









































Increasing COVID-19 Vaccine 
Uptake in the United States:

Addressing Reasons for Vaccine 
Hesitancy through Effective
Communications & Reform

Miranda Wesley

Volume Two
Edition Two
Spring 2022

 
GEORGETOWN SCIENTIFIC
RESEARCH JOURNAL

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Georgetown	Scientific	Research	Journal	

Increasing COVID-19 Vaccine Uptake in the United States: 
Addressing Reasons for Vaccine Hesitancy through Effective 
Communications & Reform  

Miranda Wesley

Department of International Health, Georgetown University, Washington, D.C. 
E-mail: mdw92@georgetown.edu
https://doi.org/10.48091/gsr.v2i2.41

Abstract

The COVID-19 pandemic has and is still adding tremendous morbidity and mortality globally. Although 
vaccines are a major component in combatting COVID-19 and are widely available in the U.S., vaccine 
uptake is a major hurdle with 24% of the population having not received any dose of a COVID-19 vaccine. 
Literature review of reasons for COVID-19 vaccine hesitancy among adults in the United States. 27 
articles included from PubMed and analyzed to find date of study, method of survey, population studied 
and generalization ability, and reasons for vaccine hesitancy or refusal. Most studies were cross-sectional 
surveys (88.89%) and conducted online (59.25%). Sample size ranged from 58 to 458,235. Populations 
studied include nationally representative U.S. (25.9%), specific populations within the U.S. (37.0%), 
specific locations within the U.S. (22.2%), and healthcare workers (14.8%). The most common reason for 
COVID-19 vaccine hesitancy is concern about side effects and general safety concerns (57.14%). Other 
significant reasons include: additional information needed (21.42%), distrust (14.28%), no reason/don’t 
know (3.57%), and antivaccine beliefs (3.57%). Just over half (51.8%) of studies were conducted before 
the FDA EUA of the Pfizer-BioNTech COVID-19 vaccine, while 37.0% were after, and 11.1% spanned 
the time period or had follow-up surveys. To increase uptake among those who are still hesitant of 
COVID-19 vaccines, the American healthcare and education system must go through reform to ensure 
healthcare for all and address systemic racism. While increasing representation in health fields, already 
working clinicians can promote vaccinations through strengthening their patient relationships, following 
up on vaccination status, sharing educational resources and personal stories, and promoting community 
efforts. Teachers and schools can implement lessons on immunizations and disease. Communication 
efforts from institutions and local community organizations must work to increase trust, address fear of 
side effects, and combat misinformation. Promotion of social values and self-efficacy, as well as authentic 
community investment and engagement, can increase trust and vaccination levels.

Keywords: COVID-19, vaccine hesitancy, communication

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1. Background

The COVID-19 pandemic has caused
tremendous morbidity and mortality around the 
world, with the United States being severely 
affected. In the U.S., there have been a total of 77 
million cases and 920,097 deaths as of February 
15, 2022.1 Although most Americans have access 
to vaccines, there are still around 146,921 daily 
cases according to the 7-day moving average cases 
and around 2,208 daily deaths according to the 7-
day moving average deaths as of February 15, 
2021.1

The 	available COVID-19 vaccines in the U.S. 
include Pfizer-BioNTech, Moderna, and Johnson 
& Johnson. The first approval issued by FDA was 
the Emergency Use Authorization (EUA) of the 
Pfizer-BioNTech COVID-19 vaccine on 
December 11, 2020.2 

Shortly after, both the Moderna and Johnson 
& Johnson vaccines were approved for emergency 
use (see Figure 1).3 The Pfizer-BioNTech vaccine 
for children ages 12 to 15 and 5 to 11 received 
EUAs on May 10th and October 29th, 2021, 
respectively (see Figure 1).3 The Pfizer-BioNTech 
vaccine received official approval	 from the FDA 
for adults on August 23rd, 2021.2 The timeline of 
approvals for different populations and age groups 
is important for research on vaccine hesitancy 
because the FDA plays a significant role in the 
establishment of trust and transparency of safety 
and effectiveness data. However, the actual roll-
out based on priority groups and ages differed 
between states in the U.S.3 

Figure 1: Timeline of U.S. COVID-19 Vaccine Approval from December 2020 to November 2021.2-3 Pfizer-
BioNTech vaccine received FDA EUA on December 11th, 2020.	

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Vaccines are essential in combatting the spread 
of the virus and deaths due to COVID-19.4 
Compared to vaccinated patients in a certain 
health system, unvaccinated patients were three 
times more likely to be infected with COVID-19, 
twice as likely to be hospitalized with COVID-19, 
and seven times more likely to die from COVID-
19.5 The stark  difference in clinical outcomes 
based on vaccination status demonstrate that 
vaccines are essential to both the health of the 
population and the burden on the healthcare 
system. 

In the U.S., 64.5% of the population are up to 
date with the COVID-19 vaccine, meaning they 
are fully vaccinated, and 76% have at least one 
dose, as of February 15, 2022.6 Most of the 24% 
that have not received one dose makes up the 
vaccine hesitant, or those with low vaccine 
confidence.7 Breaking this down by demographic 
characteristics, more of the Asian population, 
female, and older populations are vaccinated (see 
Figures 3-5).8 40.2% of the Black population is 
fully vaccinated, while 47.6% of the White 
population in the U.S. is fully vaccinated (see 
Figure 5).8 However, the differences between racial 
groups are decreasing as vaccines become more 
available with increased uptake. There is also a 
correlation between counties with high social 
vulnerability indices and low rate of vaccination, 
meaning that poverty levels are a predictor of 
vaccine uptake.9 States with the lowest total doses 
administered reported to CDC include Idaho, 
West Virginia, and many states in the Southeast 
region, as well as certain states in the Midwest (see 
Figure 2).10 There is also a stark difference in urban 
and rural regions. As of December 2021, 81.9% of 
adults in urban areas were vaccinated, while only 
69.3% of adults in rural counties were fully 
vaccinated.11 

Figure 2: Percent of Total Population with at least one 
dose of All Counties in US. Map displays higher 
vaccination rates in urban counties when compared to 
rural counties. Vaccination rates also differ by region of 
the U.S.10

Figure 3: Percent of U.S. population Vaccinated by 
Age Group. Graph displays increasing vaccination 
rates among older age groups.8

Figure 4: Percent of U.S. population Vaccinated 
by Sex. Graph displays that females are more 
vaccinated than males.8	

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Figure 5: Percent of U.S. population Vaccinated by 
Race/Ethnicity. Graph displays race/ethnicity 
distributions of the 77.6% of those fully vaccinated with 
race/ethnicity known. The Asian population has the 
highest full vaccination rate (59.5%), followed by 
American Indian/Alaska Native (58.0%), Native 
Hawaiian or Other Pacific Islander (57.4%), 
Hispanic/Latino (51.1%), White (47.6%), and Black 
(40.2%).8	

Increased vaccination rates are needed to 
protect the population from severe disease and 
reach herd immunity.5, 13 Herd immunity is when 
enough of the population becomes immune to a 
disease, through either natural infection or 
vaccination, so that there is much less spread 
through the community.12 High immunity levels in 
the community lead to indirect protection to those 
who are not immune.13 The percentage vaccinated 
and/or infected to establish herd immunity against 
COVID-19 is not clear, as variants and changing 
protection affect this number. However, increasing 
the number of vaccinated individuals can make the 
effects of COVID-19 manageable, as the risk of 
severe illness decreases and waves will not be as 
disruptive.13 Even so, the novelty of the virus and 
chance of breakthrough infection and re-infection 
can make this an impossible task. Even with 
adequate resources to vaccinate the whole 
population, the U.S. demonstrates the need to 
combat vaccine hesitancy everywhere to stop the 
impact of COVID-19.14

Vaccination is necessary for safety of those 
most at-risk by decreasing transmission, as well as 
personal protection against severe disease.5, 13 
However, there is still a large unvaccinated 
population in the U.S. To determine the reasoning 
of those who are still unvaccinated, a literature 
review of existing research on reasons for being 
unvaccinated against COVID-19 in the U.S. was 
conducted. These explanations will help 
policymakers and health communicators discover 
what messages and incentives work best to 
vaccinate the entire U.S. population against this 
deadly virus. The original hypothesis is that 
reasons for COVID-19 vaccine hesitancy in the 
US include distrust, misinformation, and lack of 
access. Therefore, these can be best combatted 
with general healthcare reform and community 
engagement, in person and on the internet. 

2. Methods

the A scoping, systematic review of published 
literature on PubMed regarding reasons for 
COVID-19 vaccine hesitancy in the United States 
was conducted from September 1, 2021, to 
November 24, 2021. 

2.1 Research Questions & Purpose of Review 

The primary question in this literature review is: 
What are the most frequently given/most common 
reasons for vaccine hesitancy and refusal among 
the U.S. population? The secondary question is: 
How are these reasons impacted by timing of the 
study and participant population? Having 
identified the reasons, the paper discusses how this 
information and nuance might be used to increase 
vaccine uptake. By pulling literature surrounding 
general low vaccine confidence and health 
communication theories, creative ways are found 
to combat the current hesitancy effecting around 
24% of the U.S. population who have not received 
one dose of the COVID-19 vaccine, and 19.2% of 
people ages 5 and older who have not received even 
one dose.7

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The purpose of this literature review is to find 
the most frequently given reasons for COVID-19 
vaccine hesitancy across the U.S. population, in 
order to identify most effective interventions to 
increase uptake. Objectives of this review include: 
1) to assess most common reasons for COVID-19
vaccine hesitancy among U.S. adults, and 2) to
analyze the best measures to combat these specific
reasons.

2.2 Search & Analysis Process 

The advanced search terms on PubMed were 
“(((COVID-19) AND (United States)) AND 
(vaccine hesitancy)) AND (reasons).” This 
resulted in a total of 38 results, which were reduced 
to 27 because of exclusion criteria detailed below. 
The inclusion criteria consist of adult population 
from the United States that include reasons for 
vaccine hesitancy. The exclusion criteria include: 
duplicates (1), articles on non-U.S. populations 
(4), non-COVID-19 specific data (2), did not 
include reasons but only incentives or 
prioritization (2), study framing and not actual 
data (1), mental health (1). 38 articles were 
scanned by both title and abstract for correct 
information relevant to the research question and 
hypothesis. The 27 articles included were 
analyzed, and information on the following was 
extracted using a table: date of study, method of 
survey, population studied and generalizability, 

and reasons for vaccine hesitancy or refusal. The 
results table (Table A1) was created with this 
information. In addition, a variable was created, 
included in the table, based on the date of survey 
on whether the study was done before or after the 
FDA EUA and actual roll-out to the general 
population. 

3. Results

The purpose of the 27 included articles was to
conduct surveys to identify the number and 
percentage of vaccine accepting, hesitant, or 
refusers within a certain population or general 
Americans, as well as find the reasons for not being 
vaccinated.  

3.1 Type of Study 

The majority of the studies were cross-
sectional surveys conducted online (59.25%), as 
well as some in-person and on the phone (see 
Table 1). There was one qualitative study with 
focus groups, as well as two studies which 
incorporated a primary survey with a follow-up 
survey after a few months (see Table 1). Sample 
sizes ranged from participants of 58 in qualitative 
interviews (Harrison et al., 2021)23 to 458,235 
from a Census survey (Tram et al., 2021)20 (see 
Table 2). 

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Table 1: Type of study by number and percentage of articles (N = 27). The majority of studies were cross-sectional 
surveys (88.89%), followed by those with follow-up surveys (14.81%), and focus group (7.40%).

Type of Study N (%) References 
Cross-sectional survey 24 (88.89%) 

Online 16 (59.25%) 16, 18, 20, 21, 22, 24, 27, 26, 28, 30, 31, 33, 
36, 38, 39, 40 

In-person 2 (7.40%) 34, 35 
Online & phone 4 (14.81%) 15, 17, 25, 32 
Online, phone, & in-
person 

1 (7.40%) 37 

Mail 1 (7.40%) 29 
Focus group 1 (7.40%) 23 
Follow-up surveys 2 (14.81%) 

Online 1 (7.40%) 19 
Phone 1 (6.40%) 41 

Table 2: Number of study participants by number and percentage of articles (N = 27). Sample sizes ranged greatly. 
The majority of sample sizes were between 1001-5000 participants (29.62% of articles).

Range of Number 
of Study 
Participants 

N (%) References 

<50 1 
(3.70%) 

41 

50-100 1 
(3.70%) 

23 

101-500 5 
(18.51%) 

17, 18, 19, 29, 31 

501-1000 4 
(14.81%) 

15, 28, 33, 36 

1001-5000 8 
(29.62%) 

21, 27, 26, 32, 34, 38, 39, 40 

5001-10000 2 
(7.40%) 

16, 35 

>10000 6 
(22.22%) 

20, 22, 24, 25, 30, 37 

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3.2 Populations Studied	
Out of the 27 articles included in this literature 

review, seven (25.9%) were nationally 
representative of the United States population. 
Ten (37.0%) surveyed specific populations across 

the United States, while six (22.2%) surveyed a 
specific location within the United States. Four 
(14.8%) of the articles focused on healthcare 
workers, one being nationally representative and 
the others surveying specific locations (Table 3).

Table 3: Number and percentage of articles by population studied (N = 27). The majority of populations studied 
were specific population across U.S. (37.0%), followed by nationally representative U.S. population (25.9%), specific 
location within U.S. (22.2%), and healthcare workers (14.8%).

Population Studied Number of 
Articles N (%) 

References & Specifics 

U.S. Population 
(Nationally 
Representative) 

7 (25.9%) 15, 18, 20, 26, 25, 32, 38 

Specific population 
across U.S. 

10 (37.0%) • Refugees17

• Adults with Multiple Sclerosis19

• Employees22

• Black community31

• Emergency department patients34

• Incarcerated population in four 
states35

• Patients with IBS36

• Parents of children who had 
COVID-1941

• Parents of children under 1240

• Groups prioritized for COVID-19 
vaccination27

Specific location 
within U.S. 

6 (22.2%) • NYC & Phoenix21

• Intellectual and development 
disabilities community in New York28

• Ohio Amish29

• Tennessee adults33

• California adults37

• Parents of children in NYC39

Healthcare workers 4 (14.8%) • Nursing home and assisted living 
facility staff in Indiana16

• Skilled nursing facility staff23

• Hospital workers in Philadelphia24

• General healthcare workers30

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3.3 Top Reasons for Hesitancy	
The majority of articles (57.14%) stated 

concern about side effects and general safety as the 
top reason for hesitancy. Of these 16 articles 
stating side effects as the main reason for 
hesitancy, twelve included general side effects, two 
included adverse/unknown effects, and two 
included general safety and effectiveness (see Table 
4). Only five articles analyzed side effect concerns, 
which include well-documented flu-like 
symptoms after receiving the COVID-19 
vaccine,17, 18, 30 rare severe adverse reactions such as 
allergic reactions and thrombosis,22, 18 and 
unknown and/or long-term effects.30, 36, 17 21.42% 
of the articles found additional information needed 
as the top reason for hesitancy among their 
population. This percentage includes those who 
“plan to wait and see if it is safe to get later” and 
those who cited lack of evidence. 10.71% of articles 
stated “mistrust in the vaccine itself” as the main 
reason for hesitancy, while one article stated 
“distrust of healthcare and other institutions” (see 

Table 4). Another article stated “no reason” or 
“don’t know” as the top reason, and one stated 
“antivaccine attitudes, beliefs, or emotions” as the 
top reason among refusers (see Table 4). 
Antivaccine attitudes, beliefs, or emotions are 
defined as not liking, wanting, or believing in 
vaccines and/or misinformation regarding vaccines 
causing certain disorders.15 

    Other important reasons with percentages in 
close proximity to the top rationale include 
swiftness of development among skilled nursing 
facility staff and New York’s intellectual and 
developmental disabilities community.28, 23 
In addition, distrust in COVID-19 vaccines 
closely followed side effects as the top reason 
among the general employed U.S. population.22 
One article also found that concerns about 
becoming infected from the vaccine and finding 
the virus to be less serious than public 
speculation differed between races as some of 
the main reasons for vaccine hesitancy.32

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 Table 4: Top reason for hesitancy by number and percentage of articles (N = 28)*. The majority of articles 
state concern of side effects and general safety as the top reason for hesitancy (57.14%), followed by additional  
information needed (21.42%), distrust (14.28%), no reason/don’t (3.57%), and antivaccine attitudes, beliefs, 
or emotions (3.57%).

Top Reason for Hesitancy Number of 
Articles N (%) 

References 

Concern about side effects & general 
safety 

16 (57.14%) 

General side effects 12 42.8%) • 16, 17, 18, 22, 24, 27, 26, 28, 29, 34, 41
• “Not sure” group15

Unknown and/or long-term 
effects 

2 (7.14%) • 30, 36

Safety & effectiveness 2 (7.14%) • 39, 40
Additional Information Needed 
(includes “plan to wait and see if it is 
safe to get later” & lack of evidence) 

6 (21.42%) • 19, 33
• “Probably not” group20

• Phoenix adults21

• “Probably will not” group25

• Hesitant group35

Distrust 4 (14.28%) 
In the vaccine 3 (10.71%) • 31

• “Definitely not” group20

• “Definitely not” group25

In healthcare or other 
institutions 

1 (3.57%) • Refusers35

No reason/don’t know 1 (3.57%) • NYC adults21

Antivaccine attitudes, beliefs, or 
emotions 

1 (3.57%) • Refusers15

*4 articles stratified the population into hesitant and refusers with separate top reasons for hesitancy.15, 20, 25, 35 1 
article has different top reasons based on location.21

*4 articles were not included because of results without clear top reason.23, 32, 37, 38

3.4 Separating the hesitant & refusers	
Four articles with top reasons for low vaccine 

confidence separated the participants between the 
hesitant and refusers with different top reasons for 
lack of vaccine uptake. The remaining nineteen 
articles differentiated between those who intended 
or had been vaccinated and those who did not 
intend and/or showed hesitancy (including 
hesitancy and refusal). Articles that separated
between hesitant and refusers found that the most 
frequently stated reason for vaccine hesitancy

 among the hesitant or unsure is side effect 
and safety concerns, as well as waiting to see if 
it is safe.15, 20, 25, 35 These same articles found 
that the most frequently stated reason for vaccine 
hesitancy among the refusers or “absolutely 
not” include distrust and beliefs. For example, 
the study by Fisher et al. (2021) found 
that among a representative sample of U.S. 
adults, 31.6% of participants were not sure 
and/or hesitant about getting the COVID-19 
vaccine, and 10.8% did not intend, or refused. 

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The most frequently stated reason for being 
unsure or hesitant was concern about side effects 
and safety (34.1%), while the reason for refusal 
was “don’t believe in, want, or feel comfortable 
with vaccines” (21.7%).15 Second, the study by 
Tram et al. (2021) found that among a 
representative sample of U.S. adults, 10.2% 
stated that they would probably not get the 
vaccine, while 8.2% stated that they would 
definitely not. The majority of probably not 
(57.0%) stated “plan to wait and see if it is safe 
and may get it later” as the main reason, while 
the majority (49.0%) of “definitely not” stated “do 
not trust the COVID-19 vaccine” as the main 
reason.20 Third, the study by Stern et al. (2021) 
found that among incarcerated individuals in 
Washington, Florida, California, and Texas, 
45.4% would refuse the vaccine, while 9.8% 
would hesitate. Among the hesitant, the majority 
were waiting for more information (54.8%). 
Among the refusers, distrust of healthcare, 
correctional, or government personnel or 
institutions was the most common reason 
(20.1%).35

3.5 Qualitative data & predictive factors 
Four of the twenty-seven articles included were 

qualitative or found correlations between vaccine 
intention/uptake and predictive factors. The 
qualitative study on skilled nursing facility staff 
found different reasons for hesitancy and gave 
more nuance to the topic. These include beliefs 
that the vaccine has been developed too fast and 
without sufficient testing, personal fear about pre-
existing medical conditions, and general distrust 
of the government and institutions. These 
interviews also found the vaccine uptake is 
a “social enterprise” and influenced 
significantly by the actions of close friends in a 
social network.23 The study by Latkin et al. 
(2021) found  differences  between   demographic 
characteristics and predictive factors for COVID-19

vaccine uptake. Among a nationally 
representative population, Black, Hispanic, 
and woman-identifying populations in the 
U.S. are the most hesitant; however, reasons 
for hesitancy differed between these 
populations. Black populations were more likely 
to state concerns about being infected from the 
vaccine itself, while White populations were 
more likely to say that COVID-19 was not as 
serious as some say it is.32 The study by Dorman 
et al. (2021) focused on the importance of 
confidence in vaccine willingness.37 Lastly, the 
study by Allen et al. (2021) found that the 
greatest predictor of vaccination was agreement 
or disagreement with the statement that vaccines 
are safe and effective.38

3.6 Timing of Study 
Just over half (51.8%; 14 out of 27) of the 

articles were done before the Federal Drug 
Administration issued an Emergency Use 
Authorization for the Pfizer-BioNTech vaccine 
in the United States on December 11, 2020, 
meaning before the actual roll-out to the 
public. These “before” surveys surrounded 
intention in a time where the vaccines were 
not yet approved for public use. 10 of the 27 
(37.0%) articles had surveys conducted after the 
first EUA, meaning that safety and effectiveness 
were proven by the FDA. The FDA EUA 
should be proof to the public of the safety and 
effectiveness of the vaccine in combatting 
COVID-19, as safety and effectiveness 
data were transparent and recommended 
to prioritized populations and supported by 
healthcare professionals (FDA, 2019).42 The 
remaining three articles included surveys both 
before and after the EUA. The follow-up 
surveys were given after the FDA EUA to the 
same participants to compare and see 
changes in vaccine uptake and reasons (Table 5).

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Table 5: Number and Percentage of articles that were before or after FDA EUA of Pfizer COVID-19 vaccine 
(Dec 11, 2020) (N = 27). The majority of studies were conducted before FDA EUA (51.8%), followed by after 
(37.0%), and spanning both before and after (11.1%).

*2 articles were comparisons with follow-up surveys.41, 19 1 article spanned from May 2020 to January 2021.26

3.7 Correlations between top reason, timing, & 
population	

Out of the eleven studies conducted before the 
FDA EUA that included a top reason, seven stated 
side effects as their top reason, three stated 
mistrust, three stated more information needed, 
and one stated no reason for vaccine hesitancy. Out 
of the nine studies conducted after the EUA that 
included top reasons, eight were side effects and 
two were distrust. Out of the three studies 
conducted over the span or follow-up both before 
and after, one stated additional information 
needed as the top reason for hesitancy and two 
stated side effects. Both follow-up surveys found 
an increase in vaccine willingness over time, as seen 
in the general trend in vaccine uptake across the 
U.S.19, 41 Although general vaccine willingness 
increased, the FDA EUA did not result in a 
decrease in concerns over side effects among 
populations studied in this literature review. A 
large number of hesitant populations were still 
concerned about side effects after the official FDA 
EUA with transparent safety data and CDC 
recommendations urging adults to get vaccinated. 

4. Discussion

4.1 General trends in reasons for vaccine hesitancy 
in the US 

It is imperative that reasons for vaccine 
hesitancy and vaccine refusal in the United States 
are addressed. There is still a significant percentage 
(35.5%) of the population not fully vaccinated 
against COVID-19 as of February 15, 2021.6 In 
addition, 24% of the population has not received 
one dose.6 It is important to recognize that 
children recently became eligible for COVID-19 
vaccination, making up a certain percentage of the 
unvaccinated population (see Figure 1). The 
majority of unvaccinated adults are those in the 
middle-age range, from 18-24 years old and 25-39 
years old (see Figure 3).8

According to the literature review on reasons 
for COVID-19 vaccine hesitancy, the most cited 
reason in 16 out of 27 (57.14%) articles is “side 
effects” and general safety concerns (see Table 3). 
The American population expressed concern about 
short-term side effects, including flu-like 
symptoms such as headache and fatigue, as a 
reason for vaccine hesitancy.17, 18, 30 Those who are 
hesitant because of side effects also expressed 
concern about long-term impacts, which include 
side effects that are “unknown” and could be 
detrimental to personal health,36, 30, 17 as well as 

Date of Study Number of Articles N 
(%) 

References 

Before 14 (51.8%) 15, 16, 18, 21, 24, 27, 29, 30, 31, 32, 33, 35, 
37, 38 

After 10 (37.0%) 17, 20, 22, 23, 25, 28, 34, 36, 39, 40 
Both* 3 (11.1%) 19, 26, 41 

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severe and adverse allergic reactions.22, 18 Fear of 
these side effects stem from transparent data on 
flu-like symptoms, rare allergic reactions, and rare 
thrombosis cases. However, fear of unknown, 
adverse, and long-term effects stems from 
misinformation, mostly found on social media and 
the internet.34, 41, 26

This finding is slightly different from the 
original hypothesis that the most common reasons 
for COVID-19 vaccine hesitancy in the U.S. 
include distrust, misinformation, and lack of 
access. The literature review also shows that 
separating the hesitant from the refusers to find the 
reasons for not being vaccinated is imperative to 
adequately address the low uptake in vaccines in 
the United States. Refusers are more likely to 
express feelings of distrust and not be vaccinated 
because of beliefs, while the hesitant are more 
worried about personal safety and side effects.20, 15 
However, similarities exist between ideas of 
concern of safety and mistrust of the vaccines. 
Lasting concerns over vaccine safety and side 
effects, even with transparent data from official 
institutions, suggest that there is distrust among all 
vaccine hesitant. Most distrust in COVID-19 
vaccines comes from pre-existing distrust in 
healthcare, misinformation and conspiracy 
theories on social media, and beliefs from one’s 
social network.23, 43   
4.2 Reasons for hesitancy among Black 
populations 

Distrust in COVID-19 vaccines spans all 
racial/ethnic, hesitant groups, but affects Black 
populations at a disproportionate rate.32 Reasons 
for COVID-19 vaccine hesitancy among Black 
Americans require recognition of structural racism 
within the medical and health fields. The history 
of racism in the medical and health fields, as well 
as with many institutions in this country, can be a 
cause for distrust in medicine.44, 31 “Medical 
mistrust” is “an understandable, rational, self-
protective response to historical and ongoing 

structural and interpersonal discrimination and 
racism in healthcare, and lack of trustworthiness of 
healthcare system and institutions in U.S. 
society”.31 Medical mistrust may lead to a 
decreased use of healthcare among Black 
Americans, which includes vaccinations, and 
decreased confidence in the safety and efficacy of 
the COVID-19 vaccines.31 Distrust in COVID-
19 vaccines also includes lack of trust in the 
government and other institutions. Bogart et al. 
(2021) found that there was a significantly high 
percentage of Black Americans who were “unsure” 
about the COVID-19 vaccines, rather than 
absolute refusers. This means that interventions 
focused on minority, specifically Black, 
populations in the U.S. must work on building 
trust through authentic representation and 
community investment (see Recommendations 
section below).      

4.3 Recommendations 
This literature review found that concerns 

around side effects and general safety, as well as 
distrust in the vaccines, are the top reasons for 
vaccine hesitancy in the U.S. Interventions and 
communications addressing the vaccine hesitant 
and refusers must focus on increasing trust and 
providing evidence. Five recommendations are 
listed below to increase COVID-19 vaccine uptake 
in the U.S. 

Communications addressing side effects: The 
most cited reason for COVID-19 vaccine 
hesitancy in the US is side effects and wanting to 
wait and see if the vaccine really is safe. In order to 
address this, communications from local health 
providers, institutions, and community organizers 
must focus on the fact that vaccines work quickly, 
do not alter DNA, and give instructions to our cells 
to make a protein that our immune cells work to 
fight off providing future protection.45 Serious side 
effects (allergic reactions and myocarditis) from 
the vaccine are highly unlikely, and those that do 

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Georgetown	Scientific	Research	Journal	

occur happen within two weeks of vaccination. 
Most side effects are flu-like symptoms and arm 
pain for about 24 hours. There is a risk of severe 
allergic reaction that can be mitigated if caught 
quickly.46 Communication must also highlight the 
fact that there is a higher risk of long-term effects 
from infection with COVID-19 than from the 
vaccine itself. These include difficulty breathing or 
shortness of breath, tiredness or fatigue, difficulty 
thinking or concentrating, cough, chest or stomach 
pain, and myocarditis, among many others.47, 48 
Communications must frame COVID-19 
vaccination as the main way to reduce the risk of 
COVID-19 and a way to increase self-efficacy and 
protect one’s health, as well as the health of the 
community.49 In addition, employers must provide 
paid time-off after vaccination for known side 
effects, such as headache and fatigue.17 

1. Interventions addressing misinformation:
Distrust stems from either medical mistrust or
misinformation and anti-vaccination
propaganda.31, 49 Misinformation on the 
internet and social media has become a 
significant issue during the COVID-19 
pandemic, as it preys on negative emotion and 
fear. Institutions, such as schools, must provide 
citizens with help in identifying 
misinformation and how they can have the 
self-efficacy to make the decision about getting 
vaccinated with the correct information. This 
is also called “misinformation literacy”.49 

2. Healthcare system reform: In order to create
trust in healthcare, there must be complete
reform to universal healthcare with better
primary care and health insurance for all. In a
nationally representative survey in September
of 2021, the Kaiser Family Foundation also
found that the lack of health insurance was the
most powerful predictor of who remained
unvaccinated.50,

 

51 This further suggests the
need for a trusted primary care physician or

general doctor for every person in the U.S. 
Quality, universal healthcare for all Americans 
would increase vaccination rates and make for 
a more equitable COVID-19 response. More 
specifically, systemic racism and distrust 
among minority populations due to 
mistreatment and underrepresentation must be 
addressed.44 The medical field must 
authentically increase representation of 
minority populations in clinical trials, medical 
schools, doctors, and institutions such as the 
CDC and FDA. Clinicians must also promote 
vaccinations to their patients through follow-
up on vaccination status, sharing educational 
resources stories, and promoting community 
efforts.52 In addition, doctor-patient 
relationships can be strengthened to increase 
trust through personal stories and quality 
care.53 

3. Education system reform: In addition, quality
education must be free and equitable in all
parts of the U.S. and world. Curricula can
teach about identifying sources and
misinformation in schools and about how
vaccines and medications work, in order to
educate the population from a young age about
the benefits of vaccination and increase health
literacy.44 The Vaccine Makers Project has a
program that can be implemented in the
classroom surrounding immunizations and
disease.54

4. Authentic community investment & 
engagement: Minority populations need to be
more heavily represented in clinical trials for
vaccines and medical field research in general.44

Trust can be built with authentic investment in
both time and resources in unvaccinated
communities, specifically in the health field.

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Figure 6: Recommendations to Increase COVID-19 Vaccinations & Vaccine Confidence in the U.S. Suggestions 
include specific communication efforts, system reform, and community-based initiatives. 

4.4 Remaining Gaps in Knowledge 

More research is needed about COVID-19 
vaccine confidence in general, as well as 
specification between demographic 
characteristics. Because of the novelty of 
COVID-19 vaccines and the virus, sustained 
research and investigation is necessary. 
Qualitative research is essential to better 
understand the nuances in vaccine hesitancy, 
including the similarities and differences between 
fear of side effects and safety versus distrust. 
Surveys must specify which side effects 
populations are most concerned about. Health 
research is needed on the impact of social media 
and social networks on COVID-19 vaccine 
uptake, as well as where these fears and ideas 
stem from. The intersections between social 
sciences and health requires more research in the 

COVID-19 context. Research is also needed on 
correlations between timing of FDA approvals 
and reasons for vaccine refusal.  

4.4 Limitations 

There are several limitations to this literature 
review. The surveys utilized did not have a 
consistent wording of questions or provide the 
same questions. Some articles differentiated 
between those who are unsure and those who 
refuse, while some divided this into a broader 
hesitant category. 

5. Conclusion

This literature review found that concerns
about side effects is the top reason for COVID-
19 vaccine hesitancy in the U.S., followed by 
need for additional information and distrust. In 
order to gain trust and therefore increase uptake 

Address all side effects in 
communication efforts:
• From local health providers, institutions, 

& community organizaters
• Known flu-like symptoms
• Extremely rare allergic reactions
• Disprove long-term effects

Address misinformation & 
increase trust:
• Communicate & teach ways to point out 

misinformation

Healthcare system reform:
• Ensure universal healthcare for all
• Increase representation of minority 

populations in health fields
• Strengthen doctor-patient relationship
• Follow-up on vaccination status
• Share stories & resources
• Promote community efforts

Education system reform:
• Universal quality education
• Curricula should include misinformation 

literacy & vaccine mechanisms

Authentic community 
investment & engagement:
• Community-based initiatives in areas with 

low vaccination rates

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Georgetown	Scientific	Research	Journal	

among those who are still hesitant of the available 
COVID-19 vaccines, the American healthcare 
and education system must go through reform to 
address systemic racism. While increasing 
representation in health fields, already working 
clinicians can promote vaccinations through 
strengthening their patient relationships, 
following up on vaccination status, sharing 
educational resources and personal stories, and 
promoting community efforts. Teachers and 
schools can implement lessons on immunizations 
and disease. Communication efforts from 
institutions and local community organizations 
must work to increase trust, address fear of side 
effects, and combat misinformation, while also 
promoting social and self-efficacy values. 
Promotion of social values and authentic 
community investment and engagement can 
increase trust and vaccinations. Vaccination of 
the global population is necessary to combat this 
virus. Addressing hesitancies to COVID-19 
vaccines can increase uptake in order to protect 
all. 

Acknowledgments 

I thank Chelsea Toldeo, MA, MPH, Sr. Health 
Communications Advisor – ASRT, contracting 
for CDC’s Immunization Service Division, 
Atlanta, GA, for aiding me in the editing process 
and providing expertise in the matter. I thank Dr. 
Margaret Baker, Associate Professor at 
Georgetown University’s Department of 
International Health, for being my advisor 
during this entire process.	

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Appendix 
Table A1. PubMed search results: “covid-19 united states vaccine hesitancy reasons”

Authors, Year, 
Title 

Purpose of 
Study 

Method Before, 
After, or 
Both 
FDA 
EUA of 
Pfizer 
(Dec 11, 
2020) 

Population studied 
(sample size, can it 
be generalized, 
specific location 
within US) 

Reason(s) for hesitancy 
(with percentages) 

Fisher, et al. 
(2020). 
Attitudes 
Toward a 
Potential 
SARS-CoV-2 
Vaccine: A 
Survey of U.S. 
Adults15 

To assess 
intent to be 
vaccinated 
against 
COVID-19 
among a 
representative 
sample of 
adults in the 
United States 
and identify 
predictors of 
and reasons 
for vaccine 
hesitancy. 

Online or 
telephone 
cross-
sectional 
survey, 
fielded from 
16 through 
20 April 
2020. 

Before 991 AmeriSpeak 
panel members 
responded 

Approximately 
1000 adults drawn 
from the 
AmeriSpeak 
probability-based 
research panel, 
covering 
approximately 97% 
of the U.S. 
household 
population. 

16.1% response rate 

Of the 31.6% who were 
not sure about being 
vaccinated & the 10.8% 
who did not intend to 
be vaccinated, 72.1% 
(n=220 not sure & 
n=83 no) responded 
with reasons. 

The most common 
reasons cited by 
participants who were 
not sure whether they 
will be vaccinated 
included specific 
concerns about the 
vaccine (such as safety 
or effectiveness) (57.3% 
of not sure) or a need 
for more information 
(22.3% of not sure) 

In contrast, the most 
common reasons 
provided by 
participants who did 
not intend to be 
vaccinated included 
antivaccine attitudes, 
beliefs, or emotions 
(56.6% of no), and lack 
of trust (32.5% of no) 

More specific top 
reasons: 34.1% of not 
sure: side effects, safety 
& 21.7% of no: don’t 
believe in, want, or feel 

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comfortable with 
vaccines 

Unroe, et al. 
(2021). 
Willingness of 
Long-Term 
Care Staff to 
Receive a 
COVID-19 
Vaccine: A 
Single State 
Survey16 

To plan for 
coronavirus 
infectious 
disease 2019 
(COVID-19) 
vaccine 
distribution, 
the Indiana 
Department 
of Health 
surveyed 
nursing home 
and assisted 
living facility 
staff. 

Cross-
sectional 
analysis of an 
anonymous 
survey sent 
via text 
message link 
to personal 
cell phones 
and emails in 
November of 
2020 

Before Nursing home and 
assisted living 
facility staff in 
Indiana 

8,243 responses – 
sent to 23,232 

November 2020 

Of those unwilling to 
take the vaccine when 
first available (55% of 
participants), 44% 
would consider in the 
future. Concerns about 
side effects was the 
primary reason for 
vaccine hesitancy (70% 
of those unwilling). 
- Health concerns

(34%)
- Questioning

effectiveness (20%)
- Religious reasons

(12%)

Characteristics 
associated with 
increased willingness 
were age over 60, male, 
and white race (P < 
.0001). 

Zhang, et al. 
(2021). 
Acceptance of 
COVID-19 
Vaccine 
Among 
Refugees in 
the United 
States17  

Little is 
known about 
COVID-19 
vaccination 
intentions 
among refugee 
communities 
in the United 
States. The 
objective of 
this study was 
to measure 
COVID-19 
vaccination 
intentions 
among a 
sample of 
refugees in the 
United States 
and the 
reasons for 
their vaccine 
acceptance or 
hesitancy. 

Email and 
text message 
anonymous 
online 
surveys to 
refugee 
populations 
in US  
From 
December 
2020 through 
January 2021 
(very 
beginning of 
roll-out, 
approved 
vaccines) 

After 435 respondents, 
refugees in the US 

70.3% intended to get 
vaccine, 7.6% no, 
22.1% unsure 

Reasons: Among 
respondents who were 
unsure about receiving 
the COVID-19 vaccine 
or who did not intend 
to receive the vaccine, 
most were worried 
about side effects 
(71.3%), followed by 
concerns about the 
effectiveness of a 
COVID-19 vaccine 
(12.4%) and a fear of 
needles (8.5%). 

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Georgetown	Scientific	Research	Journal	

Solís Arce, et 
al. (2021). 
COVID-19 
vaccine 
acceptance and 
hesitancy in 
low- and 
middle-income 
countries18 

Comparison 
of vaccination 
between 
LMICs and 
US and Russia 

Online, 
Cross-
sectional 
survey 
conducted 
Dec 4-5, 
2020 

Before 462 of U.S. 
participants replied 
with reasons for 
vaccine hesitancy, 
1313 replied with 
reasons for getting 
vaccine 

nationally 
representative 
sample of adult 
internet users 
recruited through 
the market research 
firm Lucid 

Acceptance rate in US 
is 64.6% 

Vaccine hesitancy 
reasons: concern about 
side effects (79.3% of 
hesitant), skepticism 
about effectiveness 
(46.8%), lack of 
concern about 
COVID-19 infection 
(39.3%) 

Ehde, et al. 
(2021). 
COVID-19 
vaccine 
hesitancy in 
adults with 
multiple 
sclerosis in the 
United States: 
A follow up 
survey during 
the initial 
vaccine rollout 
in 202119

To assess 
COVID-19 
vaccine 
hesitancy 
before and 
after roll-out 
among adults 
with MS in 
the U.S. 

2 online 
surveys in 
April/May 
2020 and 
Jan/Feb 2021 

1 before 
1 after 

Adults with MS 
living in the US (N 
= 359) 

Participants who were 
vaccine hesitant 
(20.3%) reported 
concerns about the 
long-term effects of the 
vaccine, the vaccine 
approval process, and 
the potential impact of 
the vaccine given their 
own health 
conditions/history. 

90% of hesitant wanted 
additional information 
about the vaccine 
before deciding 

Vaccine willingness 
among this group 
increased over time 

Tram, et al. 
(2021). 
Deliberation, 
Dissent, and 
Distrust: 
Understanding 
distinct drivers 
of COVID-19 
vaccine 
hesitancy in 
the United 
States20 

To assess 
reasons for 
COVID-19 
vaccine 
hesitancy and 
refusal in the 
U.S. 

Data analysis 
of the US 
Census 
Bureau’s 
Household 
Pulse Survey 
(biweekly 
cross-
sectional 
survey of US 
households) 
in Jan-March 
2021 

After 459,235 
participants in Jan-
March 2021 

Representative 
because 
weighted 

140 million 
housing units 
contacted 

10.2% reported that 
they would probably 
not get the vaccine & 
8.2% that they would 
definitely not get a 
vaccine 

Those who expressed 
reluctance invoked 
mostly “deliberative” 
reasons, while those 
who rejected the 
vaccine were also likely 
to invoke reasons of 
“dissent” or “distrust 

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Georgetown	Scientific	Research	Journal	

“probably not”: 
deliberative reasons – 
“plan to wait and see if 
it is safe and may get it 
later” (57.0%), “concern 
about possible side 
effects” (52.1%), “other 
people need it more 
than I do right now” 
(26.7%) 

“definitely not”: distrust 
– do not trust the
COVID-19 vaccine
(49.0%) & do not trust
the government (40%)

Trent, et al. 
(2021). Trust 
in government, 
intention to 
vaccinate and 
COVID-19 
vaccine 
hesitancy: A 
comparative 
survey of five 
large cities in 
the US, UK, 
and Australia21

To identify 
predictors of 
willingness to 
vaccinate 
against 
COVID-19 in 
five cities with 
varying 
COVID-19 
incidence in 
the US, UK, 
and Australia. 

Online, 
cross-
sectional 
survey of 
adults from 
Dynata’s 
research 
panel in July-
September 
2020. 

Before Adults aged 18 and 
over in Sydney, 
Melbourne, 
London, New York 
City, or Phoenix. 

1204 adults in 
NYC 
500 adults in 
Phoenix 

May NOT be 
representative of 
entire population 

Participants with high 
or very high confidence 
in their current 
government were less 
likely to be willing to 
receive the vaccine 

Highest reason in NYC 
for not vaccinating is 
no reason/don’t know 
(42% of hesitant in 
NYC) 

Highest reason in 
Phoenix is not sure or 
waiting for more 
information (30%) 

King, et al. 
(2021). 
COVID-19 
vaccine 
hesitancy 
January-May 
2021 among 
18-64 year old
US adults by
employment
and
occupation22

Vaccine 
hesitancy in 
US by 
employment 
status and 
occupation 
category 

Online, 
cross-
sectional 
survey on 
Facebook 
from Jan to 
May 2021 

After US adults 18-64 
years completed an 
online COVID-19 
survey 3,179,174 
times from January 
6-May 19, 2021.

Employed 
participants that 
responded with 
reasons: 55375 

Data on employed 
participants 

Over half of employed 
hesitant participants 
reported concerns 
about side effects 
(51.7%), not trusting 
COVID-19 vaccines 
(51.3%), and not liking 
vaccines in general 
(15%) 

Over a third didn’t 
believe they needed the 
vaccine (45.1%), didn’t 
trust the government 
(44.6%), and/or were 

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Georgetown	Scientific	Research	Journal	

waiting to see if it was 
safe (35.2%) 

Harrison, et al. 
(2021). 
“Somebody 
Like Me : 
Understanding 
COVID-19 
vaccine 
hesitancy 
among staff in 
skilled nursing 
facilities23

To describe 
reasons for 
COVID-19 
vaccine 
hesitancy 
reported by 
staff of skilled 
nursing 
facilities and 
understand 
factors that 
could 
potentially 
reduce 
hesitancy 

Focus groups 
(qualitative 
interviews) 
with 58 staff 
members 
were 
conducted 
virtually over 
Zoom in Dec 
2020 

After 58 skilled nursing 
facility staff in U.S. 

Small sample 
size 

Reasons for hesitancy: 
beliefs that the vaccine 
has been developed too 
fast and without 
sufficient testing; 
personal fear about pre-
existing medical 
conditions, and more 
general distrust of the 
government  

Vaccine uptake is a 
social enterprise. 

Momplaisir, et 
al. (2021). 
Racial/Ethnic 
Differences in 
COVID-19 
Vaccine 
Hesitancy 
Among 
HCWs in 2 
large academic 
hospitals24

To assess 
hesitancy to 
COVID-19 
vaccination 
among 
HCWs across 
different 
racial/ethnic 
groups and 
assess factors 
associated 
with vaccine 
hesitancy. 

Online, 
cross-
sectional 
survey study 
was 
conducted 
among 
HCWs from 
2 large 
academic 
hospitals (ie, 
a children’s 
hospital and 
an adult 
hospital) over 
a 3-week 
period in 
November 
and 
December 
2020. 

Before 12,034 HCWs at 2 
hospitals in 
Philadelphia who 
responded to the 
survey (34.5% 
response rate) 

Among 5440 HCWs 
with vaccine hesitancy, 
reasons given for 
hesitancy included 
concerns about side 
effects (4737 
individuals [87.1%]), 
newness of the vaccine 
(4306 individuals 
[79.2%]), and lack of 
vaccine knowledge 
(4091 individuals 
[75.2%]). 

Nguyen, et al. 
(2021). 
COVID-19 
Vaccination 
Intent, 
Perceptions, 
and Reasons 
for Not 
Vaccinating 
Among 
Groups 

To assess 
vaccine intent, 
perceptions, 
and reasons 
among 
prioritized 
groups in the 
US as of Sept 
and Dec 2020 

Online CDC 
surveys in 
Sept and Dec 
2020 

Before Representative 
sample of 
prioritized US 
adults (3541 in Oct 
and 2033 in Dec) 

Groups for 
prioritization 
(essential workers, 
underlying medical 
conditions, aged 65 
and over) 

Among adults in the 
December surveys who 
did not intend to get 
vaccinated (32.1% of 
participants), the main 
reasons most frequently 
cited were concerns 
about side effects and 
safety of the COVID-
19 vaccine (29.8%), 
planning to wait to see 
if the vaccine is safe 

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Georgetown	Scientific	Research	Journal	

Prioritized for 
Early 
Vaccination – 
United States, 
September and 
December 
202025

and consider receiving 
it later (14.5%), lack of 
trust in the government 
(12.5%), and concern 
that COVID-19 
vaccines were 
developed too quickly 
(10.4%)  

Mondal, et al. 
(2021). 
Sociodemogra
phic predictors 
of COVID-19 
vaccine 
acceptance: a 
nationwide 
US-based 
survey study26

Our primary 
objective was 
to determine 
the relative 
influence of 
sociodemogra
phic 
predictors on 
COVID-19 
vaccine 
acceptance. 
The secondary 
objectives 
were to 
understand 
the reasons 
behind vaccine 
refusal and 
compare 
COVID-19 
vaccine 
acceptance 
with influenza 
vaccine 
uptake. 

Online cross-
sectional 
survey 
conducted 
between May 
2020 and Jan 
2021 

Both 
(mostly 
before) 

2978 participants in 
US 

Nationally 
representative 

Information channels:  
Both vaccine-compliant 
and vaccine-hesitant 
groups had equivalent 
reliance on television, 
social interaction and 
social media (e.g. 
Facebook) to acquire 
COVID-19-related 
information. 
However, a 
significantly higher 
number of vaccine-
compliant participants 
gained COVID-19 
information from the 
CDC and other official 
health websites. 

18.9% not accepting of 
vaccine 

Potential adverse effects 
(84.2%), followed by 
doubt about vaccine 
efficacy (44.4%), were 
the primary reasons 
reported by the 
vaccine-hesitant group. 
Even 51.0% of the 
vaccine-compliant 
participants were 
concerned about 
adverse effects; 
however, only 5.4% 
doubted the efficacy of 
the vaccine.  

Also have racial/ethnic 
breakdown of reasons 

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Georgetown	Scientific	Research	Journal	

Nguyen, et al. 
(2021). 
Changes in 
COVID-19 
vaccination 
receipt and 
intention to 
vaccinate by 
socioeconomic 
characteristics 
and geographic 
area, United 
States, January 
6 – March 29, 
202127

The purpose 
of this study 
was to 
examine 
changes in 
vaccine 
intentions and 
attitudes by 
sociodemogra
phic 
characteristics 
and 
geographic 
areas, factors 
associated 
with 
vaccination 
intent, and 
reasons for 
non-
vaccination 
among a 
nationally 
representative 
sample of U.S. 
adults. 

Household 
Pulse Survey 
from Jan to 
March 2021 
Online & 
phone cross-
sectional 
survey 

After Approx. 75,000 
respondents, U.S. 
adults 

Response rates of 
6.4-7.5% 

Reasons for not getting 
vaccinated changed 
slightly from January to 
March 
(The belief that a 
vaccine is not needed 
increased by more than 
five percentage points 
from early January to 
late March.) 

In late March, among 
“probably will”: plan to 
wait and see if it’s safe 
(54.5%), concern about 
possible side effects 
(50.9%), other people 
need it more right now 
(35.5%) 

Among probably will 
not: plan to wait (56%), 
side effects (51.1%), 
other people need it 
more right now (25.4), 
don’t trust COVID 
vaccines (25) 

Definitely not: concern 
about side effects 
(46.5%), don’t trust 
COVID-19 vaccines 
(47.9), don’t trust 
government (40.1) 

7.6% in late March do 
NOT plan to be 
vaccinated – reasons 
above 

Iadarola, et al. 
(2021). 
COVID-19 
vaccine 
perceptions in 
New York 
State’s 
intellectual and 
developmental 

To explore 
COVID-19 
vaccine 
perceptions in 
individuals 
with IDD, 
their family 
members, and 
those who 
work with 

Online 
survey 
distributed to 
a 
convenience 
sample of 
IDD 
Organization
s throughout 
NY state 

After New York’s 
intellectual and 
development 
disabilities 
community 

825 respondents 

25% hesitant - 
Concerns about side 
effects (16%) and 
swiftness of vaccine 
(15%) development, 
being an “experiment” 
for the vaccine (14%) 
and not trusting 
government (14%) 

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Georgetown	Scientific	Research	Journal	

disabilities 
community28

them, to 
inform a 
statewide 
vaccine 
information 
and messaging 
project. 

Jan-Feb 2021 Regarding trusted 
sources of vaccine 
information, health 
professionals ranked 
highest (92%), followed 
by friends and family 
(74%). Newspapers and 
television were trusted 
by twice as many 
people as social media. 

Scott, et al. 
(2021). 
Vaccination 
patterns of the 
northeast Ohio 
Amish 
revisited29

To evaluate; 
the rate and 
influences of 
vaccine 
hesitancy 
compared to a 
decade ago, 
vaccination 
patterns 
between 
Amish 
affiliations, 
vaccine 
practices of 
Amish special 
needs 
children, and 
the Amish's 
acceptance of 
a COVID-19 
vaccine. 

April 2020, 
survey mailed 
to 1000 
Amish 
families 

Before 391 respondents of 
Ohio Amish 

75% would reject a 
COVID vaccine 

Fear of adverse effects 
was the most common 
reason to reject vaccines 
(83.9% of refusers) & 
46% believed that shots 
could have dangerous 
preservatives or 
chemicals in them. 

Families that accepted 
vaccines were more 
likely to cite a 
healthcare worker as 
the primary influence 
to vaccinate. Wives 
were more likely to cite 
their spouse as the 
primary influence to 
vaccinate. Families that 
rejected vaccines were 
more likely to state 
their bishop was the 
most influential person 
on vaccination. 

Meyer, et al. 
(2021). Trends 
in Health Care 
Worker 
intentions to 
receive 
COVID-19 
vaccine and 
reasons for 
hesitancy30

To assess 
intentions of 
employees of a 
health care 
system before 
COVID-19 
vaccine 
distribution to 
receive a 
vaccine and to 
understand 
their reasons 

Online 
Nonidentifia
ble 
administrativ
e survey data 
Sent in Dec 
2020 

Before 16292 employees – 
HCWs across U.S. 

68.5% response rate 

28.4% undecided on 
vaccine, 16.3% said no 

Most (90.3% [6569 
employees]) of those 
who responded no or 
undecided reported 
concerns about 
unknown risks of the 
vaccines, 44.3% (3226 
employees) reported 
they wanted to wait 
until others’ vaccine 

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Georgetown	Scientific	Research	Journal	

for hesitancy 
to do so. 

experiences are known, 
and 21.1% (1539 
employees) reported 
that they do not trust 
the rushed FDA 
process. More than 
one-half (57.4% [4187 
employees]) cited 
concerns about known 
adverse effects, such as 
headache and fatigue. 

Bogart, et al. 
(2021). 
COVID-19 
vaccine 
intentions and 
mistrust in a 
national 
sample of 
Black 
Americans31

To assess 
vaccine 
intentions and 
reasons for 
hesitancy 
among the 
Black 
American 
population 

Web-based 
survey in 
Nov-Dec 
2020 

Before 207 Black 
American 
participants in 
RAND American 
Life Panel 

Nationally 
representative 

Overall, 35% agreed or 
strongly agreed that 
they would not get a 
COVID-19 vaccine, 
40% agreed or strongly 
agreed that they would 
get vaccinated, and 25% 
reported "don't know." 
Significant 
multivariable predictors 
of not wanting to get 
vaccinated included 
high mistrust of the 
vaccine itself (e.g., 
concerns about harm 
and side effects), OR 
(95% CI) = 2.2 (1.2-
3.9), p = .007, and weak 
subjective norms for 
vaccination in one's 
close social network, 
OR (95% CI) = 0.6 
(0.4-0.7), p < .001. 

Latkin, et al. 
(2021). Mask 
usage, social 
distancing, 
racial, and 
gender 
correlates of 
COVID-19 
vaccine 
intentions 
among adults 
in the US32 

Assess vaccine 
intentions and 
hesitancy 
among 
American 
adults 

National 
panel survey, 
online & 
telephone in 
May 2020 

Before 1,056 respondents, 
nationally 
representative 

53.6% yes, 16.7% no, 
29.7% unsure 

A sub-analysis among 
respondents who did 
not plan to obtain a 
COVID-19 vaccine 
(16.7%) indicated that 
the Black population, 
compared to White, 
were almost twice as 
likely to report 
concerns about 
becoming infected from 
the vaccine. In contrast, 
Whites, compared to 

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Georgetown	Scientific	Research	Journal	

other racial/ethnic 
groups, were more than 
twice as likely to report 
that one of the reasons 
for not intending to get 
a vaccine was that “the 
coronavirus outbreak is 
not as serious as some 
people say it is.” These 
findings are from a 
subsample and 
highlight the 
importance of studies 
examining racial/ethnic 
differences in vaccine 
intentions. 

Gatwood, et 
al. (2021). 
Factors 
influencing 
likelihood of 
COVID-19 
vaccination: a 
survey of 
Tennessee 
adults33

To examine 
the vaccine-
related beliefs 
and behaviors 
associated 
with likely 
hesitancy 
toward 
vaccination 
against 
coronavirus 
disease 2019 
(COVID-19) 
among 
nonelderly 
adults. 

Online cross-
sectional 
survey in 
June 2020 

Before TN adults 18-64 
who were not 
healthcare 
providers 

1,000 completed 
responses (62.9% 
response rate) 

54.1% had some 
hesitancy 

Three leading reasons 
for being hesitant 
toward COVID-19 
vaccination emerged: 
lack of sufficient 
effectiveness evidence 
(32.1%), perceived lack 
of disease risk (24.6%), 
and vaccine safety 
concerns (23.2%). 

Approximately one-
third (34.4%) of 
respondents indicated 
some historical vaccine 
hesitancy, and only 
21.4% indicated always 
getting a seasonal 
influenza vaccination. 

Rodriguez, et 
al. (2021). The 
rapid 
evaluation of 
COVID-19 
vaccination in 
emergency 
departments 
for 
underserved 
patients study34

Emergency 
departments 
(EDs) often 
serve 
vulnerable 
populations 
who may lack 
primary care 
and have 
suffered 
disproportiona
te COVID-19 

In-person 
cross-
sectional 
survey 
Dec 2020 to 
March 2021 

After ED patients during 
their visits to 15 
safety net EDs in 
14 US cities 

2,301 participants 
(89.4% response 
rate) 

61% stated they would 
accept vaccine, rest are 
hesitant 

3 primary reasons for 
vaccine hesitancy were 
similar for those with 
and without a source of 
regular medical care: 
concerns about side 
effects and safety 
(65%), need for more 

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Georgetown	Scientific	Research	Journal	

pandemic 
effects. 
Comparing 
patients 
having and 
lacking a 
regular source 
of medical 
care and other 
ED patient 
characteristics, 
we assessed 
COVID-19 
vaccine 
hesitancy, 
reasons for not 
wanting the 
vaccine, 
perceived 
access to 
vaccine sites, 
and 
willingness to 
get the vaccine 
as part of ED 
care. 

information (47%), and 
having heard stories in 
the media or online 
(24%). The fourth most 
common reason for 
respondents who had 
primary care was “don’t 
believe the vaccine will 
work”; in respondents 
who lacked primary 
care, the fourth most 
common reason was 
“not worried about 
getting COVID-19 
infection” 

Differences between 
those who had primary 
care and those who did 
not 

Stern, et al. 
(2021). 
Willingness to 
receive a 
COVID-19 
vaccination 
among 
incarcerated or 
detained 
persons in 
correctional 
and detention 
facilities35

To assess 
vaccination 
willingness 
and intent 
among 
incarcerated 
populations in 
the US 

Sept to Dec 
2020 
Interviews 

Before 3 prisons and 13 
jails in 4 states 
(Washington, 
Florida, California, 
Texas) 

5,110 participants 
(64.2% response 
rate) 

45.4% would refuse, 
9.8% would hesitate 

Common reasons 
reported for COVID-
19 vaccine hesitancy 
were waiting for more 
information (54.8%) 
and efficacy or safety 
concerns (31.0%). The 
most common reason 
for COVID-19 
vaccination refusal was 
distrust of health care, 
correctional, or 
government personnel 
or institutions (20.1%). 

Dalal, et al. 
(2021). 
COVID-19 
vaccination 
intent and 
perceptions 

To assess 
vaccine uptake 
and hesitancy 
among IBD 
population 

Dec to Jan 
2021 
Anonymous 
survey online 

After 906 participants 
with IBS in 
Boston, MA & 
from social media 

8.1% response rate 

Rates of COVID-19 
vaccination intent were 
80.9% for local and 
60.0% for SM 
participants.  

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Georgetown	Scientific	Research	Journal	

among patients 
with 
inflammatory 
bowel disease36

Not representative 
of national IBD 
population 

The hesitant 
participants most 
commonly selected 
“concern that long-
term safety of vaccines 
is unknown” (64.4% 
local, 70.1% SM) and 
“prefer to see how 
others tolerate vaccine 
first” (62.2% local, 
55.6% SM). 
Approximately 70% 
desire data regarding 
vaccine safety/efficacy 
among patients with 
IBD 

Dorman, et al. 
(2021). Factors 
associated with 
willingness to 
be vaccinated 
against 
COVID-19 in 
a large 
convenience 
sample37

To assess 
factors of 
hesitancy and 
receipt of 
vaccination 
among 
Californian 
adults 

Internet 
survey, face 
to face and 
telephone 
interviews 
Oct and Nov 
2020 

Before 26,324 respondents 
Large convenience 
sample in 
California 

Response rate 
unknown 

Measures from 5C 
scale: confidence, 
complacency, 
convenience, calculates 
risks and benefits, 
concern for others 

For the sample as a 
whole, confidence in 
the safety of the vaccine 
was the strongest 
predictor of willingness 
to be vaccinated, 
followed by concern for 
protecting others and 
whether or not one 
believed that COVID-
19 was serious enough 
to warrant vaccination 

Not sure exact 
percentages 

Allen, et al. 
(2021). Why 
are some 
people 
reluctant to be 
vaccinated for 
COVID-19? 
A cross-
sectional 
survey among 
U.S. adults in 

To assess 
cognitive, 
attitudinal and 
normative 
beliefs 
associated 
with not 
intending to 
get a 
COVID-19 
vaccine among 

Online cross-
sectional 
survey of US 
adults 
May-June 
2020 

Before 1219 respondents 

Nationally 
representative 
sample of US 
adults 

64% response rate 

17.7% no & 24.2% 
unsure 

Those who strongly 
disagreed with 
statements that most 
vaccines are very safe 
and/or effective were 
more likely to say they 
would not get the 
vaccine, compared with 
those who strongly 

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Georgetown	Scientific	Research	Journal	

May-June 
202038

American 
adults 

believed most vaccines 
are very safe/effective 
(78.1% vs. 5.0%)  

Those who strongly 
disagreed with 
statements that they 
themselves and 
everyone else in society 
has a responsibility to 
be vaccinated were 
more likely to indicate 
they would not get a 
COVID-19 vaccine, 
compared with those 
who strongly agreed 
with these statements 
(77.2% vs 4.8%)  

When asked about not 
needing to be 
vaccinated if everyone 
else were vaccinated, 
results were mixed. 
Those who strongly 
opposed this statement 
were most likely to 
report an intention to 
vaccinate (74%), while 
those who strongly 
agreed were most likely 
to indicate they 
would not get the 
vaccine (45.3%). Those 
who were neutral about 
this statement were the 
most likely to report 
that they were unsure 
about vaccination 
(42.4%).  

Regarding trust of 
public authorities, half 
(49%) of those who 
strongly disagreed that 
public authorities 
decide about which 
vaccines to recommend 
based on the best 
interests of the 

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Georgetown	Scientific	Research	Journal	

community and that 
public authorities 
should be able to 
mandate vaccination 
reported that they did 
not intend to be 
vaccinated. 

Teasdale, et al. 
(2021). 
Parental plans 
to vaccinate 
children for 
COVID-19 in 
New York 
city39

To assess 
intent among 
caregivers in 
NYC to 
vaccinate their 
young 
children, and 
assess reasons 
for hesitancy 

Online 
survey from 
March 9-
April 11, 
2021 

After 1,119 parents and 
caregivers of 
children under 12 
(no response rate 
given) 

Representative of 
NYC population of 
parents 

61.9% planned to 
vaccinate, 14.8% no, 
23.3% unsure 

Reasons for hesitancy: 
safety & effectiveness 
(81.2%), believe 
children are at low-risk 
for COVID-19 and 
don’t need vaccination 
(21.7%), medical 
reasons (16.6%), 
religious or 
philosophical reasons 
(9.5%)  

Teasdale, et al. 
(2021). Plans 
to Vaccinate 
Children for 
Coronavirus 
Disease 2019: 
A Survey of 
United States 
Parents40

To assess 
intent among 
caregivers in 
the U.S. to 
vaccinate their 
young 
children, and 
assess reasons 
for hesitancy 

Online, 
Community-
based, 
nonprobabilit
y survey 

March 2021 

After 2074 parents of 
children under 12 

Representative of 
US population 

49.4% plan to vaccinate 
child, 25.6% no, 25.0% 
unsure 

Reasons: potential 
safety or effectiveness 
concerns (78.2%), 
believe children are at 
low-risk of infection 
and do not need to be 
vaccinated (23.0%), 
medical reasons 
(11.2%), religious 
reasons (8.5%) 

Teherani, et al. 
(2021). Intent 
to Vaccinate 
SARS-CoV-2 
Infected 
Children in 
US 
Households: A 
Survey41

To assess 
vaccination 
intent among 
caregivers in 
the U.S. with 
children who 
had previously 
been infected 
with COVID-
19 

2 phone 
interviews of 
19-question
survey
April-Nov
2020 & Dec-
Jan 2021

1 before 
& 1 after 

102 in April-Nov 
2020 (initial survey) 
& 45 in Dec-Jan 
2021 (follow-up 
survey) 

51% initial 
response rate, 44% 
for follow-up 

Guardians of 
children who had a 
laboratory-
confirmed 

Initial: 45% endorsed 
vaccination for child, 
43% not, 12% might 

24 respondents from 
follow-up survey listed 
reasons for vaccine 
hesitancy: safety and 
side effect concerns 
(50%), lack of 
information (37.5%), 
can give you COVID-
19 illness (16.67%) 

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Georgetown	Scientific	Research	Journal	

diagnosis of 
COVID-19 (not 
nationally 
representative) 

40



41




	Table of Contents
	Letter From the Editors
	Increasing COVID-19 Vaccine Uptake in the United States: Addressing Reasons for Vaccine Hesitancy th
	An Analysis of the Effects of Frequency and Type of Physical Activity on Self-Esteem in Adolescent M
	Addressing American Obesity: A Policy Proposal
	The Select Agent Regulations: Structure and Stricture
	An Evaluation of the Human Impact of Climatic Factors in Cook County, Illinois
	An Evaluation of Food Insecurity in the D.C. Community
	About the Authors
	Meet the Staff
	Acknowledgements




