Deliberation, Dissent, and Distrust: Understanding Distinct Drivers of Coronavirus Disease 2019 Vaccine Hesitancy in the United States

Abstract

Background: Despite the availability of safe and efficacious coronavirus disease 2019 vaccines, a significant proportion of the American public remains unvaccinated and does not appear to be immediately interested in receiving the vaccine.

Methods: In this study, we analyzed data from the US Census Bureau's Household Pulse Survey, a biweekly cross-sectional survey of US households. We estimated the prevalence of vaccine hesitancy across states and nationally and assessed the predictors of vaccine hesitancy and vaccine rejection. In addition, we examined the underlying reasons for vaccine hesitancy, grouped into thematic categories.

Results: A total of 459 235 participants were surveyed from 6 January to 29 March 2021. While vaccine uptake increased from 7.7% to 47%, vaccine hesitancy rates remained relatively fixed: overall, 10.2% reported that they would probably not get a vaccine and 8.2% that they would definitely not get a vaccine. Income, education, and state political leaning strongly predicted vaccine hesitancy. However, while both female sex and black race were factors predicting hesitancy, among those who were hesitant, these same characteristics predicted vaccine reluctance rather than rejection. Those who expressed reluctance invoked mostly "deliberative" reasons, while those who rejected the vaccine were also likely to invoke reasons of "dissent" or "distrust."

Conclusions: Vaccine hesitancy comprises a sizable proportion of the population and is large enough to threaten achieving herd immunity. Distinct subgroups of hesitancy have distinctive sociodemographic associations as well as cognitive and affective predilections. Segmented public health solutions are needed to target interventions and optimize vaccine uptake.

Keywords: COVID-19; COVID-19 vaccine; vaccine hesitancy.

Figure 1.

Vaccine uptake and intention to receive vaccine over time. A, Overall (large graph), by state political leaning (top right), and by the states with least and greatest vaccine hesitancy, Massachusetts and Wyoming, respectively (bottom). B, Stratification by race (top row), education (middle), and age group (bottom).

Figure 2.

Vaccine hesitancy by state between January and March 2021 (defined as an intention to “probably NOT” or “definitely NOT” get a vaccine), overall and stratified by race.

Figure 3.

Reasons for vaccine hesitancy by vaccine intention. Reasons are grouped by category. Those who will “probably NOT” receive the vaccine are represented by blue bars; those who will “definitely NOT,” by pink bars. Abbreviation: COVID-19, coronavirus disease 2019.

Figure 4.

Reasons for vaccine rejection (“definitely NOT”) versus reluctance (“probably NOT”) among those who are vaccine hesitant. Odds ratios (ORs) were estimated from a survey-weighted logistic regression model, adjusted for sociodemographic factors. ORs >1 indicate significant association with vaccine rejection (pink shaded area); ORs <1, significant association with vaccine reluctance (blue shaded area). Colors of the points on the graph represent categories of reasons: dissent (red), distrust (yellow), and deliberation (blue). Error bars represent 95% confidence intervals (CIs). Abbreviation: COVID-19, coronavirus disease 2019.

Figure 5.

Proportional Venn diagram showing vaccine intentions characterized by categories of reasons: dissent (red), distrust (yellow), and deliberation (blue).