key: cord-0732389-y5e4b3un
authors: Nguyen, Kimberly H.; Anneser, Elyssa; Toppo, Alexander; Allen, Jennifer D.; Scott Parott, J.; Corlin, Laura
title: Disparities in national and state estimates of COVID-19 vaccination receipt and intent to vaccinate by race/ethnicity, income, and age group among adults ≥ 18 years, United States
date: 2021-11-18
journal: Vaccine
DOI: 10.1016/j.vaccine.2021.11.040
sha: 9c960422a020b1156afb4f10511f13fbafd898cd
doc_id: 732389
cord_uid: y5e4b3un

INTRODUCTION: COVID-19 morbidity and mortality has disproportionately affected vulnerable populations such as minority racial/ethnic groups. Understanding disparities in vaccine intentions and reasons for vaccine hesitancy are important for developing effective strategies for ameliorating racial/ethnic COVID-19 inequities. METHODS: Using six waves of the large, nationally representative Census Bureau’s Household Pulse Survey data from January 6-March 29, 2021 (n=459,235), we examined national and state estimates for vaccination intent, defined as receipt of ≥1 dose of the COVID-19 vaccine or definite intent to be vaccinated, by race/ethnicity with stratification by household income and age group. In separate logistic regression models, we also examined the interaction between race/ethnicity and household income, and race/ethnicity and age group, and its association with vaccination intent. Lastly, we examined reasons for not vaccinating by race/ethnicity. RESULTS: Vaccination intent differed by racial/ethnic group, household income, and age group nationally and by Health and Human Services (HHS) region and state. A significant interaction was observed between race/ethnicity and household income (F(8,72)=4.50, p<0.001), and race/ethnicity and age group (F(8,72)=15.66, p<0.001). Non-Hispanic Black adults with lower income (<$35,000) and younger age (18-49 years) were least likely to intend to vaccinate. Similar disparities across racial/ethnic groups were seen across most HHS regions and states. Concerns about possible side effects and effectiveness were significantly higher among all minority groups compared to non-Hispanic White adults. CONCLUSION: Disparities in vaccination intent by racial/ethnic groups underscore the need for interventions and recommendations designed to improve vaccination coverage and confidence in underserved communities, such as younger and lower income racial/ethnic minority groups. Efforts to reduce disparities and barriers to vaccination are needed to achieve equity in vaccination coverage, and ultimately, to curb COVID-19 transmission.

if any, are reasons that you [probably will/probably won't/definitely won't] get a COVID-19 vaccine". Response options were: 1) I am concerned about possible side effects of a COVID-19 vaccine, 2) I don't know if a COVID-19 vaccine will work, 3) I don't believe I need a COVID-19 vaccine, 4) I don't like vaccines, 5) My doctor has not recommended it, 6) I plan to wait and see if it is safe and may get it later, 7) I think other people need it more than I do right now, 8) I am concerned about the cost of a COVID-19 vaccine, 9) I don't trust COVID-19 vaccines, 10) I don't trust the government, and 11) Other (please specify).

Sociodemographic variables assessed were age group, sex, race/ethnicity, educational status, annual household income, insurance status, previous COVID-19 diagnosis, and geographic area (HHS region and state). Age was categorized as 18-49, 50-64, and ≥65 years. Race/ethnicity was categorized as NH White, NH Black, Hispanic, NH Asian, and NH other/multiple race.

Educational status was categorized as high school degree or less, some college/college degree, and above college degree. Annual household income was categorized as <$35,000, $35,000-$74,999, and ≥$75,000. Insurance status was defined as having or not having insurance. Previous COVID-19 diagnosis was defined as a "yes" response to the following question: "Has a doctor or other healthcare provider ever told you that you have COVID-19?" Analyses by region, categorized as 10 Health and Human Services regions, 18 and state were also determined.

To examine vaccination intent by geographic area and race/ethnicity with stratification by income level and age group, data were combined for six waves of data collection from January 6 to March 29, 2021 (1/6-1/18, 1/20-2/1, 2/3-2/15, 2/17-3/1, 3/3-3/15, 3/17-3/29). Because the vaccination intent questions were only asked of those who were not vaccinated, assessing intent over time would show bias as more people got vaccinated (reducing the sample size of those who are asked about intent). To reduce this potential for bias, vaccination intent was assessed among everyone in the sample, including those who were vaccinated. Because the vaccine was not available to everyone from January to March 2021, and in order to examine disparities in vaccination coverage and intent to be vaccinated, vaccination intent was defined as receiving ≥1

dose of COVID-19 vaccine or reporting that one would "definitely" be vaccinated in the future since people who definitely intent to be vaccinated would likely be in the vaccinated group had the vaccine been available to them at the time.

Sociodemographic characteristics of the sample population was assessed. Vaccination intent was examined by socioeconomic characteristics and then stratified by race/ethnicity, income, age, and geographic area. Reasons for not getting vaccinated were assessed by race/ethnicity and different levels of vaccination intent (probably, probably not and definitely not). All estimates with relative standard errors greater than 30% were suppressed. Contrast tests for the differences in proportions, comparing each category to the referent category were conducted with a 0.05 significance level (α=0.05). A logistic regression model was estimated to examine the interaction between race/ethnicity and annual household income on COVID-19 vaccination receipt (≥1 dose) and intent to get vaccinated, after controlling for age group, sex, educational status, HHS region, survey cycle, and prior COVID-19 diagnosis. A separate logistic regression model was estimated to examine the interaction between race/ethnicity and age group, adjusted for the same set of covariates. We used adjusted Wald tests to assess overall interaction terms. All analyses accounted for the survey design to ensure a nationally representative sample using Stata v16. 1 .

Approximately 52% of respondents were 18-49 years, 26% are 50-64 years, and 22% are over 65 years ( Table 1 ). The majority of respondents were female (52%), NH White (63%), have at least some college education (61%), have annual household incomes of ≥$75,000 (57%), and are insured (92%). Fourteen percent of respondents reported having a prior diagnosis of COVID-19.

Overall, vaccination intent was highest among NH Asians (78.3%; 95% confidence interval (CI): 77.4-79. 3) , and lowest among NH Blacks (50.4; 95% CI: 49. 5-51.4) . Across all sociodemographic characteristics, vaccination intent was lowest among NH Blacks and NH other racial groups (Table 2 ). This trend was particularly strong among those with lower income levels ( Table 2) . Vaccination intent was also lower among those who had a previous COVID-19 diagnosis or were not sure if they had a previous diagnosis of COVID-19 compared to those who have not, with the lowest intent among NH Blacks (30.2%) compared to NH Whites (51.2%) among those who were not sure if they had a previous COVID-19 diagnosis.

In multivariable models, a significant interaction was observed between race/ethnicity and income ( Figure 1 ; F(8,72) = 4.50, p < 0.001)) as well as between race/ethnicity and age group ( Figure 2 ; F(8,72) = 15.66, p < 0.001)). NH Black and NH other/multiple racial groups had the lowest proportion of adults intending to get vaccinated across all income levels, and the effect of income was smaller among non-Hispanic Asian and Hispanic adults ( Figure 1 ). For example, the difference in the predicted probability of intent to vaccinate between NH Black individuals at the highest income level compared to the lowest income level was 9.5 percentage points (61.8% versus 52.3%) whereas the difference in the predicted probability of intent to vaccinate between NH Asian individuals at the highest income level compared to the lowest income level was 2.1 percentage points (77.1% versus 75.0%). Furthermore, people aged 18-49 years were less likely to intend to get vaccinated than people aged 65 years and older; however, the differences by age group depended on individuals' racial/ethnic group ( Figure 2 ). For example, the difference in the predicted probability of intent to vaccinate between the oldest age group of NH Blacks compared to the youngest was larger than that for any other racial/ethnic group (38. 4 All inter-and intra-group comparisons were statistically significant (p < 0.05) with the following exceptions: Among people with intermediate incomes, there were not significant differences between people who identify as Hispanic and non-Hispanic White (p = 0.008) or between people who identify as non-Hispanic Black and non-Hispanic other (p = 0.117) ( Figure 1 ). Among people in the oldest age group, there were not significant differences between people who identify as Hispanic or non-Hispanic Black (p = 0.902) ( Figure 2 ). There were not significant differences between people in the middle and highest income groups who identified as non-Hispanic Black (p = 0.054), Hispanic (p = 0.342), or non-Hispanic other (p = 0.456). Finally, there were not significant differences between people in the lowest and middle income groups who identified as non-Hispanic Asian (p = 0.129).

Vaccination intent differed by racial/ethnic group, household income, and age group, overall and by geographic area. Nationally, among people with an income <$35,000, intent was lowest among NH Black (41.5%) and NH other/multiple racial groups (46.1%) (Supplemental table 1 Reasons for not getting vaccinated also differed by race/ethnic group (Table 3) . Among those who probably will get vaccinated, concerns about possible side effects and effectiveness were significantly higher among all race/ethnic minority groups compared to NH White adults. For example, concerns about possible side effects ranged from 51.8% to 57.5% among minority groups compared to 49.5% among NH White adults. Furthermore, concerns about effectiveness of the vaccine ranged from 18.7% to 21.2% among minority groups compared to 16.3% among NH White adults. Among those who will probably not get vaccinated, lack of trust in the vaccine was higher among NH Blacks (28.5%) compared to NH Whites (24.2%), and concerns about the cost was higher among NH other/multiple racial groups (7.3%) compared to NH Whites (5.3%).

Among adults who will definitely not get vaccinated, lack of doctor recommendation (9.8%) and other reasons for not getting vaccinated (29.5%) were higher among NH other/multiple racial groups than NH Whites (6.8% and 17.6%, respectively). Furthermore, 30% of NH other/multiple racial groups who said they would definitely not get vaccinated reported other reasons for not getting vaccinated, which is higher than seen among NH Whites (18%), suggesting there may be other reasons for non-vaccination among these groups. While not specifically stated, other reasons for not getting vaccinated may include access and logistical issues, such as time and transportation.

Vaccination intent varies by sociodemographic characteristics and geographic areas across all racial/ethnic groups. Prior studies have shown that people with lower socioeconomic status, younger age, and are non-Hispanic Black were less likely to get vaccinated or intend to get vaccinated. [12] [13] [14] [15] 20 however, this is the first nationally representative study to show that vaccination intent differs by income and age group within racial/ethnic groups. Furthermore, the interaction between race/ethnicity and income and age group were found across most HHS regions and states. While this study provides data in early 2021 at the state of the vaccination campaign, data from more recent surveys suggest that disparities in vaccination coverage and intent by age and race/ethnicity continue to exist but are closing for some race groups. [22] [23] Intention to vaccinate was lowest among NH Blacks and NH other/multiple racial groups with incomes <$35,000 and between ages 18-49 years, with lower levels of intent to vaccinate across each income and age group compared to their respective NH White counterparts. While this study only examined vaccination coverage and intent among adults, studies have found that vaccination and intent among parents is highly correlated with their willingness to vaccinate their children ages 12-17 years, for which the Pfizer-BioNTech vaccine has been approved. As a result, gaps and disparities in vaccination coverage and intent among adults are likely to be similar among adolescent children as well, highlighting the importance of addressing the disparities in vaccination and intent found in this study.

This study demonstrates that the most vulnerable populations are NH Black and NH other/multiple racial groups, particularly those who are younger and have lower incomes.

Although the vaccine is free for everyone in the U.S., adults of every racial/ethnic group mentioned cost as a barrier to vaccination (though more frequently in adults of NH other/multiple races than NH white adults). This suggests the need to clarify misinformation about the cost of the vaccines and emphasize the availability of the vaccines for all. Beyond this misperception about cost, however, even among those with the highest incomes, intent among NH Blacks and NH other/multiple racial groups are still much lower than those of NH Whites of similar incomes, suggesting ongoing reasons for vaccine hesitancy beyond simply access or misperception barriers in these populations. We find that concerns about possible vaccine side effects and effectiveness, lack of recommendation from a health care provider, and lack of trust in COVID-19 vaccines were significantly higher among NH Blacks and/or NH other/multiple racial groups compared to NH White adults. Indeed, other research identifies trust-and specifically, trust in science and medicine, which is lower among NH Black and Hispanic individuals than NH Whites and Asians-as a major predictor of vaccine hesitancy even after adjusting for a range of predictors including partisanship, ideology, education, income and region. 23 The history of racism in the US, which research has previously been found to be associated with a lack of trust in influenza vaccines, is likely also in play with the COVID-19 vaccine in these communities. [24] [25] Furthermore, 30% of NH other/multiple racial groups who said they would definitely not get vaccinated reported other reasons for not getting vaccinated, which is higher than seen among NH Whites (18%), reinforcing the notion that the determinates of trust in vaccines are complex and operate differently in different racial/ethnic communities.

Our results reinforce the recognized importance of strategies for reducing COVID-19 vaccine hesitancy and increasing trust in these populations through community-sensitive messages from trusted sources about the safety and effectiveness of vaccines, ensuring that healthcare providers are recommending (or having discussions about the importance of) vaccination, and addressing access barriers to vaccination by having vaccines available in convenient locations. [26] [27] [28] This study also demonstrates high vaccination intent among NH Asian adults compared to NH White adults. A lower proportion of NH Asians reported that they did not believe they needed a vaccine and did not trust the government compared to NH Whites. NH Asian adults were also less likely to report lack of trust in COVID-19 vaccines compared to NH Black and Hispanic adults. These results suggest that perceived need and confidence in vaccines and trust in the government may be contributing factors to the higher vaccination coverage and intent among this group. Understanding motivators for vaccination, such as protecting the health of families and communities and resuming work, school, and social activities, is also important for developing appropriate strategies and interventions to increase vaccination coverage among all populations.

Emphasizing the importance of vaccines in protecting one's health and that of loves ones, as well as building trust in vaccines and the health professionals who recommend them, will help contribute to improving vaccination coverage and confidence among all racial/ethnic groups.

The findings in this study are subject to several limitations. First, COVID-19 vaccination status and diagnosis were based on self-report, which may not accurately reflect actual vaccination status or disease history for some respondents. Second, the HPS has a low response rate (<10%); however, non-response bias assessment conducted by the Census Bureau found that the survey weights adjusted for most of this bias, even though some bias may remain. 29 Finally, because data from January to March 2021 were used in this analysis, these results might not be reflective of the current prevalence of vaccine confidence. However, patterns in vaccination intent disparities by race/ethnicity, income, and age group are likely to be similar. Disparities in vaccine confidence by racial/ethnic groups underscore the need for targeted interventions and messages to reach vulnerable communities, such as younger and lower income racial/ethnic minority groups, many of which are experiencing a disproportionate burden of COVID-19 infections and deaths. Despite the vaccine being available to everyone for free, over 25% of all adults in the U.S. have not received at least 1 dose of the COVID-19 vaccine as of August 2021. 30 Understanding more about the reasons for ongoing levels of hesitancy and other access barriers to vaccination will lead to actionable interventions and recommendations designed to improve vaccination coverage and confidence, particularly among communities who are most vulnerable to COVID-19 infection and severe health outcomes. Efforts to reduce disparities and barriers to vaccination, and increase public trust and confidence, are needed to achieve equity in vaccination coverage, and ultimately, bring an end to the pandemic. Abbreviations: NH = non-Hispanic; COVID-19 = coronavirus disease 2019; CI = confidence interval.

* Vaccination intent is defined as receiving ≥1 dose of COVID-19 vaccine or definitely will get vaccinated † Significant differences in proportions comparing each group to the referent group (non-Hispanic white individuals)

Abbreviations: NH-W = Non-Hispanic White; NH-B = Non-Hispanic Black; H = Hispanic; NH-A = Non-Hispanic Asian, NH-O = Non-Hispanic other/multiple race category Abbreviations: COVID-19 = coronavirus disease 2019; CI = confidence interval. * Vaccination intent is defined as receiving ≥1 dose of COVID-19 vaccine or definitely will get vaccinated † Significant differences in proportions comparing each group to the referent group (non-Hispanic white individuals from the same income group) ‡ Estimate was suppressed due to a relative standard error of >30%. Abbreviations: NH = non-Hispanic; COVID-19 = coronavirus disease 2019; CI = confidence interval.

* Vaccination intent is defined as receiving ≥1 dose of COVID-19 vaccine or definitely will get vaccinated † Significant differences in proportions comparing each group to the referent group (non-Hispanic white individuals from the same age group) ‡ Estimate was suppressed due to a relative standard error of >30%.

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