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A Covid-19 vaccination center in London. | Dinendra Haria/SOPA Images/LightRocket via Getty Images

The UK has world-leading vaccine enthusiasm. What can the rest of the world learn?

Vaccines are gradually becoming more widely available across the United States. But as the fight to ensure everyone can access them continues, the US is also entering the second phase of its vaccination campaign against Covid-19: the fight against vaccine hesitancy.

About 26 percent of Americans say they won’t take a vaccine, according to an April 21-26 CNN poll. Getting the pandemic under control in the US could be challenging without their buy-in.

Meanwhile, in the United Kingdom vaccine hesitancy sits much lower; government polling shows it’s around 6 percent. This is not necessarily because the British are inherently more enthusiastic about vaccination. Last summer, a poll found that 75 percent of Americans and 71 percent of British people were open to taking a vaccine if one existed and was recommended by their government.

But in the year since then, vaccine hesitancy in the US has stayed about the same, while vaccine hesitancy in the UK has plummeted to the lowest in the world. The UK has administered 75 doses per 100 people, and 95 percent of people over age 50 have gotten their first vaccine dose. To be clear, the US vaccine effort has been going well, too. But there is growing concern that hesitancy might keep the country from reaching herd immunity and slow progress toward normalcy. The UK, apparently, doesn’t face that same challenge.

All of this raises an urgent question on the vaccine hesitancy front: What is the UK doing right that the US could learn from?

It’s a difficult question to answer definitively. Vaccine hesitancy researchers have conducted lots of polling over the last year, but polling is much better at answering the question of what people believe, rather than why they believe it. A few factors make the vaccine rollout in the UK different from every other vaccine rollout in the world, from the country’s national health care system to its policy of delayed second doses to its information ecosystem. Those differences could help explain how the UK has been able to curb vaccine hesitancy.

Researchers I spoke to emphasized that all of their theories about how the UK has kept hesitancy low were very much speculative and not yet backed up by solid evidence. But those theories are still worth considering as the US tries to convince more Americans to get vaccinated.

The UK’s restrained reaction to bad news about the vaccines

One of the tactics that distinguishes the UK from the US, and much of the world, is its approach to regulation and public communication in response to bad news about the vaccines. It’s an approach that could well have helped develop greater public trust in the vaccines.

“In the UK, the medical communication has been pretty excellent,” David Comerford, an economist at the University of Stirling’s Behavioural Science Centre in the UK who researches vaccine hesitancy, told me. He focused particularly on how UK authorities reacted to and communicated about rare complications involving the vaccines that came out in news reports.

As millions of people have been vaccinated against Covid-19, some rare side effects have cropped up. The Johnson & Johnson and Oxford/AstraZeneca vaccines appear to, in extremely rare circumstances, cause an unusual kind of blood clotting.

In the US, the FDA and CDC immediately paused distribution of the Johnson & Johnson vaccine. After the announcement, public confidence in the Johnson & Johnson vaccine fell immediately, and the pause coincided with a peak in daily vaccinations in the US. Vaccinations have been falling ever since then, across all age groups. (It’s not clear how much the slowdown in the overall vaccination rate is related to the pause or news of rare side effects; experts expected a drop for all vaccines around this time as supply began to outstrip demand.)

The EU’s response was similar to the US’s — it paused the Oxford/AstraZeneca vaccine. And, as with the US, that move coincided with confidence in the vaccine plummeting.

By contrast, the UK did not pause the vaccine. Instead, the National Health Service (NHS) updated its vaccine guidelines to recommend that people under 30 or with a predisposition to blood clots get the Moderna or Pfizer/BioNTech vaccines instead, and to advise people on what symptoms to watch for.

Researchers at the University of Stirling found that despite pervasive news coverage of the blood clots, vaccine hesitancy in the UK did not change at all. That’s in distinct contrast to the EU, where it rose; in the U.S., polls have differed.

“The US did a U-turn, suspending delivery of the J&J vaccine,” Comerford told me. (The US has resumed delivery of the Johnson & Johnson vaccine since we spoke.) “Several EU countries did two U-turns, suspending delivery of the AZ vaccine and then, a few days later, resuming delivery of it. The UK did a course adjustment. If regulators were taxi drivers, who would you feel more confident having at the wheel?”

It’s more convenient to get a vaccine in the UK

Another factor to consider is the disparity in the vaccine rollout between the UK and the US. Simply put: The UK has a centralized rollout run by the NHS, while the US’s is more fractured and confusing.

One reason people are hesitant about being vaccinated is that it’s a hassle. About half of hesitant unvaccinated people who say they intend to “wait and see” before deciding whether to get the vaccine, tell pollsters that they’d get the vaccine if it were offered at a routine medical appointment. But for most of the spring, getting the vaccine in the US has been decidedly inconvenient.

First, there’s scheduling. When the US rollout began, states and many counties set up their own system for vaccine appointments. Many pharmacy chains, hospital networks, and pop-up sites administering vaccines frequently have their own system too. Convenience has greatly improved now as vaccine availability in the US has exploded and more vaccine sites — including walk-in venues — have opened, but it took a while to get there. Compare that with the UK, where all vaccine scheduling was done through the NHS, on a single website, from the outset.

A second factor that made UK vaccination more convenient: the system for determining eligibility. For the last four months, every US state (and some counties) has made its own determinations about who is eligible for the vaccine. In mid-March, polls found that 30 percent of Americans didn’t know if they were eligible for a Covid-19 vaccine. Hispanic and low-income Americans were most likely to report uncertainty about whether they were eligible.

In the UK, vaccines were first available in nursing homes; since then, they have been made available to steadily descending age groups. Vaccines are now available to people 40 and older, with vaccination for 35-year-olds coming soon. (The UK has given out nearly as many vaccine doses as the US, but because the UK has less hesitancy and far more uptake, it hasn’t expanded eligibility as much, according to experts I spoke with.) The fact that the rules are the same everywhere instead of a state-by-state patchwork makes the system less confusing.

Additionally, since there’s centralization of health care records in the UK, the NHS knows who is eligible for a vaccine and contacts — by phone, email, or text — everyone who becomes eligible for a vaccine to let them know they’re eligible. No such system exists in the US, which compounds the complexities of the rollout.

In a poll released February 8, nearly 90 percent of respondents in the UK expressed satisfaction with their government’s efforts to obtain vaccines; 80 percent felt that the government was doing a good job getting the vaccines distributed as soon as possible; 75 percent felt that the prioritization scheme was good. In the US at the same time, 44 percent of respondents were satisfied with the vaccination process (though satisfaction has grown since then).

“If you are trying to find an institution that folks in the UK across the spectrum can latch onto and appreciate, the NHS is that institution,” Comerford told me. “There was a lot of goodwill even before the pandemic, but since then, it’s compounded.”

So the UK rollout was popular, centralized, conducted by a beloved national institution, and easy to sign up for. It’s easy to see how that might have helped people want to get vaccinated. It might not tell the whole story — convenience may be a factor for the “wait and see” crowd, but what about the “definitely not” group? — but it’s an intriguing partial explanation for the UK’s success against hesitancy.

Nothing increases confidence in vaccinations like vaccinations do

One way to decrease vaccine hesitancy is to vaccinate lots of people.

This is clear from both US and UK hesitancy data: Hesitancy falls as more people are vaccinated. One element of the UK’s exceptionally low hesitancy, the Guardian’s editorial board has argued, is that more people know someone who has gotten the shot: “The more people get the vaccine, the more normal it becomes. A virtuous circle of confidence develops.”

That’s a trend we’ve seen in the US, too. As more people get their shot, those who said they want to “wait and see” about the vaccine are increasingly taking the leap.

For months now, the UK has been a global leader in the number of people with at least one shot. That figure now stands at about 52 percent, compared to 45 percent for the US. One possible reason the UK has taken such a lead over the rest of the world (except Israel) is its choice to distribute more first doses for the vaccine while delaying second doses for up to 12 weeks.

The rationale for that policy choice was simple. You have two people eligible for a vaccine. Does it make sense to vaccinate the one who’s already been vaccinated with a second dose, or the one who hasn’t received a dose at all?

The UK took the latter approach, getting as many doses into as many arms as possible, even if it came at the expense of pushing back the second shot for many people. Britain’s health officials ruled that it was acceptable to delay second doses of the Covid-19 vaccines for up to three months. As a result, while the UK has distributed slightly fewer shots per capita than the US, more people have been partially vaccinated, and the country has seen a larger drop in hospitalizations and deaths.

At the time the NHS made this decision in January, some observers wondered whether breaking from the recommended regimen would lead to higher vaccine hesitancy in the UK. Normally, vaccines are given out exactly the way they are tested in clinical trials. The British government “took punts on things before there was data to support them,” said Jeremy Brown, a professor of respiratory infection at University College London and one of the scientists who advised on the UK vaccine deployment.

Certainly in the US, during the January debate over whether to delay second doses, experts cited vaccine hesitancy as a consideration against such an approach. Experts told the New York Times that they worried delaying the second dose would undermine trust in vaccination and increase vaccine hesitancy, making it harder to get everybody vaccinated.

In the UK, at least, that doesn’t seem to have been the case — and it’s fair to wonder whether the increase in people who’ve been partially vaccinated, and the rapid fall in hospitalizations and deaths, engendered trust and changed some vaccine-skeptical minds.

In the UK, partisanship and right-wing populism have worked in the vaccine’s favor

One of the more striking findings in polling about hesitancy in the US has been the partisan breakdown. Conservatives in the US are far more likely to be vaccine-hesitant than liberals in the US. In the most recent CNN polling, 44 percent of Republicans — and only 8 percent of Democrats — said they will not try to get vaccinated. That partisan divide in vaccine confidence drives much of the US’s hesitancy problem.

Those attitudes are amplified by right-wing media. Tucker Carlson has argued on Fox News for vaccine skepticism, saying the vaccine is a tool for “social control.”Democrats believe vaccines are the answer to everything,” he said in November. “‘Shh. Don’t ask questions. Just take the shot.’”

In the UK, that kind of partisan dynamic hasn’t been a factor — or may actually be working against hesitancy. “My speculation is that it’s a national pride thing,” Tom Chivers, a science journalist in the UK, told me when I asked why the British were so eager to get vaccinated. “The UK has had a nightmare response in many ways on Covid but unambiguously got the vaccines and science generally right, so I have a sense that we are fiercely proud of it.”

The populist right in the UK is generally suspicious of the EU and proud of Britain’s scientific and technical achievements. So when the EU worried about blood clots, the populist right in Britain rallied … behind the vaccine. “The media has been pretty solidly pro-vaccination,” Chivers told me. “Even the much-criticised Sun ran an amazing splash headline the day after a clotting story: ‘0.0000095%: your chance of a deadly clot.’”

Comerford pointed me to the Daily Mail from the day the EU suspended the Oxford/AstraZeneca vaccine:

In populist UK media, the vaccine was framed as a national achievement, and vaccine hesitancy as the provenance of the EU, recklessly rejecting the Oxford/AstraZeneca vaccine. As a result, in the UK, people from across the political spectrum, including the populist right, are pro-vaccine. In the US, on the other hand, right-wing media has taken a different tack, and conservative Americans tend to be vaccine skeptical.

Why did things turn out that way? After all, Moderna and Pfizer are US companies and the vaccines were developed on Trump’s watch. Why didn’t the US populist right embrace the triumph of American science? Is it because the vaccine and an aggressive response to Covid-19 — lockdowns, social distancing, mask-wearing — came to be coded as liberal? Or that Trump tended to minimize the virus (even as he took credit for Operation Warp Speed)?

And those questions come with another big question: Is it too late? Could US conservative media still run the UK tabloid playbook and change some minds? Or is vaccine hesitancy too embedded in the US conservative identity for the government and other institutions to be able to do much about it?

Vaccine hesitancy, like public opinion on any other complex topic, likely has many sources. “There are probably a million factors,” Chivers told me, and he’s almost certainly right.

Over the next few years, as the world attempts a global vaccination campaign to end this pandemic, everyone will no doubt learn a lot more about what drives hesitancy, how to effectively counter it, and how to run a rollout in a way that reassures the vaccine-hesitant. These are early days, and our understanding of what drives hesitancy is still limited. But what we do know so far points at the importance of clarity, trust, a functioning health care system, and perhaps a touch of patriotism to get a vast society on board.

Author: Kelsey Piper

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