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. Author manuscript; available in PMC: 2025 Aug 1.
Published before final editing as: J Racial Ethn Health Disparities. 2025 Mar 17:10.1007/s40615-025-02384-y. doi: 10.1007/s40615-025-02384-y

Relationships between vaccine knowledge, hesitancy, and conspiracy beliefs on COVID-19, influenza, and HPV vaccination

Sabrina L Dickey a, Ibrahim Yigit a,b, Allysha C Maragh-Bass c, Maria Leonora G Comello d, Marie CD Stoner e, Margo Adams Larsen f, Kathryn E Muessig a,b, Audrey E Pettifor c, Henna Budhwani a,b, Lisa B Hightow-Weidman a,b
PMCID: PMC12316188  NIHMSID: NIHMS2097644  PMID: 40097889

Abstract

Introduction:

The COVID-19 pandemic highlighted the centuries old issue of vaccine hesitancy and exposed healthcare inequities harming Black young adults. Despite vaccines being able to reduce COVID-19, human papillomavirus [HPV], and influenza morbidity and mortality, they are underutilized. An examination of socio-behavioral factors to understand motivators and barriers to vaccine uptake within Black communities is necessary to improve preventative health.

Methods:

We conducted an online survey of 360 Black young adults, aged 18 and 29 years in the southern United States. Participants were part of a larger randomized-controlled trial which evaluated a digital health intervention for receiving the COVID-19 vaccine. A correlation analysis and a series of logistic regressions were performed to examine the relationships between vaccination knowledge, hesitancy, and conspiracy beliefs for vaccination status for COVID-19, HPV, and influenza.

Results:

Vaccine hesitancy and conspiracy beliefs were negatively associated with COVID-19 vaccination (Adjusted Odds Ratio (AOR)=.45, Confidence Interval (CI):[.284, .722], p<.001; AOR=.37, CI[.217, .628], p<.001, respectively], but vaccination knowledge was not (p=.295). Vaccination hesitancy was negatively associated with ever having accepted HPV vaccination (AOR=.66, CI[.477, 1.56], p=.011). Vaccination hesitancy, conspiracy beliefs, and knowledge were not significantly associated with influenza vaccination.

Conclusions:

Vaccine hesitancy remains a pertinent factor affecting southern Black young adults. Vaccine-related conspiracy beliefs emerged amidst the COVID-19 pandemic and was significant for refusal of the COVID-19 vaccine. Results indicate the need for continued public health efforts to address vaccine hesitancy and conspiracies among southern Black young adults and providing reputable information from trusted sources recognized by this population.

Keywords: Vaccine hesitancy, vaccine knowledge, vaccine-related conspiracy beliefs, COVID-19, influenza, HPV, Black young adults

INTRODUCTION

During the height of the COVID pandemic in January 2020, young adults reported the highest cumulative rate of the COVID-19 infection in the United States (US) (1). The issue of COVID-19 vaccine hesitancy was indicated as a primary barrier for increasing vaccination rates in the US (2). Factors surrounding vaccine hesitancy among young adults, specifically Black young adults include a variety of issues such as, family and social responsibilities, conspiracy theories, mistrust in the government, seemingly profit driven emphasis by pharmaceutical companies, lack of equity, and society’s lack of correcting injustices (3,4). Given that young adults are known to have asymptomatic infections and engage in active social lives they are at a higher risk for transmitting COVID-19 infection to others and increasing the spread of COVID-19 among their social networks and communities (1)

After the COVID-19 pandemic, conspiracy beliefs pertaining to vaccine hesitancy became more prominent (5) Belief in conspiracy center around secrecy and malevolent intentions which can harm the public (6) Conspiracy theories typically arise from salient social and political events which purport various secret plots among significant individuals (5) A study on the impact of conspiracy theories and receiving a vaccination revealed belief in conspiracy theories regarding infectious disease “negatively impacts their health behaviors concerning vaccination” (5). A unique attribute regarding conspiracy theories is that belief in conspiracy theories may occur without an individual being aware (7). Thus, the negative impact of belief in conspiracy theories and the unknowingly acceptance of conspiracy beliefs towards vaccine warrants an examination of this factor among young Black adults receiving the COVID-19, HPV, and influenza vaccines.

In 2023, the Centers for Disease Control and Prevention (CDC) indicated approximately 70% of the US population had completed a COVID-19 primary series (8) Despite a rise in the COVID-19 vaccination rates, over the pandemic, COVID-19 vaccine hesitancy is still evident in 2023 through data from the (CDC), which indicates 15.3% of Black individuals indicated they will definitely receive a COVID-19 vaccine compared to 62.5% of White individuals (9). In 2021, the CDC conducted a national survey to examine COVID-19 vaccination rates and intent to vaccinate among adults 18–39 years (10). Results from the survey indicated Black adults who were younger had the lowest vaccination rates and intention to receive a COVID-19 vaccine (10) Literature regarding vaccine hesitancy among the black population exists [6,7, 9,10], however there is a lack of literature which is focused on vaccine hesitancy among young Black adults. The gap in literature regarding vaccination behaviors among Black young adults warrants our current study, which explores vaccine knowledge, hesitancy and conspiracy beliefs on COVID-19 as well as influenza and the HPV vaccine among Black young adults.

In the US, racial minority groups experience more adverse outcomes and higher mortality rates from vaccine preventable diseases, namely COVID-19, HPV, and influenza compared to White individuals (11–18) Vaccine hesitancy is a serious concern, particularly in the Black community, as it results in a reduced likelihood that individuals will access and accept COVID-19, HPV, and influenza vaccination (19–24). Even though over 90% of cancers caused by HPV could be averted by receiving the HPV vaccine, uptake among Black communities is low (25–28). A study utilizing data from the Health Information National Trends Survey from 2017 to 2020 indicated Black participants had lower knowledge and awareness of the HPV vaccine compared to White participants, 63% vs 70.2% and 57.6% vs 68.2%, respectively (29) Data from the CDC indicated that non-Hispanic Black females aged 18 to 26 years had lower HPV vaccination rates compared to non-Hispanic Whites of the same age, 44.7% and 57.9%, respectively [31]. The results of a related study found that fewer Black young adults (24.9%) received HPV vaccination compared to White young adults (28.3%) (28)The US Department of Health and Human Services identified that only 20% of young men received the HPV vaccine (30) Lower HPV vaccination rates among male college students is indicated to be the result of decreased awareness and knowledge of the HPV vaccine (31) A narrative review of the literature regarding barriers among boys and young men receiving the HPV vaccine revealed five primary barriers listed as follows “(1) lack of knowledge, (2) vaccine hesitancy in general, (3) lack of recommendation from and/or discussions with healthcare providers, (4) cost and logistics, and (5) the idea that HPV vaccination may promote promiscuity” (32). The HPV vaccine can be given as early as age 9, however the CDC and the Advisory Committee on Immunization Practices (ACIP) recommends everyone through the age of 26 years receive the HPV vaccine (33)When considering the early age for receiving the influenza vaccine, 9–12 years, it is the parents’ decision, and the presence of vaccine hesitancy may undoubtedly impact the rates of HPV vaccinations and their perception of the usefulness of the vaccine during an individual’s life(33). Thus, when examining barriers for receiving vaccines the need for parental consent is a plausible reason for disparities in vaccinations. However, unlike the HPV vaccine the influenza vaccine is not associated with sexual activity, which may be a facilitating factor for receiving the vaccine.

According to the CDC and the ACIP, anyone six months and older, without contraindications, should receive a routine annual influenza vaccination (34). The recommendation from these two prominent organizations underscores the importance for receiving an influenza vaccination(34) Additionally, the Black population encounters increased rates of comorbidities (e.g., high blood pressure, diabetes, obesity), which places them at a higher risk for experiencing adverse health outcomes if they are diagnosed with influenza (35,36) Therefore, an examination of vaccine hesitancy for receiving the influenza vaccine among the understudied sample, young Black adults may indicate factors that can decrease the presence of vaccine hesitancy.

During the 2021–2022 influenza season, there was a 2.5% decrease in influenza vaccinations from 49.4% to 46.9% in the US [34]. Among those who received the influenza vaccine that year, Black adults had lower vaccination rates, 42% compared to White adults, 54% (37). Current data for 2022–2023 influenza season indicates a similar trend with non-Hispanic Black adults continuing to have lower rates for influenza vaccination compared to non-Hispanic White adults, 42.5% and 51.4 % respectively (38) Influenza vaccine hesitancy is influenced by multiple factors including age, lower vaccination rates among college students, lower education, lack of knowledge about the influenza vaccine, and lack of vaccine confidence (39–44). Similar to the COVID-19 vaccine, the development and implementation of the first influenza vaccine in 1942, saved countless lives, but was mired in hesitancy that exists to the present day (45–48) Vaccine hesitancy for the influenza vaccine also seemed to be associated with people of color, particularly Black and African Americans as well as various social determinants of health (SDOH) (i.e., insurance, neighborhood and built environment, education) (48–52)The discrimination and racism encountered within the Black population has also been associated with a lower likelihood of receiving the influenza vaccine (35,45,53).

The World Health Organization identified the significant role of vaccine hesitancy on a global scale by recognizing vaccine hesitancy among the ten threats to global health [8]. Vaccine hesitancy is produced through a combination of factors dependent on sentiments towards vaccination, personal attitudes, and beliefs, and is marked by a sense of indecision [8]. In its simplest terms, vaccine hesitancy is defined, as “to delay in acceptance or refusal of vaccines despite the availability of vaccination services” (54) Thus, this shift may have also been a consequence, which led to vaccine hesitancy [51]. Vaccine hesitancy threatens to undo progress made towards improving life expectancy preventing avoidable morbidity and mortality (39–41). To further understand the salience of vaccine hesitancy among the young Black adults, a subset of researchers in the current study adapted the National Institute on Minority Health and Health Disparities Research Framework to develop a Conceptual Model of Vaccine Hesitancy for African American young adults (55). The model fills an essential gap for understanding and addressing vaccine hesitancy among African American or Black young adults (56,57).

Despite vaccination being an impactful strategy in reducing morbidity and mortality rates from preventable diseases, vaccination can be met with disapproval and skepticism (58). The opposition to vaccinations has typically centered on two primary themes with the first being that the perceived harms outweigh the benefits and the second based in body autonomy against mandatory vaccinations (39,59–61). Vaccine hesitancy has existed since the release of the smallpox vaccine in the nineteenth century (39), and prior research has suggested that vaccine hesitancy towards the HPV and influenza vaccines is higher as compared to other childhood vaccines such as measles, mumps, and rubella (61) Recently, research has indicated a notable increase in vaccine hesitancy, during the COVID-19 pandemic (40)

A focus on decreasing vaccine hesitancy within the Black community is a salient topic, given data from the CDC on the life expectancy among Blacks as 72.8 years compared to 77.5 years among Whites and the 2.1 times higher mortality rate from COVID-19 among Blacks vs Whites (62,63) Vaccine hesitancy within Black communities, regardless of vaccination type, is driven by common elements, namely lack of access, misinformation, racism, discrimination, mistrust of the health care system, and health care costs(64) These factors stem from the unethical treatment of Black Americans in research, such as the Tuskegee experiment and the Henrietta Lacks cells, which lead to avoidance of the present-day medical system (64). Many Black individuals in the US have a long history of experiencing higher rates of poverty, racism, decreased access to health care and insurance, medical mistrust, and various comorbidities (i.e., obesity, heart disease, respiratory illnesses, diabetes) which placed them at a higher risk for mortality from COVID-19 (45,65–70)The higher rate of mortality from COVID-19 within the Black community also stemmed from the disproportionately higher rate of vaccine hesitancy within the Black population when compared to the White population (63,71). When considering the occurrence of vaccine hesitancy within the Black community it is imperative to recognize there were increased adverse outcomes from COVID-19 as a result of structural issues and multiple social determinants of health SDOH (72–74). The various SDOH such as, lower reading level, lack of confidence in childhood vaccines, living in unsafe areas, and being younger were continuously present in Black communities, can take years to overcome, and may cause continued health issues for future generations (64,71,75) The historical mis-treatment of Black communities, is not easy to overcome and is evident among the decreased rates of utilizing the healthcare system and engaging in preventive health behaviors such as receiving vaccinations (45,65,68). Distrust and misinformation regarding the vaccine appeared to spread easily through marginalized populations, such as the Black community, which reinforced vaccine hesitancy (19,73,76,77) Vaccine hesitancy for the COVID-19 vaccine within the Black community is an ongoing issue, and as previously noted this hesitancy has also been prevalent amongst vaccines for influenza and HPV.

The identification of modern causes of vaccine hesitancy is needed to understand which interventions are appropriate and the type of public health efforts that will be the most effective among marginalized populations. There is a need to address vaccine hesitancy among Black communities using methods that are culturally acceptable and address the unique drivers of hesitancy in these groups. Considering these priorities, we conducted the Tough Talks for COVID-19 (TT-C) randomized controlled trial (RCT) to improve rates of COVID-19 vaccine acceptance by reducing hesitancy among Black young adults in the southern US (55). During the conduct of this study, in addition to collecting pre-post data on COVID-19 vaccine acceptance, we collected data receiving the HPV and influenza vaccines (78) Thus, our research question explores the relationships between the variables of vaccine knowledge, vaccine hesitancy, and vaccine-related conspiracy beliefs [a form of hesitancy that was emergent in the COVID-19 pandemic] for an association with COVID-19, HPV, and influenza vaccine uptake (19,23,40,61).

METHODS

Parent Study

The TT-C study (R01MD016834, NCT05490329) included a RCT of a digital health intervention designed to reduce vaccine hesitancy and promote COVID-19 vaccine uptake. The study was conducted in Alabama, Georgia, and North Carolina among a sample of Black young adults. Additional details can be found in the protocol paper (78).

Data and Sample

Participants included 360 young adults aged between 18 and 29 years, who identified as African American or Black; were fluent in English; were current residents of Alabama (N=67), Georgia (N=160), or North Carolina (N=133); were able to provide informed written consent; and “[had] not received full COVID vaccine series (including vaccination and booster).” Self-reported survey data was collected from participants at multiple time points; validated scales were used when available. Some scales that were originally developed for pediatric or parent populations were adapted for use among young adults. The analyses presented herein were completed using the study’s baseline data prior to any intervention.

Measures

Vaccination Knowledge

General vaccination knowledge was assessed using four items adapted from Zingg and Siegrist’s scale, measuring people’s knowledge about vaccination (79). Items had true-false response options, with higher mean scores indicating greater knowledge about vaccines. Sample items are “Vaccines increase the occurrence of allergies” [false] and “The doses of vaccines used in humans are not dangerous for humans” (true). Cronbach’s alpha was calculated as .60.

Vaccination Hesitancy

Vaccine hesitancy was measured with the10-item Vaccine Hesitancy Scale, where items were rated on a 5-point Likert-type scale (1=Strongly disagree to 5=Strongly agree) (80) Sample items included “Vaccines are important for my health” and “Vaccines are effective.” Some items were reverse coded and composite scores were calculated using the mean of the items, with higher scores indicating higher vaccination hesitancy. In this study, Cronbach’s alpha was .89.

Vaccine-related Conspiracy Beliefs

Conspiracy beliefs related to vaccines were assessed using six items adapted1 from the Vaccine Conspiracy Beliefs Scale (81). Items were rated on a 4-point Likert type scale (1=Strongly disagree to 4=Strongly agree) and included “Vaccine safety data are often fabricated” and “People are deceived into thinking that vaccines are safe.” Total scores were calculated using the mean of the items, with higher scores indicating stronger conspiracy beliefs about vaccination. Cronbach’s alpha was .90.

Self-reported Vaccination for COVID-19, HPV and Influenza

Vaccination status was assessed using the stem question “Have you ever received…” for COVID-19, HPV, and influenza separately, with response options of no (0) and yes (1). For COVID-19 vaccination, participants were asked, “How many total shots have you received?” while for influenza, they were asked “Have you received a flu vaccine in the last 12 months?”, with no (0) and yes (1) response options.

Statistical Analyses

After calculating descriptive statistics using baseline data, a correlation analysis was performed to examine relationships between study variables. To determine the predictors of vaccination status for COVID-19, HPV, and influenza, we conducted three separate logistic regression analyses. In these analyses, the primary independent variables were vaccination knowledge, vaccination hesitancy, and vaccine-related conspiracy beliefs and covariates included sex assigned at birth and age (whenever they have a significant relationship with the outcome). All analyses were cross-sectional, mean scores for all the independent variables were calculated, missing responses were treated as null in mean calculations, and the data were analyzed using SPSS v.27.

Ethics Review and Approval

The TT-C study was approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill, University of Alabama at Birmingham, and Florida State University.

RESULTS

Table 1 includes descriptive statistics for the sample. The mean age of the participants was 23.7 years (Standard Deviation [SD]=3.4; range: 18–29 years), 259 (83.1%) were female, 170 (47.2%) reported having private insurance, 131 (36.4%) had a college degree, and the majority (42.5%) reported full-time employment. Almost one third (33.1%) reported being completely unvaccinated against COVID-19 (e.g., no primary dose), while the remaining two-thirds (n = 236) included 27 participants (11.4%) who received only one dose, 136 participants (57.6%) who received two doses, 70 participants (29.7%) who received three doses, and 3 participants (1.3%) who received four doses. Two-hundred-eight (57.8%) had received HPV vaccination, and 259 (71.9%) had ever received an influenza vaccine. Mean scores were .79 (SD=.31, range: 0–1) for vaccination knowledge, 2.42 (SD=.78, range: 0–5) for vaccination hesitancy, and 3.48 (SD=.75, range: 1–5) for vaccine-related conspiracy beliefs.

Table 1.

Descriptive statistics (N=360)

N %
State
 Alabama 67 18.6
 Georgia 160 44.4
 North Carolina 133 36.9
Sex at birth
 Male 61 16.9
 Female 299 83.1
Ethnicity
 Hispanic 16 4.4
 Non-Hispanic 344 95.6
Insurance
 No insurance 42 11.7
 Private 170 47.2
 Public 126 35.0
 Do not know 16 4.4
 Prefer not to answer 6 1.7
Education level
 Have never gone to school -
 5th or less -
 6th to 8th grade -
 9th to 12th grade, no diploma 16 4.4
 High school graduate or GED completed 88 24.4
 Some college level/technical/vocational degree 131 36.4
 Bachelor’s degree 88 24.4
 Other advanced degree (Master’s, Doctoral degree) 34 9.4
 Prefer not to answer 3 0.8
Working status
 Working, full-time 153 42.5
 Working, part-time 51 14.2
 Not working, but looking for work 48 13.3
 Not working, and not looking for work 3 0.8
 A student 86 23.9
 Disabled, permanently or temporarily 7 1.9
 Other 10 2.8
Total household income
 Less than $15,000 70 19.4
 $15,000–$19,999 36 10.0
 $20,000–$24,999 20 5.6
 $25,000–$34,999 48 13.3
 $35,000–$49,999 63 17.5
 $50,000–$74,999 46 12.8
 $75,000–$99,999 25 6.9
 $100,000 and above 18 5.0
 Do not know 23 6.4
 Prefer not to answer 11 3.1
Vaccination behaviors
 Have you ever received a COVID-19 vaccine?
  Yes 236 65.6
  No 119 33.1
 Have you ever received a flu vaccine?
  Yes 259 71.9
  No 83 23.1
 Have you ever had an HPV vaccination?
  Yes 208 57.8
  No 88 24.4
M(SD) range
Age, years 23.72(3.42) 18–29
Vaccination knowledge .79(.31) 0–1
Vaccination hesitancy 2.42(.78) 1–5
Vaccine-related conspiracy beliefs 3.48(.75) 1–5
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As shown in Table 2, vaccination knowledge was significantly and positively correlated with vaccination for COVID-19 (r=.35, p<.001), while vaccination hesitancy and vaccine-related conspiracy beliefs were significantly and negatively correlated with vaccination for COVID-19 (r=−.48, p<.001; r=−.49, p<.001, respectively). Vaccination hesitancy and vaccine-related conspiracy beliefs were also significantly and negatively correlated with having ever vaccinated for influenza2 (r=−.14, p=.008; r=−.11, p=.048, respectively). Vaccine hesitancy was also significantly and negatively correlated with HPV vaccination [r=−.15, p=.010]. Lastly, among demographic data, sex assigned at birth was also significantly and positively correlated with HPV vaccination (r=.23, p=<.001), indicating that individuals assigned female at birth were more likely to report having been vaccinated for HPV compared to those assigned male at birth.

Table 2.

Correlation coefficients

Variables 1 2 3 4 5 6 7 8
1. Vaccination knowledge -
2. Vaccination hesitancy .49** -
3. Vaccine-related conspiracy beliefs .57** .70** -
4. Vaccination for COVID-19 .35** .48** .49** -
5. Vaccination for flu .06 .14** −.11* .07 -
6. Vaccination for HPV .11 .15** −09 .06 .30** -
7. Sex at birth .03 −.02 .01 .08 .07 .23** -
8. Age −.04 .09 .13** .02 .01 .04 .00 -
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*

p < .05,

**

p < .01.

Based on significant correlation coefficients, we conducted three logistic regression analyses for each outcome (i.e., COVID-19, HPV, and influenza vaccinations). Results of logistic regression analyses are presented in Table 3. Vaccination hesitancy (B=−.79, adjusted odds ratio [AOR]=.45, 95% Confidence Interval (CI)[.284, .722], p<.001) and vaccine-related conspiracy beliefs (B=−.99, AOR=.37, CI[.217, .628], p<.001) were associated with a decreased likelihood of vaccination for COVID-19. Specifically, individuals with higher vaccination hesitancy or stronger conspiracy beliefs were significantly less likely to have been vaccinated for COVID-19. In contrast, vaccination knowledge was not significantly associated with COVID-19 vaccination in the regression analysis (B=.52, AOR=1.68, CI[.636, 4.45], p=.295). Vaccination hesitancy (B=−.42, AOR=.66, CI[.477, 1.56], p=.011) and sex assigned at birth (B=1.40, AOR=4.07, CI[2.04, 8.15], p<.001) were associated with vaccination for HPV. The negative association with vaccination hesitancy indicates that higher hesitancy reduces the likelihood of HPV vaccination. The positive association with sex assigned at birth highlights that individuals assigned female at birth were significantly more likely to have received the HPV vaccine. Neither vaccination hesitancy (B=−.43, AOR=.65, CI[.413, 1.02], p=.065) nor vaccine-related conspiracy beliefs (B=−.02, AOR=.98, CI[.615, 1.56], p=.934) were associated with vaccination for influenza.

Table 3.

Results of regression analyses

Outcome: COVID-19 vaccination
Predictors AOR CI p
Vaccination knowledge 1.68 .636, 4.45 .295
Vaccination hesitancy .45 .284, .722 < .001
Vaccine-related conspiracy beliefs .37 .217, .628 < .001
Outcome: Influenza vaccination
Vaccination hesitancy .65 .413, 1.02 .065
Vaccine-related conspiracy beliefs .98 .615, 1.56 .934
Outcome: HPV vaccination
Vaccination hesitancy .66 .477, .907 .011
Sex assigned at birth 4.07 2.04, 8.15 <.001
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DISCUSSION

From the conduct of our trial, we found varied support for our research question that vaccine knowledge, vaccine hesitancy, and vaccine-related conspiracy beliefs would be associated with COVID-19, HPV, and influenza vaccine uptake. In logistic regression models, vaccine knowledge was not associated with uptake of any of the three vaccines of interest. However, vaccine hesitancy and conspiracy beliefs were negatively associated with COVID-19 vaccination. Our findings mirror the results of a longitudinal study regarding vaccination conspiracy theories and vaccination hesitancy. In the study conducted by Coelho et. al., (2022), their findings indicated that an increase in vaccine related conspiracy theories led to increases in vaccine hesitancy for the HPV vaccine (82) The results from study highlight that conspiracy theories are a factor in causing lower HPV vaccination rates (82)Vaccination hesitancy was negatively associated with ever having received the HPV vaccination, but none of these variables were associated with the influenza vaccine. Findings suggest the salience of vaccine hesitancy to COVID-19 and HPV vaccination and that, perhaps, uptake of the influenza vaccine functions via different mechanism of behavior change. For example, individuals may change their behavior by receiving an influenza vaccine based on their perceptions of the potency of the influenza vaccine. Thus, unlike COVID-19, which can cause long term COVID-19, individuals may perceive the influenza vaccine as safer, even though receiving the COVID-19 vaccine does not cause one to contract COVID-19 (83). Similarly, the HPV vaccine protects against various strains of cancer among men and women (29,33) which again, may seem to be a more potent vaccine compared to the influenza vaccine. The perceived seriousness of the COVID-19 and HPV vaccines, may inhibit the receipt of those vaccines and motivate a behavior change for individuals to receive the influenza vaccine due to a perception of being less threatening to their health.

Neither vaccine knowledge, hesitancy, nor conspiracy beliefs were associated with vaccination for influenza, an annual vaccine that has been available the longest among the three vaccines we examined in this study. In our sample, influenza vaccination had the highest uptake (71.9%), compared to COVID-19 (65.6%) and HPV (57.8%). Despite the annual promotion of the influenza vaccination, nearly a quarter of the sample never received an influenza vaccine.

The COVID-19 vaccine was the only one of our three vaccines of interest that indicated a moderate, statistically significant correlation for the bivariate analysis between all three variables, namely, vaccination knowledge, vaccination hesitancy, and vaccine-related conspiracy beliefs. The associations between the COVID-19 vaccination and vaccination hesitancy and vaccine-related conspiracy beliefs maintained statistical significance in the logical analysis. Hence, the only vaccine which supported our assumptions for an association of uptake with vaccine knowledge, vaccine hesitancy, and vaccine-related conspiracy beliefs was the COVID-19 vaccine.

Thus, it is imperative to examine strategies to increase COVID-19 vaccinations and promote preventive behaviors among young adults to decrease the transmission of infection to individuals with a higher risk of adverse outcomes from the infection (84). The literature was limited regarding the simultaneous study of vaccine knowledge, hesitancy, and conspiracy beliefs for COVID-19, HPV, and influenza vaccines among Black young adults. Our study addresses this gap and provides data regarding variables which may influence vaccine hesitancy among Black young adults. Results provide a foundation for considering how knowledge of vaccines and belief in conspiracy theories influences vaccine hesitancy for receiving the COVID-19, HPV, and influenza vaccine among Black young adults. It is critical to learn from the variables influencing vaccine hesitancy to develop strategies for increasing vaccine acceptance and to prevent an occurrence of increased vaccine hesitancy among underserved and underrepresented populations (64).

Public health efforts to reduce vaccine hesitancy and vaccine-related conspiracy beliefs could focus on reducing misinformation, promoting conversations with healthcare providers to discuss conspiracy theory beliefs, and increasing messages regarding protective health (85). Our results indicated the HPV had some of the lowest vaccination rates, which is aligned with CDC data (26,28,30,86). Similarly, previous studies indicated Black young adults had significantly lower HPV vaccination rates due to the lack of knowledge and awareness of the HPV vaccine (24,87,88)The results from our study regarding vaccine hesitancy in relation to the HPV vaccine is considered multifaceted and unique in that the majority of HPV infections are contracted during sexually activity (89) Despite the HPV vaccine’s ability to prevent multiple forms of cancer, vaccine hesitancy could rise from cultural aspects more specific to the Black population, such as the stigma related to sexual route of transmission, which was not examined in the study, but is identified as a deterrent for receiving the HPV vaccine (16). For example, HPV vaccine hesitancy suggest parents do not vaccine their children due to their religious beliefs and desire for their children to remain sexually pure (89) It is the parents’ perception that allowing their children to receive the HPV vaccine is promoting sexually activity (89). Morales-Campos et. at., (2023) also indicated the parents’ personal beliefs regarding Additional results from our study indicated a relationship between the HPV vaccine and assigned sex at birth among the bivariate analysis. Our finding is aligned with other studies, which indicated that females are more likely than males to receive the HPV vaccine (2,90)However, the HPV vaccine was first available to females in 2006 before becoming available to males in 2011 (91). The four-year difference in availability of the HPV vaccine among females and males must be considered when viewing the higher frequency of HPV vaccination occurring among females. Development of interventions focused on promoting HPV vaccination among those assigned male at birth may be warranted to promote uptake and decrease the gender gap.

Social media is prevalent among young adults; however, it was not a variable that was examined in the current study. However, we would be remiss not to indicate the prevalence of social media use and a lack of credible education on vaccines may have led younger populations to be more susceptible to vaccine-conspiracy related theories and/or beliefs (92). Further the high prevalence of social media use among young adults potentially contributed to the widespread dissemination of misinformation that increased susceptibility to vaccine-related conspiracy theories (93). Morales-Campos et. al., (2023) indicated social media was a prominent factor in the spread of misinformation about the HPV vaccine.

In many parts of the US, young Black adults have the lowest rates of vaccination for COVID-19, HPV, and influenza but have higher rates of adverse outcomes from these conditions compared to their White counterparts (19,27,94) Results from this study provide insight for historical and social factors which may decrease vaccine hesitancy among Black young adults. Thus, specifically tailored strategies and interventions could be considered for increasing vaccine uptake of COVID-19, HPV, and influenza among young Black adults. Our suggestion is mirrored by findings indicating a low HPV vaccination rate among Black individuals may be offset by tailored communication strategies focusing on the HPV vaccine (24). Similarly, messages that are listed on multiple social media platforms, which are known to be appealing to young adults, along with using relatable same race individuals to promote vaccine uptake could be valuable strategies to decrease hesitancy (92,95).

Limitations

Findings should be applied with consideration of limitations. Self-report of vaccination could be considered a limitation; however, we did collect COVID-19 vaccination cards to verify vaccination status. While we acknowledge obtaining proof of HPV and influenza vaccination reduces errors, we did not obtain medical records verification. Additionally, the literature indicated varying results regarding the influence of the COVID-19 pandemic on influenza vaccination (96). Thus, the research team did not take into account the influence of the COVID-19 pandemic on participants decision to receive the influenza vaccine, which is a limitation of the study. The influence of social media could have been a pertinent factor for COVID-19, HPV, and influenza vaccination, which was not examined in the study. Similarly, our use of online recruitment could be a barrier for individuals to participate. This study assessed general vaccination knowledge using four items, which, while practical, demonstrated a relatively low internal consistency. Additionally, the scale did not differentiate between knowledge about specific vaccines, which may have limited its ability to capture nuanced differences in respondents’ understanding of distinct vaccination types. Future research should consider employing more comprehensive instruments with improved reliability that assess vaccine-specific knowledge to provide a deeper understanding of these variations. For COVID-19 vaccination, we used the variable indicating whether participants had ever received the COVID-19 vaccine. We did not include the number of doses in the analyses because our goal was to measure general willingness to get vaccinated, and the sample sizes of groups with different numbers of doses were insufficient for cross-group analyses. Future research should aim to recruit larger samples to examine how willingness to vaccinate may differ across groups based on the number of doses received, providing a more nuanced understanding of vaccination behavior and its determinants. The literature revealed various historical factors which influenced vaccine hesitancy as well as issues of trust, poverty, lack of education, lack of access to healthcare, however these issues were not examined in the current study, which can be considered a limitation. (10,58,97)Finally, the dominant variant type of COVID-19, shifted over the course of this study, potentially affecting participants view on the urgency to be vaccinated.

CONCLUSION

This study provides valuable data on conditions that can impede vaccine uptake among a specific population that encounters ongoing health disparities. Vaccine hesitancy and vaccine-related conspiracy beliefs were shown to influence uptake to various degrees. Findings from our study elucidate key variables that may adversely impact both individual and population health. Findings support an ongoing need to address vaccine hesitancy and recognize the extent that conspiracy beliefs have on populations who already have a mistrust of the health care system through community engaged scholarship.

Funding

Research reported in this publication was supported by the National Institute of Minority Health Disparities (NIMHD) of the National Institutes of Health (NIH) under Award Number R01MD016834. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Footnotes

Conflicts of Interest/Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Ethics Approval

This study was performed in line with the principles of the Declaration of Helsinki and ethical approval was granted by the Institutional Review Boards of the University of North Carolina at Chapel Hill, University of Alabama at Birmingham, and Florida State University. All study materials and procedures were reviewed and approved by the Institutional Review Boards of the University of North Carolina, Chapel Hill (IRB, #21–1746) and Florida State University (STUDY00003617).

Consent to Participate

Informed consent was obtained from all individual participants included in the study.

Consent for Publication

Participants did not provide any photos, videos, or images for the study. An informed consent was obtained from all participants included in the study.

1

The adaptations made to the original items primarily involved rephrasing the statements for clarity and inclusivity. Some items were expanded to provide more specific examples, such as “The government is experimenting with vaccines on the Black community,” while others were adjusted for grammatical accuracy or to simplify language, such as changing “People are deceived about vaccine efficacy” to “People are deceived into thinking that vaccines are safe.” One item [“Immunizing children is harmful and this fact is covered up”] was removed due to its irrelevance.

2

Vaccination hesitancy and vaccine-related conspiracy beliefs were also significantly and negatively correlated with vaccination for influenza in the last 12 months [r=−.26, p<.001; r=−.25, p<.001, n=163, respectively].

Availability of data and material

The data sets generated during this study will be shared in compliance with NIH data sharing policies and will be made available by request to the senior author on reasonable request.

Code availability

The data sets generated during this study will be shared in compliance with NIH data sharing policies and will be made available by request to the senior author on reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data sets generated during this study will be shared in compliance with NIH data sharing policies and will be made available by request to the senior author on reasonable request.

The data sets generated during this study will be shared in compliance with NIH data sharing policies and will be made available by request to the senior author on reasonable request.

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