COVID-19 Vaccine Hesitancy in South Asian Americans

Suhaila Khan , Tonima Ashrafi , Saiyara Sheik , Tasfia Khanb , Yusufal Mamoonb

aSHK Global Health
bResearch Ambitions, Bangladesh Medical Association of North America
cQueens Hospital Center


This review article investigated the factors that contributed to the COVID-19 vaccine hesitancy in South Asian Americans and other communities of color in the US. Only a few studies were done on South Asian Americans. The factors contributing to COVID19 vaccine hesitancy in South Asian Americans were: concerns about the safety and lack of access to healthcare (language barrier). Many other factors found in other communities of color in the US were: lower education, lower income, younger people, women, rural residents, conservative/Republican political bias, social media’s influence, lack of trust in government, and previous adherence (pre-pandemic) to general immunization.

We recommend the following strategies to increase vaccination rates among South Asian Americans:

  • Develop health education/messaging programs for South Asian Americans that are culturally and linguistically appropriate.
  •  Include social media influencers and the medical community early in messaging strategies.
  •  Invest more on research on South Asian Americans to find which other factors also affect these communities.

COVID-19 vaccine hesitancy in South Asian Americans exists and should be addressed just like in every other community of color in the US. Information is very much needed to raise the awareness about the need for vaccines, increase vaccination rates, find strategies for overcoming vaccine hesitancy, and significantly reduce morbidity and mortality from COVID-19.


Keyword:     COVID-19 Vaccine Hesitancy US South Asian American Bangladeshi American Nepalese American Asian Indian

COVID-19 Vaccine Hesitancy in South Asian Americans

Suhaila Khan , Tonima Ashrafi , Saiyara Sheik , Tasfia Khanb , Yusufal Mamoonb

aSHK Global Health
bResearch Ambitions, Bangladesh Medical Association of North America
cQueens Hospital Center


The Coronavirus Disease 2019 (COVID-19) is a respiratory disease in humans caused by a virus named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (CDC 2021). COVID-19 was very contagious, spread quickly around the world in 2020, and caused a global pandemic with high morbidity and mortality in both developed and developing countries.

The United States (US) was also hit hard by the COVID-19 crisis with an estimated: 146 million cases, 6.4 million hospitalizations, and 1.1 million deaths.1 In the US, communities of color disproportionately suffered from the highest burden of illness and death from COVID-19. African Americans, Hispanic/Latinos, Asian Americans Native Hawaiians, Pacific Islanders were much more likely to be hospitalized or die from COVID-19 compared to White Americans.2,3 One study reported that the death rate was double for Asian American, African American, and Hispanic/Latino American patients.4

South Asian Americans are part of the Asian American diaspora, and also suffered greatly from very high COVID- 19 morbidity and mortality rates – patients, caregivers, and healthcare workers alike (e.g., Bangladeshi American physicians). While this is well known anecdotally in these communities, data are not available (not collected or reported).

Aggregated Asian American data masks the considerable differences across this heterogeneous community – cases, hospitalizations, deaths. For example, the CDC reported COVID- 19 cases and deaths that aggregated Asian Americans, Native Hawaiians, and Pacific Islanders – show no heterogeneity (see Figure below).5 However, disaggregated Asian American data showed much variation in the COVID-19 hospitalization rates among Chinese, Indian, Filipino, Japanese, Korean, and Vietnamese Americans.6

One study from New York public hospital system reported that South Asian American patients had the highest rates of COVID-19 positivity (30.8%) and hospitalization (51.6%) among Asian American patients, second to Hispanic/Latino and African American patients. Chinese American patients had the highest mortality rate of 35.7% of all racial and ethnic groups.7 A community based study reported that Bangladeshi Americans made up less than 8% of NYC’s Asian population, but accounted for 20% of COVID-19 deaths.8

There are several ways to prevent the spread of viral infectious diseases (including COVID-19), e.g., vaccination, wearing masks, washing hands, and social distancing. In combination with hygiene and behavior, vaccination is the most effective method for reducing viral infection and dissemination, and the severity of the disease. Creating herd immunity by vaccinating the majority of the population is considered the most effective method of combating viral infections like COVID-19. However, even the most effective vaccine will be ineffective if it is not administered at high rates. The World Health Organization (WHO) reported vaccine hesitancy as one of the top ten global health problems even before the COVID-19 pandemic started. Vaccine hesitancy refers to “…the reluctance or refusal to vaccinate despite the availability of vaccines”.

Study Objective

Thus, this study conducted a literature review to understand and identify the predictors of COVID-19 vaccine hesitancy in South Asian Americans in the US. This was done to understand if the high disparities seen in COVID-19 mortality and morbidity also exist in the area of vaccine hesitancy for these communities.


Study Design

This study conducted a search of peer-reviewed articles in electronic and public databases such as PubMed and Google scholar. Databases like these yielded very limited number of articles on South Asian Americans. For example, a quick search on PubMed illustrated this paucity (accessed 8/30/23):

COVID-19 vaccine hesitancy in US (560 results)


” in South Asian American (2 results)

in Asian American (34 results)

in Native Hawaiian/Pacific Islander (3 results)

” in African American (34 results)

in Hispanic/Latino (25 results)

in American Indian/Alaska Native (2 results)

Thus, this review also searched journals and websites that focused on South Asian American and Asian American healthcare issues. The review process was as follows: read the abstracts (180 articles), read the full text (85 articles), met all the inclusion criteria (33 articles), highlighted South Asian Americans (6 articles).

Search Terms and Inclusion-Exclusion Criteria

The key search terms were:

•    COVID-19 vaccine hesitancy in US, South Asian American.
•    Asian Indian, Bangladeshi American, Nepalese American, Filipino American, Asian American, African American, Hispanic/Latino – these terms were added as very few articles were found using             only the phrase “South Asian American”.
•    The inclusion criteria were:
•    Studies that investigated COVID-19 vaccine hesitancy in US.
•    Cross-sectional studies and surveys.
•    Articles published during January 2020 to August 2023.

•    The exclusion criteria were:
•    Studies published in a language other than English.
•    Preprint articles with no evidence of a peer review process. Review articles and narratives.


The US public's stance towards COVID-19 immunization was complex and influenced by many factors. Many studies were available on COVID-19 vaccine hesitancy in the US. However, only a few were available on South Asian Americans. Since there were so few articles on South Asian Americans (and even Asian Americans), this review also explored predictors of vaccine hesitancy in other communities of color (e.g., African Americans, Hispanic/Latino Americans) who share some similar traits such as co-morbidities (e.g., high diabetes, hypertension).

Factors Contributing to COVID-19 Vaccine Hesitancy in South Asian Americans.

  • Concerns about vaccine safety (side effects)10
  • Lack of access to healthcare (e.g., linguistic barriers)11

One study from Michigan reported that South Asian Americans (sample included Asian Indian, Bangladeshi, Burmese) had more concerns about vaccine safety compared to East Asian Americans or South East Asian Americans.10 One study from New York City reported that 25% of Asian Americans had not received one or more doses of the COVID-19 vaccine. Their disaggregated data showed that more Bangladeshi Americans (47%) and Nepalese Americans (87%) had not received one or more doses of COVID-19 vaccine. 34% Asian Americans faced language barriers (e.g., need for interpreter, translated materials) during COVID-19. Wait time for an interpreter for Bangladeshi Americans were the highest (65%) and filing for unemployment for Nepalese Americans were the highest (68%). For these communities it was lack of access rather than vaccine hesitancy in not getting vaccinated.11 Another study reported that women and older Asian Americans were more vaccine hesitant. This study included Asian Indians but lumped them into “Other/Mixed Culture” because of small sample size.12

Factors Contributing to COVID-19 Vaccine Hesitancy in Other Communities of Color in the US

The factors contributing to COVID-19 vaccine hesitancy in other communities of color were:

  1. Concerns about vaccine safety (side effects) and efficacy13,15-18,20,25,28
  2. Lack of access to healthcare13,23
  3. Socio-demographic characteristics:

O Race/ethnicity - African American, Hispanic/Latino,

Native Hawaiian, Pacific Islander, American Indian/Alaska Native13-28

O Education - low/less than bachelor’s degree14,16,18 21,27,28 Household income - low17-19,23,27,28

  • Gender - women13,21,23,27
  • Age - young people13,20,21
  • Residence – rural 19,28

      4. Communication and Social media’s influence

  • Social media’s negative influence15,23,26,28-33
  • Lack of messaging from medical community/primary care physicians16,21

      5. Lack of trust in government/government resources 14,15,17,20,22,25
      6. Political bias - Conservative/Republican13,19,27
      7. Pre-pandemic factors14,27

  • Adherence to general immunization
  • Historical biomedical and healthcare-related mistrust

Figure 2: Factors contributing to COVID-19 Vaccine Hesitancy in South Asian Americans (orange boxes)

Concerns about COVID-19 Vaccine Safety and Efficacy

There were a lot of concerns about the safety and/or efficacy of the COVID-19 vaccines in African Americans and Hispanic/Latino Americans. These were due to: lack of faith in the scientific endeavors, their expedited development (too rushed, research cut corners on testing safety/efficacy), "Operation Warp Speed" nomenclature, anti- vaccine propaganda campaigns, negative rumors, misinformation, autism, etc. The concerns about the side effects were: whether they are temporary, would they get sick from the live coronavirus in the vaccine, would it effect pregnant women, etc.

Lack of Access to Healthcare

Lack of access to healthcare also led to lower vaccination rates. These were: insufficient public transportation, cost, lack of flexibility in working hours (for those from low income households), and lower access and interaction with healthcare professionals.

Socio-demographic Factors

Many socio-demographic characteristics were associated with COVID-19 vaccine hesitancy.


African Americans and Hispanic/Latino Americans reported much higher levels of vaccine hesitancy compared to Whites in the US.

Lower Education (less than bachelor’s degree)

Lower education (less than bachelor’s degree) was associated with more vaccine hesitancy due to more COVID-19 vaccine apprehension and less understanding of vaccine-related scientific investigations.

Lower Household Income

Respondents from lower-income backgrounds were less likely to get vaccinated than higher income households. Lower income people were more anxious about missing work, and vaccine shots were less accessible in low-income regions.

Gender - women

Women were more likely than men to postpone or refuse the COVID-19 vaccines. Their reasons were: the vaccine was too new, afraid of adverse effects, and negative impact on fertility and pregnancy (COVID-19 vaccine clinical trials had excluded pregnant and breastfeeding women)

Age – younger people

The COVID-19 vaccine hesitancy was higher in this demographic group than any other age groups. Young people were often healthier and had fewer fears of COVID- 19-related illnesses and deaths.

Rural Residents

COVID-19 vaccine hesitancy was higher in rural areas than in urban areas. Rural residents believed their risk of exposure to COVID-19 was lower than urban residents due to lower population density and less use of public transportation. Rural residents also thought that the severity of COVID-19 had been exaggerated.

Political Bias – Conservative/Republican

More vaccine hesitancy was seen in conservative/Republican voters compared to liberal/Democratic voters. Conservatives/Republicans did not feel COVID-19 was a big concern.

Communications and Social Media’s Influence

Many studies reported that people relied on social media for their COVID-19 information including COVID-19 vaccines (e.g., Facebook, Twitter, Instagram, Snapchat, TikTok, YouTube, etc.). One study reported more than 400 anti-vaccine accounts on these social media platforms with 58 million followers (most of whom live in the US). Another study reported that less than 10% information on social media was from the medical community. Reviews of Twitter and Facebook posts showed numerous posts related to COVID-19 that were: anti-vaccine, false information, conspiracy theories, and anti-government. A study mentioned the influence (positive and negative) of prominent public figures on people’s attitudes about getting vaccinated. Most of these studies did not analyze by race/ethnicity but were considered important in the vaccine hesitancy discussions.

Lack of Messaging from Medical Community/Primary Care Physicians

People mentioned that their vaccine hesitancy was also related to not hearing any unified message from the medical community or their primary care provider physicians early in the pandemic. PCPs were not included in the early vaccination discussions.

Lack of Trust in Government/Government Resources

The historical impact of systematic racism and the unfavorable experiences encountered by ethnic minorities (particularly African Americans) in the healthcare system also lead to COVID-19 vaccine hesitancy. There has also been concern about the inadequate or lack of inclusion of ethnic minorities in clinical trials. Social media platforms promoted anti-government messaging.

Pre-pandemic Factors

There is a strong correlation between COVID-19 vaccine hesitancy and: adherence to general immunization and historical biomedical and healthcare mistrust.


The factors contributing to vaccine hesitancy in South Asian Americans were: vaccine safety concerns and lack of access to healthcare. Many other predictors (along with these) were found in other communities of color in the US, e.g., socio-demographic 

factors (low education, low income, women, younger people, rural residence, Republican political affiliation), social media’s influence, lack of trust of government, and pre-pandemic factors.

Although vaccine hesitancy usually diminishes over time as more and more people take it, implementing some immediate strategies will expedite vaccine acceptance faster. For example,

  • Develop health education/messaging programs for South Asian Americans with culturally and linguistically appropriate information about the benefits of vaccination.
  • Include social media influencers early in messaging strategies.
  • Invest more on research studies on South Asian Americans to find which other factors also affect these communities. It is important to find out if the numerous factors associated with COVID-19 vaccine hesitancy seen in other communities of color are also seen in South Asian Americans.
  • Predictors identified in other communities of color may be used as proxies till direct data are available. However, this is not a long term solution.
  • There should be more research on social media’s use that included socio-demographic variables.
  • Engage multiple sectors (government, private, non- profit, faith, civil society – in health, medical, economy, environment) and leverage knowledge, expertise, reach and resources, and benefit from their combined and varied strengths.


Vaccine hesitancy in South Asian Americans exist and should be addressed just like in every other community of color in the US. Such information is very much needed by policymakers and health programmers to raise awareness about the need for vaccines, increase vaccination rates, find strategies for overcoming vaccine hesitancy and achieving equity in COVID-19 vaccination, and keep reducing morbidity and mortality from COVID-19


Many thanks to Dr.s Tanzina Afroze and Umme J. Ferdaus for their assistance in the initial literature review. This project was supported by SHK Global Health and Research Ambitions-Bangladesh Medical Association of North America (BMANA). This project was partially supported by the National Council of Asian Pacific Islanders Physicians (NCAPIP) through a funding by The Walmart Foundation.



1. CDC.COVID-19 Data Tracker. Centers for Disease Control and Prevention. Accessed10/23/23.

2.  Hooper MW, Nápoles AM, Pérez-Stable EJ. COVID-19 and Racial/Ethnic  Disparities.  JAMA.   May    2020. 10.1001/jama.2020.8598

3. Chu JN, Tsoh JY, Ong E, Ponce NA. The Hidden Colors of Coronavirus: the Burden of Attributable COVID-19 Deaths. Journal of General Internal Medicine. Jan 2021. doi:10.1007/s11606-020-06497-

4. Rubin-Miller, Alban C, Artiga S, Sullivan S. COVID-19 Racial Disparities in Testing, Infection, Hospitalization, and Death: Analysis of Epic Patient Data. Kaiser Family Foundation. Sep 2020. racial-disparities-testing-infection-hospitalization-death- analysis- epic-patient-data/

5. CDC. COVID-19 Case Line-Level Data, 2019 US Census, HHS Protect; Visualization: Data, Analytics & Visualization Task Force and CDC CPR DEO Situational Awareness Public. Accessed April 2023.

6. Li J, Chhoa D, Palaniappan L, Hays KJ, Pressman A, Wang NE. Disparities in COVID-19 Testing and Outcomes among Asian American and Pacific Islanders: an Observational Study in a Large Health Care System. BMC Public Health, 23. 251 (2023). Doi:10.1186/s12889-023-15089-w

7. Marcello RK, Dolle J, Tariq A, et al. Disaggregating Asian Race Reveals COVID-19 Disparities among Asian American Patients at New York City's Public Hospital System. Public Health Rep. 2022;137(2):317-325. doi:10.1177/00333549211061313

8. Hussain M, Qureshi S, Sridaran L, Suryanarayanan S. The Disparate Impact of COVID-19 Across South Asian American Communities. Asian American Policy Review. Vol. 31 (2020-21). Apr 2021. disparate-impact- of-covid-19-across-south-asian- american-communities/

9. WHO. Ten Threats to Global Health in 2019. World Health Organization. Accessed 4/30/23. room/spotlight/ten-threats- to-global-health-in-2019

10. Wu TY, Ford O, Rainville AJ, Yang X, et al. Perceptions of COVID-19 Vaccine, Racism, and Social Vulnerability: An Examination among East Asian Americans, Southeast Asian Americans, South Asian Americans, and Others. Vaccines (Basel). 2022;10(8):1333. Aug 2022. doi:10.3390/vaccines10081333

11. NYC COVID-19 CHRNA. NYC COVID-19 Community Resources and Needs Assessment. NYU Center for the Study of Asian American  Health, Coalition for Asian 

American Children and Families, Chinese-American Planning Council. covid-19-community-resources-and-needs-assessment- nyc-covid-19-chrna/

12. Park VT, Dougan M, Meyer O, Nam B, et. al. Differences in COVID-19 Vaccine Concerns Among Asian Americans and Pacific Islanders: The COMPASS Survey. J Racial Ethn Health Disparities. 2022 Jun;9(3):979-991. doi: 10.1007/s40615-021-01037-0. Apr 2021.

13. Callaghan T, Moghtaderi A, Lueck JA, et al. Correlates and Disparities of Intention to Vaccinate against COVID- 19. Soc Sci Med. 2021;272:113638. doi:10.1016/j.socscimed.2020.113638

14. Fisher KA, Bloomstone SJ, Walder J, Crawford S, Fouayzi H, Mazor KM. Attitudes Toward a Potential SARS-CoV-2 Vaccine : A Survey of U.S. Adults. Ann Intern Med. 2020;173(12):964-973. doi:10.7326/M20- 3569

15. King WC, Rubinstein M, Reinhart A, Mejia R. Time Trends, Factors Associated with, and Reasons for COVID-19 Vaccine Hesitancy: A Massive Online Survey of US adults from January-May 2021. PLoS One. 2021;16(12):e0260731. Dec         2021. doi:10.1371/journal.pone.0260731

16. Johnson KD, Akingbola O, Anderson J, et al. Combatting a "Twin-demic": A Quantitative Assessment of COVID- 19 and Influenza Vaccine Hesitancy in Primary Care Patients. Health Promot Perspect. 2021;11(2):179-185. May 2021. doi:10.34172/hpp.2021.22

17. Luo H, Qu H, Basu R, Rafferty AP, Patil SP, Cummings DM. Willingness to Get a COVID-19 Vaccine and Reasons for Hesitancy Among Medicare Beneficiaries: Results From a National Survey. J Public Health Manag Pract.            2022;28(1):70-76.


18. Willis DE, Andersen JA, Bryant-Moore K, et al. COVID- 19 Vaccine Hesitancy: Race/ethnicity, trust, and fear. Clin   Transl Sci. 2021;14(6):2200-2207. doi:10.1111/cts.13077

19. Khubchandani J, Sharma S, Price JH, Wiblishauser MJ, Sharma M, Webb FJ. COVID-19 Vaccination Hesitancy in the United States: A Rapid National Assessment. J Community Health. 2021;46(2):270-277. doi:10.1007/s10900-020-00958-x

20. Fernández-Penny FE, Jolkovsky EL, Shofer FS, et al. COVID-19 Vaccine Hesitancy among Patients in Two Urban Emergency Departments. Acad Emerg Med. 2021;28(10):1100-1107. doi:10.1111/acem.14376

21. Willis DE, Montgomery BE, Selig JP, Andersen JA, Shah SK, Li J, Reece S, Alik D, McElfish PA. COVID- 

19 Vaccine Hesitancy and Racial Discrimination among US Adults. DOI: 10.1016/j.pmedr.2022.102074

22. Bagasra A, Doan S, Allen CT. Racial Differences in Institutional Trust and COVID-19 Vaccine Hesitancy and Refusal. BMC Public Health. 2021; 21: 2104. Nov 2021. doi: 10.1186/s12889-021-12195- 5

23. Moon I, Han J, Kim K. Determinants of COVID-19 Vaccine Hesitancy: 2020 California Health Interview Survey. Prev Med Rep. Jun 2023; 33: 102200. doi: 10.1016/j.pmedr.2023.102200

24. Rane MS, Kochhar S, Poehlein E, et al. Determinants and Trends of COVID-19 Vaccine Hesitancy and Vaccine Uptake in a National Cohort of US Adults: A Longitudinal Study. Am J Epidemiol. 2022;191(4):570-583. doi:10.1093/aje/kwab293

25. Harrison J, Berry S, Mor V, Gifford D. "Somebody Like Me": Understanding COVID-19 Vaccine Hesitancy among Staff in Skilled Nursing Facilities. J Am Med Dir Assoc. Jun 2021;22(6):1133-1137. doi:10.1016/j.jamda.2021.03.012

26. Fridman A, Gershon R, Gneezy A. COVID-19 and Vaccine Hesitancy: A Longitudinal Study. PLoS One. 2021;16(4):e0250123. Apr 2021. doi:10.1371/journal.pone.0250123

27. Ruiz JB, Bell RA. Predictors of Intention to Vaccinate against COVID-19: Results of a Nationwide Survey. Vaccine. 2021;39(7):1080-1086. doi:10.1016/j.vaccine.2021.01.010

28. Kricorian K, Civen R, Equils O. COVID-19 Vaccine Hesitancy: Misinformation and Perceptions of Vaccine Safety. Hum Vaccin Immunother. 2022;18(1):1950504. doi:10.1080/21645515.2021.1950504

29. Hernandez RG, Hagen L, Walker K, O'Leary H, Lengacher C. The COVID-19 Vaccine Social Media Infodemic: Healthcare Providers' Missed Dose in Addressing Misinformation and Vaccine Hesitancy. Hum Vaccin   Immunother. 2021;17(9):2962-2964. doi:10.1080/21645515.2021.1912551

30. 3Eibensteiner F, Ritschl V, Nawaz FA, et al. People's Willingness to Vaccinate Against COVID-19 Despite Their Safety

Concerns: Twitter Poll Analysis. J Med Internet Res. 2021;23(4):e28973. Apr 2021. doi:10.2196/28973

31. Pullan S, Dey M. Vaccine Hesitancy and Anti-vaccination in the Time of COVID-19: A Google Trends Analysis. Vaccine. 2021;39(14):1877-1881. doi:10.1016/j.vaccine.2021.03.019

32. CCDH. The Anti-vaxx Industry. How Big Tech Powers and Profits from Vaccine Misinformation. Center for Countering Digital Hate. 2020. The-Anti-Vaxx-Industry.pdf

33. 3Bokemper SE, Huber GA, Gerber AS, James EK, Omer SB. Timing of COVID-19 Vaccine Approval and Endorsement by public figures.  Vaccine. 2021;39(5):825-829. doi:10.1016/j.vaccine.2020.12.048