COVID-19 vaccination hesitancy and uptake: Perspectives from people released from the Federal Bureau of Prisons

The study addresses why people incarcerated in U.S. federal prisons hesitated to receive COVID-19 vaccines and what influenced uptake during and after incarceration. Prisons experienced substantially higher COVID-19 case and death rates than the general population due to crowding, comorbidities, and limited healthcare access. Although vaccines became available in late 2020 and guidance recommended prioritizing both staff and residents, many systems prioritized staff, and overall uptake by both groups was mixed. Broader societal polarization, historical and ongoing medical mistreatment of minoritized communities, and high levels of institutional distrust likely shaped decisions. The purpose of this study was to qualitatively examine vaccine perceptions, rollout experiences, and determinants of acceptance among people incarcerated in the Federal Bureau of Prisons (BOP) and subsequently released.

Prior work shows correctional settings had higher COVID-19 morbidity and mortality than the general population, with mixed vaccination uptake among staff and residents in 2021. Several states deprioritized residents relative to staff, and uptake among residents did not clearly improve with prioritization policies alone. In the general U.S. population, hesitancy correlates with perceived low risk, conservative political views, and concerns about rapid vaccine development and safety. Among minoritized communities, hesitancy is linked to historical abuses and mistrust of medical institutions. Limited studies specific to incarcerated populations have reported distrust of carceral health systems, negative prior healthcare experiences, and trauma from pandemic policies as drivers of hesitancy. This study contributes qualitative insights on how carceral context, structural conditions, and staff behaviors influence vaccine decisions.

Design: Semi-structured qualitative phone interviews using a directed content analysis approach. Sampling and recruitment: Convenience sample of adults formerly incarcerated in Federal Bureau of Prisons (BOP) facilities who were incarcerated before and during the COVID-19 pandemic (from March 2020) and released thereafter. Participants were referred via public defenders and publicly appointed attorneys; study participation was not disclosed to referral sources or the BOP. Eligibility: Age ≥18, English-speaking, incarcerated prior to and released after March 2020. Data collection: Recruitment and interviews occurred August–October 2021. Interviews (approximately 60 minutes) were audio-recorded via Google Voice; participants received a $50 gift card. Interview guide: Explored experiences of incarceration during COVID-19 with focus on vaccine prioritization, acceptance, counseling, and perceptions during custody and post-release. Analysis: Transcripts were professionally transcribed and coded in Dedoose by two coders (CK, MS). A codebook was developed deductively (from a priori domains) and inductively (from emergent data). Two transcripts were double-coded with consensus via weekly meetings; remaining transcripts were single-coded. Analysis was theory-informed by the Conceptual Model of Vaccine Hesitancy and the Social Ecological Model, assessing multilevel influences (individual, interpersonal, community, societal) on vaccination decisions. Ethics: Approved by the Johns Hopkins Bloomberg School of Public Health IRB.

Sample: 21 former BOP residents from multiple facilities; 9 reported confirmed COVID-19 while incarcerated; 12 reported chronic illnesses. Vaccine access in custody: For 10 participants, vaccines were not yet developed before release; 3 noted no availability at their facility before release; 1 was not offered a vaccine despite rollout. Seven were offered vaccination in custody: 3 accepted, 3 declined, and 1 wanted vaccination but was recorded as a refusal when seeking medical guidance. Themes: (1) Prioritization perceptions: Participants often agreed staff were vectors and should be vaccinated first, but low staff uptake and lax precautions undermined perceived benefits. Resident prioritization sometimes seemed arbitrary; limited supply and messaging led residents to feel devalued. (2) Reluctance in custody: Concerns about rapid development, safety, and side effects; beliefs in natural immunity after prior infection; and deep distrust of the carceral system and government (with references to historical abuses) deterred vaccination. (3) Staff influence and lack of counseling: Observed staff hesitancy reduced resident confidence; facilities provided minimal education or individualized counseling; questions were dismissed; some refusals were recorded despite expressed interest pending medical advice. (4) Acceptance in custody: Some accepted vaccination to protect themselves/others, maintain essential worker jobs, or due to impending release and anticipated higher exposure risk. (5) Post-release uptake: Twelve participants were vaccinated after release, citing better access to reliable information, counseling from community clinicians, and encouragement from trusted family; many stated they would not have vaccinated while incarcerated due to mistrust of the prison system. (6) Continued refusal post-release: Five declined vaccination post-release, citing ongoing distrust and reliance on perceived natural immunity, while employing mitigation behaviors like distancing.

Findings indicate that COVID-19 vaccination decisions among people incarcerated in federal facilities reflect multilevel influences: constrained access during custody, absent or poor-quality counseling, and pervasive distrust of the carceral system and staff—compounded by staff hesitancy and inconsistent safety practices. While concerns about breakthrough infections and natural immunity mirror broader societal debates, the carceral context uniquely amplifies mistrust and undermines perceived legitimacy of health interventions. Results align with other studies in correctional settings reporting complex hesitancy drivers and lower acceptance among Black and Latinx residents. Interventions should emphasize comprehensive, responsive vaccine counseling; improved resident-provider communication; use of trusted external clinicians; and strategies to address systemic distrust. Enhancing staff vaccination (potentially via mandates or strong institutional norms) may indirectly improve resident confidence. Given ongoing and seasonal COVID-19 risks, equitable allocation and tailored communication in correctional facilities remain essential.

COVID-19 vaccine uptake is critical for protecting residents and staff in carceral settings. In this study, hesitancy centered on receiving vaccination while incarcerated rather than vaccination per se, as many participants vaccinated after release. Perceived illegitimacy of the vaccine within the prison context—driven by lack of trust and limited endorsement by staff—was central. Efforts to improve uptake should prioritize transparent communication, robust counseling by trusted providers, and institutional accountability and transparency to rebuild trust and support public health initiatives.

Findings derive from a small, convenience sample of individuals incarcerated in federal BOP facilities and may not generalize to other systems or populations. Recall bias is possible as participants described past experiences. The study did not directly assess influences of political ideology or exposure to misinformation/conspiracy theories. BOP guidance during the period emphasized scientific information but gave limited direction on counseling or addressing trust, which may have affected experiences.