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As COVID-19 cases rise in Massachusetts, threatening the state’s recovery, a key question looms: What will it take to persuade the holdouts to overcome mistrust and misinformation and get immunized?

More than 70 percent of the population has received one dose — an enviable rate compared to many parts of the country. Still, that means more than 2 million people remain unprotected from the coronavirus and its potent variants.

“It’s always a mixed bag as we get to the population that is most resistant to taking the vaccine,” said Michael Curry, CEO of the Massachusetts League of Community Health Centers.

For some, the reasons “include continued distrust in our health care system, in terms of historical abuse, neglect, and underinvestment in communities of color and immigrant communities,” Curry said.

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For others, “there is a false sense of protection.” Younger, healthier individuals tend not to believe the virus poses a real threat, he said. They also fear, despite research to the contrary, “that these vaccines haven’t been fully tested, that we don’t fully know what the outcome of taking a vaccine will be.”

Unvaccinated Bay Staters tend to be young, according to data from the Department of Public Health. Over 30 percent of residents age 12 to 29 have not been immunized (children under 12 are not yet eligible for vaccines). About 20 percent of residents age 30 to 49 and less than 10 percent of those above age 65 have not received shots.

A significant proportion of the state’s Black and Hispanic population is also unvaccinated, at 46 percent and 48 percent, respectively, compared with 35 percent of white people and 31 percent of Asians.

Geographically, counties in Western Massachusetts like Berkshire and Hampden also tend to have larger portions of unvaccinated residents.

The Globe asked its followers on Instagram to share why they are unvaccinated, and their answers revealed the challenges in convincing holdouts to get shots. Most respondents expressed skepticism about vaccine safety, and said they fear there will be long-term side effects.

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“I’m not taking a vaccine that has been created and developed in under a year, for it to god forbid have lasting health effects that may make me infertile,” wrote one user, who like many other respondents, declined to share her name. “I’m good for a bit.”

A handful of respondents also referenced the fact that the vaccines have not yet received full approval from the Food and Drug Administration. Thus far, the shots have been administered under an emergency use authorization. That has been a “real sticking point” for a segment of unvaccinated individuals, according to Curry, and a challenge for state and local public health officials to address.

“We have to find a way to explain that ‘emergency use’ does not mean they’re not efficacious and that these drugs will soon move to a full approval,” Curry said. “We have to address the fact that some believe this was done too quickly, when in fact, this was medical advancement borne out over many years.”

Others who responded to the query said they have held off on getting shots because they are pregnant or have complex health issues, like cancer and autoimmune diseases. A 35-year-old woman said she was worried about the potential effects on her unborn child, but “will absolutely be getting vaccinated after the baby arrives.”

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Curry said he believes misinformation has contributed to such vaccine hesitancy. Fears about the vaccine impacting fertility and pregnancy, for example, are unfounded but have nonetheless spread online.

One respondent — Michelle, 22, a beauty professional — referenced the history of medical abuse against racial minorities, and said that as a Puerto Rican, she is “hesitant to trust the pharmaceutical industry.”

Another user illustrated the inequities that have marked the pandemic, saying she has “scarce resources” and has faced economic barriers to receiving a vaccine.

A few said they are under 18, and their parents will not allow them to be vaccinated. Others invoked their religious beliefs and phobias.

Considering the multitude of reasons that individuals are unvaccinated, Curry said, it’s important not to “vax shame.”

“It doesn’t work, writ large, and it actually may drive people even further to dig in and not take the vaccine,” he said. “If we’re going to shame anybody, let’s shame the liars. Let’s shame the people who are giving them that misinformation.”

Curry believes a better approach is to “meet people where they are” and have fact-based conversations about the vaccine. That is “longer-term work” that will require significant resources and “the people power to engage each and every one of those folks that have expressed some reservations,” he said.

Across the state, much of that hard work has been taken on by community organizations and activists, with funding from state and local governments.

In Chelsea, concentrated outreach efforts have changed the city’s narrative from high infection rates to high vaccination rates. Once the epicenter of the pandemic, the city now has over 66 percent of its residents fully vaccinated.

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Chelsea City Manager Thomas Ambrosino said three organizations have been key: Chelsea Black Community, La Colaborativa, and GreenRoots.

“We have outstanding community-based organizations here with trusted local leaders,” Ambrosino said. “They have stepped up immensely to help. They worked very hard to get the message out to their stakeholders.”

It’s a difficult task, said Roseann Bongiovanni, executive director of GreenRoots, a community organization focused on the urban environment and public health in Chelsea and East Boston.

“There are still folks that are fearful, there are still folks that are reluctant . . . they might still be believing disinformation,” Bongiovanni said. “These are the folks that we are targeting now; this is where the work gets even harder.

“It’s really about relationships and trust,” she added.

GreenRoots has hired five “vaccine ambassadors” to go door to door helping residents figure out where, when, and how to get appointments — sometimes even escorting people there, Bongiovanni said.

The ambassadors are part-time positions hired by GreenRoots and paid $22 an hour with federal vaccination equity grant money administered by the state. GreenRoots prioritized hiring ambassadors who could speak multiple languages and were multiracial and multigenerational, she said.

Chelsea Black Community runs the city’s weekend vaccination clinic at a senior center across the street from City Hall, Fridays through Mondays. The last few Saturdays, they added a little extra flair to the clinic, turning it into a celebratory “Vaccine Festival,” with a photo booth, giveaways, raffles, and free hot dogs, sodas, and churros.

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But in other parts of state, efforts to boost vaccination rates have languished, discouraging health officials on the front lines.

Mark Bushee, health director for the Foothills Health District, which covers the Western Massachusetts towns of Whately and Goshen, acknowledged it’s been difficult to boost vaccination rates in his area. Just 40 percent and 33 percent of town residents, respectively, have received at least one dose.

“It’s just hard convincing people,” Bushee said. “It’s an uphill battle trying to get people to change their minds.”

Bushee in part attributes the low vaccination rates in Whately and Goshen — population 1,451 and 1,157 — to fear and lack of understanding. He also believes it’s now primarily the staunch antivaxxers who are holding out.

“If people haven’t been vaccinated yet, it’s a choice,” he said.

Curry, of the Massachusetts League of Community Health Centers, said he is optimistic the state’s numbers will continue to climb.

“I’m hopeful, but I’m anxious, and there’s an urgency that I want to continue to see in Massachusetts, despite the fact that we’re in a better place than many other states,” he said. “We can’t strive to be the best of the worst. We have to really try to get these vaccines into the remaining arms in a way that we can eliminate the hospitalizations and deaths altogether.”


Camille Caldera can be reached at camille.caldera@globe.com. Tonya Alanez can be reached at tonya.alanez@globe.com or 617-929-1579. Follow her on Twitter @talanez.