It’s been more than a year since mass vaccinations began in the US. Still, vaccination rates remain dangerously low in many states, and public health experts are struggling to fully understand vaccine hesitancy and anti-vax sentiment.
Certainly, the politicization of covid-19 public health measures has played a role in shaping many decisions. Republicans are less likely than Democrat voters to be vaccinated, and at the state level, lower vaccination rates are tightly correlated with higher levels of support for the Republican party.
However, Brookings Institution researchers have found that this relationship was almost nonexistent in one demographic group: the elderly who live in skilled nursing facilities. After analyzing vaccination and voting data, they discovered that the political environment outside a nursing home did not strongly predict the likelihood that its residents were vaccinated, a finding that could hold valuable lessons about public health messaging and vaccine roll-outs.
Sarah Reber, a visiting fellow at Brookings, and associate professor of public policy at the UCLA Luskin School of Public Affairs, and Cyrus Kosar, an assistant professor of health services at Brown University, first reported this anomaly last August.
Specifically, they found that in several states where Trump won the largest share of votes in the 2020 election, vaccination rates for nursing home residents were higher than would be expected by the red-blue vaccination divide in the general population. In a few blue states, vaccination rates were lower than the trend would suggest.
For example, in the Dakotas, which Trump carried by a wide margin in 2020, vaccination rates among nursing home residents outperformed those of blue states like Oregon and Washington. In California, where Trump won less than 40% of the vote, vaccination rates among nursing home residents hovered just above 80% in early 2021, far below a blue state like Vermont, where 94% of nursing home residents were fully vaccinated.
Overall, their number-crunching turned up some correlation between politics and nursing home resident vaccination, to be sure, but it was almost negligible. The red-blue divide was more evident in nursing home staff vaccination rates, which basically match those of non-elderly adults, says Reber.
However, nursing homes residents were also first to be eligible for vaccination in late 2020 and early 2021. Perhaps that would explain why nursing home residents were less swayed by politics, the researchers theorized. When it was the elderly’s turn to get the jabs, the loud minority who oppose vaccination or claim that vaccines violate personal freedoms had yet to fully saturate social media sites, talk shows, and podcasts with their views and misinformation.
To find out if timing explained their results, the pair recently updated their analysis to include the rate of booster shot uptake, reasoning that by the time boosters arrived in mid-2021, nursing home residents had plenty of time to see vaccination through a severely tainted lens. Once again, the researchers detected virtually no correlation between a state’s political environment and the percentage of seniors in nursing homes who were boosted by late 2021.
Normally you would expect politics to seep into nursing home environments, says Reber, especially because many people in nursing homes also suffer from cognitive decline and have substitute decision-makers—often adult children and other family members who live in the nearby community—who have to give consent before a resident can be inoculated or receive medical treatment. So why are vaccination rates in nursing homes seemingly so much less influenced by wider political divisions?
There is no data or survey that can point to one reason, says Reber, but she believes the answer might lie in data about flu shot rates within nursing homes, which are also not strongly correlated with voting patterns.
There is wide variation across states in how thoroughly nursing homes get residents vaccinated against the flu, but the reasons for the differences are unclear. “Nursing homes in some states are consistently more able to deliver life-saving vaccines to residents, whether it is annual flu vaccines, the primary COVID-19 series, or COVID-19 boosters,” the researchers write in their Brookings report. “Little is known about what explains these state-level differences—which could be related to differences in state-level policy; nursing home funding, staffing, or practices; or the characteristics of residents.”
“Whatever is driving that is probably what’s driving the variation in covid vaccination for nursing homes,” Reber tells Quartz. Understanding why some states excel at vaccinations might point to methods for improving covid-19 vaccine and booster shot uptake in states with consistently lagging coverage, such as Florida, Nevada, and Arizona.
Reber also acknowledges that the extreme threat covid-19 poses to the elderly could be a factor at play. Of the more than 800,000 covid deaths in the US since the pandemic began, about 75% were among those age 65 and older. “It does seem like the higher the risk, the less politicized vaccination is,” says Reber, pointing to higher covid-19 vaccine acceptance among people who are 65 and older. (The same has been true of flu shots.)
“Nursing homes have been such a high-risk setting that people may be paying more attention to that than to other aspects of their identity that might be driving the decision to vaccinate,” she says.
By bringing clinics and needles inside individual care homes, the institutions also removed logistical barriers to getting vaccinated, which might also explain the relatively higher vaccination rates in this group as a whole.
Finally, another possibility—one not discussed by the researchers—is that the elderly in nursing homes are old enough to remember polio’s wrath in the middle of the last century, and they recall how vaccines eradicated the risk of acquiring that disabling illness. Perhaps that experience makes it less likely they would ever frame vaccines as ideological.
Although her work didn’t survey nursing home residents about their beliefs and values, Reber says that public health experts do need to continue investigating the roots of vaccine politicization. General vaccine hesitancy for other reasons has a longer history, she says, but if you look at flu vaccination rates for people over 55 from prior to the pandemic, it’s not correlated with Trump’s vote share, “so this is new, this kind of vaccine hesitancy in political conservatives, or Republicans, or Trump supporters—it’s not clear exactly which category is the right way of describing it.”
It’s also not clear whether this kind of thinking will eventually expand to color people’s views of other vaccines and standard childhood vaccination series, she adds. “To me that means we need to think about messaging and messengers for that group,” says Reber. “Who is a trusted source of information and what kinds of messages work?”