COVID-19 vaccine hesitancy cannot fully explain disparities in vaccination coverage across the contiguous United States

Vaccine hesitancy has been identified as a major obstacle preventing comprehensive coverage against the COVID-19 pandemic. However, few studies have analyzed the association between ex-ante vaccine hesi-tancy and ex-post vaccination coverage. This study leveraged one-year county-level data across the con-tiguous United States to examine whether the prospective vaccine hesitancy eventually translates into differential vaccination rates, and whether vaccine hesitancy can explain socioeconomic, racial, and par-tisan disparities in vaccine uptake. A set of structural equation modeling was fitted with vaccine hesi-tancy and vaccination rate as endogenous variables, controlling for various potential confounders. The results demonstrated a significant negative link between vaccine hesitancy and vaccination rate, with the difference between the two continuously widening over time. Counties with higher socioeconomic statuses, more Asian and Hispanic populations, more elderly residents, greater health insurance coverage, and more Democrats presented lower vaccine hesitancy and higher vaccination rates. However, underly-ing determinants of vaccination coverage and vaccine hesitancy were divergent regarding their different associations with exogenous variables. Mediation analysis further demonstrated that indirect effects from exogenous variables to vaccination coverage via vaccine hesitancy only partially explained corre-sponding total effects, challenging the popular narrative that portrays vaccine hesitancy as a root cause of disparities in vaccination. Our study highlights the need of well-funded, targeted, and ongoing initia-tives to reduce persisting vaccination inequities.(c) 2022 Elsevier Ltd. All rights reserved.