Covid vaccines, vaccine hesitancy and women
Why are women more likely to be vaccine hesitant?
With women's health issues becoming a more popular topic in the media; I thought it would be a good aspect of hesitancy to address. To start, I`m going to repeat something I`ve said before. As with everything, it's not a unilateral issue. It's a framework of interlinked scientific, social, and philosophical issues. However, there`s added complexity here. It's not controversial to say that women have faced inequities in healthcare and other aspects of their lives historically. They still do to some degree; depending on the culture and geographical region they live in. Therefore, talking about vaccine hesitancy in women involves additional layers of complexity that aren't there when we talk about hesitancy in men, or even when we just talk about vaccine hesitancy as a concept. There are very real experiences and emotions women have had. I believe that this complexity is what makes hesitancy in women worth exploring individually, and that's what I`ll do in this blog post.
This is particularly crucial to think about during the pregnancy period; which is arguably the most vulnerable period in a woman's life, as well as being vulnerable for the foetus. Thus, making decisions such as vaccinating during such a vulnerable period are higher stakes; as the health of both mother and baby need to be considered. Even when the question of the potential impact of vaccines on fertility are brought into question; it can spark significant emotion. This is regardless of whether or not the evidence shows vaccines impact fertility or not.
All factors considered, it becomes unsurprising that across the literature, women are less likely than men to vaccinate. A 2022 study by Zintel and her colleagues in Nature on gender differences in the intent to vaccinate against COVID-19 found lower vaccination intentions in women than men. Further, a 2022 study by Lara Steinmetz revealed that women are more likely to be vaccine hesitant than men due to perceived lack of safety of the vaccine, and the novelty of the COVID 19 virus. In a 2023 study from Rami Masadeh and colleagues, showed moderate COVID-19 vaccine hesitancy scores in pregnant and breastfeeding women, as well as women planning a pregnancy. In this case it was due to lower levels of perceived risk from COVID-19, and low perceived benefit of vaccination. Further, in a 2023 study by Viviana Moschese and her colleagues revealed that unemployed pregnant women were als less likely to accept vaccination. The same study showed that even if their healthcare provider made a strong recommendation, still only 38% of women in the study would vaccinate. Clearly this is a significant issue in the context of women's healthcare; however the medical community has only just recently begun to even become aware of it; let alone beginning the long process of improving communication and therefore trust between healthcare providers and female patients.
Well, like many marginalised groups, women have experienced historical mistreatment by healthcare systems. Historically, women have been treated as second class citizens. An article published on theconversation.com revealed that experiences of women who gave birth between the 1940s and 1990s revealed that poor relationships with doctors, midwives and nurses defined women’s recollections of their births and their satisfaction with their care. Women often felt they received excellent medical care; however their emotional needs were left unmet
Further, in 1837, it was revealed that painful experimental drug trials were conducted on impoverished women at a local hospital in Glasgow. In Canada, recent news stories have reported how indigenous women have been sterilised, pregnancies terminated, and other surgeries without their consent. Indigenous women in Canada have long faced such challenges in reproductive care, and have had to travel far south to attain even basic infant and maternal care;with requests for improved healthcare in Canada being denied. Unfortunately, this is far from the only story. Henrietta Lacks`was a Black female cervical cancer patient whose cells became HeLa cells, the first immortalised human cell line (meaning her cancer cells divided and replaced themselves indefinitely). Despite revolutionising many aspects of medical research (ie. vaccine production, fertility and cancer treatments among many others) Henrietta's cells were taken without the knowledge or consent of either her or her family. Informed consent wasn`t factored in.
So why is that so important? Consent is becoming extremely topical in many aspects of life; and healthcare is certainly no different. We are extremely vulnerable when under the care of healthcare providers - if an exam is physically invasive it will also be emotionally invasive to some degree. Being given autonomy and empathy means we have some degree of control over what happens. It also means we feel less isolated in the experience we are having. All of these can help neutralise all the emotion one might be feeling when they are undergoing a medical procedure or receiving difficult medical news. Not get rid of emotion entirely (and anyway, that would be unhealthy), but neutralise and regulate the intense emotions that are inevitable following sad news from the doctor. I had to do a lot of reflecting on this one, but I think it is worth the time for everyone; whether they`re a healthcare professional or patient. We`ll all be patient at least once in our lives.
Further; the majority of medical research, historically, has been conducted in Caucasian men. That means that healthcare providers often have to make difficult decisions for female patients without a solid information base, or guidance. It has also led to conditions in women being under-researched and under-diagnosed. For example; autoimmune diseases, for example, affect approximately 8% of the global population, but 78% of those affected are women. Women are also more likely to develop autoimmune conditions such as rheumatoid arthritis, multiple sclerosis, and suffer heart attacks, as well as experiencing different sets of symptoms than males. Further, according to a study conducted by the CDC, women are also at higher risk of many infectious diseases, and also experience more severe illness relative to men for a variety of reasons. For instance, in an analysis of New York`s HIV reporting data, it was discovered that 35% of new HIV diagnoses in 2001 were in women, compared with 28% before 2001. Men and women also have differing risk factor profiles for acute myocardial infarctions (meaning heart attacks). Women are also more likely to experience symptoms of anxiety and depression than men; this is due to a variety of factors including economic, social, hormonal as well as other biological factors. Gender differences also play an important factor in developing eating disorders such as anorexia nervosa, bulimia, and binge eating. From this evidence, it is clear that increasing education around women's health issues for healthcare providers of all specialities is crucial in improving the quality of healthcare for women of all ages and nationalities.
Although there has been progress in this; there is unfortunately quite a long way to go. This applies especially to women suffering from chronic pain. A 2018 review gendered bias towards patients experiencing chronic pain found that women reporting pain symptoms to physicians were likely to be labelled as hysterical, fabricating the symptoms, and receiving diagnosis of mental health issues as opposed to adequate medication for their pain. For example, delayed diagnosis and thus treatment in conditions such as PCOS (Polycystic Ovarian Syndrome) and endometriosis are common due to dismissal of women`s pain. Physicians are four times more likely to recommend a knee replacement for a man than a woman with the same knee injury. The poorer quality care women received compared to men after suffering a heart attack was to blame for 8,243 preventable deaths between 2003-2013 in England and Wales. Not only this, a 2022 review of women's experiences of gestational diabetes mellitus healthcare discovered that inadequate information was a key challenge women faced, as well as significant mental distress. Further, positive relationships with healthcare providers was a critical factor in their healthcare experience. Another 2022 study examined women's experiences of pre-eclampsia (a condition described by the CDC as when a woman who previously had normal blood pressure suddenly develops high blood pressure* and protein in her urine or other problems after 20 weeks of pregnancy.) The study found that the women found the diagnosis incomprehensible; ambivalent feelings when the unexpected happened, received confusing contradictory messages, and that they required continuous information.
So, now we've established that vaccine hesitancy is clearly an issue in women; and I`ve also explored some reasons why. Now comes the next obvious question; what to do about it? Or can anything be done? Well, seeing as it's a multidimensional issue, it won't surprise you that the approach to solving it will also be multipronged. Not every way we try to address it will work on every individual. There are also a small proportion who unfortunately are at the extremist end of the spectrum and won't be convinced. However, with that said, they`re a minority. Meaning they don`t represent the vast majority of women who are hesitant about vaccines. That's actually a really crucial point because it allows us as a society to approach the problem with an accurate picture of it. With that in mind; let's have a look at some approaches that have been discussed in the literature to address it.
One of the most effective methods of addressing vaccine hesitancy that has been cited again and again in the literature is a positive recommendation from healthcare providers. Now, of course this doesn't mean that HCP advocacy will work with all women all the time. That said, it highlights the principle that healthcare providers are at the forefront of the conversation with women about various types of vaccines. For instance, a 2023 study of Italian physicians by Ricco and colleagues found that increasing knowledge of the physicians about the medical difficulties of frequently encountered pathogens could help increase their engagement in vaccine promotion. Further, a study published in January 2023 found that a phone call from a trusted physician using “loss-messaging” (ie. emphasising the risks to remaining unvaccinated/undervaccinated) was among the most effective methods to decrease vaccine hesitancy in high-risk adults, which pregnant women qualify as. Therefore, it's absolutely key that they`re engaged and aware of the key healthcare concerns and challenges facing pregnant and nonpregnant women; and educated on how to address them.
There are several layers to an effective vaccination campaign within any marginalised group of people. One is being relayed from a trusted healthcare provider; which I`ve just discussed the importance of. The other is that information is relayed to them in a relatable way. In my view, some questions to think about are; what is their communication style like? Are there specific words, phrases, and so on that would really resonate with the target population of women? Why? Again, this may require a bit more thought depending on how marginalised the group is. Women from ethnic minorities, for instance, may have had very difficult experiences with healthcare throughout their lives. This may be an instance where communication style may need to be closely considered.
However, the main goal is to build long term confidence in vaccines. So the question becomes; how do you create that longer term change? Well, techniques that encourage self-reflection tend to stick long-term; and such techniques have been shown to be effective. Of course, I don`t speak for everyone. However I can imagine that this is because it gives people a sense of control. People like their decision-making to be self-directed. Put simply, people don`t want to feel like they`re being told what to do . With that in mind, I`ll explore some approaches that have been used to address vaccine hesitancy in women.
The first is stories; especially stories describing the consequences of not vaccinating. There are countless testimonials online and offline of individuals who have had experiences with vaccine preventable diseases ie. measles and flu, which I wrote about. Powerful narratives are one of the most effective ways to emotionally engage an audience.That emotional engagement can in turn, stimulate self reflection and longer term changes in how that person makes decisions about vaccines.
Another way to achieve this effect is by asking questions that make patients consider the future consequences of their decisions. This is known as Motivational Interviewing. This takes the form of the physician asking the patient questions designed to consider how their current choices may impact their future. Again, it's based on the same principle as the other two approaches - stimulating self reflection. Now, it's been known for a while in scientific and medical circles that the outlined approaches make people more receptive to vaccination; however I haven't seen the self-reflection element of it being discussed.
With that, I`ll summarise. It's a framework of interlinked issues; and there`s an additional complexity when you factor in historical trauma that women have experienced in healthcare, and continue to. Also, it isn't simply about the vaccines; it's about how we communicate about them. Thanks for reading