1
https://doi.org/10.11606/s1518-8787.2021055003903
Original Article
Rev Saude Publica. 2021;55:97
Running away from the jab: factors 
associated with COVID-19 vaccine 
hesitancy in Brazil
Marco Antonio Catussi PaschoalottoI
, Eduardo Polena Pacheco Araújo CostaI
, Sara Valente 
de AlmeidaI,II
, Joana CimaIII
, Joana Gomes da CostaIV
, João Vasco SantosV,VI,VII
, 
Pedro Pita BarrosI
, Claudia Souza PassadorVIII
, João Luiz PassadorVIII
I Universidade NOVA de Lisboa. Nova School of Business and Economics. Carcavelos, Portugal
II Imperial College London. Faculty of Health Sciences. London, England
III Universidade do Minho. Núcleo de Investigação em Políticas Económicas e Empresariais. Braga, Portugal 
IV Universidade do Porto. Faculdade de Economia e Gestão. Porto, Portugal
V Universidade do Porto. Faculdade de Medicina. MEDCIDS – Departamento Medicina da Comunidade, 
Informação e Decisão em Saúde. Porto, Portugal
VI Universidade do Porto. Faculdade de Medicina. Centro de Investigação em Tecnologias e Serviços de Saúde. 
Porto, Portugal
VII ARS Norte. ACES Grande Porto VIII - Espinho/Gaia. Unidade de Saúde Pública. Vila Nova de Gaia, Portugal
VIII Universidade de São Paulo. Faculdade de Economia, Administração e Contabilidade de Ribeirão Preto. 
Ribeirão Preto, São Paulo, Brasil
ABSTRACT
OBJECTIVE: To investigate how sociodemographic conditions, political factors, organizational 
confidence, and non-pharmaceutical interventions compliance affect the COVID-19 vaccine 
hesitancy in Brazil. 
METHODS: Data collection took place between November 25th, 2020 and January 11th, 2021 
using a nationwide online survey. Subsequently, the researches performed a descriptive analysis 
on the main variables and used logistic regression models to investigate the factors associated 
with COVID-19 vaccine hesitancy. 
RESULTS: Less concern over vaccine side effects could improve the willingness to be vaccinated 
(probability changed by 7.7 pp; p < 0.10). The current vaccine distrust espoused by the Brazilian 
president is associated with vaccine hesitancy, among his voter base. Lower performance 
perception (“Very Bad” with 10.7 pp; p < 0.01) or higher political opposition (left-oriented) 
regarding the current presidency is associated with the willingness to be vaccinated. Higher 
compliance with non-pharmaceutical interventions (NPIs) is usually positively associated with 
the willingness to take the COVID-19 vaccine (+1 score to NPI compliance index is associated 
with higher willingness to be vaccinated by 1.4 pp, p < 0.05).
CONCLUSION: Willingness to be vaccinated is strongly associated with political leaning, 
perceived federal government performance, vaccine side effects, and compliance with 
non-pharmaceutical interventions (NPIs).
DESCRIPTORS: COVID-19 Vaccines. Vaccination Refusal. Socioeconomic Factors. Political 
Activism. Health Knowledge, Attitudes, Practice.
Correspondence: 
Marco Antonio Catussi Paschoalotto 
Travessa do Hospital, 18 - 2° andar 
1150-187 Lisboa, Portugal 
E-mail: marcocatussi@gmail.com
Received: May 27, 2021
Approved: Jul 19, 2021
How to cite: Paschoalotto MAC, 
Costa EPPA, Valente-de-Almeida 
S, Cima J, Gomes-da-Costa 
J, Santos JV, et al. Running 
away from the jab: Factors 
Associated with COVID-19 
Vaccine Hesitancy in Brazil. 
Rev Saude Publica. 2021;55:97. 
https://doi.org/10.11606/s1518-
8787.2021055003903
Copyright: This is an open-access 
article distributed under the 
terms of the Creative Commons 
Attribution License, which permits 
unrestricted use, distribution, and 
reproduction in any medium, 
provided that the original author 
and source are credited.
http://www.rsp.fsp.usp.br/
2
Factors associated with COVID-19 vaccine hesitancy 
Paschoalotto MAC et al.
https://doi.org/10.11606/s1518-8787.2021055003903
INTRODUCTION
By July 2021, the COVID-19 pandemic had already resulted in more than 186 million cases  
and 4 million deaths worldwide, with Brazil ranking third place in the number of cases and  
second in the number of deaths1. In a global effort to contain the spread of the new virus,  
countries adopted several non-pharmacological interventions (NPI) such as social 
distancing2–4 and face mask use5. But despite the importance of such measures, the solution 
to the pandemic rests on the success of vaccination programs6,7. 
After the extraordinary efforts made to rapidly research and develop effective COVID-19 
vaccines and their recent rollout, researchers and the media have pointed to a growing 
concern regarding public confidence in the vaccination process. In fact, “anti-vaccine 
movements” can foster vaccine hesitancy, reducing the population’s willingness  
to be vaccinated6–13.
Several surveys have been used to characterize behaviours concerning vaccine hesitancy 
and NPI compliance10–18. According to the existing literature, sociodemographic conditions 
(e.g., education, age, or job occupation)10,18–20 and political and organizational trust 
aspects5,8–10,12,13, can affect people’s willingness to be vaccinated.
One of the countries with the highest number of COVID-19 cases and deaths1, 
Brazil has a population of diverse sociodemographic backgrounds20–23 and is governed 
by a president with a long history of questioning scientific findings, including  
vaccine efficacy and safety24–26. Reducing vaccine hesitancy will largely determine 
Brazil’s – and other low-middle income countries (LMICs) – success in controlling the  
current pandemic.
Given this context, this study investigates the factors associated with COVID-19 vaccine 
hesitancy in Brazil. Using a nationwide online survey, we analyse how sociodemographic 
conditions, political factors, organizational confidence, and non-pharmaceutical 
interventions compliance influence the population’s willingness to be vaccinated. 
METHODS
This study was approved by the Research Ethics Committee at NOVA School of Business 
and Economics (Portugal) on November 23rd, 2020, via letter sent by the Scientific Council’s 
president. Regarding Brazilian ethical standards, the research complied with the National 
Health Council Resolution 466/12a. In its first page, the online survey highlighted the 
research characteristics and information, anonymity assurance, data protection, and a 
consent form. 
Data
Data collection took place between November 25th, 2020 and January 11th, 2021, period  
before the second COVID-19 wave, considered the deadliest so far, and before the first 
COVID-19 vaccine (Coronavac – Sinovac/Butantã) was introduced. Using an online survey 
built on Qualtrics software and disseminated on different social networks (Facebook, 
Instagram, WhatsApp, and email groups), we sought to collect a diversified base of  
responses from all Brazilian regions and different social sectors. 
Table 1 describes the survey data and compares it to the national averages.
Our sample comprised 1,623 valid responsesb, collected from almost all Brazilian 
states and capitals, but mainly from São Paulo (67%). While not representative of 
the Brazilian population, the study sample comes close to some sociodemographic 
characteristics, such as gender, age, residence area, number of households and  
professional situation27.  
a Ministério da Saúde (BR), 
Conselho Nacional de 
Saúde. Resolução Nº 466 de 
12 de dezembro de 2012. 
Aprova diretrizes e normas 
regulamentadoras de pesquisas 
envolvendo seres humanos. 
Diário Oficial da União. 13 jun 
2013; Seção 1: 59. Available 
from: https://conselho.saude.gov.
br/resolucoes/2012/Reso466.pdf
b These responses include all 
completed and submitted 
responses recorded after 
validation testing. Participants 
were given the option not 
to disclose their political 
preferences, perception of 
vaccine side effects, perception 
of the federal government, and 
compliance levels.
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Factors associated with COVID-19 vaccine hesitancy 
Paschoalotto MAC et al.
https://doi.org/10.11606/s1518-8787.2021055003903
Table 1. Sample characteristics (Survey Data) x National characteristics (National Data).
Variable
Survey Data
National Data
States and municipalities (number)a
States
24
27
Capitals
20
27
Municipalities
263
5,570
Gender (%)
Male
37.9
48.2
Female
61.7
51.8
Other/No answer
0.4
Age (%)
≤ 18 years
0.9
< 19 years
33.1
19 to 25 years
30.6
20 to 24 years
9.0
26 to 32 years
20.9
25 to 34 years
17.1
33 to 45 years
27.4
35 to 44 years
14.0
46 to 64 years
18.4
45 to 64 years
19.2
65 to 79 years
1.9
65 to 79 years
6.0
≥ 80 years 
0.1
≥ 80 years 
1.6
Education (%)
Elementary school
0.5
55.8
High school
14.4
30.1
University – Bachelor
40.5
14.1
University – MBAs and specializations
20.8
University – Master’s
14.1
University – Doctorate
9.7
Residence area (%)
Urban
97.4
84.4
Rural
2.6
15.6
Households (%; average number)
One/Live alone
7.9
30.9
Two
33.3
Three
26.9
30.4
Four
20.7
22.8
Five
7.2
10.0
More than five
4.0
5.9
Professional situation (%)
Retired
2.8
Out of the 
workforce
37.2
Student
21.2
Unemployed
6.5
Unoccupied
6.6
Public server
17.2
Occupied
39.1
Worker – Own business
10.9
Worker – SME enterprises
15.4
Worker – Big enterprises
22.1
Other/No answer
3.9
Other
17.1
a Sample comprising 88.9% of the Brazilian states, 74.7% of the Brazilian capitals, and 4.7% of the Brazilian 
municipalities. More than 75% of the Brazilian municipalities are characterized as “small” (< 25,000 inhabitants), 
reducing the likelihood of achieving a substantial representativeness for them (31).
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Factors associated with COVID-19 vaccine hesitancy 
Paschoalotto MAC et al.
https://doi.org/10.11606/s1518-8787.2021055003903
Beyond sociodemographic conditions, we also have collected data regarding political factors, 
organizational confidence, NPI compliance, perception of vaccine side effects and vaccine 
hesitancy (Appendix 1). 
Respondents were asked to disclose their political leaning on a scale of 1 (Far Left) to 7 (Far 
Right) and to qualitatively evaluate (Very Bad, Bad, Good and Very Good) their perception 
of several institutions’ performance concerning the COVID-19 pandemic, including the 
Federal Government.
Regarding NPI compliance – mandatory mask use, social distancing (1,5 meters), respiratory 
etiquette, hand washing and staying at home –, respondents were asked to disclose their 
agreement level using a 5-point scale (disagree – agree), and their compliance level (never, 
rarely, frequently, and always) (Appendix 1). By means of a Principal Content Analysis (PCA), 
we used these questions to create a composite indicator labelled as “Compliance Index,” 
which represents 47.68% of the explanatory power of the total variables. Each measure 
contributed to the compliance index with different weights: mandatory mask use – 19.86%; 
social distancing (1.5 meters) – 21.84%; respiratory etiquette – 16.87%; hand washing – 
20.49%; and staying at home, if possible – 20.94%.
As for vaccines, respondents were asked about their perception of vaccine side effects and 
willingness to be vaccinated (no, maybe, and yes).
Data Analysis
We performed a set of bivariate analyses to understand the association between key 
variables – NPI Compliance Index, Age (years), Gender, Schooling level, Vaccine side effect, 
Political leaning and Government performance (Federal) – and willingness to take the 
COVID-19 vaccine. Subsequently, we used logistic regression models to estimate COVID-19 
vaccine hesitancy. Using willingness to be vaccinated (measured by no/maybe (0), and yes 
(1)) as the dependent variable, the first model considers the baseline sociodemographic 
conditions as independent variables; the second model, in turn, includes political 
leaning, organizational confidence, non-pharmaceutical interventions compliance, and 
vaccine side effects as independent variables. Results are presented as Odds Ratios (OR), 
which indicate the odds of a dependent variable occurring in the presence or absence 
of the reference group, and as marginal effects (dy/dx), which tells us, in percentage 
points (pp), how a dependent variable changes when an explanatory variable changes,  
ceteris paribus.
RESULTS
Descriptive Statistics
Regarding the willingness to take the COVID-19 vaccine, 70% of the sample showed to be 
willing to take the COVID-19 shot, while almost 30% exhibited some degree of hesitancy 
(“not” or “maybe”) (Figure A). Such willingness to be vaccinated assumes that a vaccine is 
available for a given individual.
Plots 1B to 1H show the association between willingness to be vaccinated and the 
independent variables. Divided into tertiles, the NPI Compliance Index (Figure B) ranges 
from lower compliance (1) to higher compliance (3) levels, suggesting a possible association 
between this variable and willingness to be vaccine, with a higher percentage of “Yes” at 
the level “3”, than at the level “1.” Such findings may reflect the population’s level of concern: 
more concerned individuals are willing to be vaccinated and show higher compliance with 
sanitary measures.
As for the association between age and willingness to be vaccinated (Figure C), younger (less 
than 25 years) and older (more than 65 years) individuals showed higher levels of hesitancy, 
5
Factors associated with COVID-19 vaccine hesitancy 
Paschoalotto MAC et al.
https://doi.org/10.11606/s1518-8787.2021055003903
Figure. Bivariate analysis plots (except for 1A), respectively: Willingness to be vaccinated (A); Willingness to be vaccinated and NPI 
Compliance Index (B); Willingness to be vaccinated and Age (C); Willingness to be vaccinated and Gender (D); Willingness to be vaccinated 
and Schooling level (E); Willingness to be vaccinated and Vaccine side effects (F); Willingness to be vaccinated and Political leaning (G); 
Willingness to be vaccinated and Federal Government performance (H).
A
B
C
D
E
F
G
H
100
80
60
40
20
0
Willingness to COVID-19 Vaccine
No
Maybe
1
2
3
NPI Compliance Index
Gender
Age (years)
Female
Male
1
2
3
4
5
6
7
Political position
Government performance
Very bad
Bad
Average
Good
Very
good
University
High school
Elementary
school
Schooling
Disagree
Partially
disagree
Neutral
Partially
agree
Agree
Yes
Vaccine side effect
<18 yrs
19–25 yrs 26–32 yrs 33–45 yrs 46–65 yrs
>65 yrs
100
80
60
40
20
0
100
80
60
40
20
0
100
80
60
40
20
0
100
80
60
40
20
0
100
80
60
40
20
0
100
80
60
40
20
0
100
80
60
40
20
0
6
Factors associated with COVID-19 vaccine hesitancy 
Paschoalotto MAC et al.
https://doi.org/10.11606/s1518-8787.2021055003903
while those between 26 and 65 years old were less hesitant. In our sample, women showed 
greater hesitancy regarding the COVID-19 vaccine than men (Figure D).
As expected, the analysis found a strong association between schooling level and vaccine 
hesitancy (Figure E): individuals with only elementary schooling show vaccine hesitancy 
levels up to four times higher than those with higher schooling levels. Moreover, individuals 
more concerned with vaccine side effects show greater hesitancy in their willingness to be 
vaccinated (Figure F).
In our sample, right-wing individuals – generally more favorable to the current government – 
show higher levels of vaccine hesitancy than left-wing individuals. Together with the previous 
findings, this suggests that distrust in government is associated with higher compliance 
and vaccine acceptance, possibly due to high levels of concern (Figure G). We observed 
a similar inverse relationship between perception of government and willingness to be 
vaccinated (Figure H): respondents who scored government action as “Very bad” showed 
and 86% willingness to be vaccinated; among those who scored the government action as 
“Very good”, in turn, this willingness drops to 38%.
Logistic Regression Models
In this study, we performed two regression models to estimate the factors associated 
with the willingness to take the COVID-19 vaccine. While model 1 includes only 
sociodemographic characteristics, model 2 considers the participants’ opinion on vaccine 
side effects, political leaning, perception of federal government performance and the 
compliance indexc. This section focuses on the marginal effects analysis, but full results 
are shown below (Table 2).
In both models, age group does not seem to explain willingness to be vaccinated. Being 
retired is associated with the probability of taking the COVID-19 vaccine by 17.9 pp 
(p < 0.01) and by 14.5 pp (p < 0.05) in the first and second model, respectively, being the 
only professional situation with significant impact on the dependent variable – relative to 
being unemployed (baseline group). Although we found a positive impact associated with 
being male in the first model, this loses significance once we control for opinion on vaccine 
effects and compliance index. We observed similar results regarding educational variables 
such as Master’s and PhD programs.
The second model shows a negative and statistically significant association between fear of 
vaccine side effects and willingness to be vaccinated. Respondents who answered having 
no concern over vaccine side effects show higher levels of willingness to be vaccinated, 
with their probability changing by 7.7 pp (p < 0.10). On the other hand, individuals with 
high levels of concern about side effects have lower willingness to be vaccinated, varying 
by 34.4 pp (p < 0.01). Regarding political leaning, results show an association between being 
left-oriented and willingness to take the vaccine. Rating the government’s performance 
as “very bad” affects the probability of agreeing to be vaccinated by 10.7 pp (p < 0.01). 
The compliance index, which gives us an indicator of the participants’ overall level of 
compliance with all preventive measures, is in turn positively associated with willingness 
to vaccinate. An extra score on the compliance index means a 1.4 pp (p < 0.05) change in 
the probability of agreeing to vaccinate. 
c Compliance Index explained in 
detail in the methods section.
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Factors associated with COVID-19 vaccine hesitancy 
Paschoalotto MAC et al.
https://doi.org/10.11606/s1518-8787.2021055003903
Table 2. Logit models analyzing the explanatory capacity of the independent variables concerning the 
willingness to be vaccinated.
(1)
(1)
(2)
(2)
OR
dydx
OR
dydx
Compliance Index
1.123b
0.014b
Age (years)
(baseline group ≤ 18)
19–25
0.912
-0.018
0.951
-0.006
26–32
1.014
0.003
0.841
-0.020
33–45
1.002
0.0004
0.877
-0.015
46–64
0.785
-0.048
0.597
-0.063
≥ 65
0.447
-0.174
0.619
-0.058
Gender
(baseline group: Female)
Male
1.324b
0.054b
1.218
0.023
Professional situation
(baseline group: Unemployed)
Retired
2.93b 
0.179c
3.867a
0.145b
Student
1.391
0.066
1.012
0.002
Other
0.834
-0.039
1.080
0.010
Public server
1.424
0.070
1.405
0.042
Worker – Big enterprises
1.178
0.034
1.829
0.072
Worker – SME enterprises
1.122
0.024
1.266
0.029
Worker – Own business
0.936
-0.014
1.225
0.025
Schooling level 
(baseline group: Elementary school)
High school
2.940
0.246
2.856
0.127
University – Bachelor
1.960
0.161
1.218
0.027
University – MBAs and specializations
2.827
0.238
1.700
0.069
University – Master
4.747a
0.328
2.692
0.121
University – PhD
5.103a
0.338∗
2.049
0.091
Vaccine side effects 
(baseline group: do not disagree or agree)
Fully disagree
3.454a
0.077b
Partially disagree
2.346a
0.060b
Partially agree
0.503b
-0.077c
Fully agree
0.108c
-0.344c
Political leaning 
(baseline group: Center)
1- Far left
0.896
-0.014
2
1.869b
0.072b
3
1.553a
0.053a
5
0.690
-0.050
6
0.476c
-0.104b
7 - Far right
0.388b
-0.136b
Federal government - Performance 
(baseline group: Fair)
Very bad
2.355c
0.107c
Bad
1.337
0.039
Good
0.699
-0.052
Very good
0.532
-0.095
N
1,623
1,623
1,261
1,261
a, b, c: indicate significance at 10%, 5% and 1% level, respectively.
Note: We also ran ordered logit models, which presented the same significative results.
8
Factors associated with COVID-19 vaccine hesitancy 
Paschoalotto MAC et al.
https://doi.org/10.11606/s1518-8787.2021055003903
DISCUSSION
This study investigated the association between social characteristics, political factors, 
and organizational performance and vaccine hesitancy in Brazil, contributing to 
understanding vaccine hesitancy factors in a LMIC context.
Our main finding suggests a negative association between positive perception of the federal 
government’s performance and willingness to be vaccinated, similar to previous studies 
on the likelihood of getting vaccinated in Brazil26. It also corroborates a North-American 
study, conducted during the Trump Administration, which suggested higher vaccine 
hesitancy among Trump supporters18. This phenomenon can be explained by  the current 
Brazilian president’s negationist remarks regarding the COVID-19 pandemic and his 
position against compliance with NPIs and being vaccinated – a political scenario similar 
to the Trump administration24,25,28. 
Regarding political leaning, our results show that espousing far-right ideology is positively 
associated with vaccine hesitancy, while being centre-left is associated with vaccine 
acceptance. This finding corroborates other studies on anti-vaccine movements and 
ideological isolation11–13,26) and reinforces the importance of political leadership in promoting 
compliance and public trust during crisis.
The NPI compliance index also provided interesting results, showing a positive association 
with willingness to be vaccinated. Such index is an innovative approach already used in 
previous studies4,10,18 and our results are in agreement with the literature5,11,13. We found 
a similar association regarding vaccine side effects, with more concerned individuals 
showing a positive association with willingness to be vaccinated. Such results highlight 
the importance of public communication about NPIs and vaccines.
This research has two major limitations. First, the method of data collection prevented 
us from obtaining a representative sample, particularly regarding the vulnerable 
population, which was underrepresented. Research shows that the most vulnerable 
individuals (with low schooling levels and high poverty levels) may express least 
willingness to be vaccinated10,18–20. If we transpose this scenario to the Brazilian context, 
then our vaccine hesitancy estimates should be interpreted as a lower bound. Like 
previous studies with convenient sampling methods17,18, however, the present study 
can still be used to derive significant policies. Even if the sample is not representative 
of the entire population, it can be for particular groups. Second, some respondents 
were not comfortable disclosing their political leanings, thus reducing the number of 
observations available in the second model. If such respondents are not distributed 
randomly, then the results may be biased.
Overall, the study contributes to a better understanding of vaccine hesitancy factors in a 
low-to-middle income country. Vaccine hesitancy is associated with multiple factors, such 
as NPIs compliance, sociodemographic and employment characteristics, political leaning, 
and public perception of government performance. Willingness to be vaccinated in Brazil 
is strongly associated with political leaning, perceived federal government performance, 
vaccine side effects, and compliance with non-pharmaceutical interventions. We found a 
strong association between vaccine hesitancy and being right-wing and positive perception 
of government performance. These findings suggest that the current distrust shown by the 
Brazilian president regarding vaccines contributes to vaccine hesitancy among his voter 
base. Individuals who oppose the current government, in turn, show higher willingness to 
be vaccinated.
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Funding: Eduardo Costa was funded by Fundação para a Ciência e a Tecnologia (FCT) under PhD grant number 
BD128545/2017. Joana Gomes da Costa was funded by Fundação para a Ciência e a Tecnologia (FCT) under PhD 
grant number SFRH/BD/140727/2018. The remaining authors have no financial relationships relevant to this 
article to disclose.
Authors’ Contribution: Study design and planning: MACP, EPPAC, SVA, JC, JGC, JVS, PPB, CSP, JLP. Data 
collection, analysis and interpretation: MACP, EPPAC, SVA, JC, JGC, JVS, PPB, CSP, JLP. Manuscript drafting or 
review: MACP, EPPAC, SVA, JC, JGC, JVS, PPB, CSP, JLP. Approval of the final version: MACP, EPPAC, SVA, JC, JGC, 
JVS, PPB, CSP, JLP. Public responsibility for the content of the article: MACP, EPPAC, SVA, JC, JGC, JVS, PPB, CSP, JLP.
Conflict of Interests: The authors declare no conflict of interest.

Running away from the jab: factors associated with COVID-19 vaccine hesitancy in Brazil.
Paschoalotto, Marco Antonio Catussi,Costa, Eduardo Polena Pacheco Araújo,Almeida, Sara Valente de,Cima, Joana,Costa, Joana Gomes da,Santos, João Vasco,Barros, Pedro Pita,Passador, Claudia Souza,Passador, João Luiz