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What is driving COVID-19 vaccine hesitancy among American adults?

A new, large national survey in the USA, led by ISGlobal and CUNY SPH, shows that lower income and conservative ideology are associated with vaccine hesitancy

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Photo: Josh Wilburne on Unsplash

Lower income and conservative ideology were strongly associated with unwillingness to get vaccinated, while people having tested positive for COVID-19 or having a family member who did so were more likely to accept vaccination, according to a new survey among adults in the USA, led by the Barcelona Institute for Global Health (ISGlobal), an institution supported by ”la Caixa” Foundation, and the CUNY Graduate School of Public Health and Health Policy. The survey results, published in Scientific Reports, also reveal that half of those who are unwilling to be vaccinated are unlikely to change their minds.

ISGlobal researcher Jeffrey V. Lazarus and colleagues surveyed 6,037 adults in April 2021 to identify their attitudes towards vaccination against COVID-19. One third of the participants came from across the USA and two thirds were from the four major metropolitan areas: New York, Los Angeles, Dallas and Chicago.

More than 80% of participants in the national sample agreed that COVID-19 is a dangerous health threat and a majority were in favour of vaccine mandates for employees and students. But 1 in 4 did not believe that the dangers of COVID-19 exceed those of the vaccine. And 21.4% of participants from across the USA were unwilling to be vaccinated against COVID-19 (compared to 19.7% in Dallas, 11.5% in Los Angeles, 11.2% in Chicago and 10.1% in New York). Of those unwilling to be vaccinated, half said that nothing would convince them to receive the vaccine, and cited safety concerns as the main reason.

Unwillingness to be vaccinated tended to be higher among those who held conservative political views, had a lower household income and had not previously tested positive for COVID-19. In contrast, respondents who reported that they or another household member had tested positive for COVID-19 were strongly motivated to accept vaccination. Education level, race, age and sex did not seem to have a major influence on vaccine acceptance. The study results also validated the use of the COVID-VAC tool - which contains 6 items on perceptions of risk, trust, safety, and efficacy- as a reliable way to measure vaccine acceptance in a given population.

“Our findings suggest that, while vaccination mandates are likely to be broadly accepted, additional, targeted interventions are needed to increase COVID-19 vaccine uptake among those with conservative political views and low household income,” says J. Lazarus, senior author of the study. For example, by linking vaccine coverage with returning to work or garnering support from vaccine advocates or media channels with conservative views.


El-Mohandes A, White TM, Wyka K, Rauh L, Rabin K, Kimball SJ, Ratzan SC and Lazarus JV.  COVID‑19 vaccine acceptance among adults in four major US metropolitan areas and nationwide. Scientific Reports. Nov 2021.