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

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 policymakers 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.