Background
Vaccine hesitancy is a barrier to Covid-19 vaccine uptake and displays a social gradient, compounding health disparities. While social gradients are a vital concept in health, they flatten distinctions between types of disadvantaged community. This paper focuses on vaccine hesitance in post-industrial and de-industrialising coalfields. The social consequences of the decline of coal mining may present barriers to vaccine uptake.

Methods
We ran parallel surveys in Wales (N=4187) and US states overlapping with central Appalachia (N=4864), to examine whether vaccine attitudes and uptake varied between areas with different coal mining histories. These surveys were accompanied by qualitative interviews of 36 residents of these coalfields to explore vaccination decisions and triangulate with survey data.

Results
Factor analysis identified four axes of attitudes in the survey data: vaccine confidence, covid scepticism, vaccine individualism, and concerned confusion. These themes were echoed in the interviews. Vaccine confidence was lower; and covid scepticism, vaccine individualism, and concerned confusion higher, in residents of areas of Wales with greater mining extent and where pits closed during certain periods. Residents of former US coal counties had lower vaccine confidence and higher covid scepticism, while those in current coal counties had greater vaccine individualism and concerned confusion. In former US coal counties and Welsh areas where pits closed since 1980, vaccine uptake was lower. Differences could not be explained by respondents’ income and education. In the interviews, norms of social solidarity were often invoked by vaccinated respondents, while unvaccinated respondents did not frame decisions in the context of the industrial history of their areas.

Discussion
The legacy of coal-mining’s decline presents barriers to public health campaigns. We show evidence of this across two historically significant coalfields. Attention is needed to avert negative public health consequences of global energy transition.