When the words “West Virginia” appear in health stories written by national media, it’s seldom good news. The state faces long-standing health care challenges, ranking near the bottom in a number of often-cited health outcomes.
So it was with considerable pride that in the early days of coronavirus vaccine availability, the state was lauded for its successes in getting needles into arms. One month into the rollout, a higher percentage of West Virginians had received a second dose than residents of any other state – and most countries, for that matter.
Granted, the state is among the nation’s least populated. It has roughly as many people as the city of Phoenix, but they’re dispersed across 24,000 square miles. This created a logistical challenge, and addressing it was a factor in the rollout’s early success. The state brought the National Guard on board to coordinate logistics and networked with local pharmacies – many of them independently owned, in remote communities – to provide vaccines to long-term care facilities.
But West Virginia is no longer out front. Recent Centers for Disease Control and Prevention data indicates that the state now ranks 43rd in percentage of residents fully vaccinated. Only three states (Alabama, Mississippi and Wyoming) have lower rates among those aged 18 to 64.
There’s no single reason the state has fallen behind, but among the factors is the red state/blue state divide we’re seeing across Appalachia and the nation at large. In July, Kaiser Family Foundation research found that 47 percent of residents in U.S. counties won by Biden were fully vaccinated, compared to 35 percent of those in counties won by Trump. Each of West Virginia’s 55 counties went for Trump.
But researchers in the state say it’s not so simple. Dan Totzkay, an assistant professor in West Virginia University’s Department of Communication Studies, said that drawing conclusions based on one’s political persuasion – or age, or urban/rural residency – is overly simplistic and counterproductive, and that surveys and focus groups aren’t rendering such clear distinctions.
Totzkay is a member of the information team within the West Virginia Joint Interagency Task Force for COVID-19 Vaccines. The team has been monitoring perceptions of the vaccine and crafting responses.
Julia Fraustino, also an information team member and an assistant professor of strategic communications in WVU’s Reed College of Media, said that reaching more West Virginians, across all demographics, requires addressing access, awareness and confidence.
Certainly, there are those who won’t be persuaded – or not easily so. Gov. Jim Justice has been blunt in voicing his concerns for getting the most intransigent vaccinated.
“I hate to say this, is what would put them over the edge is an awful lot of people die,” he told ABC News. The only thing that’s going to convince the most resistant West Virgnians, he said, “is a catastrophe that none of us want.”
But a significant percentage of those who are not yet vaccinated, health officials say, are among the “movable middle”: those who if given easy access to the vaccine and provided with answers to their questions and concerns will be receptive.
Across Appalachia, trusted members of their communities are assuming those duties.
Addressing Specific Concerns
Results of a Washington Post-ABC News poll released in July indicated that 29 percent of Americans said they were unlikely to get vaccinated, including 20 percent who said they definitely would not.
With the Delta variant surging throughout the country in the past weeks, hospitalizations and deaths have risen by more than 20 percent. CDC director Rochelle Walensky has said that more than 97 percent of those hospitalized are unvaccinated; Anthony Fauci, chief medical advisor to President Biden, estimated the unvaccinated account for more than 99 percent of recent deaths.
A great many of those unvaccinated, we’re told, are simply “hesitant,” and can be persuaded. But West Virginia’s COVID-19 task force members don’t use the word “hesitancy.”
“Our goal is to increase vaccine ‘confidence,’” Totzkay said. He describes a continuum. “There’s a wide swath of people who might not be first in line to get vaccinated, but it doesn’t mean they’re opposed,” or even hesitant. “There are people with reasonable questions that they just need answers to.”
The task force’s job, Totzkay said, is to help people move themselves “along that continuum towards increased confidence.”
Language is critical. Fraustino stressed that they’re careful to say “choosing vaccination,” underscoring that it is a choice.
“We see it as our job to give them the most scientifically sound evidence we can in the most unbiased way possible,” she said, “so they can make an informed decision to choose vaccination for themselves or their family.”
They’re also avoiding the term “mass vaccination sites,” opting for “community vaccination clinics,” recognizing that West Virginians don’t generally react well to anything that suggests groupthink.
Information team members have found that the questions people have about the vaccine fall into several categories. Learning the specific source of concern is vital to changing a mind.
The most frequent questions are around the safety of the vaccine. “We do know that these vaccines are safe and they are effective, and that they have undergone the most rigorous safety monitoring in U.S. history for vaccines,” Fraustino said, “and that they’ve been administered safely to millions of Americans.”
There are questions about the severity of COVID-19; answering these requires educating people on the risk of severe illness, hospitalization and death from the disease.
There are questions about the effectiveness of the vaccine, which statistics such as those cited by Walensky and Fauci will underscore.
And then, Fraustino said, there’s the question of, “What do you think others who are important to you think you should be doing? Do you think those in your circle think that you should be getting vaccinated, think that you should be getting your children vaccinated?”
Trusted voices, she stressed, are essential.
Among the services the Charleston, West Virginia-based Partnership of African American Churches, or PAAC, provides is behavioral health care and substance-use disorder treatment. In response to a crisis, it’s now deploying teams throughout the state to offer the coronavirus vaccine.
“When the pandemic hit,” PAAC CEO Rev. James Patterson said, “we knew there was a disparity, and that there was mistrust in communities of color.”
Helping build trust are family and fellow church members. PAAC has partnered with NAACP chapters and sororities and fraternities. “With the sororities and fraternities, we get a lot of trusted voices, up and down the age spectrum, that can be out there helping spread the news and get people to accept the vaccine,” Patterson said.
But they alone can’t overcome mistrust.
Mistrust in our nation’s health care system runs deep – across race, ethnicity, class, gender, all expressions of identity – and it’s a primary barrier to vaccination for many. Patterson urges providers to embrace the importance of cultural competence, to attempt to understand belief systems and lived experience.
Essential to that is acknowledging that a lot of people have been mistreated by the health care system.
Patterson, 69, grew up in a segregated world, the Piedmont region of North Carolina. As a child, he went to a doctor who saw both Black and white patients. But the Black patients entered his office from a separate waiting room and were seen strictly as time permitted after the white patients had all received care. He recalls being administered a suppository and having to rush out into the woods to relieve himself.
Such blatant disparities in treatment may be largely in the past, but implicit, often unconscious, biases endure. Providers must take into consideration “how this person may or may not have been treated by the health care system, up to this point, for no other reasons than because of their gender, because of their sexual preference, because of their color,” Patterson said. Building trust for the vaccine requires acknowledging past wrongs.
A Shift in Attitudes?
People who are adamantly opposed to the vaccine, for whatever reason, are almost impossible to break through to, Patterson conceded. “Not that we don’t try. But we’re focusing on that movable middle, getting a substantial amount of those folks vaccinated.”
Totzkay said that as the Delta variant spreads and the death toll rises, he and his task force colleagues have begun to sense a shift in attitudes toward the vaccine. “We’re seeing some impact on people’s motivation to get vaccinated,” he said, “but there’s variability in that.”
Fraustino said a message they’re particularly stressing is the heightened risk to children as the case rate rises. It’s yet unclear if the Delta variant causes more severe disease in children, but the math is simple: more people infected means more kids infected and, thereby, the greater the risk of more severely infected kids.
Many parents continue to hold on to the perception, Fraustino said, “that children are immune to it or, if they get it, it’s just going to be another cold like they get at school all the time.”
The information team’s task is to continue to educate all West Virginians, she said, “about the potential long-term ramifications of COVID-19 disease and the increased transmissibility of the variance.”
Patterson said the plan is for PAAC’s vaccination teams to set up in each of West Virginia’s 55 counties. To date, they’ve reached 20-plus. Some days they’ve vaccinated more than 300 people; other days, it may be fewer than a dozen. The numbers were declining, he said, but are now again accelerating.
“Some people are genuinely afraid of the vaccine,” Patterson said, but more are growing even more fearful of the virus, having witnessed family, friends and neighbors suffering and dying.