Why Relationships Rule Vaccination Rates

Sometimes it's not what you know; it's who you know.

Posted Feb 16, 2021

Two people can share the same home but live in different worlds. Family ties and close, reciprocal friendships influence much of our lives, from fashion to career choice to our emotions. Though we grow from children into adults whose sense of normal tends to resemble other members of our community, evidence suggests we can maintain only a limited number of relationships. So while family members have people in common, they often have distinct networks of friends.

Add people and the effect multiplies. Cliques form. People collect friends who don’t know one another. Someone a person considers a friend might not feel the same way. Groups split, accumulating differences until each inhabits its own reality. Individuals find themselves members of an assortment of groups, navigating through disparate voices on a daily basis. So, when researchers learned that 77.8% of nursing home residents but only 37.5% of nursing home staff have been vaccinated against COVID-19, perhaps they shouldn’t have been surprised.

But they were. Most people outside of nursing homes who learn of this result probably are, likely because we expect a higher uptake from medical professionals than from laypeople. So why this result?

One factor often cited as a possible reason why people refuse vaccines is socioeconomic status. The thinking is that people who are higher on the socioeconomic ladder are more likely to vaccinate and that nursing home residents, paying an average of $100,000 per year (in New York) to live in a nursing home, are economically better off than nursing home staff. This explanation is unlikely.

A meta analysis studying connections between socioeconomic status and flu vaccination rates found that while a relationship exists between socioeconomic status and flu vaccination rates, the relationship isn’t clear because the various studies used different definitions of socioeconomic status. Some used income. Others used income and other factors. Unless researchers choose to study the same factors, it is hard to draw precise conclusions from this body of work.

The analysis also found a positive relationship (in countries without universal healthcare) between private insurance coverage and vaccination, with private insurance serving as a possible proxy for being economically well off. However, private insurance companies and Medicare generally don’t cover long term care, and very few people purchase long-term care policies. As a result, more than 70% of nursing home residents in New York, for example, receive Medicaid, which has low income and asset limits. Therefore, socioeconomic status is unlikely to drive this disparity.

Another factor cited as a possible reason for this result is race. The thinking here is that African-Americans are overrepresented in nursing home staff but underrepresented in nursing home residents, and that documented lower rates of vaccination cause the disparity. However, African-Americans comprise about 14% of the U.S. population, about 12% of nursing home residents, and about 30% of long term care workers. There is evidence African-Americans have received the COVID-19 vaccine at lower rates than white Americans (at the time of publication, the author has received the first dose without side effects), but the study in question doesn’t contain enough data to conclude that race is the primary cause of the disparities in nursing homes. There aren't enough African-American long term care workers to account for the vaccination rate among nursing home staff.  

Dividing people into groups to learn who is and isn’t choosing to get the vaccine is useful. If health departments know that certain groups are choosing not to get vaccinated, then they can devote more resources to efforts for those groups. However, this strategy can also lead researchers and reporters to explain the behavior of people who hesitate or refuse to get vaccinated via the fundamental attribution error, assuming members of specific groups refuse for reasons endemic to that group.   

For example, articles often paint African-American hesitancy as a response to racism. These articles cite cultural memory of the Tuskegee Study of Untreated Syphilis in the Negro Male conducted by the United States Public Health Service and the Centers for Disease Control and Prevention between 1932 and 1972 (and other incidents) as the sole reason African-Americans distrust doctors or vaccines.

There are several issues with this reasoning. First, it assumes 44 million people know the same things and think exactly the same way, when African-Americans are as diverse as any group. Second, we humans are notorious for misremembering events soon after they happen. Third, emotional connections help with recall, but research suggests the 600 men in the study had close relationships with 3,000 to 9,000 others. Certainly, people outside this circle learned what happened, had emotional reactions to it, studied it, and use it in their decision making, but the study participants and their families settled with the U.S. government in 1974, nearly two generations ago. (And, anecdotally, the author has never had a conversation about it.) Fear of racism can be a contributing factor, but there is a simpler, more inclusive, and more likely culprit: fear of the vaccine.

The earliest evidence of vaccination comes from India, China, and Africa. A 10th century Chinese method involved grinding smallpox scabs and blowing them up people’s noses. When knowledge of this common practice first reached the colonies in 1707, in part from an enslaved African man named Onesimus, Bostonian Cotton Mather set out to immunize as many people as possible. In return, someone bombed his house, accusing him of spreading the disease and defying the will of God

Today, what’s left out of reports on vaccine hesitancy is what people actually say when they refuse: “I don’t know what’s in that,” or “If I don’t have the disease, why do I need to get the vaccine?” These statements are echoed by people across racial and socioeconomic lines. 

However, trust allays fear. Some of us are fortunate; we trade outrageous hot dog references with a friend who researches the virus. Or we watch science videos using mousetraps and ping pong balls to demonstrate how herd immunity works. But, we also trust personal doctors, brands, and close friends. We might balk at first (not everyone is an early adopter), but any of those relationships can help someone to overcome concerns they might get sick by purposely infecting themselves with a weaker form of the virus (in the case of RNA vaccines, not even that). A person’s network also helps. If several members of a network choose to get a vaccine, others will follow. 

Where does this leave nursing homes? Other (important) considerations aside, a resident has a doctor-patient relationship with the nursing home. Some portion of the uptake among residents is likely explained by the trust people place in their caregivers. Staff members don’t have the same relationship. The doctors are colleagues or bosses, and despite a close working environment, 68% of employees are either not engaged or actively disengaged from their jobs. Thus, bosses and staff live different worlds, unable to unlock the trust necessary to convince them the vaccine is safe.