COVID Vaccine Hesitancy: 90 Million
Still on the Fence

Kathleen Doheny

August 10, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

COVID-19 vaccinations are once again on the upswing, the rise fueled by growing anxiety about the highly contagious Delta variant now responsible for most COVID infections in the U.S.

At a briefing Thursday, Jeff Zients, the White House COVID-19 response coordinator, said more than 864,000 Americans had been vaccinated in the previous 24 hours, the highest in a single day since July 3. And more than 580,000 of those were first doses. Nearly 50% of the U.S. population, or 165.6 million people, had been fully vaccinated as of Aug. 5, according to the CDC.

Yet hesitancy lingers. About 90 million Americans are eligible for the vaccine now but have not gotten it. While some of these still unvaccinated people may actually be hesitant — that is, they have serious questions about the safety or effectiveness of the vaccines — many just outright refuse to get vaccinated. Even now, experts are looking at approaches that may change minds.

Tracking Hesitancy Trends

Overall, COVID-19 vaccine hesitancy declined by about one-third from January through May, according to a study in the preprint server medRxiv posted July 23. The study is not yet peer-reviewed. Researchers from Carnegie Mellon University and the University of Pittsburgh evaluated the responses of more than 5 million U.S. adults who completed an online survey about COVID-19 vaccination and answered questions about education, race, and other personal details.

The researchers evaluated about 1 million responses each month to track trends over the 5-month study period. Next, they looked at how hesitancy changed, or did not, in groups of different races, education levels, ages, and other characteristics. To define hesitancy, the researchers asked participants if they would take a vaccine were it offered to them today. Those who said ''probably not" or ''definitely not" were termed vaccine-hesitant. Those who said "yes" or "probably" were classified as vaccine-accepting.

Profiles of the Hesitant

In general, COVID vaccine hesitancy was higher among those ages 18 to 24 than older people and non-Asian populations, says study senior author Robin Mejia, PhD, an assistant research professor of statistics and data at Carnegie Mellon.

While stereotypes about those with higher education levels or certain ethic groups more likely to get the vaccine abound, the new research did not always fit those notions. During the 5-month study period, those with a high school education showed the most movement toward vaccination and away from their previous hesitancy. The eye-opener: By May, the group with PhDs were more hesitant than those with lower educational levels.

Hesitancy declined across virtually all racial groups, with Black people and Pacific Islanders having the largest decreases over the study period. By May, those two groups, along with Hispanics and Asians, were seen as less hesitant than whites. Hesitancy decreased with age in almost every racial group, Mejia says. That’s not surprising, she says, since the risk of severe illness if you’re infected with COVID rises with age.

While the percentage of people saying they probably would not get vaccinated has come down over the past 5 months, Mejia says, the percentage of people saying they definitely won’t get vaccinated has not, suggesting a hard-core group whose hesitancy has not budged.

Other findings:

  • About 50% of people in all categories of hesitancy were concerned about side effects.

  • Those who said they would ''definitely not" get a vaccine were more likely to say they didn't trust the vaccine or didn’t trust the government.

  • Those who said a lack of trust was a reason they haven’t been vaccinated only appeared to have doubts about the COVID-19 vaccine, not those for other diseases.

  • Many said they were hesitant because they wanted to wait ''to see if it's safe" or they were waiting on ''full" FDA approval, beyond the emergency use authorization the FDA has given the vaccines so far.

More Trends: Impact of Politics, Financial Struggles

New York University researchers surveyed 3,000 people in April, when vaccines had become available. They found that politics and personal finances impacted the decision to get vaccinated. Their study is due to be published as a preprint and is not yet peer-reviewed.

"We found Democrats far and away the most likely to be vaccinated," says Rachael Piltch-Loeb, PhD, an associate research scientist at the New York University School of Global Public Health.

At the time of the survey, about half of the respondents had already been vaccinated, says Piltch-Loeb, who is also a public health preparedness fellow at the Harvard T.H. Chan School of Public Health in Boston.

Those who had financial hardship during the pandemic, due to job loss or other issues, ''were more likely to be vaccine refusers," Piltch-Loeb says. Those on Medicaid were least likely to be vaccinated, she says, perhaps because they thought there was a fee for the vaccine and they couldn't afford it.

Those who had been diagnosed with COVID-19 fell into two camps: either eager to take the vaccine or refusing it. But having someone they knew die of COVID-19 reduced hesitancy. "If individuals knew someone who died of COVID, they were far more likely to already be vaccinated [at the time of the survey]," she says.

Changing Minds: Faith-Based Persuasion

So, what else reduces hesitancy?

Hearing about the benefits of the coronavirus vaccine from religious leaders can sway people, experts say.

"Clergy are often trusted voices, and houses of worship are trusted sites," says Rabbi David Saperstein, director emeritus of the Religious Action Center of Reform Judaism in Washington, DC. He is one of the core group involved in Faiths4vaccines, a multifaith movement launched in January. It includes religious leaders and medical professionals devoted to increasing vaccination rates. Its goals are to combat hesitancy and advance equitable distribution of vaccines.

The organization partners with numerous faith-based groups, representing millions of people across the country. It has helped to set up vaccination sites in houses of worship, where people often feel more comfortable than at a clinic or pharmacy. Because houses of worship often lack staff such as nurses to help run a program, they often partner with nearby pharmacies or hospitals, he says.

"When clergy speak out and reassure people and put [vaccines] in the values of public health and preventive medicine, those messages resonated with people," Saperstein says. When those of faith realize that the vaccine is an expression of love for their neighbors, it can become easier.

Changing Minds: Family and Friends

Don't drown hesitant family and friends with numbers and statistics to persuade them to get vaccinated, says Susan Whitbourne, PhD, a professor emerita of psychology at the University of Massachusetts. "They can always find another statistic they like better."

Appeal to the heart, not the head, she suggests.

"It's all about getting the person to realize, on a personal level, it can happen to you," she says, and you should talk about the need to protect parents, children, or grandchildren. "You have to find the pathway that is going to work with that person."

Hesitancy is sometimes used as a coping mechanism, believes Molly Allen, PsyD, a clinical psychologist in Wichita, KS. Some of her hesitant patients ''are overly focused on the immediate negative experience rather than the long-term benefit [of protecting health]."

It's a way to reduce their overall stress level. These people may think, "If I don’t get the shot I won't have to deal with the anxiety" that can come with the pain of the needle and any after-effects of the shot such as fever, chills, or a sore arm, she says. But they're ignoring, of course, the risk of getting COVID-19.

If a friend or family member expresses these concerns, Allen suggest that you listen and then ''express your concern for them" while focusing on the long-term positives, not the short-term negatives. Try: "I really don’t want to see you get super-ill with a preventable disease."

Stories From the Formerly Hesitant

A doctor's input can be powerful, too. In the end, that's what convinced Elizabeth Greenaway of Williamsport, PA, to get the COVID vaccine after lots of soul-searching.

"I was very hesitant because I felt it was too new," says Greenaway, a marketing consultant.

Over and over, she weighed the pros, cons, and what-ifs.

I started praying about the decision. If I am meant to get it, I need to feel more at peace. Elizabeth Greenaway, Williamsport, PA

"The statistics are on my side," she recalls thinking. "I'm 34, pretty healthy."

A devout Christian, her faith weighed in.

"A lot of conservative Christians are hesitant," she says. "I started praying about the decision. If I am meant to get it, I need to feel more at peace."

Her husband, she says, didn't feel strongly one way or the other. She thought about their young daughter, Emma, and who would care for her if she got COVID and couldn't be at home. But she also worried a lot about long-term vaccine side effects.

Then she happened to see a video featuring Paul Offit, MD, a pediatric infectious disease specialist and vaccine expert at Children's Hospital of Philadelphia, where the Greenaways take their daughter for care. Offit is not Emma's doctor, but Greenaway was struck by his video message.

"He said these long-term effects [of vaccines that she worried about] show up within 6 weeks of getting the vaccine. That spoke volumes to me,” she says.

With more time, knowing more people who got the vaccine with no issues, and more prayer, the hesitancy faded.

She got vaccinated and now reaches out to others like her — conservative, Christian Republicans — to reconsider their hesitancy. CNN interviewed Greenaway and then brought on Offit to hear the story and introduce them onscreen.

"It's incredibly heartening," he said, praising Greenaway's decision. "She's saying, 'It's not just [about] me. I can spread it to my mother or my child. For a contagious disease, you aren't just making a decision for yourself."


News briefing, the White House, Aug. 5, 2021.

CDC: "COVID-19 Vaccinations in the United States."

Robin Mejia, PhD, assistant research professor of statistics and data science, Carnegie Mellon University, Pittsburgh.

Rachael Piltch-Loeb, PhD, associate research scientist, NYU School of Public Health; public health preparedness fellow, Harvard T.H. Chan School of Public Health, Boston.

Rabbi David Saperstein, director emeritus, Religious Action Center of Reform Judaism, Washington, DC.; core group,

Susan Whitbourne, PhD, professor emerita of psychology, University of Massachusetts, Amherst; faculty fellow, Institute of Gerontology, University of Massachusetts, Boston.

Molly Allen, PsyD, clinical psychologist, Wichita, KS.

Elizabeth Greenaway, marketing consultant, Williamsport, PA.

medRxiv: "Time trends and factors related toCOVID-19 vaccine hesitancy from January-May 2021 among US adults: Findings form a large-scale national survey."

Psychology Today: "3 Ways to Change the Mind of Your Vaccine-Hesitant Loved One."