PSYCHOSOCIAL FACTORS VACCINE HESITANCY
Author Note
I would like to acknowledgment the individuals who supervised and assisted me with
this project: Drs. Elizabeth Larsen, Justin Hackett, Joel Press, Craig Fox, and Mr.
Loring Prest
Correspondence concerning this article should be addressed to Dillon L. Shash at
sha9901@calu.edu
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PSYCHOSOCIAL FACTORS VACCINE HESITANCY
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Abstract
Background: The COVID-19 pandemic has caused millions of deaths worldwide.
Fortunately, multiple vaccines now exist and are readily available to the majority of
people. While all the available vaccines demonstrate high efficacy rates, some
reporting above 90% protection from infection, any vaccine is only effective if it is
accepted. Thus, vaccine hesitancy poses a threat to the success of controlling and
mitigating the pandemic. While vaccine hesitancy is multidimensional, the related
psychosocial factors are arguably the most crucial to understand and address.
Unfortunately, due largely to the novelty of the situation, the determinants of COVID19 vaccine hesitancy are not well studied. Therefore, the objectives of this study are:
(1) to understand the psychological and sociological factors that contribute to COVID19 vaccine hesitancy; (2) systemically review and report the current literature on the
topic of interest.
Methods: A systematic literature review was conducted on March 14, 2021 to identify
articles of interest. Search terms included those related to covid-19 and vaccine
hesitancy. Multiple databases were utilized including PsycINFO, SocINDEX,
MEDLINE Complete, and others.
Original research studies that were relevant to the topic of interest were included in the
review. The search was limited by date range, including articles published from 20192021.
Results: This review followed PRISMA guidelines. Given the search terms and
limitations, 122 articles were reviewed. Ultimately, 42 articles were included in the
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
study.
Discussion: Gender, SES, political influence, and social media, were commonly
reported social factors. Health beliefs, perceptions of COVID-19 and/or the vaccines,
and trust in healthcare providers and science were commonly reported psychological
factors.
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PSYCHOSOCIAL FACTORS VACCINE HESITANCY
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Introduction
The COVID-19 pandemic has caused mass mortality around the world.
Vaccines will largely be responsible for the success of mitigating and controlling the
virus. However, vaccine hesitancy will serve as a prominent barrier to against mass
vaccination efforts. This systematic review uses the World Health Organization’s
model of vaccine hesitancy to understand the psychosocial factors that currently relate
to COVID-19 vaccine hesitancy. It should be noted that vaccine hesitancy is not
synonymous with anti-vaccination and thus the focus of this review is specifically
interested in vaccine hesitancy.
Methods
To better understand and organize the current literature on the psychosocial
factors related to COVID-19 vaccine hesitancy, a systematic review was performed.
Such a review allows the researcher and the eventual consumer to conceptualize the
literature as a collective whole. The methods described below allow a researcher to
follow the same search and review process used in this article to then produce the
same results, and also allow the consumer to understand the exact methodology used.
It is important to note that this review followed PRISMA guidelines, a structured
method for reporting systematic reviews, and thus is organized as such (Page et al.,
2021). Additionally, a model of vaccine hesitancy provided in a report by the Strategic
Advisory Group of Experts on Immunization serves as the basis for study inclusion as
well as the presentation of results (Eskola et al., 2014). The model is presented in
Figure 1.
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
Figure 1
SAGE Working Group Determinants of Vaccine Hesitancy Matrix
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PSYCHOSOCIAL FACTORS VACCINE HESITANCY
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Information Sources and Search Strategy
A search was performed on March 14, 2021 using online resources offered
through the library’s website of California University of Pennsylvania. It total, six
databases were utilized in the search: APA PsycArticles, APA PsycInfo, MEDLINE
Complete, Psychology and Behavioral Sciences Collection, SocINDEX with Full Text,
and Sociological Collection. Due to the psychosocial focus on the review, the author
considered these databases as the most capable of providing an extensive list of
relevant articles. Search terms were divided between two search fields. The first search
field pertained to terms related to COVID-19, and was formatted as follows: “covid19” or “coronavirus” or “2019-ncov” or “sars-cov-2” or “cov-19”. The second search
field included terms related to vaccine hesitancy with an “AND” separating it from the
first search field and was formatted as follows: “vaccine hesitancy” or “vaccine
refusal” or “vaccine acceptance” or “anti-vaccine” or “anti-vaccination”. Quotation
marks were included around each search term or phrase to ensure it would be searched
for exactly as written. In both search fields, the terms were limited to the abstract of the
articles. This step was taken to enhance the relevancy of the resulting articles. The
search was also limited by date, including articles only from the range of 2019 to
2021. This step was taken to also enhance relevancy as the COVID-19 pandemic
began in the year 2019. Due to the nature of the review, the search was also limited to
peer reviewed journal articles. It should be noted that as an expander, items were
searched within the full-text of the article. Finally, duplicate articles were removed
automatically.
Synthesis and Selection of Studies
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
The final number of articles that resulted from the library search were then
exported as a CSV file which was then converted and uploaded to Microsoft Excel
(Microsoft 365, Version 2104). The articles were automatically formatted to include
available information such as the article title, authors, DOI, abstract, and various other
fields. All articles were there reviewed to determine inclusion. Original research
articles with a major focus on the psychosocial factors related to COVID-19 vaccine
hesitancy were included in the review. However, numerous articles did not meet this
inclusion criteria and were thus excluded from this review. Despite limitations present
in the search, multiple non-empirical articles were included in the final set. Such
articles included commentaries, clinical opinion/guidelines, systematic and metaanalytic reviews, and any other format that was not an original research study were
excluded. Additionally, any article deemed irrelevant to the topic of interest was also
excluded. Specifically, this review was interested only with factors contributing to
vaccine hesitancy concerning COVID-19 vaccines. As stated previously, vaccine
hesitancy is not synonymous with anti-vaccination and thus articles discussing such
were excluded. Also, those lacking a focus on COVID-19 related vaccine hesitancy in
major part or in full were excluded. Finally, articles that were not in the English
language and did not provide information for a translated article were excluded due to
the lingual limitations of the author.
Quality and Bias Assessment
The author of this review served as the sole researcher and thus was
responsible for conducting the library search, synthesizing the studies, determining
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PSYCHOSOCIAL FACTORS VACCINE HESITANCY
8
study inclusion and exclusion, and performing the quality assessment. To reduce bias
and increase consistency, articles were reviewed multiple times and on different
occasions. Specific software or instruments to assist in quality assessment were not
utilized in this review. However, numerous characteristics of the studies reviewed
were considered when assessing quality. Such characteristics include: sample size and
demographics, presence of validated measures, statistical analysis/analyses used,
author reported limitations, and definitions of key terms. General characteristics of
research studies and statistical interpretation used to assess quality were also
considered (e.g. larger sample sizes increase the generalizability of the study). Finally,
it should be noted that the author corresponded with and received guidance from the
individuals referenced in the acknowledgment while completing this article.
Results
This review ultimately included 42 studies from six different databases. This
final count started from an original search total of 518 results, which was then reduced
to 122 after the search limitations were applied. The process of how the final number
of studies were chosen for inclusion is represented in Figure 2. Ultimately, all 42
included articles represented original research studies with a grand total sample size of
n = 121,013 (Females n = 75,032; Males n = 32,972; Non-binary n = 32; Other
categories n = 12,977). A vaccine hesitancy rate was explicitly reported in 17 studies
(M = 31 %; SD = 18% CI {13, 49}). Studies mainly took place in the United States,
but numerous countries were represented in all: China, Egypt, Cameroon, France,
England, Japan, Kuwait, Turkey, Italy, Qatar, Jordan, United Kingdom, Dominican
Republic, among others.
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
Figure 2
PRISMA 2020 Flow Diagram
Identification
Identification of studies via databases
Records identified from:
Databases (n = 518)
Records removed before
screening:
Records removed from limit
to peer reviewed (n = 84)
Records removed from limit
to dates 2019-2021 (n = 21)
Records removed from limit
to abstract first search field
(n = 162)
Records removed from limit
to abstract second search
field (n = 118)
Duplicate records removed
(n = 11)
Included
Screening
Records screened
(n = 122)
Reports assessed for eligibility
(n = 122)
Studies included in review
(n = 4)
Reports excluded:
Relevancy (n = 39)
Non-empirical (n = 28)
Strength of Focus (n = 11)
Article withdrawn (n = 2)
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PSYCHOSOCIAL FACTORS VACCINE HESITANCY
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Contextual Influences
Contextual influences include the social, political, cultural, and economic
factors related to vaccine hesitancy (Eskola et al., 2014). For a full description of the
facets listed below, see the Appendix. In total, this section includes 41 entries.
Communication and Media Environment
A total of seven studies were included in this facet, all of which found that media
consumption has a significant effect on vaccine intention. Six of the studies reported
that consumption of information via social media was related to negative attitudes
towards a COVID- 19 vaccine and thus an overall increased rate of hesitancy (Alabdulla
et al., 2021; Dinga et al., 2021; Murphy et al., 2021; Romer & Jamieson 2020; Saied et
al., 2021; Sallam et al., 2021). In contrast, one study reported a positive effect of
consumption of mainstream news sources on vaccine acceptance (Salali & Uysal, 2020).
Influential leaders, immunization program gatekeepers and anti- or pro-vaccination
lobbies
Only one study was included in this facet. The study found that opinions on
COVID-19 vaccines produced by the World Health Organization and the US Centers
for Disease Control were correlated with higher acceptance rates than when compared
to opinions coming from US President Donald Trump (Kreps et al., 2020).
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
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Religion/culture/gender/socio-economic
Table 1
Article findings for Religion/culture/gender/socio-economic facet
Author(s) Gender Ethnicity
Income
Religion
AlMohaithef &
Padhi
(2020)
Alqudeimat Male**
et al. (2021)
Bell et al.
(2020)
Callaghan et Female
al. (2021) *
Chen et al
(2021)
NS
Detoc et al. Male**
(2020)
Ditekemena NS
et al. (2021)
Freeman et Female
al. (2020) *
GagneuxBrunon et al.
(2021)
Gerussi et
al. (2021)
Hursh et al.
(2020)
Khubchanda
ni et al.
(2021)
Male**
-
-
-
Marital
Status
Married**
-
NS
-
Married**
Lower
income*;
Higher
income*
*
Higher
income*
*
Higher
income*
*
-
-
Non-white*
Black*
NS
-
Black and
mixed*
Middle
income*
*; High
income*
*
Lower
income*
Religiosity
*
-
Education
level
Postgraduate
or higher**
NS
-
-
Higher
education**
-
-
Lower
education**
-
-
-
NS
NS
NS
Not single
or
widowed*
-
Lower
education*
-
-
-
-
NS
NS
NS
-
-
-
Male**
NS
-
-
-
-
Female
*
AfricanAmericans*;
Hispanics*
-
NS
Lower
income*
-
Lower
education*
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
Kreps et al. Female
(2020) *
Kuter et al. Male**
(2021)
Latkin et al. Female
(2021) *
Malik et al.
(2020)
Meier et al.
(2021)
Mercadante
& Law (in
press)
Male**
Montagni et
al. (2021)
Murphy et
al. (2021)
Olagoke et
al. (2020)
Pogue et al.
(2020)
Female
*
Female
*
NS
Male**
Nonbinary*
NS
Roozenbeek Male*
et al. (2020)
Salali & Male**
Uysal (2020)
Sallam et al. Male**
(2021)
Schwarzinge
r et al.
(2021)
Scott et al.
(2021)
Shekhar et
al. (2021)
Skjefte et al.
(2021)
Female
*
Female
*
-
Black*
Black*;
Hispanic*;
Multiple/Oth
er races*
Black*;
Hispanic*
Asian**;
Black*
Non-Black**
NS
-
Higher
income*
*
-
Black*;
American
Indian**;
Alaska
Native**;
Asian/South
Asian**
-
Lower
income*;
Higher
income*
*
Non-Irish*
Lower
income*
NS
Black*
NS
NS
-
-
Swartzentrub
er Amish*
Black*;
Lantinx*
-
-
Higher
income*
*
Higher
income*
*
-
Higher
income*
Lower
income*
12
NS
-
Religious
belief*
-
Higher
education**
Postgraduate
**
-
NS
Lower
education*
-
-
-
-
-
-
-
NS
-
NS
-
NS
Religiosity NS
*
-
NS
Higher
education**
Higher
education**
Higher
education**
-
-
NS
-
-
-
-
Higher
education*
Higher
education**
-
-
-
-
-
NS
-
Single*
Lower
education*
Higher
education*
Lower
education*
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
Unroe et al. Male** White**
(2021)
Wang et al. Male**
(2021)
Yigit et al. Female
(2021) *
Yoda & Male**
Katsuyama
(2021)
Note. NS = Not significant
*Increased vaccine hesitancy
**Increased vaccine acceptance
-
Religiosity
*
Unmarried
**
Religiosity
*
Religiosity
*
13
NS
Higher
education*
-
A total of 33 studies were included in this facet and are outlined in Table 1. Of
them, 24 concluded that gender was a significant factor relating to vaccine hesitancy
and acceptance. Within these articles, 14 report male gender as the predominant factor
with 13 articles finding it related to increased vaccine acceptance. In contrast, 10
articles reported female gender as the predominant factor, all of which finding related
to increases in vaccine hesitancy. One article reported non-binary participants as the
predominant gender related to increases vaccine hesitancy. Regarding race, 15 articles
reported significant correlations to vaccine hesitancy. African American/Black
participants most commonly reported attitudes and behaviors indicative of vaccine
hesitancy in 10 of the articles. In terms of income, 13 articles reported significant
correlations with six finding low incomes most strongly related to vaccine hesitancy.
Six articles mention religion and religious beliefs as playing a role in attitudes and
behaviors indicative of vaccine hesitancy. Only five articles found marital status as a
significant factor and the results are mixed when considering its relationship to
vaccine uptake. Finally, 17 articles reported education level as a significant factor with
highly consistent results of lower education levels leading to increased vaccine
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
14
hesitancy and higher levels leading to increased acceptance.
Individual and Group Influences
Individual and Group Influences include the social psychological factors that
relate to vaccine hesitancy (Eskola et al., 2014). For a full description of the facets
listed below, see the Appendix. In total, this section includes 19 articles.
Beliefs, attitudes about health and prevention
Five articles were included in this facet. Three of the articles found that
participants with certain beliefs about health and prevention, such as a preference for
natural immunity via exposure as well as support for various forms of non-empirical
medical treatments like homeopathy, were positively correlated with vaccine hesitancy
(Alabdulla et al., 2021; Alqudeimat et al., 2021; Čavojová et al., (2020). Additionally,
another study found that external health locus of control was positively correlated with
vaccine hesitancy (Olagoke et al., 2020). In contrast, health engagement was positively
correlated with vaccine acceptance (Graffigna et al., 2020).
Health system and providers-trust and personal experience
Table 2
Article findings for Health system and provider-trust and personal experience facet
Authors Health
Government/Institutions Vaccines
Experts/Scientists
System
Al-Mohaithef High trust
& Padhi increased
(2020) vaccine
acceptance
Bell et al.
High trust increased
Low trust
increased
(2020)
vaccine acceptance
vaccine
hesitancy
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
Callaghan et
al. (2021)
-
-
Ditekemena et
al. (2021)
-
-
Freeman et High mistrust
al., (2020) increased
vaccine
hesitancy
Lucia et al.
(2020)
-
-
15
-
Low trust
increased
vaccine
hesitancy
High mistrust
increased
vaccine
hesitancy
-
Murphy et al. Low trust
(2021) increased
vaccine
hesitancy
Palamenghi et
al. (2020)
Low trust increased
vaccine hesitancy
Pogue et al. Low trust
(2020) increased
vaccine
hesitancy
Prati (2020)
-
Low trust increased
vaccine hesitancy
-
Low trust increased
vaccine hesitancy
Low trust increased
vaccine hesitancy
-
Roozenbeek et
al. (2020)
-
Shekhar et al. Low trust
(2021) increased
vaccine
hesitancy
Skjefte et al.
(2021)
Wong et al. High trust
(2021) increased
vaccine
acceptance
-
-
-
High trust
increased vaccine
acceptance
-
-
High trust
increased vaccine
acceptance
Low trust
increased vaccine
hesitancy
High trust
increased vaccine
acceptance
-
-
-
Low trust
increased vaccine
hesitancy
-
High trust
increased vaccine
acceptance
-
Low trust increased
vaccine hesitancy
High trust increased
vaccine acceptance
-
High trust
increased
vaccine
acceptance
A total of 14 articles were included in this facet and are outlined in Table 2. Six
studies found that trust in the health system was correlated with vaccine uptake where
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
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high trust correlated with acceptance and low trust with hesitancy. Seven studies
reported significant correlations with trust in government and institutions with five of
the studies finding low trust increased vaccine hesitancy and the remaining two studies
finding high trust increased acceptance. Four studies report trust in vaccines
themselves as the related variable to vaccine intention, three of which finding low trust
increased hesitancy and one finding high trust increased acceptance. Finally, six
studies referenced trust in experts or scientists where high trust increased vaccine
acceptance in four of the studies and low trust increased hesitancy in two.
Discussion
This systematic review highlights the diversity and significance of the
psychosocial factors related to vaccine hesitancy. Specifically, this review outlines the
psychological and sociodemographic factors related to vaccine hesitancy as it pertains
to COVID-19 vaccines. To this regard, there are numerous sociodemographic factors
related to vaccine hesitancy including race, gender, religion, and socioeconomic status
(see table 1). Social media appears to be related to vaccine hesitancy in a number of
ways. In the most general sense, social media use has been associated with negative
views about vaccines including that they are unsafe and ineffective (Wilson &
Wiysonge, 2020). Additionally, social media is used as a medium to spread antivaccine views and gather supporters of the anti-vaccine movement (Johnson et al.,
2020). Race is yet another factor greatly contributing to vaccine hesitancy as shown by
a preprint article of over one million participants that found African Americans to have
the highest rates of hesitancy (Nguyen et al., 2021). Of course, many psychological
factors are also involved in accepting vaccines. Belief and trust in healthcare providers,
PSYCHOSOCIAL FACTORS VACCINE HESITANCY
science, politicians, vaccines, and a host of other sources seem to play a significant
role (Hamel et al., 2020). This review is not without its limitations. Search limitations
and study selection may have removed articles that would have otherwise been
included and contributed to the review. Additionally, due to the author’s status as the
sole researcher and reviewer there is an inherent, perhaps moderate level of bias. In
conclusion, future reviews should include studies and data about vaccine hesitancy
after COVID- 19 vaccines are widely available.
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PSYCHOSOCIAL FACTORS VACCINE HESITANCY
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Appendix
Figure A1
Description of Contextual Influences (Eskola et al., 2014)
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Figure A2
Description of Individual and Group Influences (Eskola et al., 2014)
29