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An Analysis of the Determinants of Vaccine Hesitancy. Can the World Learn from the US Experience?

While efforts to vaccinate the general public have been trending in a positive direction, Vaccine Hesitancy is a global issue. Many infectious disease physicians, epidemiologists, and Public Health Authorities fear that Vaccine Hesitancy will indefinitely prolong the pandemic, as the Delta Variant currently ravages through the unvaccinated population. In an attempt to understand this global phenomenon, we looked at the United States’ vaccine rollout. In particular, we examined the determinants of vaccine hesitancy in the USA. Our empirical model reveals that Vaccine Hesitancy is significantly impacted by factors such as Median Income, Political Affiliation, Percentage of population that is White/Caucasian, Total Cases, Individuals without Health Insurance, and Education level. We use data from all 50 states in the US. Policy makers in other countries can greatly benefit from the findings of our empirical results. Some incentive structures should be introduced as quickly as possible to achieve a high vaccination rate in the country. State’s experience of Vaccine Hesitancy as a baseline of sorts for the greater global community to understand, and reduce hesitancy in their vaccine rollouts.


Introduction
Let us imagine that it is currently June 13th, 2023. Karen Smith, a 35 years old white woman stumbles into an emergency room, suffering from a 101 degree Fahrenheit fever. She reports major shortness of breath, loss of taste or smell. She complains of a sore, and irritable throat, congestion, runny nose and she has been nauseated with occasional vomiting for the past few days. She tells her emergency doctor that she had COVID-19 in the month of August 10th, 2021. She is a Republican, high school dropout, residing in a rural area outside of Martins Ferry, Ohio. Martins Ferry has a population of just over 6,000, where she works at a local gas station at minimum wage. Karen had refused to get vaccinated, and ended up contracting the corona virus months after most people got their shots. Why did she refuse? Could it be because of politics? Could it be her stance on government control? Was it a post she saw on social media she was hooked on? She cannot really pinpoint one reason why she chose to not get vaccinated but her lungs which have patchy diffuse interstitial pneumonia are paying the price for her decision to go without vaccination. By the end of the day on June 14th, 2023 she is hooked up to a ventilator in the ICU. What could Karen have done differently to prevent this? How did we fail to provide her with the needed incentives, information and education to get the vaccination? Is vaccination really safe? Would she have prevented her from being in this situation had she been informed about all the facts about vaccines, its efficacy and potential side effects? Who will pay for Karen's decisions? Tax payers will spend billions of dollars on behalf of the vaccine refusers. It could be even more over the next few decades, with all the complications they could develop. How did we arrive at this point? What went so horribly wrong for us to be in this situation? The purpose of this paper is to take a deep, deep dive into the reasoning behind vaccine hesitancy, and inform the true opportunity cost of hesitancy to the average person, as well as relaying the vaccine's technical history.
Specifically, we identified the factors that are important in determining vaccine hesitancy. We then offer policy implications, and recommendations. The paper is organized in the following manner. Section II discusses the historical development of the COVID-19 Pandemic. Section III examines the availability of vaccines throughout the world, their inventors and producers, and countries where these are authorized for use. Next, in Section IV, we discuss the literature review of the issues surrounding vaccine hesitancy.
Section V examines the results of our research and empirical model. Section VI reveals our conclusion and potential policy recommendations.

Historical Development of COVID-19
A novel Coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) called COVID-19 by WHO denoting the year of discovery was discovered in Wuhan, China in late 2019. It rapidly spread across the world and appeared in the United States officially in January 2020, but it is believed by infectious disease physicians to have probably been here since November 2019. This virus first arrived from Wuhan China to California, USA in December of 2019 and the same virus also arrived at NY city from Europe in December of 2019. (Zhu, N. et al., 2021) Covid-19 had rapidly spread all across the world before the medical professionals could realize that it www.scholink.org/ojs/index.php/ibes International Business & Economics Studies Vol. 3, No. 4, 2021 3 Published by SCHOLINK INC.
was a novel virus. The mechanism of spread was through global travel for both business and pleasure among people who were already infected before developing symptoms and from asymptomatic infections. It is spread through both aerosols from breathing and talking, and respiratory droplets from loud talking, laughing, coughing, and sneezing. (Greenhalgh, 2021) The lack of physical distancing and mask wearing furthered the rate of spread. (Rabi et al., 2020) Unfortunately, along with the spread of the virus, the world population was divided into three different groups of people. First group believes that in order to combat this global pandemic, we must develop the vaccine as quickly as possible and simply vaccinate as many people in the world as fast as possible.
Second group of people were not able to have access to vaccines due to lack of availability and monetary resources. The third group of population simply do not accept the vaccination as the solution to the pandemic problems. We focus on the third group of people and attempt to understand the reasons and factors behind their hesitancy. Specifically, the purpose of this paper is to identify the factors that are important in determining the extent of vaccine hesitancy that exists in the world and offer some sound empirical evidence by evaluating data from the USA from 50 states. We further explore and expose the myth behind some misinformation surrounding different vaccines available today.  infections and is infecting younger patients in their 20s, 30s, and 40s many of which are filling up ICUs. (Yong, 2021). They become very ill for more quickly (within 4 days) and rapidly deteriorate requiring oxygen and intubation. This is because the viral load of this variant is 1000-1260 times higher than the original Covid-19 virus. (Jing et al., 2021) This very high nasal and oral viral load is leading to easier transmission through aerosols from breathing or close physical proximity. Mild to asymptomatic breakthrough infections are occurring among the vaccinated whose nasal and oral viral load is the same as among the infected unvaccinated making the breakthrough infections as contagious. This is why the recommendation to wear masks indoors and among crowds by leading infectious disease physicians, epidemiologists, and Public Health officials has resumed. Children are accounting for 20% of new Delta Covid 19 infections and a substantial number require hospitalization and 1/3 of the hospitalized require ICU admission. (Yong, 2021)  Toprol thinks that 8 months is too long to wait for a booster because research has shown immunity begins to decline at the five to sixth month mark leaving vaccinated people more vulnerable to infection. This leaves two to three months without adequate protection, He also thinks that the waning immunity over has much to do with the Delta variant's contagious nature. He also notes that relaxation of mitigation actions including wearing the proper type of mask indoors or in a crowd, physical distancing, may be contributing, but are harder to measure (CSantucci, Jeanine, 2021).
The unchecked spread in multiple states and counties with very low vaccination rates leads to increased replication of the delta variant which creates more opportunities to create more potentially deleterious mutations which are proving to escape vaccine induced antibodies leading to more breakthrough infections in the fully vaccinated individuals. The mRNA vaccines remain the most effective against the delta variants. (Liu et al., 2021). Other factors which will lead to more infections are laws in Florida and Texas against mask and vaccine mandates in Florida and Texas. A lawsuit has been filed by the Missouri attorney general to stop mask mandates in schools. (Gonzales, 2021) These efforts to pass laws against mitigation efforts will lead to more infections and prevent the U.S. from ever achieving herd immunity.
By comparison, during the 1918 flu pandemic 50 million people died worldwide and 675,000 in the U.S.
Mortality was high in people younger than 5 years old, 20-40 years old, and 65 years and older. The high mortality in healthy people, including those in the 20 to 40 year old age group, was a unique feature of this pandemic. (Yong, 2021) Mask wearing was an issue in the 1918 flu pandemic, but there were many local newspapers which listed the people who were ill, which allowed people in communities to see that folks around them were dying. identified as Democrats were much more likely to exhibit stable attitudes, and intentions of receiving the vaccine. Those who were less likely to receive the vaccine attributed their response to risk perception, as many saw the vaccine as untested, as others did not view the virus' impact as serious as had been reported (Fridman, 2021). This spread has widened as vaccine misinformation has proliferated both on cable news, social media, and conspiracy theories.
A study by the International Monetary Fund examines the phenomenon of Vaccine Hesitancy, and its impact on the prolongment of the Pandemic, and associated health restrictions. Using individual-level surveys developed by YouGov and Imperial College London, this study aimed to reveal the determinants of Vaccine Hesitancy on the global, and national levels through their empirical findings. The first major factors relating to vaccine hesitancy were examined through a demographic lens, as age, gender, race, and socioeconomic status all contributed to an individual's willingness, or lack thereof, to receive the vaccination. Unsurprisingly, political leanings, as well as perceptions of the virus, also were shown to be heavy determinants of vaccine hesitancy. Government and scientific trust, misinformation, and fear of side effects all accumulated a large degree of hesitancy in this area of focus. Using this accumulated data, the study also revealed through it's SIR model, that the present, and future rates of vaccine hesitancy can severely impact the future trajectory of COVID-19 case counts, and subsequently, restrictions to mitigate the spread. This model forecasted, with the current rates of vaccine refusal, and hesitancy, that the count of cases, as well as deaths, and hospitalizations, will rise in the coming fall/winter months (Khan, 2021).
The report from the Journal of Community Health uncovers the breakdown of those hesitant to receive theCOVID-19 vaccination. Those who are less likely to receive the shot are typically young, conservative leaning, with little education, and less disposable income. However, the greatest denominator actually is not entirely observable through a demographic breakdown. This article argues that perception is the greatest indicator of vaccination, or not. The perceived threat of COVID-19, and its symptoms are not viewed equally. Some do not feel that it is as seriousas advertised, and that the Vaccine's unproven long-term effects are more of a concern. Through a multi-item valid, and reliable questionnaire published by mTurk, this study revealed that lower-income, less educated individuals were far more likely to not receive the vaccine due to fear of side effects, or perceptions of the virus not being that serious. Vaccine Hesitancy was also higher in African-Americans, and Hispanic communities, as well as those in rural areas, especially in the Northeastern United States. A large contingent of those who identified as Republican (29%) also reported that they would not likely be vaccinated (Khubchandani, 2021 throughout the United States, and looks to establish the key characteristics that under-vaccinated areas share. The article notes that the Biden Administration has placed Vaccine Equity as a priority in their rollouts of the different vaccines, however, the issue is more tangible at a local level. The study points out that earlier in 2021, the CDC determined that areas with higher social vulnerability were more likely to have below average vaccination rates. Notably, the study observed that vaccination rates do not necessarily correspond with COVID infection rates, and impacts. In fact, counties with higher transmissions rates, surprisingly, saw higher vaccination rates. This led to the KFF brief to examine population density, and observe that more urban, metropolitan areas saw greater vaccination rates than the more rural, desolate counties (Tolbert, 2021). A research report featured in the New England Journal of Medicine discusses how the supply of vaccines in the U.S. has exceeded their demands, and how some certain policies, and programs could improve the vaccination rate. The NEJM targets herd immunity around 80% of the population receiving the vaccine, however, the nation currently sitsat just under 50%. The growing concern is that this level will stagnate without a large push to nudge those in the middle into receiving the shot. Monetary incentives, such as a lottery program, have been noted to be not impactful at worst, and provided middling returns at best. This article notes that a key component of incentive programs needs to address those who are hesitant, not simply just to those who would have received the vaccine to begin with. In order to significantly impact the vaccination rates in a positive direction, these programs and strategies should aim to instill public confidence in the vaccine, and its rollout systems. Importantly, these strategies should aim to remove barriers that have kept poorer populations, people of color, minorities, and those in rural areas from receiving the vaccine .

Empirical Model
The vaccine hesitancy varies greatly in the country. hesitancy of 9 percent and over 60 percent. In order to address the disparity in the rate of vaccine hesitancy, state officials need available data to target incentive programs where vaccine hesitancy rate is significantly higher.
In our empirical model, we first identify the factors that determine vaccine hesitancy in the United States.
The model specified to estimate the coefficients associated with the determinants are given in the equation 1 below. The cross sectional data set used to estimate the model is for 50 states in the US. We utilized the most up to date data as of Aug 9, 2021. The definitions and sources of the variables used in our model are presented in Table 5. reports of the Electoral College from the 2020 Presidential General Election, we determined which states voted Republican or Democrat. We expect a negative coefficient to be associated with this variable, indicating that Republicans are more likely to be hesitant. According to PLOS One's report on the demographics of the unvaccinated, 49% of all unvaccinated people identified as Republican. 29% of that group reported that they were "Hesitant to Very Hesitant". We have identified Republican states as (0), and Democratic as (1) in our data.
• (%WH) measures the percentage of population within the state that is White/Caucasian. We expect a positive coefficient to be associated with this variable, indicating that White people are more likely to be more hesitant. According to the KFF's report on unvaccinated individuals, White adults account for the largest share of the unvaccinated population (57%).
• expect a negative coefficient to be associated with this variable, indicating that individuals from states with a higher number of confirmed cases are more likely to be hesitant. Studies from the KFF have pointed to population density being a contributing factor to total cases, especially in areas with higher hesitancy. • (W/HI) represents the percentage of the population that is currently without any health insurance within the state. We expect a positive coefficient to be associated with this variable, indicating that individuals without Health Insurance are more likely to be hesitant.
• (EDU) represents the percentage of the population with a bachelor's degree or higher within the state.
We expect a negative coefficient to be associated with this variable, indicating that individuals with at least a bachelor's degree or higher are less likely to be hesitant.  well as other countries with more developed vaccine access to send vaccines to low and developing countries to help speed up the process of getting people vaccinated. However, given the scope of this task, as well as most nations lagging behind their vaccination goals, this effort appears to be in vain.
There are many counties with extremely low vaccination rates as low as 20% adjacent to more urban areas which may have 40% or more vaccinated, which has led to widespread infection in a large geographic area as demonstrated by many of the Southern and conservative states and counties throughout the rest of the U.S, Most people in much of the U.S. have discontinued mitigation strategies such and wearing a mask and practicing social distancing which has facilitated the rapid spread of the delta variant. India is an example of a dense unvaccinated population due to a lack of access to vaccines.
This widespread unchecked infection in a dense population has given the Covid-19 virus ample opportunity to form many mutations from the many replications as it spreads to new hosts leading to delta variant which has rapidly spread across the world. (Young, p. 2921) The delta variant has a number of mutations that increase the viral load in the oropharynx by 1,000-1,260 times the original virus with the effect of increased transmission, shorter incubation period, and more severe illness in those who become ill. (Jing et al., 2021) The result of this continued widespread low vaccination rate will lead to the virus becoming endemic. This will allow a more rapid evolution of variants with mutations which are likely to escape both convalescent and vaccine immunity. (Liu et al., 2021) Herd immunity is unlikely to ever be achieved since the medical community is unable to vaccinate as many people as possible in a short period of time in both the U.S. and all across the world. (Aschwanden, 2021) Given the results from estimating the empirical model specified in equation 1, we are in agreement with the current literature regarding the factors that determine the variation of vaccine hesitancy in different states within the United States. Policy makers around the world must pay particular attention to these factors identified in our findings.
In this section, we move forward to evaluate the economic consequences of persistent vaccine hesitancy. As the world tackles this pandemic, and inch toward the goal of herd immunity, we must compose incentive structures targeted at hesitant individuals. Using the results from our empirical model, and regression, we can determine multiple factors that can help identify potential hesitant individuals. We believe that this focused strategy would be much more effective at increasing the vaccination rate, compared with more general incentive strategies that encompass most citizens.
Increasing the overall vaccination rate throughout the United States, as well as throughout the world must be the number one priority, and to do so, vaccine hesitancy must be greatly decreased. Through our variables that we identified correlating with vaccine hesitancy, we can identify individuals more likely to be vaccine hesitant, and target them with positive messaging, information/education, and incentives. What can be done to counter some of these economic effects that are severely hampering the nation's economic ability? We believe a complete perspective change is required. To combat vaccine hesitancy, and its resulting loss in economic output, we must begin to view Vaccine Hesitancy as a negative externality that must be addressed by providing economic incentives to reduce the externalities. One recommendation is directed at the Public Sector, and has been shown to be incredibly fruitful when utilized: incentivizing employees to receive the vaccine. Achieving herd immunity is critical according to the Journal of American Medical Association (JAMA). Robert Litan, a non-resident Senior Fellow in the Economic Studies Program at the Brookings Institution, believes that the COVID vaccine can be observed as a positive externality. He believes a solution could be to compensate every vaccinated individual with $1,000. Harvard economist, and former chair of Economic Advisors for the Bush administration, Gregory Mankiw, champions this position as "textbook" economics. (Forbes, 2020) Vanguard, an asset management giant, followed this strategy, proposing a $1,000 incentive to any employee that receives the vaccine. Vanguard has given their 16,500 eligible employees until Oct 1, 2021 Using the United State's experience as our template for the greater world, we can look at similar variables from different nations to predict, and identify potentially hesitant individuals. We would assume the variable Political Affiliation (POLAF) would have to be tweaked, understanding that the rest of the world does not necessarily abide by the two party system that the States do. Health coverage would similarly need to be reevaluated, given the vast differences in European and American Health Systems. However, education, median income, total cases, and percent white could all be used as indicators of potential hesitancy throughout the world. Vaccine Hesitancy is the single greatest roadblock on the path to a return to normalcy. Without serious policy, societal, and administrative changes the costs of prolonging the COVID-19 pandemic could be momentous. In order to minimize vaccine hesitancy, and its consequences, we must again look at the determinants to understand where it comes from. There is no one singular reason for the majority of vaccine hesitant individuals, in many cases, it is a perfect storm of the determinants we quantified, compounded by misinformation, and a divided societal climate. As seen in our empirical model: median income, political affiliation, education level, total cases, and percentages of the population that is white and without health insurance, all are defined as determinants of vaccine hesitancy.
Vaccine Hesitancy is the single greatest roadblock on the path to a return to normalcy. Without serious policy, societal, and administrative changes the costs of prolonging the COVID-19 pandemic could be momentous. In order to minimize vaccine hesitancy, and its consequences, we must again look at the determinants to understand where it comes from. There is no one singular reason for the majority of vaccine hesitant individuals, in many cases, it is a perfect storm of the determinants we quantified, compounded by misinformation, and a divided societal climate. As seen in our empirical model: median income, political affiliation, education level, total cases, and percentages of the population that is white and without health insurance, all are defined as determinants of vaccine hesitancy.