Moving the Needle on Vaccine Hesitancy

Since distribution of the COVID-19 vaccines started, there’s been limited supply and competition to get vaccinated. Equity has remained a central challenge throughout the pandemic and many are working to ensure equitable processes. This is no easy feat and will be an ongoing issue. But over time, the lack of supply will be a problem of the past and a new roadblock will emerge front and center: vaccine hesitancy. 

The Three C’s of Vaccine Hesitancy

The concept of vaccine hesitancy is not new. The World Health Organization’s Strategic Advisory Group of Experts defines vaccine hesitancy as a “delay in acceptance or refusal of vaccines despite availability of vaccine services … influenced by factors such as complacency, convenience, and confidence.”

Complacency, convenience, and confidence. This three C’s framework for addressing COVID-19 vaccine hesitancy will become increasingly important in the coming weeks as Colorado’s COVID-19 distribution plan moves into phases that include larger groups of the population. Focuses will need to shift to ensure we don’t stall progress on ending the pandemic.  

A person’s decision to receive the vaccine can be influenced by one, two, or all three of the C’s.


Trust in the efficacy and safety of the COVID-19 vaccine, the health care system, and in the motivation of the policymakers are components of confidence. People have many reasons for lacking confidence in the vaccine.

False claims and misinformation can play a role. The Center for Countering Digital Hate found that 150 of the largest anti-vaccination accounts on social media gained 8 million followers since January 2020.

But in other cases, the issue of confidence is rooted in historical discrimination in the medical system. How do you prove trustworthiness of a system that has a history of wronging communities, such as the forced sterilization of Native American and Black women as recently as the 1970s?

The speed at which the vaccine was developed and the use of mRNA technology are also issues of confidence and trust in its safety. In a recent poll conducted by the Associated Press-NORC Center for Public Affairs Research, only 48% of adults said they definitely will get the vaccine or have already received it. Six in 10 of those who weren’t sure they would get the COVID-19 vaccine said they were concerned about possible side effects. Nearly half (48%) reported they planned on waiting to see if the vaccine was safe and would possibly get it later, while 38% said they didn’t trust the vaccine. 


Complacency refers to the perception that the risk of COVID-19 is low. We’ve already seen this in the form of so-called anti-maskers. Many have cast doubt as to whether the virus is real or severe, so they are likely to believe that they don’t need a vaccine. People in this group might also hold the mistaken belief that the risk of vaccine side effects is higher than the risk of the disease.


When the vaccine is readily available to all who want it, other barriers of convenience will become more important. Policymakers have already addressed one important aspect of convenience: cost — the COVID-19 vaccine is free. But cost comes in a different form too: time. Not all people can take time off work to get vaccinated or have a reliable mode of transportation. Those who are homebound or are people with limited mobility may also face barriers. What can be done to ensure quality service is being provided in a culturally competent, comfortable, and convenient time and place to meet people where they are?

Vaccine Hesitancy is a Continuum, and People are Movable

The good news about vaccine hesitancy is that it’s not a firm binary where people are either vaccine hesitant or they’re not. Rather, it is a continuum from complete acceptance to complete refusal — and many people fall somewhere in between. In the AP-NORC poll, half of adults expressed some form of hesitancy, with 19% saying they probably will get the vaccine, 17% saying they probably will not, and 15% saying they definitely will not.

A Continuum of Vaccine Hesitancy

Complete AcceptanceAccept But UnsureAccept Some, Delay, and Refuse SomeRefuse But UnsureComplete Refusal

Addressing vaccine hesitancy requires a concerted and collaborative effort among health care providers, public health leaders, legislators, and community leaders. Public health interventions can help move people along this spectrum toward acceptance. By viewing COVID-19 vaccine hesitancy in the three C’s framework, we can understand the different pieces that contribute to a complex problem, and the strategies to address them.

Tackling Complacency and Improving Confidence and Convenience

Health care providers talking with patients can make a difference in complacency, especially to combat misinformation that is easily circulated online. A strong recommendation from a health care provider is a key factor in vaccine acceptance.

Confidence can be addressed through both individual-level efforts and community-wide media campaigns. Health care providers can take the time to address individual concerns in a culturally competent way. Clear messaging should be promoted in the media from legislators and community and public health leaders that lay out the facts of vaccine safety and how it was developed, like those created by the Colorado Vaccine Equity Taskforce.

To address convenience, vaccination campaigns need to prioritize efforts to be culturally responsive to connect to communities that are harder to reach.

Much of this work is already being done. Denver Indian Health and Family Services called patients to directly engage with them and answer questions they had about the vaccine to address complacency and confidence. Bringing vaccines directly into places like Denver’s oldest Black church, Shorter Community AME, has addressed both confidence and convenience. These are the initiatives that can make COVID-19 vaccination a success and end the pandemic.

Like other efforts we’ve seen to stop the virus so far, the common theme still applies to vaccination: Stopping the virus takes all of us. Each of us is responsible for the success of vaccination efforts, and by taking an equitable approach to vaccination to ensure no one is left behind, we can protect ourselves, our families, and our state.

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