Overcoming Vaccine Hesitancy Inside Prisons and Jails

by Maria Sofia Peña

Since the beginning of the COVID-19 pandemic, jails and prisons across the country have been virus hotspots, with case rates in prisons four to five times higher than those in the general population.[1] With the emergence of the Delta variant, the urgency of protecting incarcerated people against severe illness and hospitalization has only increased. One obstacle is incarcerated people’s hesitancy to receive the vaccine. Why are incarcerated people refusing the vaccine? And how can correctional authorities combat remaining hesitancy?

With the new Delta variant spreading rapidly, every state has seen an uptick in COVID-19 cases.[2] New data suggests that the Delta variant can spread as easily as chicken pox, and symptoms are more severe than the original version of the virus.[3] The recent release of an internal CDC document reveals that although vaccinated people with breakthrough infections may spread the virus as easily as unvaccinated people, the vaccine still protects against the severity of the disease and hospitalization.[4] The Delta variant is a scary development in the global battle against COVID-19, and our confined population remains at a heightened risk.

Generally, incarcerated people have chronic health issues at higher rates than the general population.[5] What’s more, Black incarcerated people are likely to be hit harder — social determinants of health such as socioeconomic status, physical environment, and access to healthcare disproportionately affect both Black and incarcerated communities.[6] Considering that Black people are overrepresented in incarcerated populations in the United States, the risks for COVID-19 complications for Black incarcerated populations are compounded. Therefore, in places with high risk of transmission, such as prisons, high vaccination rates should be reached in order to protect these highly at risk populations against severe infection and hospitalization.

Now that the vaccine is nationally available to the general population, and by extension to the incarcerated population, many correctional institutions have made impressive progress with their vaccine rollout. As of July 29, 2021, around 67 percent of people incarcerated nationally have received at least one dose of the vaccine,[7] compared to 57 percent of the general population.[8] Higher vaccination rates on the inside, however, are not necessarily indicative of lower community spread; incarcerated people are confined in small, highly condensed areas, where social distancing is difficult.

For example, the DOC with the highest reported vaccination rate, Minnesota, has 82 percent of its incarcerated population vaccinated, compared with 58 percent of Minnesota’s general population.[9] However, as of July 29, the DOC had a test positivity rate of 3.5 percent while the most recent statewide positivity rate was lower, at 2.2 percent.[10] Considering that since the end of July, Delta variant cases have dramatically increased nationwide, positivity rates are expected to rise in all settings. There is still much we don’t know about transmission of COVID-19 by vaccinated individuals, but these rates nevertheless demonstrate the higher risk of transmission inside facilities than outside regardless of vaccination. It is clear that the high risk of transmission inside prisons and jails means it is necessary for more people to be vaccinated to protect against severe illness.

Despite relatively high vaccination rates, there remains plenty of vaccine hesitancy among incarcerated people. In Hawaii, as of late June, 2021, around 1,500 incarcerated people had been vaccinated, while around 1,100 had refused the vaccine.[11] Montana’s DOC is experiencing a similar 50 percent vaccine refusal rate.[12]

At a federal prison in Danbury, Connecticut in April 2021, almost 300 residents had refused to get vaccinated.[13] An update from July 29th found that had actually increased to 341 residents — of the 927 people incarcerated in Danbury, 586 are vaccinated.[14] Vaccine hesitancy continues to be an issue across the country, but why?

Causes of hesitancy

A recent report co-authored by members of the CDC and the UCLA Law COVID Behind Bars Data Project surveyed people incarcerated in three prisons and 13 jails across four states to understand why incarcerated people are refusing the vaccine. They found that primary reasons for vaccine hesitancy include lack of information and safety concerns.[15] Many incarcerated people, especially when the vaccine was first introduced, did not have enough information to make an informed decision, and unlike those of us on the outside, were not able to do their own research.[16] At the Allenwood Federal Prison Complex in Pennsylvania, where more than half of the incarcerated population refused the vaccine when it was first offered, resident Andres Azner expressed his frustration to the New York Times: “They didn’t give me enough time to think about it. They didn’t give me enough information to make a solid, sound, prudent decision. They kind of just tried to force it upon me. And, no, no, I’m not taking it.”[17]

It doesn’t help that in many facilities correctional officers are refusing the vaccination; — during initial stages of the rollout, at alarming rates.[18] To make matters worse, there have been reports of staff spreading myths about harmful side effects.[19]

The CDC and UCLA Law report also found that primary reasons for vaccine hesitancy included a historical distrust of healthcare, correctional, and governmental personnel.[20] The United States’ history of medical racism, experimentation, and coercive medical procedures on incarcerated people, Black communities, and other communities of color has created a community belief in the untrustworthiness of medical authority. The 1930s Tuskegee experiments on Black men[21] and the 1963 sterilization of incarcerated men without their consent by University of Washington researchers,[22] are just two instances of medical researchers’ abuse of Black and incarcerated populations. More recently, between 2006 and 2010, almost 150 women incarcerated in California were sterilized without consent.[23] It doesn’t help that there have been mistakes in vaccine distribution: in April, for example, the Iowa DOC gave almost 80 incarcerated people overdoses of the COVID-19 vaccine.[24] Distrust of healthcare and correctional authorities, compounded with lack of access to information and doubts about safety of the shot, has allowed vaccine hesitancy to remain in incarcerated populations.

To combat hesitancy, correctional authorities across the country have offered incentives to raise vaccination rates with varying success. Virginia, for example, offered free stamps, telephone credits, and care packages to get vaccinated.[25] Similarly, Pennsylvania offered an incentive of $25,[26] and Maryland offered snack packages and other food items.[27] However, some incarcerated people find incentives such as these insulting. Jonathan Brooks, who is incarcerated at Wake Correctional Center in North Carolina and had not planned on getting vaccinated, told the New York Times in May, “That’s something that we are required to have anyway — phone calls and receiving visits from our loved ones — so to actually recommend something like that to get us to take the vaccine, I feel like that’s really a slap in the face.”[28]

Other states have offered good time credits to incarcerated people who get vaccinated — a promising alternative that couples incentives with decarceration. The Delaware DOC offered credits that shorten people’s sentences by a few days, in addition to free snacks and a free video visit with family members.[29]

Similarly, North Carolina allowed incarcerated people to be released five days earlier if they got vaccinated, and as of June 2, almost 10,000 people had their sentences shortened through this initiative.[30] This policy seems to be persuasive: when the incentive was started in January 2021 as the vaccine first became available, only around six percent of the state’s incarcerated population had been vaccinated.[31] As of July 29, almost 65% of incarcerated people in North Carolina have received at least one dose of a vaccine.[32]

Judges in Hall and Dawson Counties in Georgia, two of the state’s counties with the lowest vaccination rates, offered good time credits to incentivize vaccination in May as the vaccine first became widely available to people incarcerated in Georgia’s DOC. By June, several dozen people had their sentences shortened.[33] Because, as Georgia Court administrator Jason Stephenson has remarked, the court does not track how many people receive the credit, it is difficult to analyze the direct impact of this policy on vaccine uptake. Nevertheless, before the policy began, as of April 30 Georgia’s DOC vaccination rate was around 26 percent.[34] Now, Georgia DOC’s vaccination rate is strong, at 63 percent.[35]

Although implementing good time credit incentives is a possible way to encourage vaccine uptake, educational programming in correctional facilities is also necessary. Incentives alone, without being paired with education initiatives, likely take advantage of incarcerated people’s desires to see their loved ones, be released early, or receive much needed cash or food items, potentially compromising their medical autonomy.

Increasing education about the vaccine seems to reduce hesitancy. A study conducted by the University of Kansas found that while women leaving jail had high vaccine hesitancy, a health app that gave helpful information reduced resistance to health messaging and increased the women’s health literacy.[36] Although vaccines were not widely available at the time of the study and the researchers did not follow up with the interviewed women about their vaccination statuses, increased health literacy allows individuals to, at the very least, make more informed decisions about vaccination.

In practice, education initiatives have proved effective. In April, 35.8 percent of people incarcerated in Vermont DOC facilities had refused vaccination.[37] In response, the DOC surveyed the population to understand why there was such large amounts of hesitancy, and then responded to these concerns with a video featuring the Vermont Defender General and other public health and correctional leaders. As of June 30, 2021, the vaccine refusal rate had decreased to 24 percent, and although it is hard to isolate the video as the sole cause, the DOC does attribute the reduced hesitancy to its education initiative.[38]

In order to most effectively conduct education initiatives, experts such as Tom Frieden, the former director of the CDC, note that health campaigns should utilize “trusted messengers and trusted messages” to reduce vaccine hesitancy among historically medically abused and marginalized communities such as incarcerated populations.[39] As Robert Blendon, a professor at Harvard T.H. Chan School of Public Health, explained, “As we continue to talk to people about the virus, waving journal studies and talking points won’t work in many communities.”[40] In an environment so structured around power hierarchies, in which incarcerated people have been consistently subjected to abuses of power, an important tenet of any vaccine education initiative must be the building of trust between the messengers and those who are hesitant to receive the vaccine. An effective response to communities’ distrust of healthcare and correctional authorities should involve enlisting of community leaders as credible messengers to lead public health awareness and educational campaigns.

This strategy has been employed in communities on the outside to increase vaccine uptake. For example, some Latino communities in D.C. have promotoras de salud, trusted community members trained as health workers who work to dispel misinformation about the vaccine. Similarly, Springfield-Greene, Missouri’s “Finish Strong 417 Neighbor to Neighbor” program hires trusted members of communities with low vaccine uptake as credible messengers to provide education to folks feeling hesitant about the vaccine.[41] Charlotte, North Carolina’s “Faith and Vaccine Initiative ‘’ similarly trains university students with ties to communities with high vaccine hesitancy as ambassadors who plan vaccine awareness initiatives alongside faith community and nonprofit leaders.

There are correctional authorities across the country who have employed similar credible messenger strategies, designing vaccine education campaigns in collaboration with people who are formerly or currently incarcerated. In Rhode Island, formerly incarcerated people helped develop the DOC’s vaccine education initiative, enlisting two nurses who had long term, trusting relationships with people currently incarcerated there to go from cell to cell answering questions about the vaccine and receiving informed consent.[42]

Massachusetts correctional authorities designed their vaccine awareness campaign around input from people previously incarcerated at the Massachusetts DOC, and created an educational video featuring community leaders including pastors.[43] The DOC first released the video in January 2021, when the vaccine first became available to people incarcerated in the Massachusetts DOC, so it is hard to directly analyze the effects of the education campaign.[44] The DOC currently has a high vaccination rate though, with 76 percent of its population having received at least one vaccine dose.[45]

In Illinois, the DOC selected currently incarcerated individuals to serve as peer educators, or “vaccine ambassadors,” who asked health officials questions that their communities had about the vaccine, and communicated answers back to the rest of the population. The DOC began this program when the vaccine initially became available to incarcerated people in Illinois, so it is difficult to analyze the effects of the program alone on vaccine uptake in the state’s facilities. Nevertheless, the DOC found the response to this program “overwhelmingly positive,” and as of late May, nearly 70 percent of people incarcerated at the Illinois DOC had been vaccinated.[46] Similarly, the Marshall Project has suggested that community leaders inside facilities, such as lifers or gang leaders, should be enlisted to initiate peer-led vaccination campaigns.[47]

The new Delta variant poses an even higher risk to incarcerated people than COVID-19 had, and although much is unknown about the vaccine’s effect on transmission rates, we know that it has a higher transmission and infection rate than the original COVID-19 virus did. We simply must have increased vaccination rates inside correctional facilities to protect people from severe illness, hospitalization and death. As cases continue to rise across the country, hesitancy due to lack of information and mistrust of medical authorities poses a significant barrier to the safety of people who are incarcerated. Good time credit incentives, coupled with education initiatives which utilize community leaders as trusted messengers, could go a long way in increasing vaccine uptake among incarcerated people, protecting them from the ongoing threat of COVID-19, and the increasing threat of the Delta variant.

Maria Sofia Peña is currently a senior at Brown University, majoring in International and Public Affairs and Applied Mathematics. Maria Sofia is passionate about criminal justice reform and carceral state abolition, and interned remotely at JPI the summer of 2021.

[1] Tiana Herring and Emily Widra, “Just over Half of Incarcerated People Are Vaccinated, despite Being Locked in COVID-19 Epicenters,” Prison Policy Initiative, May 18, 2021, https://www.prisonpolicy.org/blog/2021/05/18/vaccinationrates/.

[2] Morgan Maner, Forrest Behne, and Kate Lemasters, “Blog,” COVID Prison Project, July 30, 2021, https://covidprisonproject.com/blog/.

[3] Carolyn Y. Johnson, Yasmeen Abutaleb, and Joel Achenbach, “‘The War Has Changed’: Internal CDC Document Urges New Messaging, Warns Delta Infections Likely More Severe,” The Washington Post (WP Company, July 29, 2021), https://www.washingtonpost.com/health/2021/07/29/cdc-mask-guidance/.

[4] Apoorva Mandavilli, “Behind the Masks, a Mystery: How Often Do the Vaccinated Spread the Virus?,” The New York Times (The New York Times, July 29, 2021), https://www.nytimes.com/2021/07/29/health/cdc-masks-vaccinated-transmission.html.

[5] Pam Bailey, “Vaccination in Prisons Requires Credible Messengers,” Medium (The Shadow, March 3, 2021), https://medium.com/the-shadow/vaccination-in-prisons-requires-credible-messengers-30ece75b6159.

[6] Antonella Portugal, “COVID-19 and Reentry,” Justice Policy Institute, May 5, 2020, https://justicepolicy.medium.com/covid-19-and-reentry-e98e5c01572a.

[7] “COVID-19 Vaccinations — System Report,” COVID Prison Project, July 30, 2021, https://covidprisonproject.com/covid-19-vaccinations-system-report/.

[8] “CDC COVID Data Tracker,” Centers for Disease Control and Prevention, accessed July 30, 2021, https://covid.cdc.gov/covid-data-tracker/#vaccinations.

[9] Maner, Behne, and Lemasters, “Blog,” https://covidprisonproject.com/blog/.

[10] “COVID-19 Weekly Report,” Minnesota Dept. of Health, July 29, 2021, https://www.health.state.mn.us/diseases/coronavirus/stats/#wtrmap1.

[11] Kevin Dayton, “More than Half of Hawaii’s Inmates Have Been Vaccinated Against COVID-19,” Honolulu Civil Beat, June 25, 2021, https://www.civilbeat.org/2021/06/more-than-half-of-hawaiis-inmates-have-been-vaccinated-against-covid-19/.

[12] Elijah Collins, “Montana Inmates Still Remain Hesitant about COVID-19 Vaccines,” KULR-8, June 9, 2021, https://www.kulr8.com/regional/montana-inmates-still-remain-hesitant-about-covid-19-vaccines/article_e023706f-7edc-58fd-8f2a-2b770714e164.html.

[13] Pat Eaton-Robb, “Nearly 40% of Danbury FCI Inmates Refusing Covid-19 Vaccine,” NBC Connecticut, April 23, 2021, https://www.nbcconnecticut.com/news/coronavirus/nearly-40-of-danbury-fci-inmates-refusing-covid-19-vaccine/2473628/?_osource=SocialFlowFB_CTBrand&fbclid=IwAR3SIYTvG48xmT_magd1E71-jhwxHKUACqtADunQxfXLz7NGA7YJoGUDVfw.

[14] “BOP: COVID-19 Updates,” Federal Bureau of Prisons, July 29, 2021, https://www.bop.gov/coronavirus/.

[15] Poornima Rajeshwar and Erika Tyagi, “Vaccine Hesitancy behind Bars: Some Causes and Concerns,” UCLA Law COVID-19 Behind Bars Data Project, April 15, 2021, https://uclacovidbehindbars.org/blog/vaccine-hesitancy.

[16] Nicole Lewis, “We Asked People behind Bars How They Feel about Getting Vaccinated,” The Marshall Project, March 1, 2021, https://www.themarshallproject.org/2021/03/01/we-asked-people-behind-bars-how-they-feel-about-getting-vaccinated.

[17] Ann Hinga Klein, “Some Prisons Are Offering Skeptical Inmates Incentives to Consent to Vaccination,” The New York Times, January 19, 2021, https://www.nytimes.com/live/2021/01/19/world/covid-19-coronavirus/some-prisons-are-offering-skeptical-inmates-incentives-to-consent-to-vaccination.

[18] Byrhonda Lyons, “Majority of Guards AT COVID-Wracked California Prisons Refusing Vaccination,” Times of San Diego, May 15, 2021, https://timesofsandiego.com/politics/2021/05/15/majority-of-guards-at-covid-wracked-california-prisons-refusing-vaccination/.

[19] Rajeshwar and Tyagi, “Vaccine Hesitancy behind Bars” https://uclacovidbehindbars.org/blog/vaccine-hesitancy.

[20] Rajeshwar and Tyagi

[21] Fran Kritz, “‘Trusted Messengers, Trusted Messages’: How to Overcome Vaccine Hesitancy,” NPR, December 24, 2020, https://www.npr.org/sections/health-shots/2020/12/24/948776228/trusted-messengers-trusted-messages-how-to-overcome-vaccine-hesitancy.

[22] Lewis, “We Asked People behind Bars” https://www.themarshallproject.org/2021/03/01/we-asked-people-behind-bars-how-they-feel-about-getting-vaccinated.

[23] Lewis

[24] Morgan Winsor, “77 Inmates at Iowa Prison given Overdoses of COVID-19 Vaccine, Officials Say,” ABC news (ABC News Network, April 22, 2021), https://abcnews.go.com/Health/77-inmates-iowa-prison-overdoses-covid-19-vaccine/story?id=77237044.

[25] Lewis, “We Asked People behind Bars” https://www.themarshallproject.org/2021/03/01/we-asked-people-behind-bars-how-they-feel-about-getting-vaccinated.

[26] Lewis

[27] Phillip Jackson, “Vaccine Incentives Go to Prison: Maryland Corrections Department Offers Cookies, Snacks to Spur Interest,” baltimoresun.com (Baltimore Sun, May 14, 2021), https://www.baltimoresun.com/coronavirus/bs-md-corrections-department-snacks-covid-20210514-aqlmkeyv6zecpgvyztwdh3fhfy-story.html.

[28] Klein and Turcotte, “Vaccinations Are Lagging,” https://www.nytimes.com/2021/05/22/us/covid-prison-vaccine.html.

[29] Ann Hinga Klein, “Some Prisons Are Offering Skeptical Inmates Incentives to Consent to Vaccination,” The New York Times, January 19, 2021, https://www.nytimes.com/live/2021/01/19/world/covid-19-coronavirus/some-prisons-are-offering-skeptical-inmates-incentives-to-consent-to-vaccination.

[30] “Reducing Jail and Prison Populations during the Covid-19 Pandemic,” Brennan Center for Justice, July 14, 2021, https://www.brennancenter.org/our-work/research-reports/reducing-jail-and-prison-populations-during-covid-19-pandemic.

[31] Joedy McCreary, “Get the Shots, Get Out 5 Days Early: Nearly 10K Prisoners in NC So Far Reach Vaccine Incentive,” CBS17, June 2, 2021, https://www.cbs17.com/news/north-carolina-news/get-the-shots-get-out-5-days-early-nearly-10k-prisoners-in-nc-so-far-reach-vaccine-incentive/.

[32] “COVID-19 Vaccinations — System Report,” COVID Prison Project, July 30, 2021, https://covidprisonproject.com/covid-19-vaccinations-system-report/.

[33] “Reducing Jail and Prison Populations,” https://www.brennancenter.org/our-work/research-reports/reducing-jail-and-prison-populations-during-covid-19-pandemic.

[34] Maner, Behne, and Lemasters, “Blog,” https://covidprisonproject.com/blog/.

[35] “COVID-19 Vaccinations — System Report,” https://covidprisonproject.com/covid-19-vaccinations-system-report/.

[36] ​​Mike Krings, “Study: Women Leaving Jail Have High Vaccine Hesitancy; Health App Reduces Resistance, Boosts Literacy,” The University of Kansas, June 14, 2021, https://news.ku.edu/2021/06/11/study-women-leaving-jail-have-high-vaccine-hesitancy-health-app-reduces-resistance-boosts.

[37] Alan J. Keays, “More and More Vermont Prisoners Are Refusing Vaccinations Against Covid-19,” VTDigger, April 20, 2021, https://vtdigger.org/2021/04/20/more-and-more-vermont-prisoners-are-refusing-vaccinations-against-covid-19/.

[38] Alan J. Keays, “More Vermont Prisoners Opting to Get Vaccinated Against Covid-19,” VTDigger, June 30, 2021, https://vtdigger.org/2021/06/30/more-vermont-prisoners-opting-to-get-vaccinated-against-covid-19/.

[39] Kritz, “‘Trusted Messengers, Trusted Messages’ https://www.npr.org/sections/health-shots/2020/12/24/948776228/trusted-messengers-trusted-messages-how-to-overcome-vaccine-hesitancy.

[40] Kritz

[41] Andrew Sullender, “Health Department Encourages Vaccines by Hiring Help in Communities Hardest Hit by Virus,” Springfield News-Leader, July 12, 2021, https://www.news-leader.com/story/news/politics/2021/07/12/springfield-greene-county-health-department-hires-communities-hardest-hit-covid-vaccine-hesitancy/7915198002/.

[42] Lewis, “We Asked People behind Bars” https://www.themarshallproject.org/2021/03/01/we-asked-people-behind-bars-how-they-feel-about-getting-vaccinated.

[43] Dave Collins, “Prisons Need Better Vaccine Education for Inmates, Advocates Say,” PBS (Public Broadcasting Service, April 8, 2021), https://www.pbs.org/newshour/health/prisons-need-better-vaccine-education-for-inmates-advocates-say.

[44] Steph Solis, “Massachusetts Inmates Can Get Prison Time Reduced If They Get the COVID Vaccine,” MassLive, February 3, 2021, https://www.masslive.com/coronavirus/2021/02/massachusetts-inmates-can-get-prison-time-reduced-if-they-get-the-covid-vaccine.html.

[45] “COVID-19 Vaccinations — System Report,” https://covidprisonproject.com/covid-19-vaccinations-system-report/.

[46] Caroline Brew and Russell Leung, “Chicago Groups Use Education Campaigns to Encourage Prison Vaccinations,” The Daily Northwestern, May 28, 2021, https://dailynorthwestern.com/2021/05/28/city/chicago-legal-advocacy-groups-use-education-campaigns-to-encourage-vaccination-among-incarcerated-individuals/.

[47] Lewis, “We Asked People behind Bars” https://www.themarshallproject.org/2021/03/01/we-asked-people-behind-bars-how-they-feel-about-getting-vaccinated.