Almost everyone in Colorado who eagerly wanted a coronavirus vaccine has gotten one. Now comes the hard part.

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Last week, Aurora City Council member Juan Marcano posted a message on Twitter that just a few weeks ago would have caused an online stampede among hoards of Coloradans desperately seeking a coronavirus vaccine.

“We still have a ton of openings to fill for the #COVID19Vaccine event at the Aurora Municipal Center this Saturday and Sunday!,” he wrote. “Please share these links out to everyone you know so we can get #COVID behind us!”

By Saturday morning, though, the stampede hadn’t materialized.

“This is still true!” Marcano wrote again on Twitter, referencing his earlier message about available appointments. “Please get vaccinated if you are able!”

Colorado has reached a critical pivot point in its vaccination efforts. Approximately 2.5 million people — roughly 43% of the state’s total population and 53% of the population eligible to receive a shot — have gotten at least a first dose of vaccine.

But the number of shots given per day appears to be falling, after hitting a high of 79,480 doses administered on April 9. Colorado vaccine providers administered more than 411,000 doses during the week of April 4. The following week, the number dropped to just under 399,000 doses. More recent data is not yet available because of reporting delays.

The Colorado map on the appointment-finding website Vaccine Spotter is filled with green dots, indicating open slots. A site run in conjunction with the state Health Department is similarly flush with appointments.

While vaccination rates are increasing, the state remains far below the 70% to 80% of people needed to be immunized to reach herd immunity. What had once mostly been an issue of logistics — efficiently distributing available vaccine doses to meet overwhelming demand — has become a puzzle of persuasion: It’s time to convince people still on the fence about the vaccine to get their shot.

“Now a different kind of hard work begins,” said Dr. Josh Williams, a Denver Health pediatrician who has studied why people are hesitant to receive vaccines.

This hard work won’t likely yield the same rapid results as the first half of the campaign, when state officials set up a system to distribute three brand new vaccines to millions of people in under five months. Instead, it will require one-on-one conversations and attention to individual worries. It will require patience and even a little humility, as health professionals respond to concerns without passing judgment.

In short, it will take time. And that means reaching the close-enough-to-normal promise of herd immunity will, too.

“We just need to continue to provide factual information and transparency so that Coloradans can make the choice that’s best for them,” said Jill Hunsaker Ryan, the executive director of the Colorado Department of Public Health and Environment.

Confronting vaccine hesitancy

The first thing to understand about vaccine hesitancy, say those who have studied it closely, is that it’s not what you think it is.

While the people who get the most attention are those opposed to all vaccines based on arguments that often lack scientific merit, they make up a small portion of vaccine holdouts. Instead, most people who are hesitant to receive a vaccine think of themselves as pro-vaccination, and their concerns are grounded in something rational, said Jennifer Reich, a sociologist at the University of Colorado Denver who has written extensively about vaccines.

“I start with the premise that everyone is trying to do the best they can with what information they have and to make a decision that feels authentic to them and aligns with their beliefs and values,” Reich said.

People who don’t have paid sick leave, for instance, may worry about getting a vaccine with side effects that could cause them to miss work. People who don’t have a regular medical provider may be uncertain where they can go to get good information. People who have been discriminated against in the medical system may not trust that health professionals have their best interests at heart.

In her research, Reich has found that close to a third of American parents don’t vaccinate their children on the recommended schedule. They delay or space out some vaccinations based on these types of individual concerns.

“That’s no longer a fringe group,” she said.

The reason vaccines can be subject to widespread hesitancy is that they face a challenge almost no other medical intervention does: They are given to healthy people. That means, in the perception of the people receiving them, vaccines must be immaculately safe and also tangibly necessary, Reich said. Anything short of that could cause someone to think twice about getting the shot.

Here the coronavirus vaccines begin running into hurdles.

The vaccines are safe and effective. But they are also very new, meaning researchers are still learning about rare side effects. The recent pause in administering the vaccine made by Johnson & Johnson over concerns about extremely rare blood clots is one example of this. At least one national poll suggests the pause increased hesitancy among those still on the fence.

And, while the name of the federal program to speed the vaccines along — Operation Warp Speed — lent the effort a bit of sci-fi cool among those eager to receive a shot, it did little to allay the fears of people who worried everything was moving too fast to be safe.

On top of that, the coronavirus vaccines face another obstacle. This mishmash of public health messaging during the pandemic may have led some people to believe the vaccines are not as necessary for them.

Older Coloradans have gotten vaccinated at high rates. More than 80% of people 70 and older have received at least one dose of vaccine, in keeping with public health messaging that age is the single biggest risk factor for having a really severe case of COVID-19.

But the flip side to that message, Reich said, is that young people are more likely to believe that the coronavirus is not a big deal for them. And that shows up in the vaccination data, too.

People between the ages of 20 and 29 make up nearly 13% of those vaccinated in the state. But that age group makes up nearly 15% of the statewide population. It’s the only adult age group where its proportion of the vaccinated population underperforms its proportion in the total population. Reaching herd immunity now rests on the shoulders of the young.

“In a lot of ways, they may be a certain kind of keystone in managing the pandemic,” Reich said. “But the way it’s been messaged is that they are at really low risk of severe illness or death.”

Younger Coloradans, then, will likely need to be persuaded to get vaccinated for the good of everyone, not just for themselves. But here, too, is a challenge.

Most messaging campaigns for adult vaccinations — think of the flu vaccine, for example — do not urge inoculation as part of a community-wide solution. They focus on the benefits to the individual. Take this vaccine and you won’t get sick.

And they often have middling success. Even Gov. Jared Polis admitted at a news conference last week that he only received a flu vaccine “probably two or three years out of the last 10.”

So, the task ahead for health leaders is unprecedented. They must persuade people worried about safety that vaccines developed in record time are safe. They must persuade people who don’t think the virus is a threat to them that the vaccine is still worthwhile. And they must do it urgently, as infections and hospitalizations are already spiking among the unvaccinated, leading to a wave of severe illness among people who mistakenly calculated the risks of the pandemic.

“That feeling of wanting to wait and see might feel like the more cautious approach,” Reich said. “The challenge is that while we still have community spread, that may not be the more cautious approach. It may be less safe, but it will feel more safe.”

Messaging to those in the middle

The good news for Colorado health leaders is that the number of people who aren’t sure about getting vaccinated is shrinking.

When pollsters working for CDPHE surveyed the state in September, they found that only 32% of people planned to get vaccinated against COVID-19 as soon as they possibly could. When they asked the same question again in February, the pollsters found that 63% of people had either already gotten vaccinated or planned to as soon as they possibly could.

Among people who said in February they had become more interested in being vaccinated, the No. 1 reason was that they had seen others get vaccinated. So the campaign is exerting its own kind of gravitational pull on the hesitant.

In both polls, there was a persistent group of people opposed to the coronavirus vaccines — 20% of people in the February poll said they either wouldn’t get vaccinated or would only get vaccinated if required. (Nearly half of the people in this group said they didn’t want the vaccine because they believed it to either be unsafe or unnecessary. Another 3% — so, about 0.8% of all people surveyed — said they believed the vaccines contain microchips or are being used to control the population.)

But, for persuasion purposes, the most important group is those who are still in the middle.

In February, 18% said they wanted to wait and see. And among those wait-and-seers, safety and caution were top of mind. Nearly half of people in the group said they were concerned about side effects, while more than a quarter said they were worried vaccine development had been rushed.

This provides health officials with an angle of approach. Hunsaker Ryan, the CDPHE executive director, said the state is working with leaders in diverse communities to convey the message that the vaccines are safe and effective. This could take the shape of a community forum on Facebook or a radio ad by a local doctor.

“I think the tactics are the same, no matter the community,” Hunsaker Ryan said. “You have to find trusted messengers within that community.”

Williams, the Denver Health pediatrician, agrees that the message is less important than the relationship. Williams has studied vaccine hesitancy in religious communities. And, while survey respondents in the CDPHE poll named doctors as the people they trust the most, Williams knows that he can’t just walk into any room in the state and win people over.

“It’s about systems of trust that have already been built and already been established,” he said.

This points to the long road ahead. When those systems don’t already exist, you have to build them.

Williams said when parents express hesitancy about vaccines in his clinic, he doesn’t flood them with information. Instead, he asks questions and listens to the responses. He wants people to know that he respects their beliefs and their intellect to make decisions on their own.

“My hope,” he said, “is that it would be the first of many conversations and over time we can talk openly with one another about what the concerns are.”

Pushing too hard too soon can backfire, he said. So, too, can being judgmental.

Meanwhile, as the state is working to build this community trust, it is also developing a different kind of message.

When pollsters asked people during CDPHE’s February survey what messages would most likely persuade them to get vaccinated, statements about vaccine safety and effectiveness scored high. But the message that scored the highest had nothing to do with health. It was about normalcy: “Getting as many of us vaccinated as possible will hopefully allow us to achieve widespread community immunity, so we can get back to normal.”

Armed with this information, CDPHE has crafted a messaging campaign called “Power the Comeback,” which uses ads in English and in Spanish to encourage people to get vaccinated as a way to return to normal. The ads position vaccination as a way to reopen businesses fully and re-energize the economy.

Polis has also shared public service announcement-style images on his Facebook page focusing on entertainment, in messages directed at younger people. “Want this?” one asks over an image of a packed Red Rocks concert. “Get this,” it concludes, showing a picture of a coronavirus vaccine vial.

Another shows a crowded nightclub. “Getting the COVID-19 vaccine is our road back to the life we love — like going out to bars and nightclubs with friends,” Polis wrote.

The hard work ahead

Even with all the polling data and messaging know-how, persuading the vaccine hesitant may not be simple — as some have come to learn all too well.

Dr. Gabriel Lockhart is a critical care pulmonologist at National Jewish Health in Denver. His specialty means he has been on the coronavirus front lines since the pandemic began, both in Colorado and in New York, where he volunteered to help out during the worst of that state’s early wave.

But he also assumed another role early on in the pandemic. He became his own family’s most trusted source of information about COVID-19.

His father’s side of the family is African-American. His mother’s side is Puerto Rican. Local and national polls have shown that vaccine hesitancy is especially high among communities of color. And both sides of Lockhart’s family were skeptical of the coronavirus vaccines, beginning while they were still being developed.

Lockhart’s first step was simply one of understanding.

“I’m not trying to label folks who are nervous about the coronavirus vaccine,” he said in July, when he first began talking to his family about the vaccines. “There’s so much anger and fear and confusion about what’s going on with this pandemic things get messy and they kind of blend in together.”

Lockhart also knew why distrust of the health care system and the government ran deep within his family.

Communities of color have long suffered from health inequities in the United States. Black patients are less likely to be selected to receive kidney transplants than white patients, and Black mothers are more likely to die during pregnancy than white mothers. Puerto Ricans have low birth weight rates twice that of whites. Lockhart, himself, has asthma — something that disproportionately affects communities of color.

Lockhart once held a fellowship at Washington University in St. Louis, where the hospital for decades had been segregated. While white patients went to various specialty clinics on the hospital’s main floors, black patients were sent to the basement, regardless of their ailments.

The hospital remained segregated until the 1950s. But the impacts lasted far longer. Stories of mistreatment at the hospital were passed down through families. When Lockhart attempted to enroll patients in a clinical trial focused on reducing sedation levels in the intensive-care unit, white patients jumped at the opportunity. Black patients didn’t.

“When they heard the word research, they had no interest in learning more about it,” he said.

So, when speaking to his own family, Lockhart came prepared.

During the pandemic, his extended family began holding weekly dinners over the video-conferencing program Zoom. Lockhart prepared a 2-hour PowerPoint presentation on vaccines. It covered how they are developed, tested and checked to be sure they’re safe. It addressed conspiracy theories.

After he got his first dose of vaccine, he sent his family updates on how he was feeling — sore arm, no doubts about getting his second shot. He continued to send videos and links to articles.

He also expanded his information campaign. CDPHE enlisted Lockhart to help speak at community events. Health organizations tapped him to help conduct outreach to Black Coloradans. He had become the trusted voice in the community, the person who was the right messenger with the right message to address the right concerns.

But, while he won over some in his family, others remained skeptical — including his mother, who is also a physician. Concerns about racial discrimination subsided, but worries over the vaccines’ speed of development remained.

“That’s still been a little bit hard to overcome,” he said in January, just before he received his second shot.

Still, Lockhart vowed to continue trying to persuade her and others. The longer the vaccines are around, the more people who look like him receive them and vouch for their safety, the more the wall might come down, he believed. It will just take time.

Most recently, he’s spoken at an American Thoracic Society conference about racial disparities in the health care system. He spoke at the Cleo Robinson Parker Dance academy about the vaccine.

And, after more than six months of work, he convinced his mother to get vaccinated — “strong armed” her, he joked. His brother helped, making an appointment for himself and their mother at the same time.

It wasn’t easy. But nothing about this final phase of the pandemic will be.

The fast part of the vaccination campaign is over. Now it’s just one shot at a time.