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Press release

New study provides insights into each US state’s COVID-19 vaccination rate

Ann Arbor | October 8, 2022

Many people unvaccinated for COVID-19 remain unconvinced of its necessity, and the social and demographic factors underlying this decision vary substantially from region to region, investigators report in the American Journal of Preventive Medicine

In the first year of its availability, 84.2% of US adults received at least one dose of COVID-19 vaccine. Progress in COVID-19 vaccination slowed after April 2021, and millions of Americans remain unvaccinated. New researchopens in new tab/window in the American Journal of Preventive Medicineopens in new tab/window, published by Elsevier, finds wide geographic variance in vaccine uptake and identifies the underlying behavioral and social drivers that factor into the decision to remain unvaccinated. The findings suggest that improving COVID-19 vaccine confidence may not be solved by a “one-size-fits-all solution.”

“Many studies have explored vaccine coverage and vaccine confidence at a national level, but these are likely to vary widely by geography and sociodemographics,” said lead investigator Nina B. Masters, PhD, Epidemic Intelligence Service, and Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA. “We decided to explore state and regional trends in COVID-19 vaccine confidence and the underlying reasons for non-vaccination.”

The study used data from the National Immunization Survey-Adult COVID Module. This is a nationally representative household cellphone survey of US adults aged 18 or older. Of the 531,798 participants surveyed (April 22 to December 31, 2021), respondents who had not received a COVID-19 vaccine were then asked how likely they were (definitely, probably, probably not, definitely will not, not sure) to get vaccinated. Additional questions were asked about the individual’s concerns about COVID-19 and confidence in vaccine safety and importance.

To understand social norms, the participants were asked how many friends and family members had received a COVID-19 vaccination, and if a healthcare provider had recommended that they receive the vaccine. For practical factors, the survey asked whether one’s work or school required COVID-19 vaccination and whether they experienced any actual or perceived difficulty in accessing a vaccination. Demographic data were also collected. The analysis examined these variables nationally and for each state for each month in the survey period, to support trends over time.

In general, rural residents were less likely to be vaccinated than urban residents, but in the Southeast and Midwest, differences in vaccination coverage by urbanicity were smaller. In most states, Black and Hispanic adults were less likely to be vaccinated than White and non-Hispanic adults. However, in the South and the Southeast, where vaccination rates were low compared to the rest of the US, vaccination coverage was similar across race and ethnicity. The Southeast and Midwest had the largest proportion of unvaccinated people who indicated that they would probably get a COVID-19 vaccine or were unsure. These regions saw similar trends in concern about COVID-19 and confidence in the importance of getting vaccinated.

Geofacet map showing weighted proportion of respondents

Pictured above: Geofacet map showing weighted proportion of respondents reporting they are vaccinated, definitely will get vaccinated, probably will get vaccinated or are unsure, or probably/definitely will not get vaccinated from May–December 2021 (Credit: American Journal of Preventive Medicine).

Overall, individuals with low confidence in the importance of the vaccine were five times more likely to remain unvaccinated. This suggests that focused messaging about the benefits of vaccination, compared to the risk of the disease, remains a priority. Adults in rural areas –  as well as those with less than a college degree, without insurance, making less than $75,000/year and under 65 – had higher prevalence of non-vaccination across all regions, while associations between vaccination and race/ethnicity varied by region.

“Our analysis supports the idea that reasons for non-vaccination are personal and individual, and there are nuances and differences in this reasoning, for example, between an unvaccinated, young individual living in a rural community in the Southeast and an unvaccinated, older individual living in the Northeast who has mostly vaccinated friends and family. It’s important to meet people where they are to build confidence in vaccines,” said Dr. Masters. “The CDC has made national, regional, and state data available on the Behavioral and Social Drivers of COVID-19 vaccination through national surveys of adults and parents. State and local health departments may be able to strengthen their ongoing efforts locally by accessing these data at the CDC COVID Data Tracker: Vaccine Confidenceopens in new tab/window.”


Notes for editors

The article is Geographic Heterogeneity in Behavioral and Social Drivers of COVID-19 Vaccination,” by Nina B. Masters, PhD, Tianyi Zhou, MPH, Lu Meng, PhD, Peng-Jun Lu, PhD, Jennifer L. Kriss, PhD, Carla Black, PhD, Amel Omari, PhD, Kwanza Boone, BA, Debora Weiss, DVM, Rosalind J. Carter, PhD, Noel T. Brewer, PhD, and James A. Singleton, PhD ( in new tab/window). It appears online in advance of the American Journal of Preventive Medicine, volume 63, issue 6 (December 2022), published by Elsevier.

The article is openly available at in new tab/window.

Full text of this article is also available to credentialed journalists upon request; contact Jillian B. Morgan at +1 734 936 1590 or [email protected]opens in new tab/window. Journalists wishing to interview the authors should contact [email protected]opens in new tab/window.

Elsevier’s Novel Coronavirus Information Center provides expert-curated information for researchers, healthcare professionals and public health officials, including clinical guidance and a portal to access all of Elsevier’s COVID-19 research. All resources are freely available. We also have dedicated hubs for healthcare professionals; health educators and students; librarians; and R&D professionals. You can find these in our Coronavirus Resource Directory. 

About the American Journal of Preventive Medicine

The American Journal of Preventive Medicineopens in new tab/window is the official journal of the American College of Preventive Medicineopens in new tab/window and the Association for Prevention Teaching and Researchopens in new tab/window. It publishes articles in the areas of prevention research, teaching, practice and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. The journal features papers that address the primary and secondary prevention of important clinical, behavioral and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. The journal also publishes official policy statements from the two co-sponsoring organizations, health services research pertinent to prevention and public health, review articles, media reviews, and editorials. 

About Elsevier

As a global leader in scientific information and analytics, Elsevier helps researchers and healthcare professionals advance science and improve health outcomes for the benefit of society. We do this by facilitating insights and critical decision-making with innovative solutions based on trusted, evidence-based content and advanced AI-enabled digital technologies.

We have supported the work of our research and healthcare communities for more than 140 years. Our 9,500 employees around the world, including 2,500 technologists, are dedicated to supporting researchers, librarians, academic leaders, funders, governments, R&D-intensive companies, doctors, nurses, future healthcare professionals and educators in their critical work. Our 2,900 scientific journals and iconic reference books include the foremost titles in their fields, including Cell Press, The Lancet and Gray’s Anatomy.

Together with the Elsevier Foundationopens in new tab/window, we work in partnership with the communities we serve to advance inclusion and diversity in science, research and healthcare in developing countries and around the world.

Elsevier is part of RELXopens in new tab/window, a global provider of information-based analytics and decision tools for professional and business customers. For more information on our work, digital solutions and content, visit



Jillian B. Morgan

MPH, Managing Editor AJPM

+1 734 936 1590

E-mail Jillian B. Morgan