Meet the Four Kinds of People Holding Us Back From Full Vaccination

By Sema K. SgaierMay 18, 2021

Nicholas Konrad/The New York Times

Dr. Sgaier is the C.E.O. of Surgo Ventures, a nonprofit organization focused on using data to address health problems, including Covid-19.

Getting everyone vaccinated in the United States has become much harder now that demand for the Covid-19 vaccine is flagging. America’s vaccination strategy needs to change to address this, and it starts with understanding the specific reasons people have not been vaccinated yet.

The conventional approach to understanding whether someone will get vaccinated is asking people how likely they are to get the vaccine and then building a demographic profile based on their answers: Black, white, Latinx, Republican, Democrat. But this process isn’t enough: Just knowing that Republicans are less likely to get vaccinated doesn’t tell us how to get them vaccinated. It’s more important to understand why people are still holding out, where those people live and how to reach them.

Why are people where you live still not getting vaccinated? Select your state below.

After conducting a national survey of U.S. adults, we grouped people into distinct profiles based on their shared beliefs and barriers to getting the vaccine. This approach, borrowed from the marketing world, is called psychobehavioral segmentation. It will allow health officials to target their strategies in ways that ignore demographic categories, like age and race. In the United States, we used this approach to identify five distinct personas: the Enthusiasts, the Watchful, the Cost-Anxious, the System Distrusters and the Covid Skeptics.

People in each segment share some beliefs and barriers about Covid-19 vaccination. And each persona includes at least some of every demographic: Republicans, Black people, the middle class, young people and others.

Here are the groups health officials need to reach — and how to reach them, based on their fears, concerns and barriers.

Covid Skeptics

Share of Covid Skeptics

within the state

National average: 14%

The share of Covid Skeptics

in Arkansas is 30%,

exceeding the national

average

Share of Covid Skeptics

within the state

Maine

Alaska

National average: 14%

Wisconsin

N.H.

Vermont

North Dakota

Idaho

Montana

New York

Mass.

Minnesota

Illinois

Michigan

Wash.

Rhode

Island

Wyomin

Nevada

Ohio

Indiana

Penn.

New Jersey

Conn.

Oregon

Iowa

S.D.

West Virginia

Nebraska

Missouri

Virginia

Kentucky

Maryland

Delaware

Utah

Colorado

Calif.

S.C.

Tennessee

Arizona

Arkansas

New Mexico

N.C.

Kansas

Alabama

Oklahoma

Mississippi

Louisiana

Georgia

Florida

Texas

Hawaii

The share of Covid Skeptics

in Arkansas is 30%,

exceeding the national

average

Alaska

Maine

Share of Covid Skeptics

within the state

National average: 14%

Wisconsin

Vermont

New Hampshire

North Dakota

Idaho

Washington

Montana

Minnesota

Illinois

Michigan

New York

Massachusetts

Wyoming

Oregon

Nevada

Iowa

Indiana

Ohio

Pennsylvania

New Jersey

Connecticut

Rhode Island

South Dakota

California

Utah

Colorado

Nebraska

Missouri

Kentucky

West Virginia

Virginia

Maryland

Delaware

Arkansas

South Carolina

Arizona

New Mexico

Kansas

Tennessee

North Carolina

Alabama

Oklahoma

Mississippi

Georgia

Louisiana

Hawaii

Texas

Florida

The share of Covid Skeptics

in Arkansas is 30%, exceeding

the national average

Covid Skeptics are at the far end of the spectrum as the least likely to get vaccinated. The primary barrier for people in this group are their specific, deeply held beliefs about Covid-19. Everyone in this group believes at least one conspiracy theory related to the pandemic, whether it’s that microchips are implanted with the Covid vaccine; Covid-19 has been exploited by the government to control people; or that the pandemic was caused by a ring of people who secretly manipulate world events.

We found Covid Skeptics are common in Arkansas, North Dakota and Nevada. Considering that 84 percent of this group believe that the government is exploiting Covid-19 to control people, leaders of vaccination campaigns should consider tapping nonpolitical figures to mobilize this group. Doctors are trusted by 50 percent of this group, while scientists are trusted by 32 percent. They could also use religious leaders, who may resonate best with 9 percent of group members who say the vaccine goes against their religious beliefs.

The key to engaging this group will be to avoid trying to debunk what they believe; rather, experts need to listen, acknowledge how they feel and then share the facts. Our research finds that emphasizing that vaccination is their own, personal choice — one that can help them protect friends and family members — can also work.

Cost-Anxious

Share of Cost-Anxious

within the state

National average: 9%

The share of Cost-Anxious

people in Mississippi is 23%

Share of Cost-Anxious

within the state

Maine

National average: 9%

Wisconsin

N.H.

Vermont

Alaska

North

Dakota

Idaho

Michigan

Minnesota

Illinois

Wash.

Montana

New York

Mass.

Rhode

Island

Wyoming

New Jersey

Conn.

Penn.

S.D.

Ohio

Oregon

Nevada

Iowa

Indiana

West Virginia

Missouri

Utah

Kentucky

Virginia

Maryland

Delaware

Colorado

Nebraska

California

Arizona

Tennessee

S.C.

Arkansas

New Mexico

Kansas

N.C.

Oklahoma

Alabama

Georgia

Mississippi

Louisiana

Texas

Florida

Hawaii

The share of Cost-Anxious

people in Mississippi is 23%

Maine

Share of Cost-Anxious

within the state

National average: 9%

Wisconsin

Vermont

New Hampshire

Alaska

Idaho

Washington

Montana

North Dakota

Minnesota

Illinois

Michigan

New York

Massachusetts

Wyoming

Oregon

Nevada

South Dakota

Iowa

Indiana

Ohio

Pennsylvania

New Jersey

Connecticut

Rhode Island

West Virginia

Missouri

California

Utah

Colorado

Nebraska

Kentucky

Virginia

Maryland

Delaware

Tennessee

Arizona

New Mexico

Kansas

Arkansas

North Carolina

South Carolina

Oklahoma

Louisiana

Alabama

Georgia

Hawaii

Texas

Florida

The share of Cost-Anxious

people in Mississippi is 23%

The Cost-Anxious worry about the time and potential expense of getting vaccinated (even if it is actually free). We learned they’re dominant in states like Mississippi, where they make up 23 percent of the population, which is not surprising due to the state’s high poverty rates and low Medicaid coverage.

Public health experts have stressed the need to bring vaccines to the people; with no group is this truer than for the Cost-Anxious. Holding vaccination clinics in non-health-care locations that people frequent — like workplaces, religious venues, day cares, supermarkets, bars and restaurants — will be critical.

For this group, vaccination campaign leaders should stress that vaccination is totally free and encourage local businesses to provide paid time off for both doses.

System Distrusters

Share of System Distrusters

within the state

National average: 4%

The share of System Distrusters

in Georgia is 8%, double the

national avervage

Alaska

Maine

Share of System Distrusters

within the state

National average: 4%

Wisconsin

Vermont

N.H.

North

Dakota

Michigan

New York

Idaho

Wash.

Montana

Minnesota

Illinois

Mass.

Rhode

Island

South Dakota

Penn.

New Jersey

Oregon

Nevada

Wyoming

Iowa

Indiana

Conn.

Ohio

California

Utah

Colorado

Nebraska

Missouri

Kentucky

West Virginia

Virginia

Delaware

Arizona

New Mexico

Kansas

Arkansas

Tennessee

N.C.

S.C.

Maryland

Mississippi

Oklahoma

Alabama

Texas

Hawaii

Florida

Louisiana

Georgia

The share of System Distrusters

in Georgia is 8%, double the

national avervage

Alaska

Maine

Share of System Distrusters

within the state

National average: 4%

Wisconsin

Vermont

New Hampshire

Michigan

Idaho

New York

Washington

Montana

North Dakota

Minnesota

Illinois

Massachusetts

South Dakota

New Jersey

Oregon

Nevada

Wyoming

Iowa

Indiana

Ohio

Pennsylvania

Connecticut

Rhode Island

California

Utah

Colorado

Nebraska

Missouri

Kentucky

West Virginia

Virginia

Delaware

Arizona

New Mexico

Kansas

Arkansas

Tennessee

North Carolina

South Carolina

Maryland

The share of System Distrusters

in Georgia is 8%, double

the national avervage

Louisiana

Mississippi

Oklahoma

Alabama

Hawaii

Texas

Florida

Georgia

The System Distrusters believe that the health care system doesn't treat them fairly. Most, but not all, members of this group are people of color, and they prevail in Washington, D.C., Maryland and Georgia.

It will be important for public health officials to hold conversations — formal or informal — with trusted members of their own communities to air concerns and be transparent about efforts to vaccinate underserved communities. People in this group have low expectations that other members of their communities will get vaccinated, so making vaccinations of people they know as visible as possible will be important. Tracking and illuminating efforts to ensure the vaccine rollout is equitable and sharing that with the community is key.

The Watchful

Share of Watchful people

within the state

National average: 8%

Delaware: 17%

Maine

Alaska

Share of Watchful people

within the state

National average: 8%

Wisconsin

N.H.

Vermont

North

Dakota

Idaho

New York

Michigan

Minnesota

Illinois

Wash.

Montana

Mass.

Rhode

Island

Indiana

New Jersey

Conn.

Penn.

S.D.

Ohio

Oregon

Nevada

Iowa

Wyo.

Nebraska

Missouri

Kentucky

Maryland

Delaware

West Virginia

California

Utah

Colorado

Virginia

Arizona

Arkansas

Tennessee

New Mexico

Kansas

N.C.

S.C.

The share of Watchful

people in Delaware is 17%

Mississippi

Alabama

Louisiana

Georgia

Oklahoma

Hawaii

Florida

Texas

Share of Watchful people

within the state

Alaska

Maine

National average: 8%

Wisconsin

Vermont

New Hampshire

Montana

North Dakota

New York

Washington

Idaho

Minnesota

Illinois

Michigan

Massachusetts

Rhode Island

Oregon

Nevada

South Dakota

Iowa

Indiana

Ohio

Pennsylvania

New Jersey

Connecticut

Wyoming

Nebraska

Missouri

Kentucky

California

Utah

Colorado

West Virginia

Virginia

Maryland

South

Carolina

Arizona

New Mexico

Kansas

Arkansas

Tennessee

The share of Watchful

people in Delaware is 17%

North Carolina

Louisiana

Mississippi

Oklahoma

Georgia

Hawaii

Alabama

Florida

Texas

The Watchful are holding out to see what kind of experience their friends or neighbors have with the vaccine before committing themselves. They dominate in Delaware, making up 17 percent of the state’s population, as well as 12 percent in Hawaii and Rhode Island.

Behavioral science researchers know that establishing norms can lead to acceptance of products and could help persuade the Watchful. Encouraging those who are vaccinated to show their vaccination status with pride, both online and offline, can nudge their family, friends and networks to follow suit. The Watchful are already likely to wear masks, showing an intent to comply with social norms, so they may respond to similar altruistic messages about vaccination and get vaccinated to protect others.

For this group, experts should consider allowing for a “vaccinate later” option. Behavioral science suggests that people prefer moderate or “compromise” options over their extreme counterparts. Being able to opt-in to vaccines down the road may provide a comfortable alternative for this group.

With only 60 percent of U.S. adults having received their first shot, we are still far from President Biden’s target of 70 percent by the Fourth of July. This national average also hides an important truth: The country is a patchwork, with states like Vermont tracking higher (with 78 percent of adults having received their first dose) and states like Mississippi tracking lower (42 percent of adults). Therefore, we can’t rely on a one-size-fits-all approach.

President Biden’s aggressive Fourth of July goal will be tough to meet without understanding what drives lower vaccine confidence and where various strategies to combat it will be most effective. And we can’t stop at the state level; we need to go county by county and ZIP code by ZIP code, offering specific, localized solutions to convince the holdouts. It will also be important that everyone — not just the health care professionals and the politicians — do their part. It won’t be easy, but it must be done to ensure that more people get vaccinated.