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Published in final edited form as: Vaccine. 2025 Apr 5;53:127084. doi: 10.1016/j.vaccine.2025.127084 Search in PMC Search in PubMed View in NLM Catalog Add to search Reasons for COVID-19 vaccination late in the pandemic: a qualitative study Kimberly A Fisher Kimberly A Fisher , MD, MSc a Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US b Division of Pulmonary and Critical Care Medicine, Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US Find articles by Kimberly A Fisher a, b , Lydia Goldthwait Lydia Goldthwait a Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US Find articles by Lydia Goldthwait a , Ollie Desrochers Ollie Desrochers a Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US Find articles by Ollie Desrochers a , Melanie Zemel Melanie Zemel , MD c Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US Find articles by Melanie Zemel c , Cassandra Saphirak Cassandra Saphirak a Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US Find articles by Cassandra Saphirak a , Jeremy Malin Jeremy Malin , FNP d Family Health Center of Worcester, 26 Queen St., Worcester, MA, US Find articles by Jeremy Malin d , Rosalie Torres Stone Rosalie Torres Stone e Department of Sociology, Clark University, 950 Main St., Worcester, MA, US Find articles by Rosalie Torres Stone e , Sonal Singh Sonal Singh , MD f Department of Family and Community Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US Find articles by Sonal Singh f , Sybil Crawford Sybil Crawford , PhD g Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US Find articles by Sybil Crawford g , Kathleen M Mazor Kathleen M Mazor , EdD a Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US Find articles by Kathleen M Mazor a Author information Article notes Copyright and License information a Division of Health Systems Science, Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US b Division of Pulmonary and Critical Care Medicine, Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US c Department of Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US d Family Health Center of Worcester, 26 Queen St., Worcester, MA, US e Department of Sociology, Clark University, 950 Main St., Worcester, MA, US f Department of Family and Community Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US g Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, US ✉ Corresponding author : Kimberly A. Fisher, MD, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, [email protected] Issue date 2025 Apr 19. PMC Copyright notice PMCID: PMC12038750 NIHMSID: NIHMS2072877 PMID: 40186993 The publisher's version of this article is available at Vaccine Abstract This study elicited reasons for initiating COVID-19 vaccination in April 2022 or later. We interviewed patients (n=51) from 2 healthcare systems in central Massachusetts. Participants were 66.7% female, 39.2% White non-Hispanic, 15.7% Black non-Hispanic, and 39.2% Hispanic. The most common reason for vaccination was that it was required for something the participant wanted to do, cited by 40/51 participants as the main reason for vaccination. Social influences, reported by 27/51 participants, were mostly (n=22/27) described as secondary reasons. Increased disease risk appraisal and/or increased confidence in the vaccine were noted by 24/51 participants, also predominantly as secondary reasons (n=14/24). Requirements to be vaccinated for work, school, or to participate in activities are an important lever for promoting COVID-19 vaccine uptake. Commonly cited as secondary reasons, social influences and factors that increase disease risk appraisal and/or vaccine confidence may serve to create a foundation for vaccine requirements. Introduction The COVID-19 pandemic has been devastating, resulting in more than 1.19 million deaths in the United States (US), as of August 2024 [ 1 ]. Despite the magnitude of mortality associated with COVID-19, vaccine hesitancy has remained an ongoing problem. It has been estimated that approximately 232,000 deaths could have been prevented in the US over a 15-month period had there been more widespread acceptance of the COVID-19 vaccine [ 2 ]. Understanding the reasons and motivations for vaccination among hesitant individuals can provide insights into strategies that might increase vaccine uptake. Prior studies eliciting reasons for vaccination among “late adopters”, those who initiated vaccination long after widespread COVID-19 vaccine availability in the US, have found that the most common reason for vaccination was for individuals to protect themselves and their families [ 3 , 4 ]. However, these studies were conducted in 2021 when COVID-19 cases due to the Delta variant were surging. The goal of this study was to characterize the reasons that influenced hesitant individuals to get vaccinated by interviewing those who initiated COVID-19 vaccination even later in the pandemic course, after April 2022, when there was not a surge in COVID-19 cases. Methods Setting, Participants, and Study Design We conducted semi-structured interviews with patients from 2 healthcare systems in central Massachusetts, an academic medical center with a network of community primary care practices and a Federally Qualified Health Center. We identified patients who received their first dose of a COVID-19 vaccine on April 1, 2022, or later. We purposively sampled eligible patients to achieve a diverse sample with regards to race/ethnicity, age, and sex. Patients were invited via mailed letter with telephone follow-up. Participant eligibility was confirmed at the time of telephone follow-up. Recruitment efforts continued until thematic saturation was achieved. Interview conduct and content Interviews were conducted via telephone between September 8, 2022, and January 19, 2023, by two trained interviewers (LG, OD). Interviews focused on the participants’ main reason for getting vaccinated with probes to identify additional factors influencing their decision. All participants were asked, “What was the main thing that made you decide to get vaccinated in [month]?”. After probing to understand the main reason, interviewers asked “Was there anything else that influenced you to get vaccinated?”. This was repeated this until all reasons had been identified. All interviews were audio-recorded and transcribed. Participants were provided a $50 gift card. The study was approved by the UMass Chan Medical School Institutional Review Board. All participants provided informed consent. Analysis Using thematic analysis [ 5 ], the inter-disciplinary coding team inductively generated codes to capture participants’ reasons for vaccination. All study team members reviewed a sample of interviews to ensure the framework captured all reasons for vaccination. The framework was revised as additional interviews were reviewed and new reasons emerged. Reasons for vaccination were organized according to the Increasing Vaccination Model that specifies three domains that influence vaccine uptake: 1) what people think and feel (disease risk appraisal and vaccine confidence); 2) social processes; and 3) practical strategies [ 6 , 7 ]. Reasons were categorized as the primary reason if the participant indicated it was the main reason for vaccination. Factors that participants identified as influential, but not the main reason, were categorized as secondary. If no single reason predominated, multiple reasons were coded as primary. One interview was not comprehensible due to difficulty hearing and understanding the participant and was therefore excluded from the analysis. The remaining interviews (n=51) comprise the analytic sample and were all independently coded by two coders (LG, KF). Discrepancies in coding were discussed until consensus was achieved. A third coder (KM) was available to adjudicate unresolved discrepancies but was not needed. Transcripts were coded in Excel, then exported to SPSS (version 29) to facilitate summarization. We used descriptive statistics to summarize participants’ sociodemographic characteristics. Results Overall, participants were 66.7% female, 39.2% White non-Hispanic, 15.7% Black non-Hispanic, and 39.2% Hispanic. Additional participant characteristics are provided in Table 1 . All reasons for vaccination reported by participants aligned with the domains of the Increasing Vaccination Model. ‘Practical issues’ was the most common type of reason, reported by 41/51 participants, followed by ‘social influences’ (n=27/51), and factors that influenced ‘what people think and feel’ (n=24/51). Practical issues were more likely to be a primary reason, while social influences and factors influencing what people think and feel were more commonly described as secondary reasons ( Figure 1 ). Table 1. Sociodemographic characteristics of interview participants Characteristics N (%) Age 18 – 24 5 (9.8) 25 – 34 16 (31.4) 35 – 44 15 (29.4) 45 – 54 6 (11.8) 55 – 64 8 (15.7) 65 – 74 1 (2.0) Gender Female 34 (66.7) Male 17 (33.3) Race/ethnicity Black, non-Hispanic 8 (15.7) Hispanic 20 (39.2) White, non-Hispanic 20 (39.2) More than 1 race, non-Hispanic 2 (3.9) Declined to answer 1 (2.0) Education Less than high school 7 (13.7) High school graduate or equivalent (GED) 20 (39.2) Some college or 2-year degree (including technical and vocational training) 17 (33.3) 4-year college graduate 7 (13.7) Health system Academic medical center affiliated 37 (72.5) Federally Qualified Health Center 14 (27.5) Open in a new tab Figure 1. Open in a new tab Reasons for vaccination according to the Increasing Vaccination Model domains. Practical issues The most common practical issue cited by 40/51 participants was that COVID-19 vaccination was required for something they wanted to do such as work, attend school, travel, or go to a concert. In all cases, the requirement was the primary reason for vaccination (“ But because of the job, I was like I, I need to get it done. So I got it done for that reason only . ” #48). Another participant got vaccinated “ because we wanted to go to Canada on vacation. That was literally it ” (#10). Requirements led some participants to get vaccinated despite reservations (“ I didn’t feel comfortable [..] but I ended up doing it because of the job thing .” #59). Most participants who got vaccinated because of a requirement focused on positive aspects of what being vaccinated allowed them to do. These mostly included better job opportunities (“ I was trying to get […] a job that wasn’t in fast food ”; #141), making more money (“ because of the money, it’s a much better job than where I was working, and so […] I couldn’t turn it down ” #97), and going to school ( “it would be best for me to get vaccinated to, going to school and bettering my future” #132). Some participants were motivated by personal reasons such as supporting their children (“ I needed to get fully vaccinated in order to have a job to provide for my child ”; #369) or seeing family (“ I went to Canada to see my sister because for three years I didn’t see her and so I needed the vaccine” #298). Only one participant who got vaccinated because it was required expressed anger at the requirement, “ Basically forced because this government owns us. […] in order to feed my children, I am forced to take this damn vaccine” (#593). Two participants got vaccinated because something made it easy or overcame a logistical barrier. These include the availability of a mobile vaccine team for a homebound patient and vaccine availability at their doctor’s office (“ It was right there and so I just got it .” #28). Social influences Social influences to get vaccinated included a conversation with a healthcare provider, being influenced by friends and/or family, and wanting to protect others (altruism). A conversation with a healthcare provider was the most frequent type of social influence (n=17/51). It was the primary reason among a few participants (n=3), but in most instances (n=14), it was a secondary reason. For example, some participants facing a vaccine requirement sought out information and advice from their doctor which helped them to become more comfortable with getting vaccinated ( “because of the whole job situation and stuff, I asked her a little bit more about it. […]. She helped me in that department by giving me the information.” #141). Participants described family and friends influencing them to get vaccinated through encouragement (“ my mom was trying to encourage me to do it” ; #5), pressure ( “my mother kind of pressured me into it”; #87), helping them see that the vaccine is safe (“ the one conversation I had with my friend […] the people she’s known that had gotten the vaccine and they’re totally fine […] and I kind of trust her word” #188), and wanting to be a role model for their kids. Some participants (n=9) got vaccinated to protect others who are close to them (“ my grandmother, she’s like a transplant recipient” ; #109) as well as more generally (“ to keep other people safe” ; #535). What people think and feel The most common reason in the ‘what people think and feel’ domain was to protect themselves. Personal experience with COVID-19, seeing someone close to them become sick or die from COVID-19 (“ I didn’t think my brother would get it. I just thought, like he was strong and healthy, and […] if he got it, he was going to be okay. And he wasn’t. He actually passed away from it”; #38) or noting that friends who had been vaccinated got much less sick with COVID-19 than they did (“ But the people that got vaccinated […], my buddies, did not go through what I went through, not even close. […] It was just like a cold for them. But for me, it was like the worst pneumonia possible ”; #135) all increased participants’ motivation to get vaccinated to protect themselves. Factors that increased participants’ confidence in vaccine safety included seeing others get vaccinated without untoward effect (“ I saw that people close to me started getting vaccinated and nothing was happening ”; #113), getting information from a healthcare provider (“ I wasn’t sure of how to absorb the information I was getting about it until I talked to the doctor. And he […] explained it a little better so I could understand that this, getting the shot wouldn’t hurt me” ; #36), and talking to peers (“ I discussed it with a lot of my other employees […] and I pretty much just like became comfortable with it” ; #188). Discussion Our study provides important insights into the reasons for vaccination late in the COVID-19 pandemic (after April 2022) among a racially and ethnically diverse population. Overwhelmingly, the most common reason among participants in this study for eventually getting vaccinated was that it was required for something the participant wanted to do. Our study aligns with the results of a 2021 survey in which possible job loss was associated with increased intent to get vaccinated against COVID-19 among US adults [ 8 ]. Our findings are also consistent with those of a survey conducted in Belgium in which the two most common reasons for vaccination among hesitant individuals were to facilitate travel and “recover freedom” after instituting a COVID-19 health pass which conditions access to activities and venues on documentation of immunity [ 9 ]. The present study provides empirical evidence that suggests vaccine requirements may be effective at promoting COVID-19 vaccination among US adults, as has been suggested by others [ 10 ] and previously demonstrated for influenza vaccination among healthcare workers (HCWs) [ 11 , 12 ]. To our knowledge, this is the first study to examine reasons for vaccination among individuals who got vaccinated at such a late stage in the pandemic. A Kaiser Family Foundation (KFF) survey assessed reasons for vaccination among individuals who got vaccinated between June 1 and September 2021, just as the Delta variant was increasing in the US [ 3 ]. In this KFF survey, the most common main reason for vaccination related to disease risk appraisal (e.g., increasing cases due to the Delta variant) reported by 35% of respondents. Substantially fewer cited requirements to participate in specific activities (13%) or for work (8%) as the main reason. While differences in approach and study sample preclude definitive conclusions, the much higher frequency (nearly 80%) of respondents in our study whose main reason for vaccination was a requirement likely reflects differences in the federal rules in place at the time each study was conducted and suggests that such rules may be impactful [ 13 ]. It is also possible that vaccine requirements may be a more important lever during times when there is not a large surge in COVID-19 cases. It is notable that only one participant in our study expressed anger at having been required to be vaccinated. Requirements imposed by an employer or school may be viewed differently than mandates perceived to come from the government. Additionally, requirements may be viewed differently if the requirement enables participation in a valued activity since most study participants positively described the job or activity requiring vaccination. The absence of more widespread backlash to vaccination requirements in this study may also reflect the political context of Massachusetts as views on mandates differ by political affiliation [ 3 ]. Despite the evidence we present for the effectiveness of vaccine requirements, these must be balanced with the potential for unintended consequences such as erosion of trust in institutions [ 14 ], and/or the possibility of increasing vaccine hesitancy among individuals who feel coerced. Further studies are needed to better understand public views of vaccine requirements and how these vary by context. For example, vaccine requirements for a discretionary activity such as attending a concert are likely to be viewed differently than requirements for activities that may be considered essential. Ideally, vaccine requirements would be accompanied by strategies to foster genuine confidence in vaccination. Social influences and factors aimed at changing views of vaccination (‘what people think and feel’) were each only cited as a primary reason for vaccination among approximately one-quarter of participants. This is consistent with systematic reviews that have found that interventions aimed at changing what people think and feel are less effective at promoting vaccination than interventions that rely on direct behavior change or practical strategies [ 6 , 15 ]. However, “what people think and feel” and social influences were commonly described as secondary influences suggesting these may play an important role in establishing vaccine confidence that may be a prerequisite for practical strategies to be effective. Several limitations should be considered when interpreting these findings. First, this study was conducted among English-speaking individuals in Massachusetts limiting generalizability, particularly among individuals in states with different political views than those that predominate in Massachusetts. Second, the study design does not allow us to provide a quantitative estimate of the impact of vaccine requirements on COVID-19 vaccine uptake in the general population. Third, vaccine requirements that were in place at the time this study was conducted may no longer be in place. For example, federal rules requiring vaccination of HCWs in facilities that receive federal funding have since been suspended. Fourth, this study was not designed to systematically capture negative views of vaccine requirements as we did not include individuals subjected to a vaccine requirement who chose not to be vaccinated. Conclusions Requirements to be vaccinated for work, school, or to participate in activities were an important lever for promoting COVID-19 vaccine uptake among hesitant individuals who did not get vaccinated until very late in the COVID-19 pandemic. Their effectiveness may be enhanced by social support for vaccination and evidence of vaccine safety. Strategies that foster genuine confidence in vaccination may be especially important to avoid potential unintended consequences of vaccine requirements. Funding This work was supported by the National Institute of Minority Health and Health Disparities [grant #R01MD016883]. Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Kimberly A. Fisher reports financial support was provided by National Institute on Minority Health and Health Disparities Division of Intramural Research. Kimberly A. Fisher reports a relationship with American Thoracic Society that includes: consulting or advisory. All other others declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. 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