Intent to Receive COVID-19 Vaccine and Behavioral and Social Drivers of Vaccination by Race and Ethnicity, National Immunization Survey Adult COVID Module — United States, October 31–December 31, 2021

Summary

The COVID-19 pandemic has disproportionately affected racial and ethnic minority groups12. Equitable vaccination can reduce disparities in COVID-19-related morbidity and mortality3. Disparities in initiation of COVID-19 vaccination were present for racial and ethnic minority groups early in the rollout of COVID-19 vaccine, but several of these disparities have since narrowed or disappeared4. For example, at the end of April 2021, vaccination coverage with ≥1 dose of COVID-19 vaccine was 10-15 percentage points lower among Hispanic, Black non-Hispanic (Black), and Native Hawaiian or other Pacific IslanderA (NH/OPI) adults than it was among White non-Hispanic (White) adults, and was 15-25 percentage points lower among multiple or other race and American Indian or Alaska Native (AI/AN) adults than among White adults. By the end of November 2021, Hispanic and Asian adults had higher vaccination coverage (≥1 dose) than White adults. Black and NH/OPI adults' vaccination coverage was not significantly different than that of White adults. Disparities had narrowed, but remained, for AI/AN and multiple/other race adults nationally and for Black, Hispanic, and NH/OPI adults in some geographic areas and sociodemographic categories4.

This report assesses the sociodemographic characteristics, vaccination intent, and behavioral and social drivers (BeSD) of vaccination among adults, during October 31-December 31, 2021. The objective of this report is to describe the characteristics associated with being unvaccinated and either having intent to get vaccinated or being reluctant to get vaccinated, and to examine the potential reasons for non-vaccination.

During October 31-December 31, 2021, a higher proportion of NH/OPI (12.8%), Black (11.2%), AI/AN (10.3%), multiple/other race (9.4%), and Hispanic (9.3%) adults were unvaccinated but reported they definitely or probably will get vaccinated or were unsure ('reachable'), compared with White adults (6.2%), indicating potential for vaccination coverage to continue to increase among these populations. Within most races and ethnicities, the proportion who were reachable was highest among those who lived in the Midwest or South, were 18-29 years of age, had household incomes below poverty, or were uninsured. Reluctance to get vaccinated (reported they probably will not or definitely will not get vaccinated) was highest among AI/AN (29.1%), multiple/other race (23.5%), and White (14.8%) adults, and lowest among Black (10.2%), Hispanic (8.9%), and Asian (2.3%) adults. A substantial proportion of unvaccinated but reachable adults of all races/ethnicities were concerned about getting COVID-19 (24.1%–48.1%) and thought that the vaccine was important (41.3%–68.6%) and safe (23.0%–47.1%).

Methods

The National Immunization Survey Adult COVID Module (NIS-ACM) is a random-digit-dialed cellular telephone survey of adults age ≥18 years in all 50 states, the District of Columbia, and selected local areas and U.S. territories. Survey respondents from October 31, 2021 through December 31, 2021, who reported their race/ethnicity (97.3%) were included in this analysis. Monthly survey response rates were 23.4% (October 31-November 27) and 23.0% (November 28-December 31).

Measures

The survey included questions about COVID-19 vaccination status and intent, behavioral and social drivers of vaccination, and sociodemographic characteristics. COVID-19 vaccination status and intent were assessed by two questions: "Have you received at least one dose of a COVID-19 vaccine?" and if not, "How likely are you to get a COVID-19 vaccine? Would you say you would definitely get a vaccine, probably get a vaccine, probably not get a vaccine, definitely not get a vaccine, or are not sure?" Two vaccination intent categories were created: (1) reachable, combining those who reported they definitely will get vaccinated, probably will get vaccinated, or were unsure, and (2) reluctant to get vaccinated, combining those who reported they probably will not or definitely will not get vaccinated. Behavioral and social drivers of vaccination were assessed among respondents who were classified as reachable, and among all respondents who were unvaccinated. Behavioral and social drivers of vaccination include topics in the key domains of thinking and feeling (concern about getting COVID-19, confidence in COVID-19 vaccine importance, confidence in COVID-19 vaccine safety), social processes (healthcare provider recommended COVID-19 vaccine, friends and family are vaccinated), and practical issues (difficulty getting a COVID-19 vaccine, work or school requires a COVID-19 vaccine)5. Race/ethnicity was self-reported and based on the questions "Are you of Hispanic or Latino origin?" and "Please choose one or more of the following categories to describe your race. Are you White, Black or African American, American Indian, Alaska Native, Asian, Native Hawaiian or other Pacific Islander?" Persons were categorized into mutually exclusive categories of race and ethnicity; persons not reporting they were Hispanic were categorized by their reported race(s).

Analysis

Weighted proportions and 95% confidence intervals (CIs) were estimated for each race/ethnicity category overall, and by U.S. Census region, urbanicity, age group, annual household income, and health insurance. Data were weighted to represent the non-institutionalized U.S. adult population and calibrated to state-level vaccine administration data reported to CDC. Analyses were conducted using SAS (version 9.4) and SUDAAN (version 11; RTI International).

Results

Vaccination Intent

Overall, a higher proportion were unvaccinated but reachable among NH/OPI (12.8%), Black non-Hispanic (11.2%), AI/AN (10.3%), multiple/other race (9.4%), and Hispanic (9.3%) adults, compared with White non-Hispanic adults (6.2%) [Table 1], indicating potential for vaccination coverage to continue to increase among these populations. The proportion who were reachable was lower among Asian adults (2.2%); most Asian adults were already vaccinated (95.5%).

TABLE 1. COVID-19 vaccination^* status and intent by race/ethnicity^† and sociodemographic characteristics among adults ≥18 years— National Immunization Survey Adult COVID Module, United States, October 31-December 31, 2021

^{AI/AN = American Indian or Alaska Native; CI = confidence interval; MSA = metropolitan statistical area; NH/OPI = Native Hawaiian or other Pacific Islander.}

^{* The estimates of proportions vaccinated based on October-December 2021 data may not match the Kaplan-Meier vaccination coverage estimates shown in reference 4, which use more months of data and a different analytic method.}

^{† Persons were categorized into mutually exclusive categories of race and ethnicity; persons not reporting they were Hispanic were categorized by their reported race(s).}

^{§ MSA status was determined based on household reported city and county of residence and was grouped into three categories: MSA principal city (urban), MSA non-principal city (suburban), and non-MSA (rural). MSAs and principal cities were as defined by the U.S. Census Bureau (https://www.census.gov/programs-surveys/metro-micro.html). Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.}

Within most races/ethnicities, the proportion who were reachable was highest among those living in the Midwest (range: 6.1% Asian to 21.8% NH/OPI) or South (range: 2.4% Asian to 16.0% NH/OPI), in the 18-29 age group (range: 3.5% Asian to 22.2% Black), with household incomes below poverty (range: 1.6% Asian to 15.7% multiple/other race), or who were uninsured (range: 9.5% AI/AN to 29.6% NH/OPI). Across all races/ethnicities, the smallest reachable proportion was among adults ages ≥65 years (range: 0.3% Asian to 3.0% Black).

Vaccination Reluctance

Reluctance to get vaccinated (those who said they probably will not or definitely will not get vaccinated) differed by race and ethnicity, and was highest among AI/AN (29.1%) and multiple/other race (23.5%) adults. Vaccine reluctance was lower among Black (10.2%), Hispanic (8.9%), and Asian (2.3%) adults than among White (14.8%) adults.

Across all races and ethnicities, vaccine reluctance was lowest among adults ages ≥65 years (range: 0.0% NH/OPI to 16.9% AI/AN); age was inversely associated with vaccine reluctance, with the highest reluctance among AI/AN adults ages 18–29 years (33.6%) and 30–49 years (35.4%), and NH/OPI adults ages 18–29 years (32.1%). Across all races and ethnicities, vaccine reluctance was lowest in the Northeast, and was highest in the Midwest (White, Black, Hispanic, AI/AN, NH/OPI) or South (Asian, multiple/other race). Asian adults in most sociodemographic groups had very low reluctance (0.1%-3.6%), except in non-metropolitan statistical areas (MSAs) (22.7%) and among those who were uninsured (6.2%). Reluctance to get vaccinated was higher among AI/AN adults than among all other races and ethnicities overall and in all sociodemographic categories except non-MSAs and below poverty. Vaccine reluctance was higher in non-MSAs than in MSAs among White (22.7%), Asian (22.7%), and multiple/other race (40.5%) adults, but not among Black (10.0%) or AI/AN adults (19.9%).

Behavioral and Social Drivers of Vaccination

Among those who were reachable, the proportions of adults perceiving risk of COVID-19 and confidence in COVID-19 vaccine safety and importance varied by races/ethnicities: 24.1% to 48.1% were very or moderately concerned about getting COVID-19; 41.3% to 68.6% thought the vaccine is very or somewhat important; and 23.0% to 47.1% thought the vaccine is completely or very safe [Table 2]. Black adults who were reachable were the most concerned about getting COVID-19 (48.1% very or moderately concerned) and the most likely to think the vaccine is important (68.6% very or somewhat important). AI/AN adults who were reachable were most likely to think the vaccine is safe (47.1% completely or very safe) and to have received a healthcare provider recommendation for the vaccine (48.9%). NH/OPI adults who were reachable report the most anticipated difficulty getting a vaccine (20.5% very or somewhat difficult); anticipated difficulty varies for other race/ethnicity groups (range: 11.3% among Asian to 17.4% among multiple/other race adults).

TABLE 2. BeSD variables among adults ≥18 years who were unvaccinated but reachable^*, stratified by sociodemographic characteristics — National Immunization Survey Adult COVID Module, United States, October 31-December 31, 2021

^{AI/AN = American Indian or Alaska Native; CI = confidence interval; MSA = metropolitan statistical area; NH/OPI = Native Hawaiian or other Pacific Islander.}

^{* The estimates of proportions vaccinated based on October-December 2021 data may not match the Kaplan-Meier vaccination coverage estimates shown in reference 4, which use more months of data and a different analytic method.}

^{† Persons were categorized into mutually exclusive categories of race and ethnicity; persons not reporting they were Hispanic were categorized by their reported race(s).}

^{§ MSA status was determined based on household reported city and county of residence and was grouped into three categories: MSA principal city (urban), MSA non-principal city (suburban), and non-MSA (rural). MSAs and principal cities were as defined by the U.S. Census Bureau (https://www.census.gov/programs-surveys/metro-micro.html). Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.}

^{¶ Cells with denominator n<30 are not shown.}

Table 3 shows the behavioral and social drivers of vaccination by race/ethnicity among all unvaccinated adults. These results can be used to understand the attitudes and experiences among the combined group of unvaccinated persons across levels of intent.

TABLE 3. BeSD variables among adults ≥18 years who were unvaccinated^*, stratified by sociodemographic characteristics — National Immunization Survey Adult COVID Module, United States, October 31-December 31, 2021

^{AI/AN = American Indian or Alaska Native; CI = confidence interval; MSA = metropolitan statistical area; NH/OPI = Native Hawaiian or other Pacific Islander.}

^{* The estimates of proportions vaccinated based on October-December 2021 data may not match the Kaplan-Meier vaccination coverage estimates shown in reference 4, which use more months of data and a different analytic method.}

^{† Persons were categorized into mutually exclusive categories of race and ethnicity; persons not reporting they were Hispanic were categorized by their reported race(s).}

^{§ MSA status was determined based on household reported city and county of residence and was grouped into three categories: MSA principal city (urban), MSA non-principal city (suburban), and non-MSA (rural). MSAs and principal cities were as defined by the U.S. Census Bureau (https://www.census.gov/programs-surveys/metro-micro.html). Non-MSA areas include urban populations not located within an MSA as well as completely rural areas.}

^{¶ Cells with denominator n<30 are not shown.}

Discussion

This analysis found that substantial proportions of adults were concerned about getting COVID-19 and think the vaccine is important and safe yet remain unvaccinated. Adults of all races and ethnicities who were reachable were more concerned about getting COVID-19, more likely to think that a COVID-19 vaccine was important and safe and were more likely to have friends and family who were vaccinated, compared with those who were reluctant to get vaccinated. Public health efforts might have more impact among the reachable population. There is potential for vaccination coverage to increase among racial/ethnic minority groups; compared with White adults, more Black, Hispanic, AI/AN, and NH/OPI adults were still reachable as of October-December 2021. In particular, in the sociodemographic groups where disparities in vaccination coverage remain (such as the Midwest, urban areas, and the 18-29 age group) 4, fewer Black and Hispanic than White adults reported that they probably will not or definitely will not get vaccinated; there is the potential for improvements in vaccination coverage among these groups if evidence-based interventions are implemented6. Across all races/ethnicities and sociodemographic groups, the largest proportion of unvaccinated but reachable adults tended to be in the sociodemographic categories that are most marginalized (below poverty, uninsured), suggesting these populations may face barriers to vaccine access. Continued efforts to improve vaccination should seek to understand and address barriers among reachable adults and ways to improve vaccine confidence among those who remain reluctant to get vaccinated.

Limitations

The findings in this report are subject to several limitations. First, response rates for NIS-ACM were relatively low, although similar to other NIS surveysB. Data were weighted to mitigate possible bias resulting from incomplete sample frame (exclusion of households with no phone service or only landline telephones) or non-response, but some selection bias may persist. Second, all responses are self-reported. Vaccination receipt and intent may be subject to recall or social desirability bias. Third, the survey sampled U.S. adults who were non-institutionalized, so adults who are incarcerated or nursing home residents may not be represented.

Statement on Research Determination

This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

Authors

Jennifer L. Kriss, PhD; Mei-Chuan Hung, PhD; Anup Srivastav, PhD; Carla L. Black, PhD; Peng-jun Lu, MD; David Yankey, PhD; Laurie D. Elam-Evans, PhD; James A. Singleton, PhD

CDC COVID-19 Response Team; Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC; Leidos, Inc., Atlanta, Georgia