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Population-Wide Vaccination Hesitancy among the Amish: A County-Level Study of COVID-19 Vaccine Adoption and Implications for Public Health Policy and Practice

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Abstract

Spatially concentrated, vaccine-hesitant populations represent an ongoing challenge to public health policies that emphasize mass vaccination as a means to eradicating certain infectious diseases. Previous research suggests that Amish populations, which are spatially clustered and rapidly growing, may be undervaccinated. However, existing evidence is limited to local case studies in pre-COVID-19 contexts. Using a series of negative binomial regression models, we evaluated the association between county-level vaccination rates and the percentage of Amish in 356 Amish-populated counties in the United States from February 1, 2021 through October 31, 2022 while controlling for a set of covariates known to impact vaccination rates. Our findings suggest that, after adjusting for county-level characteristics, Amish-populated counties had approximately 1.6% (95% CI: 1.1%-2.0%; p < 0.001) lower rates of getting COVID-19 vaccines. Our findings underscore the failure of public health outreach efforts to convince Amish to accept COVID-19 vaccines. Prevailing public representations of the Amish—as an unproblematic people removed from public affairs and largely unaware of the “outside world”—may have helped Amish avoid societal pressure to vaccinate. Furthermore, because Amish are not as much “hard to reach” as “hard to vaccinate,” we suggest service providers and policy-makers avoid top-down approaches that target the Amish—including cultural competency strategies that work to reduce perceived boundaries—and instead give Amish space to either initiate bottom-up partnerships with health services or accept responsibility for undervaccination in public life.

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Data availability

Data and codes used for this study are available at https://github.com/shuai-zhou/AmishCovidVaccineAdoption.

Notes

  1. Including LaGrange, Indiana (“Amish face barriers to COVID vaccines,” Elkhart Truth, April 3, 2021); Holmes, Ohio (“‘Not surprised’: Holmes County reporting lowest COVID-19 vaccination numbers in Ohio,” Fox 8, July 28, 2021); Osceola, Michigan (“Osceola County vaccination rate among the area's lowest,” Cadillac News, June 5, 2021); Clark, Wisconsin (“Vaccine hesitancy runs deep in rural Clark County, but efforts underway to reach out,” WPR, May 25, 2021); Todd, Minnesota (“Welcome to Todd County, where just 34% of people are vaccinated,” Minnesota Reformer, July 14, 2021); and the Kalona area of Iowa (“Shunning vaccines, Iowa Amish deal with COVID-19 as a community,” The Gazette, May 17, 2021).

  2. https://covid.cdc.gov/covid-data-tracker/#county-view.

  3. Although we selected October 31, 2022, as the end date of this study, the actual date that reported COVID-19 vaccination before October 31, 2022, was October 26, 2022.

  4. https://electionlab.mit.edu/.

  5. ARDA’s classification is guided by the RELTRAD scheme (that is, “Religious Traditions”) which aggregates religious denominations into broader religious families, including evangelical Protestant (Woodberry, Park, Kellstedt, Regnerus, & Steensland, 2012). Because RELTRAD places Amish into the evangelical Protestant tradition, for our calculations, we subtracted the Amish population from the total population of this category. Edmonson County, KY, was dropped from analysis as it impossibly reported 128.72% of the population as evangelical.

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Funding

This research is supported in part by the Population Research Institute at Pennsylvania State University, which is supported by an infrastructure grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2CHD041025) and Social Environments and Population Health (T32HD007514) training grant, and USDA National Institute of Food and Agriculture and Multistate Research Project #PEN04623 (Accession #1013257). Further support was provided by a seed grant from the NIA-supported Interdisciplinary Network on Rural Population Health and Aging. Financial supporters had no role in the study design; collection, analysis, and interpretation of the data; writing the report; and the decision to submit for publication.

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Authors and Affiliations

  1. Population Research Institute, Pennsylvania State University, 601 Oswald Tower, University Park, State College, PA, USA

    Cory Anderson, Shuai Zhou & Guangqing Chi

  2. Deptartment of Agricultural Economics, Sociology, and Education, Pennsylvania State University, University Park, State College, PA, USA

    Shuai Zhou & Guangqing Chi

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  1. Cory Anderson
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  2. Shuai Zhou
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Correspondence to Cory Anderson.

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Appendix A

Appendix A

See Tables 3 and 4

Table 3 Sensitivity analysis using daily and weekly vaccination rates as the dependent variable
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Table 4 Negative binomial regression of county-level daily COVID-19 vaccination rate, january 19th, 2022
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Anderson, C., Zhou, S. & Chi, G. Population-Wide Vaccination Hesitancy among the Amish: A County-Level Study of COVID-19 Vaccine Adoption and Implications for Public Health Policy and Practice. Popul Res Policy Rev 42, 70 (2023). https://doi.org/10.1007/s11113-023-09816-9

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