Native American communities across the US faced disproportionate rates of COVID-19 infection, hospitalization, and causality. Native American susceptibility to the virus has roots in longstanding inequalities caused by federal neglect and marginalization. Community factors such as lack of access to water and culturally responsive public health information, both caused by longstanding underinvestment in Native communities, are also associated with COVID-19 spread across tribal lands.

In response to their disproportionately high burden of COVID-19, Native nations across the country have mounted very effective vaccination campaigns through the first months of the vaccination rollout. For example, the Diné Nation (Diné is what Navajo people call themselves), the largest Native nation in the US with lands spanning multiple states, has overcome a severe COVID-19 outbreak that has caused much pain and suffering to achieve early success in vaccination coverage that has outpaced the national average. Taking aggressive steps, including having drive-through clinics available in multiple sites across reservation communities and opening access to non-Native residents of counties within reservation boundaries, have helped lead to this success.

This has led to Native Americans having higher vaccination rates than other racial and ethnic groups, according to federal data. As of April 5, 2021, a third (32 percent) of Native Americans had received at least one dose of a COVID-19 vaccine, compared to 19 percent of non-Hispanic White Americans.

New Data To Inform Vaccination Outreach In Native Communities

Although there is much to celebrate across Native nations, there is still a large segment of the Native American population that is not vaccinated and does not want to get the vaccine. Even some tribal leaders have expressed real concerns about the safety of the vaccine. Naturally, these concerns have roots in the history of negative experiences Native people have had with health care systems in the US, from sterilization to discrimination in doctors’ offices.

The American COVID-19 Vaccine Poll, a new national survey focused on overcoming obstacles to full and equitable vaccination coverage, has a large oversample of Native Americans (n = 1,920) and provides needed data to inform the next phase of vaccination outreach for Native communities across the country. The Commonwealth Fund and African American Research Collaborative fielded the study with support from the Robert Wood Johnson Foundation and W.K. Kellogg Foundation, with design help from experts and scholars in vaccines, public health, medicine, health equity, and public policy at research universities including the University of California, Los Angeles, Yale, Penn State, University of New Mexico, and University of Maryland.

Native Americans are often left out of national surveys like this one, either altogether invisible or delegated to an “other” category. The inclusion of a large Native American population in this study is therefore quite notable, as it provides insight into what is needed to overcome vaccine hesitancy among Native Americans across the US.

We summarize some of the more prominent findings from the survey that can be integrated into communication and outreach programs for communities to increase vaccination rates. Moreover, our findings provide pathways for targeted areas of support for philanthropic or other public health allies who want to support Native communities in increasing vaccination rates.

Overcoming Vaccine Hesitancy

Roughly half (45 percent) of the Native American population has yet to be vaccinated, but 55 percent of the Native American population has received at least one vaccine shot. Of all racial and ethnic groups in the sample, vaccination rates of Native Americans are second to only the Asian and Pacific Islander communities. This is a really impressive finding, given the challenges tribes have faced with COVID-19; however, the survey identifies that there is much work ahead. In fact, 43 percent of Native Americans who are not vaccinated report that they do not plan to get a vaccine, higher than any other racial or ethnic group in the survey.

We highlight insights from the unvaccinated segment of the survey’s population to help highlight ways that can overcome vaccine hesitancy across tribal communities. 

When just looking at the non-vaccinated segment of the Native American sample, several important findings emerge. As reflected in exhibit 1, a higher percentage (66 percent) of Native Americans who are yet to be fully vaccinated indicate that they “definitely know how to get the vaccine,” but that still leaves a third of Native Americans across the country who need more information on the vaccination process.

Exhibit 1: Knowledge about how to get a COVID-19 vaccine among Native Americans

Source: American COVID-19 Vaccine Poll.

The survey also highlights that 13 percent of the unvaccinated population cite socioeconomic reasons for not getting the vaccine, including not having transportation or not having time to get a vaccine. This highlights that vaccine campaigns targeting Native communities may need to expand mobile vaccine clinics to allow people to get vaccinated where they are. This may include borrowing ideas being tested in other hesitant populations, expanding vaccination sites and available times to get a vaccine, and during further outreach to coordinate transportation. Given the high degrees of rurality for many Native communities, health care professionals may also have to do door-to-door outreach to provide public health education information and encourage vaccination.

Another 8 percent of the unvaccinated population believes that existing health conditions make them ineligible to receive the COVID-19 vaccine. During the height of the pandemic, some preexisting health conditions prevalent in Native American communities, such as obesity and diabetes, were cited as leading to more severe COVID-19 virus outcomes. More work needs to be done to ensure people know that even with certain preexisting conditions, vaccines are safe.

Nearly half (47.4 percent) of unvaccinated Native Americans reported that they would prefer to get a vaccine at their doctor’s office. The other most-cited locations were at a hospital (24.0 percent) or a community health clinic (13.1 percent). That these were the top three preferences cited by unvaccinated Native Americans highlights that medical facilities are highly favorable places to get a vaccine and may suggest that the unvaccinated population wants to receive the vaccine in more personal and intimate settings (rather than larger-scale mass vaccination sites). Other Native-specific places were also cited as preferred places to get the vaccine, including at an Urban Indian Health Care Clinic and a clinic on the respondent’s reservation or a tribal center (12 percent respectively).

Engaging The Unvaccinated Population In Tribal Communities

The strength of this survey lies in its ability to provide insights about how outreach campaigns may be more effective in their work to engage the unvaccinated population in tribal communities. This includes learning that Native Americans will be less likely to be moved than the general population by vaccination requirements made by their employers.

The survey also provides some useful information about what kinds of message that Native American respondents identified as compelling. Overall, the most effective messages for Native Americans that were tested in the survey focused on the protection of culture, langue, family, and elders in the community. More specifically, 34 percent of those yet to be vaccinated indicated that “getting the COVID-19 vaccine can protect the lives of my family, friends, and those I love” was a message that would make them much more likely to get the vaccine. Also, roughly 32 percent of Native American respondents who had yet to be vaccinated indicated that each of the following messages would make them much more likely to get the vaccine.

  • “The Native American community has been hit hard by COVID-19, with higher rates of Native American COVID-19 illnesses and deaths. The best way to prevent more suffering through this terrible pandemic is to get vaccinated and encourage all Native American people to do the same.”
  • “Getting vaccinated protects my community’s elders and our culture.”

Exhibit 2 below provides a list of top-rated messages that Native American respondents identified as being more effective in motivating them to get vaccinated.

Exhibit 2: Messages that are more effective in motivating Native Americans to get the COVID-19 vaccine

Source: American COVID-19 Vaccine Poll.

The survey also highlighted some of the individuals and institutions that have the highest degree of trust among Native Americans and can be influencers and messengers to encourage people to get vaccinated. Native American respondents indicated a high degree of trust in medical professionals (doctors and nurses) generally, and Native American doctors and nurses especially. Tribal leaders and tribal government were also cited as trustworthy by Native American respondents; they too can help influence and increase vaccination rates. Finally, unvaccinated individuals also noted that friends and family are effective influencers in helping encourage individuals to get vaccinated.

We know that Native American communities across the US, both urban and rural, were hit hard by the COVID-19 pandemic. Longstanding inequities present within Native communities led the spread of COVID-19. In the ongoing vaccination process, this survey highlights that a large percentage of Native Americans has received the vaccine, but there is more to be done to ensure greater vaccination rates across Native America. This survey does provide critical information about why Native Americans are vaccine-hesitant and, more importantly, ways to motivate the unvaccinated population in Native American communities to get their shot—including ensuring that messages are pushed by and developed in culturally significant and relevant ways.

To learn more about the survey results, please visit the American COVID-19 Vaccine Poll dashboard that contains results for the Native American sample and other populations.

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