Self-reported COVID-19 vaccine hesitancy and uptake among participants from different racial and ethnic groups in the United States and United Kingdom – – DC Initiative on Racial Equity
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Worldwide, racial and ethnic minorities have been disproportionately impacted by COVID-19 with increased risk of infection, its related complications, and death. In the initial phase of population-based vaccination in the United States (U.S.) and United Kingdom (U.K.), vaccine hesitancy may result in differences in uptake. We performed a cohort study among U.S. and U.K. participants who volunteered to take part in the smartphone-based COVID Symptom Study (March 2020-February 2021) and used logistic regression to estimate odds ratios of vaccine hesitancy and uptake. In the U.S. (n = 87,388), compared to white participants, vaccine hesitancy was greater for Black and Hispanic participants and those reporting more than one or other race. In the U.K. (n = 1,254,294), racial and ethnic minority participants showed similar levels of vaccine hesitancy to the U.S. However, associations between participant race and ethnicity and levels of vaccine uptake were observed to be different in the U.S. and the U.K. studies. Among U.S. participants, vaccine uptake was significantly lower among Black participants, which persisted among participants that self-reported being vaccine-willing. In contrast, statistically significant racial and ethnic disparities in vaccine uptake were not observed in the U.K sample. In this study of self-reported vaccine hesitancy and uptake, lower levels of vaccine uptake in Black participants in the U.S. during the initial vaccine rollout may be attributable to both hesitancy and disparities in access.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the COVID-19 pandemic have claimed 4.6 million lives among 221 million confirmed cases worldwide1. The speed and urgency with which multiple vaccines have been authorized for use in the United States (U.S.)2, the United Kingdom (U.K.)3,4,5, and elsewhere6 represent an unrivaled scientific achievement. However, there is a critical need for effective vaccine delivery to realize the promise of ending the pandemic. Logistical hurdles and supply chain difficulties plagued the early phase of a massive global vaccination campaign, particularly in the U.S. While rates have improved considerably in the months since, by February 2021, only 17 doses of vaccine per 100 individuals had been administered in the U.S. compared with 24 per 100 in the U.K6.

Racial and ethnic minorities are at particularly increased risk of COVID-19, its related complications, and death7,8,9. Nonetheless, eligibility for most vaccine programs has prioritized health care workers (HCW), older adults and those with comorbidities, but have not considered race or ethnicity10. In addition to concerns over fairness and availability, a substantial barrier to uptake in racial and ethnic minority communities is vaccine hesitancy, which may be rooted in ongoing discrimination and prior injustices that have resulted in deeply seated mistrust of the medical system11,12.

The U.S. and U.K. have racially and ethnically diverse populations that have been disproportionately affected by the COVID-19 pandemic7,8,9. In contrast to the U.K., which has centralized vaccine delivery and data collection through the National Health Service, initial U.S. efforts were led by fragmented state and local health authorities that had not routinely collected information on race, ethnicity, or vaccine hesitancy13 and have not adhered to uniform eligibility criteria14. In both countries, there have been reports of racial and ethnic disparities in vaccine uptake, but specific data across a broad community-based sample, particularly in the U.S., are lacking15,16,17,18.

In this work to assess the real-world impact of the initial phase of these vaccination programs, we use an established smartphone-based data collection tool19 to conduct a comparative population-based cohort study to examine country-specific variation in racial and ethnic disparities in vaccine willingness and uptake. We find that racial and ethnic minorities are up to three times as likely to report either being unsure or unwilling to obtain a COVID-19 vaccine, and though some degree of vaccine skepticism is noted among racial and ethnic minority groups in the U.S. and U.K., we observe particularly low vaccine uptake among Black individuals in the U.S., even among those willing to undergo vaccination.


Study population

From 24 March 2020 to 1 February 2021, we enrolled a total of 4,797,306 individuals (n = 370,282 U.S. participants and n = 4,427,024 U.K participants), of whom 1,605,019 individuals were active and logged at least one entry in December 2020 (i.e., 2 weeks prior to the initial vaccine questionnaire). After excluding participants who did not provide information on their racial or ethnic identity and restricting to those who responded to at least one vaccine questionnaire, a final analytic cohort of 1,341,682 individuals remained; Suppl. Fig. 1).

In the U.S., white participants tended to be older and reside in communities with higher income and educational attainment compared to Black or Hispanic participants (Suppl. Methods and Suppl. Table 1). Black and Hispanic participants more frequently reported being a frontline HCW and having previously been infected with SARS-CoV-2. Similar trends were observed among U.K. participants.

Vaccine hesitancy among racial and ethnic minorities

Among 1,228,638 individuals who answered the question on vaccine willingness, 91% of U.S. participants and 95% of U.K. study participants were willing to accept a COVID-19 vaccine if offered (Suppl. Table 2). In the U.S., participants who were hesitant (unwilling or unsure, respectively) tended to be younger, female, less likely to have had heart disease or cancer, and more likely to live in communities with lower average educational attainment and median incomes. Among frontline HCWs, 7% were unwilling to pursue vaccination and 13% were unsure, compared to 2 and 7%, respectively, across the entire U.S. study population. Similar (younger) age distributions, burden of chronic disease, proportion of frontline HCWs, and rates of prior SARS-CoV-2 infection were observed among U.K. participants.

In both the U.S. and U.K., racial and ethnic minority participants were more likely to report being unsure or unwilling to undergo vaccination. In the U.S., compared to white participants, the age-adjusted ORs for vaccine hesitancy were 3.84 (95% CI: 3.51–4.21) for Black participants, 1.69 (95% CI: 1.53–1.86) for Hispanic participants, and 1.22 (95% CI: 1.03–1.38) for Asian participants, and 2.14 (95% CI: 1.82–2.52) for those who reported other or more than one race (Table 1). Additional adjustment for relevant covariates did not materially alter these risk estimates. We performed a sensitivity analysis to address the possibility of undersampling of certain populations and to assess overall study generalizability by applying a country-level correction for age, sex, and race and ethnicity survey sampling rates using inverse probability weighting (IPW) which demonstrated comparable findings to our primary analyses, though vaccine hesitancy among Asian participants in the U.S. was no longer significantly different from white participants in the U.S. (Suppl. Table 3). Similar degrees of hesitancy were observed among racial and ethnic minorities in the U.K., which was most striking among Black participants (Table 1).

Table 1 Vaccine hesitancy by race and ethnicity according to country of enrollment.

In the U.S., we observed regional differences in willingness to be vaccinated with greater hesitancy in participants in the South (Suppl. Table 4). In the U.K., compared to participants in England, the age-adjusted ORs for vaccine hesitancy was 1.38 (1.25–1.51) for participants in Northern Ireland and 1.10 (1.06–1.15) in Wales. These were not substantially altered after additional adjustment in multivariable models.

When exploring the specific reasons for reluctance, the most frequently indicated concerns among all races and ethnicities related to long-term side effects (50–57%) and adverse reactions (45–54%). Additionally, Black and Hispanic participants cited a lack of knowledge about the vaccine (45–51%) at a higher rate than white participants (37–42%; Suppl. Table 5).

Racial and ethnic disparities in COVID-19 vaccine uptake

Based on eligibility in the initial phase of mass vaccinations, as expected, vaccinated participants tended to be older, had greater comorbidities, and were considerably more likely to be frontline HCWs (Suppl. Table 6). In the U.S., Black participants were less likely to be vaccinated than white participants (OR 0.71, 95% CI: 0.64–0.79), even after adjusting for age, region, comorbidities, and occupation as a HCW (Table 2). In a subgroup analysis, these associations persisted even when we limited analysis to participants who reported vaccine-willingness (Table 3). In contrast, in the U.K, Black, South Asian, and Middle East and East Asian participants reported lower vaccination rates than white participants in this initial phase of the vaccine rollout, though adjustment for personal and community risk factors attenuated these results. Multivariable risk estimates were comparable after inverse probability weighting (Suppl. Table 3).

Table 2 Vaccine uptake by race and ethnicity according to country of enrollment among all participants.
Table 3 Vaccine uptake by race and ethnicity according to country of enrollment among the vaccine-willing.

The disparity in vaccine uptake among Black participants compared with white participants differed significantly by country of study (Pheterogeneity < 0.001). When compared to white participants within their respective countries, Black participants were less likely to be vaccinated in the U.S. compared with Black participants in the U.K. (Fig. 1). Compared to the Northeast of the U.S., vaccine uptake was comparatively greater in other parts of the U.S. In the U.K., England appeared to have greater levels of vaccine uptake compared to other countries where increased vaccine hesitancy has been documented (Suppl. Table 7)20.

Fig. 1: Disparity in vaccine uptake by race and ethnicity according to country of enrollment.
figure 1

Risk estimates of receiving a vaccine through 1 February 2021 calculated within the country using multivariable logistic regression conditioned upon age, sex, and date of study entry and adjusted for personal history of diabetes, heart disease, lung disease, kidney disease, current smoking status, body mass index, prior reported history of COVID-19 infection, frontline healthcare worker status, and education and income at the community level. Data are presented as multivariable OR estimates ±95% CI. Pinteraction was calculated using the Wald test for the cross-product terms between race and ethnicity and country, Pinteraction = for Black vs. white and 0.106 for all other races and ethnicities compared with white participants, respectively. N = 1,110,544 for white U.K. participants, 64,144 for white U.S. participants, 8787 for Black U.K. participants, 2179 for Black U.S. participants, 35,657 U.K. participants of other races and ethnicities, and 7327 U.S. participants of other races and ethnicities, respectively. Source data are provided with this paper. CI confidence interval, OR odds ratio.

Vaccine uptake among Black participants in the U.S. study was comparable among specific sociodemographic groups, including frontline HCWs (Table 4). Notably, in the U.K. study, Black participants that were frontline HCWs had lower vaccine uptake than their white counterparts (Table 5). Black U.S. participants living in communities with lower educational attainment also had lower vaccine uptake (Table 6). Finally, no consistent differences were observed in localized vaccine symptoms (e.g., pain or swelling among others) according to race and ethnicity (Suppl. Table 8).

Table 4 Vaccine uptake by race and ethnicity according to country of enrollment among frontline healthcare workers and the general community.
Table 5 Vaccine uptake by race and ethnicity according to country of enrollment by economic deprivation.
Table 6 Vaccine uptake by race and ethnicity according to country of enrollment by educational attainment.


Among 1,341,682 participants in the U.S. and U.K., we observed increased COVID-19 vaccine hesitancy among racial and ethnic minority participants. Further, through the early phase of each country’s mass vaccination campaign (data through 1 February 2021), we revealed significant racial and ethnic disparities in uptake in the U.S., but not the U.K., even among the vaccine-willing, suggesting issues related to access may underlie the observed lower vaccine uptake among minority populations in the U.S. Interestingly, we observed a higher than anticipated rate of vaccine hesitancy among frontline HCWs, perhaps due to their substantially higher rate of prior COVID-19 infection21 and heightened concern about safety.

Our findings of greater vaccine hesitancy among minority participants confirm findings from prior investigations with smaller sample sizes22,23,24. Deep-rooted and ongoing mistrust of the medical system among people of color25 and a lack of diverse representation in clinical trials26,27 may play a role in explaining this hesitancy. Moreover, racial and ethnic minorities who have already borne the disproportionate brunt of the pandemic28,29 may have been taking a more cautious approach to new vaccines. Our data did not reveal differences in self-reports of localized injection-site reactions by race or ethnicity. Prior work specifically examining attitudes toward COVID-19 vaccines further support our findings. A recent randomized controlled trial demonstrated that COVID-19 vaccine misinformation significantly reduced vaccination intent in the U.K. and U.S30. Notably, in that study, differences in susceptibility and receptiveness were observed across sociodemographic groups.

Our results demonstrating lower early vaccine uptake among communities of color have been shown in other studies, though uptake has improved somewhat in the latter phase of the vaccine rollout31,32. A recent study of U.K. HCWs showed substantially lower vaccine uptake among racial and ethnic minorities33. Our results extend these data by concurrently examining vaccine hesitancy and vaccine uptake within the same participants from community-based samples in two countries. We found that even among the vaccine-willing participants in the US with access to smartphone technology in the early phases of the mass vaccination campaigns, Black participants were less likely to receive a vaccine, whereas in the U.K. study, no consistent disparities in vaccine uptake were observed.

The strengths of our study include the prospective population-scale enrollment of a diverse group of participants from two comparably afflicted nations using a common data collection instrument. With di

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