Surgo Ventures

What are the top COVID-19 vaccine barriers Americans worry about in each state?

The results of our national survey show the top anticipated barriers are are appointment availability, not having the time to get vaccinated, and concerns over cost

The findings of our largest survey of U.S. adults to date — 17,907 people — provide a blueprint for state and local leaders to achieve President Biden’s stated goal of ensuring 70% of U.S. adults get at least their first shot by the Fourth of July.

In analyzing the results of the survey, which was completed on April 14, 2021 in collaboration with Facebook, we identified the vaccine barriers that are currently driving reluctance among unvaccinated adults in each state.

We also identified the states where its five designated COVID-19 vaccine “personas” — The Enthusiasts, The Watchful, The Cost-Anxious, The System Distrusters, and The COVID Skeptics — are most prevalent.

As we predicted just a few weeks ago, boosting COVID vaccine uptake in the U.S. is a whole lot harder now that demand is flagging. President Biden has set a good, aggressive goal to help us overcome this challenge.

However, it won’t work without focusing on the exact reasons why people aren’t committing to get vaccinated, and offering specific, localized solutions to overcome those barriers.

States are going to have to get really creative in their solutions for bringing the vaccine as close to people as possible.

This means experimenting with different models, including neighborhood vans, making vaccines available at workplaces, supermarkets, or other convenient places, and offering smart incentives — both monetary and non-monetary — to get people to commit. There is lots of evidence from global health showing that this works.

Notably, we found that in states where unvaccinated individuals were most enthusiastic, people anticipated barriers to vaccination at much higher rates, suggesting that people don’t start thinking more concretely about barriers until they’ve confirmed that they even want to get vaccinated.

Because of this finding, we divided the survey’s key findings among barriers anticipated by U.S. adults who have not yet been vaccinated and barriers actually experienced by U.S. adults who had already been vaccinated with at least one dose.

Dataviz showing 10 different vaccine barriers for non-vaccinated people in each state. The top five states are highlighted for each barrier. At the bottom an additional graph shows non-vaccinated people in each state who don’t plan to get vaccinated.
Dataviz showing 10 different vaccine barriers for non-vaccinated people in each state. The top five states are highlighted for each barrier. At the bottom an additional graph shows non-vaccinated people in each state who don’t plan to get vaccinated.
Dataviz showing 10 different vaccine barriers for vaccinated people in each state. The top five states are highlighted for each barrier.
Dataviz showing 10 different vaccine barriers for vaccinated people in each state. The top five states are highlighted for each barrier.

Key Findings

The top reported barriers by non-vaccinated individuals are appointment availability, having the time to get vaccinated, and concerns over cost. These barriers, however, vary state by state. In Alabama and Mississippi, which have the lowest vaccination rates, policymakers will want to focus on increasing appointment availability and exploring ways to reduce the time-burden of vaccination. In Wyoming and Idaho, state officials should focus on emphasizing that vaccination is free of cost and educating on how to schedule an appointment.

  • Opportunity Area: States should focus on the barriers most prominent for their populations to immediately increase vaccine uptake. Addressing these barriers will help close the gap between vaccine intention and action for individuals already primed for vaccination.

Specific vaccine personas are more prevalent in certain states. Arkansas, North Dakota, and Nevada should focus their efforts on COVID Skeptics while Mississippi and Alaska should prioritize the concerns of the Cost-Anxious. Respectively, Delaware, Hawaii, and Rhode Island should invest in interventions for Watchful individuals, and Washington, D.C., and Maryland should develop strategies to respond to the concerns of System Distrusters.

  • Opportunity Area: States should focus on interventions that build confidence in the vaccine based on the most prevalent personas in their population. These efforts should be informed by local context, looking different even for states with the same most prevalent segment. For example, COVID misinformation circulating in Arkansas is likely different from Nevada. System Distrusters in Idaho differ from those in Georgia.

Black, Latinx, and white respondents fall across all five personas, indicating that we cannot treat racial categories as monoliths. However, there are some patterns in which personas are most prevalent. Higher proportions of white respondents identify as COVID Skeptics (17.7% in March) compared to Latinx (13.2%) and Black (10.7%) respondents. System Distrusters are more likely to identify as Black (18%) and Latinx (11%) than white (4%). Differences between racial subgroups in percentage of Enthusiasts shrunk over time. In March, over 20% of respondents from across all racial and ethnic groups identified as Enthusiasts.

  • Opportunity Area: Inequities in vaccine uptake have been reported across the country by the CDC. To close the equity gap in vaccination, we need to address the unique concerns that Black and Latinx individuals have, which our national data show are heterogenous. Ensuring racial equity in vaccination will require tackling both issues of access and concerns about vaccination. We can look state by state to see which personas and barriers are most prevalent for minority populations. By broadening the conversation around identity to include multidimensional barriers and beliefs, policymakers can take an equity-oriented approach while explicitly addressing the valid concerns of their constituents.

Vaccine personas, belief in conspiracy theories, and anticipated vaccination timelines vary across the political spectrum. Republicans remain overrepresented in the COVID Skeptic persona, but that number has fallen over time, from 33% in January to 26% in March. Republicans (61%) and Independents (41%) are much more likely to believe in any conspiracy theory compared to Democrats (25%). Across all political groups, between 20 and 30% of respondents said they want to wait at least three months to get vaccinated or don’t know when they will get vaccinated.

  • Opportunity Area: The discourse around political affiliation is not helpful in addressing underlying drivers of vaccine reluctance as it reduces individuals to one facet of their identity. Localized efforts should focus on combating misinformation around COVID-19 that spans party lines, increasing access to vaccination, and emphasizing the benefits of vaccination that most appeal to specific subpopulations, such as gathering with family, going to church, socializing with friends, traveling, and attending sporting events.

How to Address These Barriers

Following is a sampling of our proposed solutions for reaching the five vaccine personas.

The Enthusiasts

  • Make it as easy as possible for them to get the vaccine.
  • Make it visible that they’ve been vaccinated, on social media or elsewhere.

The Watchful

  • Make it visible that others are vaccinated or have positive intent to be vaccinated.
  • Capitalize on positive social norms.
  • Have health providers assuage concerns around side-effects.
  • Allow for uncertainty through a “vaccinate later” option.

The Cost-Anxious

  • Prioritize communication from credible messengers that vaccination is totally free.
  • Bring vaccines to people.
  • Offer employees paid time off to get the vaccine.
  • Make the process easy and remove “sludge” in the registration process by eliminating information that is not critical.

The System Distrusters

  • Listen and learn from community concerns.
  • Partner with trusted community organizations, providers, etc. and ensure thoughtful location choices for vaccines.
  • Make it visible that the community is getting vaccinated.
  • Track and illuminate efforts for equity in vaccine distribution.

The COVID Skeptics

  • Enlist nonpolitical figures trusted by this group as vaccine ambassadors.
  • Lead with the facts, explain how the information they’re sharing or consuming is misleading, and end by reinforcing the facts again.
  • Prevent misinformation from taking wider hold in the population.

For more information on the top barriers by state and relevant solutions, read the full survey report: Leveraging Precision Health to Increase COVID-19 Vaccine Uptake: A Geographic Overview of Barriers and Beliefs.

See a visual explainer about the COVID-19 vaccine personas and our approach to psychobehavioral segmentation here.

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