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As the U.S. faces down the threat of the more transmissible Delta variant, experts are working harder than ever to understand the concerns of vaccine "holdouts."

In interviews with public health experts, several key themes behind remaining hesitancy emerged -- including misinformation, mistrust in the medical establishment, and specific concerns among those newly eligible, such as an impact on fertility.

To better understand what's keeping about a third of U.S. adults from getting even one dose, 乌鸦传媒 started in Arkansas, which has one of the lowest vaccination rates in the country, with .

Case Study: Arkansas

Jennifer Dillaha, MD, the medical director for immunizations at the Arkansas Department of Health, said misinformation is rampant in the state, and is a key reason behind vaccine refusal.

"There is so much misinformation, and many people have misconceptions about the safety and efficacy of the vaccines," Dillaha told 乌鸦传媒. "They have difficulty sorting through the information available, and they are not able to distinguish accurate information from misinformation."

Some Arkansans think one dose of the Pfizer or Moderna vaccine is sufficient, and still more believe they have sufficient immunity from previously contracting and recovering from COVID, Dillaha said.

Dillaha also hears about individuals waiting until full FDA approval to get their shot.

"I think it's unfortunate," she said, because, "that indicates that a person really doesn't understand the safety and efficacy of the trials that have taken place."

Basically, the only evidence that remains from longer-term trials is the duration of protection, she said. People have a misconception that steps must have been skipped, or that the technology behind the mRNA vaccines is brand new.

Other southern states, including Alabama, Louisiana, and Mississippi are also struggling with low vaccination rates.

"I think in general people in the South struggle more with health literacy than in other parts of the country," Dillaha said.

Much of the south is rural, and people who struggle with health literacy need healthcare providers to help them sort through information, she said.

"We have such a healthcare provider shortage," she said.

Many people do not have an established relationship with a healthcare provider, such as a doctor or nurse, Dillaha said. However, there is an opportunity for pharmacists to help with information about vaccines. That's because even in areas with a provider shortage, the one contact people are likely to have is a pharmacist.

Vaccine hesitancy is part of the overall struggle that people have to "get health information that is accurate and reliable, and digest that information and use it to make health decisions that truly benefit them," she said.

"And to me that's what health literacy is all about," she added. "Most of the vaccine hesitancy that we see is in essence a health literacy problem."

Mistrust Persists

Natasha Williams, EdD, MPH, assistant professor of population health at NYU Grossman School of Medicine, pointed to the distrust in the medical community among people of color as another key reason behind remaining hesitancy.

Early in the vaccination rollout, there were concerns within the Black community and underserved communities, Williams said. There were task forces set up at city and state levels to help address equity and distribution, she said. However, it's not clear whether those particular efforts aided in reaching certain communities.

There should be a focus on what happened with those efforts around health equity and vaccine uptake, she said.

However, the "good news" is that, "there has been some improvement in vaccine uptake among all Americans, regardless of race, ethnicity, or other backgrounds," Williams said.

"Doctors and healthcare providers, they still remain an important resource as it relates to people getting information and who they will turn to for information about the vaccine," she said.

Families, friends, religious leaders, and the CDC are also helpful, she said, adding that taking the time to answer people's questions about the vaccine is essential.

"People really want to have their questions answered," Williams said. "I don't think it's a major request for people to have questions and to get their questions answered from trusted sources."

An important message, she said, is that "the issue of hesitancy or mistrust is really justified," she said.

To have a conversation about the vaccine with marginalized communities without acknowledging the abuse that has taken place in the healthcare system does a disservice, she said.

"We need to take a few steps back to create a path forward," Williams said.

Young People

As individuals age 12 and older are now eligible for the COVID vaccine, hesitancy among children and young adults -- and their parents -- is in sharp focus.

Sean O'Leary, MD, vice chair of the American Academy of Pediatrics Committee on Infectious Diseases, said that in general, parents who are highly motivated to vaccinate themselves are going to vaccinate their children when they're eligible.

Of potential concern are the rare incidents of myocarditis in young people following vaccination. However, O'Leary said he believes agencies have addressed the issue by pointing out that the benefits of vaccination largely outweigh the small risk of the condition.

"To me, that's the way it needed to be done," he said. "We'll see how that lands on parents."

What O'Leary believes will play a significant role in uptake this summer is vaccination within primary care offices.

Until more recently, most vaccinations were in mass vaccination clinics, he said. "Almost by definition, those who went there were highly motivated to get the vaccine." They were "not necessarily places where people were going to get a lot of questions answered."

However, pediatricians are often parents' most trusted source of vaccine information, O'Leary said. If adolescents are coming in for checkups during the summer, there is an opportunity for pediatricians to allay concerns, and "that may make a big difference," he said.

Now that storage requirements for the vaccines have been eased, pediatricians may be able to better reach parents on the fence about vaccinating their children, he said. They can say things like, "'I've gotten this for my own kids,' 'It's important for you to get it,' and 'I have it here in the office.'"

If there was not a pandemic, and if there had been hundreds of deaths in children from any other condition for which there was a vaccine, people would "jump at that," he said. "We've been numb to how severe this pandemic is."

Aisha Langford, PhD, MPH, also an assistant professor of population health at NYU Grossman School of Medicine, said that in local town halls with high school students, some of the responses from unvaccinated youth have been that they are worried about the vaccines being developed too quickly, that their parents don't want to consent to them getting the vaccine, and that they have seen misinformation that the vaccines may cause fertility issues down the line, Langford said.

In fact, she said, questions about fertility continue to come up perhaps more frequently than many others. In response, medical organizations and agencies have put out statements to try to combat that myth.

Other young people have expressed hesitation over money lotteries incentivizing vaccination, Langford said, questioning why people would have to be bribed if the vaccines were safe. Some have said that getting a laptop for college may be more valuable to them than cash, and that they are worried getting the vaccine could affect their playing sports.

One of the most important things, is simply listening and trying to understand people's unique concerns, Langford said.

Where to Move the Needle

At the current stage of vaccine rollout, most experts believe the most significant opportunity to reach more people is through the "wait and see" group.

About 25% to 30% of people are not against the COVID vaccine, but are not going to go out and get it just because someone tells them to, said Litjen Tan, PhD, chief policy and partnerships officer at the Immunization Action Coalition.

Often, the wait-and-see group simply forgets, Tan said. One of the things to remind people is that, "The time for 'wait and see' is gone." The vaccine has shown a "remarkable safety profile."

Another thing to remind people is that the Delta variant is a real issue, he said. "It's now a matter of protecting yourself and your community."

After making sure there is not an access issue, reaching people in those ways can prove effective, Tan said. Incentives can work as well.

Dillaha of the Arkansas Department of Health, also reiterated the importance of reaching people with the right message.

"One of the key things is allowing people to have the opportunity to have their questions answered and their concerns addressed," Dillaha said. "I think that can happen in a variety of settings."

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