Vaccine hesitancy at both ends of the socioeconomic spectrum: a new paradigm for understanding the role of systemic inequity

Introduction

The coronavirus disease 2019 (COVID-19) vaccine is estimated to have prevented approximately 20 million deaths globally within one year of its release (1). Despite the established safety and effectiveness of the COVID-19 vaccine, under-vaccination has caused a multitude of preventable deaths. It is estimated that over half a million deaths in the United States alone could have been prevented with vaccination (2,3). While vaccine availability certainly contributes to these numbers, worldwide survey data from 2021 indicated that 40–50% of respondents were unwilling to receive available COVID-19 vaccines, with wide variation across and within countries (4). Vaccine hesitancy includes vaccine refusal but can also involve delaying vaccination, vaccinating on an alternative schedule to that which is recommended, or vaccinating as recommended but with concerns or uncertainty (5,6). Vaccine hesitancy is a complex problem fueled by multiple sources, including a recent focus on the influence on political orientation (7) and misinformation spread through social media (8). In this paper we focus on the role of systemic inequity on vaccine hesitancy in predominantly White, economically stratified countries, specifically as it pertains to racial/ethnic identity and economic status. While the bulk of research suggests that COVID-19 vaccine hesitancy is primarily a problem in historically marginalized communities, we present research that privilege [i.e., structural advantages resulting from membership in dominant groups (9)] is a strong predictor of vaccine hesitancy and must be considered to fully understand the impact of inequity on vaccine uptake. Further, we overview population-specific strategies for reducing vaccine hesitancy, identify gaps in the existing literature, and provide a new model for understanding vaccine hesitancy across the socioeconomic spectrum.

Framework for understanding the impact of systemic inequity on vaccine hesitancy

We propose a novel framework for understanding how systemic inequity contributes to vaccine hesitancy (Figure 1). This framework rests on the inevitable disparity between those who are historically marginalized by and those who benefit from the structural advantages resulting from system inequity. Below, we outline research linking marginalization to a learned fear and mistrust of public health authority, resulting from a history of abuse and neglect. Further we show how this fear and mistrust impact vaccine hesitancy among those who have been marginalized. Additionally, we address the impact of privilege (i.e., systemic advantages) on feelings of agency and superiority to public health authority, which in turn contributes to vaccine hesitancy. While there is markedly less research on the latter process, we outline the supporting research and call for future research to address this pathway more directly.

Figure 1 Inequity leads to vaccine hesitancy across both ends of the socioeconomic spectrum.

Marginalization and vaccine hesitancy

The disparity in vaccine hesitancy between historically marginalized racial/ethnic populations and White populations in predominantly White countries is well documented. When the COVID-19 vaccine was first made available in the United States, Black individuals were more likely to express hesitancy regarding the COVID-19 vaccine (10). Outside of the United States, other predominantly White nations report similar findings. In the United Kingdom, while total sample vaccine hesitancy was 18%, 71.8% of Black participants and 42.3% of Pakistani/Bangladeshi participants reported hesitancy (11). Compounding the impact of racial/ethnic marginalization on vaccine hesitancy is the oft concurrent influence of economic marginalization. A multitude of sources have identified higher levels of COVID-19 vaccine hesitancy among low-income populations living within wealthy nations with high levels of economic disparity. A meta-analysis of data from approximately 60,000 participants from 13 countries revealed that lower-income individuals in the UK, France, Ireland, and Australia were less likely to express willingness to vaccinate in 8 of the 9 studies examined (4). A cross-sectional study of 1,189 randomly selected residents of Vaud, Switzerland reported similar data, finding that lower income individuals were less likely than wealthier individuals to vaccinate against COVID-19 (12). A similar association was found in the United States, with lower income predicting decreased trust in healthcare officials and higher levels of vaccine hesitancy (13).

Fear and mistrust of public health authority

These findings are consistent with the theory that mistrust of medical professionals is a learned, protective trait among historically marginalized individuals resulting from a history of abuse and mistreatment (14). Across the global community, COVID-19 has disproportionately impacted members of historically marginalized communities (15,16). Members of these communities experience higher levels of physical and mental health conditions due in part to economic and social factors, namely poverty and health inequity, that increase stress and limit access to health resources (17). The same inequities that contribute to higher levels of infection, morbidity, and mortality also impact trust in healthcare systems as well as public health authorities and government officials. This, in turn, impacts attitudes toward vaccinations. Members of marginalized communities have historically shown mistrust in vaccines due to experiences of healthcare inequities (18), unethical medical experimentation (19), and underrepresentation in vaccine trials (20). For example, in the United States, Black individuals were the most likely of any racial group to report COVID-19 vaccine hesitancy, citing the country’s history of racism in medical care and research as a primary reason (21). Similarly, First Nations people in Canada made up over 70% of active COVID-19 cases (despite making up about 10% of the population), and still expressed significant vaccine hesitancy, citing concern about being expendable test subjects for vaccine testing (19). These fears are not unfounded, give that despite being at the greatest risk from COVID-19, ethnic minority groups were significantly underrepresented in COVID-19 vaccine trials (20). As such, the same factors that increase risk of infection, morbidity, and mortality from COVID-19 also contribute to vaccine hesitancy in marginalized individuals. In this way, vaccine hesitancy among historically marginalized individuals makes sense. Mistrust of medical professionals is a learned, protective trait among historically marginalized individuals resulting from a history of abuse and mistreatment (14).

Take together, these findings underscore the importance of understanding the learned fear that motivates vaccine hesitancy in historically marginalized populations. These motivations explain the efficacy of vaccine messaging that emerges from within a marginalized community, particularly from trusted community leaders (22). For example, initially low vaccination rates among American Indian and Alaskan Natives increased when specific efforts were made to frame the importance of vaccination within the cultural framework of community health and protection of native culture and peoples (23). This further illustrates the importance of cultural context on vaccine messaging, as COVID-19 messaging that reduced hesitancy in one country often did not have the same impact in other countries (24). Therefore, collaborating with trusted members of historically marginalized communities to direct vaccine messaging from within the community can be a viable means of increased vaccination. Not only is the input of in-group members critical for developing culturally appropriate messaging, but trusted leaders are also far more likely to impact their community members than outsiders.

Privilege and vaccine hesitancy

While COVID-19 vaccine hesitancy may be more prevalent within historically marginalized populations, it nonetheless remains a significant problem among White and wealthy individuals in wealthy countries. For one, vaccine hesitancy in any population impacts the effectiveness of vaccines (25). Vaccine effectiveness hinges on what happens at the population-level. Vaccination thresholds, which can be upwards of 95%, must be reached to achieve herd immunity, and eliminate an infectious disease. Additionally, local rates of vaccination are even more important than state or county-wide rates, which can mask unvaccinated pockets of the population. These small pockets can provide a foothold for an infectious disease, that can lead to widespread outbreaks (26).

Further, if COVID-19 vaccine uptake mirrors that of previous vaccines, we can expect to see increased refusal in these more privileged populations. Research based on data from 2016 in Australia found that postal codes associated with higher-income populations had lower compliance with Australia’s National Immunisation Program Schedule for childhood vaccines (27). Data from 2010 and 2018 across 86 low- and middle-income countries (28) found that 10 countries showed higher childhood vaccine coverage among poor individuals than wealthy individuals in 2018. Further, none of these countries showed lower vaccine rates among the wealthy in 2010. A study from Brazil identified similar trends, assessing four birth cohorts in 1982, 1993, 2004, and 2015 for childhood vaccination coverage in relation to paternal/maternal income and education. While high vaccination coverage was prevalent in children of the uppermost socioeconomic level in 1982, this statistic was reversed by 2015, making high-income children the least vaccinated socioeconomic group (29). There is already early evidence that the COVID-19 vaccine uptake will follow a similar trend. Longitudinal data from January to October 2021 revealed that while Black American populations had greater initial COVID-19 vaccine refusal and hesitancy, both declined rapidly. On the other hand, vaccine refusal among White American populations remained constant (22). This difference may be a result of more targeted efforts to reduce hesitancy in Black populations (22), or because the factors contributing to White hesitancy are more inherently stable. Unfortunately, there is significantly less research understanding factors that contribute to COVID-19 hesitancy among privileged populations.

Agency and superiority to public health authority

With COVID-19 vaccine hesitancy already beginning to follow the trend of other vaccine-preventable diseases, it is critical to understand the motivations for vaccine hesitancy among White and wealthy populations. Despite the importance of understanding this hesitancy, there is surprisingly little research quantifying these motivations. Pre-COVID-19 interviews with a high-income vaccine hesitant sample in Perth, Australia found that vaccine hesitancy was based on an inflated sense of agency in making medical decisions without doctors or public health officials, and a preference for “natural” methods of healthcare (30). Additionally, participants reported low perceived risk of infection or disease, contrasted with a high perceived risk of vaccination. A similar study in the United States reported on interviews from 25 White mothers in a wealthy community who refused vaccination for their children (31). These participants reported high levels of perceived personal efficacy in making health decisions for their children and higher confidence in preventing illness through individual “natural” measures such as eating organic food and exercising. Additionally, these participants report lower perceived risk of infection or disease, which is contrasted with their high perceived risk of vaccination. Essentially, the privilege of healthcare and other resource access serves as a safety net for these parents, bolstering their feelings of both safety and efficacy (31).

Vaccine hesitancy among those with privilege may be more than just a product of resource access. There is evidence that individuals with high socioeconomic status perceive themselves to be more capable, hardworking, important, and deserving of resources and privileges than others (32,33). These beliefs could foster a tendency to discount vaccine messaging from public health experts. Additionally, recognition of one’s own intellectual fallibility predicts more pro-vaccine attitudes (34). Thus, it seems likely that socioeconomic advantages contribute to an inflated sense of agency, which increases the likelihood of discounting public health experts, therefore increasing overall vaccine hesitancy.

While research on reducing vaccine hesitancy among White and wealthy individuals is sparse, one pre-COVID-19 study found success in messaging that framed vaccines in terms of the “natural” processes that are valued by White and wealthy individuals in wealthy countries. Higher income parents in Australia were more likely to respond positively toward vaccinating their children when practitioners emphasized that vaccines help children’s immune systems strengthen naturally and framed side effects as indicators of “self-strengthening and body renewal” (35). Another proposed pathway to reducing vaccine hesitancy among White and wealthy individuals is the imposition of legal restrictions places on unvaccinated people (24). While controversial, this same method was the primary factor that resulted in increased seatbelt usage after targeting messaging was largely ineffective (36). Given the controversial and systemic nature of changing legislation, it makes more sense in the short-term to focus on strategies that have been demonstrated to be effective with vaccine hesitancy, while simultaneously building research on the motivations behind vaccine hesitancy in White and wealthy populations.

Directions for future research

Despite a bulk of evidence that there is vaccine hesitancy on both ends of the socioeconomic spectrum, there is a noted dearth of literature on the psychological and systemic factors that contribute to vaccine hesitancy among White and wealthy individuals in wealthy countries. Previous research has focused almost exclusively on the impact of marginalization on vaccine hesitancy, with extensive research demonstrating the impact of marginalization and mechanisms through which it contributes to vaccine hesitancy. The research linking privilege to vaccine hesitancy, however, is much less extensive and focused primarily on population-level data. As such, there is little focus on the mechanisms through which privilege leads to vaccine hesitancy, and the broader framework of inequity is ignored. A comprehensive understanding of vaccine hesitancy requires that we address this issue with individual-level data at both ends of the socioeconomic spectrum, simultaneously assessing marginalization, fear and mistrust of public health authorities, privilege, perceived agency and superiority to public health authorities, and vaccine hesitancy (Figure 1). Demonstrating the holistic impact of inequity on vaccine hesitancy reframes the problem in an important way, emphasizing that vaccine hesitancy is not just a problem in poor minority communities or in wealthy White communities, rather, it is a byproduct of an inequitable system.

We close this paper by reiterating that vaccine hesitancy is a complex and multifaceted problem. While not the only antecedent of vaccine hesitancy, systemic inequity contributes to hesitancy at both ends of the socioeconomic spectrum. Our goal here is to present potential socioeconomically specific strategies for reducing vaccine hesitancy and to provide a framework to guide future research that can support vaccine advocacy. Systemic inequity is a barrier toa better functioning society for a multitude of reasons. The more we can demonstrate the impact of systemic inequity on vaccine hesitancy, the better position we will be in to advocate for change.

Acknowledgments

Funding: This work was supported by the Colgate University Student Wage Grant (to NAR).

Footnote

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-81/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-81/coif). N.A.R. was supported by the Colgate University Student Wage Grant. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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