers, staff don't just need more information about the safety of the vaccine; they need to hear this message from a trusted source. Some facilities with better employer-employee relationships have been able to have these discussions, as a recent New Yorker article notes.

This trust between facility leadership and staff is not built overnight. Facilities lacking this culture will need to turn to a trusted source either in or around the facility. In some instances, that might be respected clinicians and staff who work in the facility. In other instances, that might be a professional organization.

Is there a role for policy in increasing staff vaccination rates? Maybe. One idea is to mandate that staff take the vaccine. The federal government has been reluctant to do that, especially because the vaccine was approved through an emergency use authorization. Although a few assisted living chains have mandated the vaccine, most companies have not chosen this route. Everyone acknowledges that mandates will have the intended effect of increasing vaccination rates among staff. However, mandates are also likely to have the unintended effect of causing some staff to leave their positions rather than get vaccinated. It all comes back to trust. Given severe staffing shortages and the challenge of recruiting new workers to these jobs, facilities can ill afford to lose more workers.

Another approach is to pay staff to take the vaccine. Some facilities have offered a free breakfast or gift cards. These rewards are nice but fairly nominal, and unlikely to move the needle much. Larger cash amounts like $500 for the first shot and $1,000 for the second shot would likely motivate more staff to get vaccinated. However, there are ethical considerations around paying staff, and funding for these payments would require government support.

At the end of the day, no matter the approach, trust and relationships will figure centrally into resolving this situation. In getting long-term care facility staff vaccinated, the messages we share matter, but so does the messenger who delivers this information.