How do you get health workers to do something as personally intimate and publicly important as getting vaccinated? The government’s response was, until this week, “get vaccinated or get out”. Those in the know have long disagreed with this. The British Medical Association is strongly in favour of vaccines and encourages all its members to get the jab – but it admits that “mandating Covid-19 vaccination raises a number of complicated ethical and practical issues”. The Royal College of Nursing strongly recommends that “all members are vaccinated as soon as they can be” – but is also clear that making the vaccine compulsory could undermine its uptake, and “significantly impact on the retention of staff”.
Both the BMA and the RCN made their stances clear to the government as early as last September. But ministers did not listen. In December, the RCN once more expressed its concerns and called on the government to delay the vaccine mandate. The government ignored it again – until now, when, with a staffing disaster approaching, ministers have been forced to acknowledge the facts and back off from compulsory vaccination.
Perhaps this U-turn is better late than never. But the danger is that in backtracking, the government has sent a message that vaccines aren’t as important as before (indeed ministers are already spinning the story to suggest that their screeching U-turn is actually due to the lowered severity of Omicron). This could undermine uptake in a different way – making people who may have been planning to have the vaccine believe it is no longer necessary to do so.
So let us be absolutely clear: the issue is not that vaccine mandates are no longer needed. They were never a good idea to begin with. If the government is to move forward without damaging vaccine uptake, it needs to acknowledge this mistake. The first step is to recognise, as the BMA and RCN have done, that the issue is not about whether NHS staff should be vaccinated. Of course they should – we are still in the middle of a serious pandemic. The issue is how to best maximise uptake of the vaccine. And all evidence points towards the fact that vaccine mandates have mixed effects, which ultimately increase people’s resistance to vaccines.
Most people who are unvaccinated are not anti-vaxxers (those who are against vaccines on principle) and are not even vaccine hesitant (those who have genuine doubts and questions about the vaccine). They are vaccine indifferent. They simply haven’t got round to it. For them, little things will make a difference (which is why there is a correlation between vaccine uptake and how far you are from a vaccination centre), as will big things. If you give them a strong reason – like mandation – to get a jab, they will. That is why, when various forms of mandation are introduced you will see an initial surge of people queueing up outside the vaccination centres, as in France.
But it is a very different story for those who do have questions and doubts – especially doubts about whether vaccines are being done to them rather than for them. In this case, compulsion runs the danger of confirming their doubts and therefore increases their resistance. If they can escape compulsion (say, by leaving a job), they will. Even if they can’t and they concede in the present, you are only storing up trouble for the future; people will always look for other ways to express their defiance, and may become even more negative about further vaccinations.
To put it slightly differently, the issue here is one of trust. When people have doubts, do they listen to those rolling out the vaccines or those opposing the vaccines? If you use compulsion (and also if you berate unvaccinated people as fools and as selfish), you damage trust and drive people who are vaccine hesitant into the arms of the anti-vaxxers who tell them “you see, they are not interested in you, they simply want to control you”.
That is why groups with lower vaccination take-up are those which have an already troubled history of trust with authorities – people who are deprived or unemployed, and, in particular groups such as Black Caribbean people, about two-thirds of whom have not yet received three jabs. It is hardly coincidental that a 2020 parliamentary report showed that a similar percentage of Black British people “do not believe that their health is equally protected by the NHS compared to white people”.
The best way to increase vaccination rates among these groups is to focus on rebuilding trust. That is why the World Health Organization stressed at the start of the vaccine rollout in January 2021 that “community engagement should be at the centre of all Covid-19 vaccine introduction activities”. That involves working in and through communities. It means starting from a position of respect: acknowledging that people have genuine and serious questions about the vaccine that need answering. It means listening to people, understanding their concerns, answering them and also not hiding any problems. The case for vaccination is strong enough without pretending vaccines are perfect, and overstating the case will only undermine trust as problems emerge.
This is painstaking work. It is not glamorous and nor is it an instant fix. But, as scientists argued early on, “participatory community engagement is cost-effective, increases uptake of vaccines, and substantially reduces healthcare resources needed to achieve high vaccination coverage”. Some of the best examples of this come from healthcare settings involving local initiatives with the support of local mosques and predominantly Black churches to reach ethnic minority healthcare workers.
There is a more general message in all this. When people don’t listen to you, the answer is not to shout louder and wave a stick. It isn’t to use compulsion. The answer is to listen more, and to respect your audience. That is the way to improve vaccination rates in the NHS. That is also the way to rebuild the trust of the public more generally. Respect the people! Now there’s an idea for this government to mull over.
Stephen Reicher is a member of the Sage subcommittee advising on behavioural science. He is a professor of psychology at the University of St Andrews, a fellow of the Royal Society of Edinburgh and an authority on crowd psychology
