---
title: Cultural Differences
tags: live-v0.1.2, behaviour, attitudes, culture
permalink: https://c19vax.scibeh.org/pages/vaxculture
---
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# Cultural differences in vaccine acceptance

[TOC]

## Monitoring cultural differences in vaccine acceptance

The first step in addressing cultural differences in vaccine acceptance is to increase awareness of existing differences. Thus, monitoring cultural differences in vaccine uptake and monitoring cultural differences in reasons of vaccine hesitancy is the basis for an appropriate public health response. Several monitoring initiatives are providing regular updates on vaccine uptake and reasons of hesitancy across the world. For example, the research data and analytics group [YouGov](https://yougov.co.uk/topics/international/articles-reports/2021/01/12/covid-19-willingness-be-vaccinated) provides regular updates across 23 countries on percentage of people who are willing to take the COVID-19 vaccination or have already done so. But there are also more detailed and country specific monitors. For example, the [OpenSAFELY](https://opensafely.org/research/2021/covid-vaccine-coverage/) initiative (NHS England) provides weekly reports on COVID-19 vaccination coverage in England.

Moreover, other research projects monitor the willingness to get vaccinated and the psychological reasons that lead to vaccine hesitancy. For example, [Murphy et al. 2021](https://www.nature.com/articles/s41467-020-20226-9) provide psychological characteristics that are associated with vaccine hesitancy in England and Ireland. Another example is the [COSMO Monitor](https://projekte.uni-erfurt.de/cosmo2020/web/) in Germany that provides weekly updates on risk perception, knowledge and prevention behaviours of the German population using representative cross-sectional samples. The World Health Organization is using the insights from the COSMO questionnaires to provide guidance to member states on how to monitor risk, knowledge and trust within populations of interest. More can be found [here](https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/publications-and-technical-guidance/risk-communication-and-community-engagement/who-tool-for-behavioural-insights-on-covid-19).

Data from vaccination roll-outs this year have shown that vaccine uptake differ across cultural-political groups, for example:

* In England (UK), vaccination uptake has been lower for some ethnic groups:

_{**Vaccination rates of adults aged 70 or over, by self-reported ethnic group 8 December 2020 to 11 March 2021, England:**}

_{Source: [Office for National Statistics](https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/coronavirusandvaccinationratesinpeopleaged70yearsandoverbysociodemographiccharacteristicengland/8december2020to11march2021) - Public Health Data Assset, National Immunisation Management Service}

* In the US, vaccination uptake has varied across political affiliation:

_{**United States, self-described vaccination status, percent of adults by political party (Democrat/leaning towards Democrats, Purely independent, Republican/leaning Republican):**}

_{Source: [YouGov/The Economist](https://docs.cdn.yougov.com/lftymxzxfl/econTabReport.pdf)}

## Cultural-political sources of vaccine hesitancy

Most people who express concerns about the COVID-19 vaccine are keen to receive accurate and detailed information about the vaccine and its safety. [Our page here](https://c19vax.scibeh.org/pages/c19vaxfacts) provides that information. Moreover, it is important to be aware of disinformation campaigns that are particularly targeting local communities (e.g. [immigrant communities](https://www.statnews.com/2017/05/08/measles-vaccines-somali/)). [Our page here](https://hackmd.io/@scibehC19vax/misinfo_myths) provides information on common myths used by vaccine deniers and how to counter them.

Likewise, many people are concerned about government policies for perfectly legitimate reasons, and not because they are misinformed or believe in conspiracy theories. Our team has discussed this issue, the boundary between legitimate concern with government policy and rejection of science, in [this document](https://docs.google.com/document/d/1bNAOmmMRFjFqWNoxpAFMPldT7wLKAZjpFj3NuXqLzKU/edit?ts=5fbba7a0).

A [recent study by YouGov](https://www.theguardian.com/society/2021/mar/07/10-of-uks-people-of-colour-would-refuse-covid-vaccine-yougov-data?CMP=Share_iOSApp_Other) explored attitudes towards the vaccine and showed that 10% of BAME people in England, Wales and Scotland say they would not get vaccinated, a figure which rises to 18% among Pakistanis and 19% among black people. By contrast, a separate survey showed only 6% of white Britons would refuse the vaccine.

Even more worryingly, data up to 15 January 2021 show substantially lower rates of COVID-19 vaccinations among over-80s from ethnic minority and deprived communities in England, with uptake by Black communities about half that by White communities ([Razai et al., 2021](https://www.bmj.com/content/372/bmj.n513)).

The reasons for vaccine hesitancy may differ among groups. For example, [Robertson et al. (2021)](https://www.sciencedirect.com/science/article/pii/S0889159121001100) found that in the UK, worries about side effects were prevalent among a greater proportion of survey respondents of Pakistani/Bangladeshi ethnicity, but a lack of trust in vaccines was cited more among Black survey respondents:

_{**Main reason given for vaccine hesitancy, by ethnic group:**}
_{Source: [Robertson et al., 2021](https://www.sciencedirect.com/science/article/pii/S0889159121001100)}

Some people may be concerned about vaccines because of the role played by western government agencies in the Global South. For example, the CIA set up a vaccination operation in Pakistan in 2011 as part of their efforts to locate Osama bin Laden ([Reardon, 2011](https://dx.doi.org/10.1126/science.333.6041.395)). The operation drew protest from the WHO and UNICEF because it undermined the perception of neutrality and impartiality of other medical missions.

A general mistrust in governmental initiatives in some parts of the world is also rooted in racialized history ([Jamison et al., 2019](https://doi.org/10.1016/j.socscimed.2018.12.020)).</span> For example, the misuse of governmental power in health campaigns during colonial times remains an issue today ([Lowes & Montero, 2018](https://scholar.harvard.edu/slowes/publications/colonial-medicine)).

It is therefore important to create an inclusive narrative that embraces as many people as possible, being aware of cultural and political reasons why people may be suspicious of health authorities. The American Psychological Association has provided a [useful document about how to build community trust](https://www.apa.org/topics/covid-19/equity-resources/building-community-trust.pdf).

Similarly, [Khan et al. (2021)](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00938-7/fulltext) note that describing immigrant groups and ethnic minorities as more vaccine hesitant places emphasis on minority groups becoming less hesitant rather than public health systems become more accessible and trustworthy. The lack of accessibility to public health services and a mistrust towards health authorities found in ethnic groups is often a major contributing factor to their lower vaccine uptake. Thus, a failure to address these concerns undermines the barriers to vaccine access for these populations. A study by [The RSA](https://www.thersa.org/press/releases/2021/ethnic-minorities-twice-as-likely-to-face-discrimination-in-local-services) found that twice as many Black and Asian respondents have encountered discrimination when accessing local services (for example the police) than White respondents. These past experiences of discrimination are associated with a lower likelihood of receiving the vaccine. Therefore, policy makers should strive to understand and effectively respond to the unique needs of communities with lower vaccine uptake and aim to reduce discriminatory practices which contribute to mistrust towards the government and public services, rather than simply labelling them as "hesitant".

<!--<span style="color:green">When we speak about discrimination, we must also remember that prejudiced perceptions about minority communities also shape attitudes towards vaccination. To build trust, we could start by recognising that vaccination is a scientific development that built on knowledge from **all** cultures, rather than solely an achievement of Western science (as it is commonly portrayed).

:::success
Our page on [historical contributions of the Muslim community to science](https://c19vax.scibeh.org/pages/islam) explains how ignoring this history is damaging to building trust and reducing hesitancy among minority ethnic communities.
:::-->

## Discriminatory practices in healthcare

Many people experience discriminatory practice in healthcare. According to a study done by [NPR and Harvard's School of Public Health in 2017](https://cdn1.sph.harvard.edu/wp-content/uploads/sites/94/2018/01/NPR-RWJF-HSPH-Discrimination-Final-Summary.pdf), 32% of African Americans, 25% of Latinas, 14% Latinos, and 16% of LGBTQ persons reported experiencing discrimination when seeking medical attention. The same study found that many people avoided seeking medical care altogether out of fear of discrimination, including 22% of African Americans, 15% of indigenous people, and 18% of people identifying as LGBTQ.

Those perceptions are, unfortunately, a reflection of reality. There is considerable evidence, for example, that African Americans are systematically [undertreated for pain relative to white Americans](https://dx.doi.org/10.1073/pnas.1516047113). At least one reason for this disparity is the widespread false belief among medical students and residents about (non-existent) [biological differences between races](https://dx.doi.org/10.1073/pnas.1516047113). These contemporary discriminatory practices occur, and must be understood against, recent abuse and maltreatment of African Americans by the U.S. medical establishment. Perhaps the most heinous instance of such abuse was the Tuskegee experiment, in which [treatment for syphillis was withheld from African American men who participated in a study without consent](https://dash.harvard.edu/bitstream/handle/1/3372911/Brandt_Racism.pdf?sequence=1&isAllowed=y).

These examples of previous unethical healthcare research in Black populations, under-representation of minorities in health research and vaccine trials, and negative experiences within a culturally insensitive healthcare system erode trust in healthcare systems ([Razai et al., 2021](https://www.bmj.com/content/372/bmj.n513)). This is further compounded by wider experience of systemic racism and discrimination---for example, the inequality in educational opportunities, or residential segregation that affects access to resources ([Egede & Walker, 2020](https://www.nejm.org/doi/full/10.1056/NEJMp2023616)).

## The discriminatory burden of COVID-19

There is no doubt that the COVID-19 pandemic has hit the poorest and underprivileged hardest ([Perry et al., 2021](https://doi.org/10.1073/pnas.2020685118); [Clince-Cole. 2020](https://doi.org/10.1080/03056244.2020.1814627)). In California, for example, Latino residents make up about 40% of the state's population but [58% of COVID cases and 48% of COVID-related deaths](https://www.latimes.com/california/story/2020-12-09/california-latinos-covid19-vaccine). In the U.S. as a whole, African-Americans and other people of color were hospitalized at a rate [more than 3 times greater](https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html) than white Americans.

## COVID-19 vaccine hesitancy and discrimination

Research indicates that groups that frequently encounter discrimination in their everyday lives have a larger degree of hesitancy towards vaccines ([UK SAGE](https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/952716/s0979-factors-influencing-vaccine-uptake-minority-ethnic-groups.pdf)).

Recent data in the UK found that COVID-19 vaccine hesitancy was particularly high in Black (71.8%), Pakistani/Bangladeshi (42.3%), Mixed (32.4%) and non-UK/Irish White (26.4%) ethnic groups ([Robertson et al., 2020](https://www.medrxiv.org/content/10.1101/2020.12.27.20248899v1)). This is corroborated by another study in the UK that found participants who self-reported as Black, Asian, Chinese, Mixed or Other ethnicity were nearly 3 times more likely to reject a COVID-19 vaccine than participants who self-reported as White British, White Irish and White Other ([Bell et al., 2020](https://doi.org/10.1016/j.vaccine.2020.10.027)). The [recent report](https://www.gov.uk/government/publications/factors-influencing-covid-19-vaccine-uptake-among-minority-ethnic-groups-17-december-2020) on factors that influence COVID-19 vaccine uptake prepared by the ethnicity sub-group of the Scientific Advisory Group for Emergencies (SAGE) reveals similiar results. Moreover, recent data on actual vaccine uptake support the notion of major differences in vaccine hesitancy among ethnic groups in the UK. That is, the proportion of individuals vaccinated against COVID-19 was highest among white people (42.5%) and lowest among black people (20.5%) [MacKenna et al., 2021](https://www.medrxiv.org/content/10.1101/2021.01.25.21250356v2.full-text). These differences in vaccine uptake between ethnic groups are even present among health staff ([Iacobucci, 2021](http://dx.doi.org/10.1136/bmj.n460)). Moreover, a recent study among 32,361 participants reveals that low-income, female gender and living with children are also strong predictors of vaccine refusal and uncertainty ([Paul et al., 2020](https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext)).

In France, 37% of low-income people, 22% of the elderly, and 36% of young women would not get the vaccine if it was available ([Peretti-Watel et al., 2020](https://dx.doi.org/10.1016/S1473-3099(20)30426-6)).

In the United States, COVID-19 vaccine hesitancy is higher among African-Americans, women, and conservatives ([Callaghan et al., 2020](https://dx.doi.org/10.2139/ssrn.3667971); [Coustasse et al., 2020](https://dx.doi.org/10.1097/JAC.0000000000000360)). Moreover, mortality rates are particularly high among ethnic minorities [Chen et al., 2021](https://www.medrxiv.org/content/10.1101/2021.01.21.21250266v1). Accordingly, the Center for Disease Control [designated communities of color as a “critical population”](https://www.cdc.gov/vaccines/imz-managers/downloads/COVID-19-Vaccination-Program-Interim_Playbook.pdf) to vaccinate and implored jurisdictions to "ensure these groups have access to vaccination services". [A recent report](https://www.propublica.org/article/vaccinating-black-americans) (18 December 2020), however, "found little in the way of concrete action to make sure that happens."

Indeed, lower uptake among certain groups can be traced to practices that disproportionately affect these groups---for example, in the USA, aspects of the vaccination roll-out affected access for Black and Latinx people. An [issue by the Scientific American](https://www.scientificamerican.com/article/the-biggest-barriers-to-covid-vaccination-for-black-and-latinx-people1/) reported that eligibility requirements for COVID-19 vaccinations, such as age (typically age 60 or above in most states), may favour White Americans, who have a longer average life expectancy than Black Americans. Moreover, poorer or lack of internet access amongst minority ethnic groups make it more difficult for them to book vaccination appointments. Language barriers and proof of eligibility requirements cause further challenges for some minority groups, such as immigrants.

<span style="color:green">[Woolf et al. (2021)](https://www.sciencedirect.com/science/article/pii/S2666776221001575?via%3Dihub) reported that despite having an increased risk of COVID-19, health care workers from ethnic minority backgrounds were significantly more likely to be vaccine hesitant than their White British colleagues. For example, 54.2% of Black Carribean healthcare workers were hesitant in comparison to White British healthcare workers (21.3%). Other factors predicting hesitancy included higher levels of COVID-19 conspiracy beliefs, being of female sex, younger age, mistrust in the government and employers, and safety concerns due to the speed of vaccine development and a lack of ethnic diversity in vaccine studies. Thus, strategies to dissipate myths surrounding COVID-19 and the vaccine as well as building trust in the government and employers is necessary to increase vaccine uptake amongst healthcare workers from ethnic minority backgrounds. As noted previously, discriminatory practices in healthcare contribute to people from ethnic minorities having feelings of mistrust towards the government and public health services; this has been shown to be evident even amongst healthcare workers. Participants in this study felt that vaccine uptake in ethnic minority communities could be increased through more inclusive and non-stigmatising health communication strategies and using trusted networks to promote the vaccine.</span>
_________________

**Podcast:** A recent podcast episode of 'Deep Breath In' by the British Medical Journal (BMJ) focuses on issues of vaccine hesitancy and discrimination. The guests are: Kevin Fenton (Regional Director of Public Health England for London) and Kamlesh Khunti (professor of Primary Care Diabetes & Vascular Medicine at the University of Leicester).

<iframe src="https://open.spotify.com/embed-podcast/episode/37vkGvCNKk7oXIT8SGiLFY" width="100%" height="232" frameborder="0" allowtransparency="true" allow="encrypted-media"></iframe>

## COVID-19 vaccine hesitancy and religious concerns

Major religions like Judaism, Jainism, Buddhism, Hinduism, Christianity and Islam support vaccination as a measure to sustain human life ([Grabenstein, 2013](https://doi.org/10.1016/j.vaccine.2013.02.026)).

However, members of religious groups are often concerned that specific vaccines may violate religious laws. Thus, religious concerns can become a driver of vaccine hesitancy. For example, some parents from Islamic communities report vaccine hesitancy because some childhood vaccines contain the enzyme trypsin that is taken from pigs, and Islamic law prohibits the use of medicine containing pig ([Ahmed et al., 2018](https://doi.org/10.1016/j.jiph.2017.09.007)). However, the European Council of Fatwa and Research stated that “The very tiny amount of the added trypsin -assuming it was unlawful – is too little to have any effect” ([ECFR, 2003](https://www.e-cfr.org/blog/2017/11/04/eleventh-ordinary-session-european-council-fatwa-research/?__cf_chl_jschl_tk__=f159987f6aa0829eafb3005026e00658bf63e1ae-1612773690-0-AdxTZ0ZczPW8igTtufKF4yCRf1VWnFPlArODvy6UZ_fPn2M98dmQeglZ93E8rtgOk61MKOl_LCcDP64M0kymxVDRIL_iOOJ1XnmPhUSFDSc5bMP8PmAk6mY_mrk0gAXR9GIB-VWONPcMF4uJOnjji9OeVSswYCzqXBAXbA57BAPExhid_OcDjhb5lJv5cre4IrZwP2uz9W-0onMy1YLI9fTFJQZNcCfVwTCUnPbv4uJ9Xs_hO4U_MlS0035z8tw9hYhRoc_evFLDC5wBkFzUJ6FePZo3YNbZgpUg3opMFeqLNqeD8usDQVIHCEvCHejAiPaHG4pxtHYF65LjWkvkksr9EyJ-MAU9gDkXIO3h01oEA_hKgUO2dRwlBUHWUw02uQFjLbE1Pbl3YSL_4rOXuUU)).

If religious concerns are raised, then position statements from representatives of religious communities are much more powerful than public health messages from health authorities. Thus, representatives of religious communities are key to address religious concerns that may fuel vaccine hesitancy and undermine public health.

It is therefore important to note that several representatives of religious communities have already published position statements that clearly support the use of vaccination to counter COVID-19:
* [British Islamic Medical Association](https://britishima.org/pfizer-biontech-covid19-vaccine/),
* [Vatican](https://press.vatican.va/content/salastampa/en/bollettino/pubblico/2020/12/21/201221c.html),
* [Islamic Religious Council of Singapore](https://www.muis.gov.sg/Media/Media-Releases/13-Dec-20-Religious-Position-on-COVID-19-Vaccine),
* [Jewish medical doctors](https://docs.google.com/document/d/1ldvpDSrzJommeevkjt6ynFaEG0FkIdlSGfRlFz9Smm8/edit).

A comprehensive list of statements and handouts addressing religious concerns can also be accessed [here](https://www.immunize.org/talking-about-vaccines/religious-concerns.asp).

----

## Engaging with communities

Cultural and religious sensitivities must be considered by public health professionals. An important step in that direction, and to tackle the big issue of discrimination, is to form pro-active groups dedicated to engagement with the communities concerned. The importance of community engagement is also highlighted in the [recent report](https://www.gov.uk/government/publications/factors-influencing-covid-19-vaccine-uptake-among-minority-ethnic-groups-17-december-2020) by the ethnicity sub-group of the Scientific Advisory Group for Emergencies (SAGE).

:::warning
In engaging with communities, it is worth recognising that the scientific knowledge that enabled medical progress such as vaccination was built on a wide base of contributions from around the world.

Our page on the **[historical contributions of communities to science](https://c19vax.scibeh.org/pages/islam)** explains that scientific achievements of minority communities have often been obscured, which can contribute to a sense of discrimination and distrust that affects vaccine confidence. Enabling all communities to take pride in their role in scientific progress could work towards building trust and confidence.
:::

One practical example is the [Bristol Race Equality Covid-19 Steering Group](https://www.bristol.gov.uk/mayor/bristol-race-equality-covid-19-steering-group) set up by the Bristol City Council to address policy recommendations relating to the impact of COVID-19 on Black, Asian and minority ethnic (BAME) communities. The groups has representatives from 25 communities.

The group already produced a [rapid review](https://arc-w.nihr.ac.uk/news/arc-west-rapid-review-explores-disproportionate-impact-of-covid-19-on-black-asian-and-minority-ethnic-communities/) that provides stakeholder insights into factors affecting the impact of COVID-19 on BAME communities.

They also hold webinars that are particularly designed to address vaccine confidence issues within minority ethnic communities (the video below records an example).

_________________

**Video:** Recording of the webinar on the Covid-19 Vaccine by the Bristol Race Equality COVID-19 Steering Group, on the initiative of Deputy Mayor Asher Craig, to “give residents in the city an opportunity to find out more about how the jabs work”. An additional event with a similar approach was also conducted by the South Gloucestershire Race Equality Network. All activities were coordinated within the Healthier Together Integrated Care System (ICS), including Bristol City Council, South Gloucestershire Local Authority and North Somerset Local Authority.

{%youtube MYHZdnxGwyI %}

Pre and post analysis of the event indicated that it had a significant impact on levels of confidence about the vaccine and on likelihood to take up the vaccine when offered. Critically, attendees shared something they had learned with around three other people on average, meaning that the overall reach of a single event was over 1,300 people. Further aspects of the effectiveness of this type of webinar on the audiences’ confidence in vaccination are currently being evaluated

----

The community engagement plan developed by Bristol City Council is shown below. Although it is specific to the City of Bristol, the general ideas should be of broader interest.

{%pdf https://www.cogsciwa.com/wp-content/uploads/2021/03/Vaccine-Local-Engagement-Plan-final-draft.pdf %}

----

**Video:** by _The Guardian_ supporting the vaccines, with statements by Black, Asian and minority ethnic celebrities.
UPDATE: This video has been screened by ITV, Channel 4, Channel 5, Sky and STV. Find more information [here](https://www.bbc.com/news/entertainment-arts-56101990).

{%youtube OsCJKh6B6xw %}

----

To communicate well with communities, it is important to provide plain language meanings to complex medical terminology about immunisation and vaccine development. In New South Wales, Australia, the Multicultural Health Communication Service has developed a [glossary](https://www.mhcs.health.nsw.gov.au/glossary/covid-19-glossary) to assist with this (see video below).

{%youtube vmDVUVB2Rtk %}

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There is also a lot to learn from vaccination campaigns that aimed to address inequalities in immunisation before COVID-19. A recent systematic review identified scientifically evaluated interventions to reduce inequalities in vaccine uptake in children and adolescents ([Crocker-Buque et al., 2017](https://jech.bmj.com/content/71/1/87.long)).
The most promising interventions were locally designed and consisted of multiple components. For example, the community-developed program ‘[Start Right](https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2007.121046)’ addressed vaccine-uptake among children in Latino, low-income communities. The team designed bilingual and community-appropriate immunisation-promotion materials; trained peer health educators; implemented personalised immunisation outreach and promotion within social service; provided outreach, education, and reminders to parents; and supported provider immunisation delivery. The result: Children in Start Right reported higher (11.1%) immunisation coverage rates than did control children ([Findley et al., 2008](https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2007.121046)).
The effectiveness of multicomponent campaigns reveal: There is no one-size fits all approach in communication about vaccination. In fact, the World Health Organization has repeatedly addressed the necessity to acknowledge and monitor inequity in immunisation ([Boyce et al., 2019](https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2019.24.2.1800204?crawler=true)) and tailor communication approaches to the needs of diverse communities ([WHO, 2019](https://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/2019/tip-tailoring-immunization-programmes-2019)).

:::success
Would you like to find out more about cultural differences in vaccine acceptance? We created a search query specifically for this page, which links you to other interesting resources like Twitter threads, blogposts, websites, videos and more. Check out the search query that we generated specifically for this page [here](https://hypothes.is/groups/Jk8bYJdN/behsci?q=vaccine+hesitancy+ethnicity).

Would you like to know more about how we generated the search queries and how our underlying knowledge base works? Click [here](https://hackmd.io/B3R70tuNTiGy6wi9HObuSQ) to learn more.
:::

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_{Page contributors: Philipp Schmid, Stephan Lewandowsky, Dawn Holford, Alex Ward-Booth, Natasja D. McCabe, Zoe Ikeotuonye}

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