COVID-19 Vaccine Acceptance Among the General Public in the United States

As of February 2021, the COVID-19 pandemic has claimed the lives of over 500,000 individuals in the United States.(1) Disease transmission occurs primarily via aerosolized droplets from infected individuals. In response to this airborne mode of transmission, social distancing, frequent handwashing, and the use of face coverings and masks have been encouraged to limit the spread of COVID-19.(2) The severity of symptoms associated with COVID-19 is related to sex, age, comorbid conditions, general health status, and race or ethnicity.(3-5) For instance, individuals who are at an increased risk of severe illness from COVID-19 include those with cancer, type 2 diabetes, cardiovascular disease, obesity, smoking history, and other preexisting conditions.(6) In the United States, 80% of COVID-19 deaths are among those aged 65 and older.(6) Compared with individuals aged 18 to 29 years old, those aged 65 to 74 are 5 times more likely to be hospitalized and 90 times more likely to die of COVID-19. Those aged 85 years and older are 13 times more likely to be hospitalized and 630 times more likely to die of COVID-19.(6) COVID-19 has disproportionately affected minority groups. Non-Hispanic Black individuals are 1.4 times more likely to contract COVID-19, 3.7 times more likely to be hospitalized, and 2.8 times more likely to die of COVID-19 compared with whites.(7,8) Hispanic individuals are 1.7 times more likely to contract COVID-19, 4.1 times more likely to be hospitalized, and 2.8 times more likely to die from COVID-19 in comparison with white, non-Hispanic individuals.(7) Hypotheses as to why COVID-19 disproportionately affects Blacks and Hispanics include the increased likelihood of these individuals to live in densely populated areas, reside in multigenerational households, utilize public transportation, and work in service-related occupations that may increase potential virus exposure.(9-12) Other potential factors include an increased rate of preexisting health conditions that raise the likelihood of developing COVID-19 and dying from its complications, including hypertension, diabetes, and cardiovascular disease.(11,12)

The importance of public health communication also was highlighted during the COVID-19 pandemic, with the CDC issuing several recommendations at the beginning of the pandemic that changed as the time passed. For example, the CDC initially suggested that the general public not wear face masks due to shortages, then later recommended that only those with symptoms should wear face masks, and finally recommended that all individuals should wear masks in public. The lack of clarity and the contradictory nature of CDC guidelines added to the general public’s confusion as to the proper response, further undermining confidence in public health policies surrounding COVID-19. Compounding all of this was the “infodemic” on various social media outlets and news stations.(13) These platforms profoundly affected perceptions of social issues as well as individuals’ responses to the information they consumed. Misinformation about demographics affected by COVID-19, the severity of the disease, and the economic impact of COVID-19 compounded the preexisting distrust of public health and government officials. The result has been that significant subsets of the United States population refuse to socially distance and don face masks when in public, ultimately causing massive second and third waves of the pandemic.

Trust in public health policies and government is paramount in tackling public health issues, especially in terms of emerging diseases. Over the past 30 years, there has been an observed increase in vaccine hesitancy, which has allowed diseases that were on the verge of eradication, such as measles, to reemerge.(14) One group has posited that vaccine hesitancy is on a continuum, reflecting social norms in certain communities, a distrust of public health, and a lack of understanding of vaccines.(15) Not all hesitant individuals refuse to vaccinate—many individuals demonstrate hesitant attitudes and still fully vaccinate themselves and their children. Further, vaccines may be victims of their own success, because we are now approximately two generations away from the last widespread outbreaks of deadly childhood diseases, which made vaccine acceptance so widespread in previous decades.(15) In addition, the spurious link between autism and the MMR vaccine created substantial panic and distrust around vaccination that persists today, despite the large body of literature that has disproved any link between the two.(14)

Understanding and gauging levels of vaccine acceptance and hesitancy is only one part of the larger picture.

Among the innumerable conflicting opinions regarding mask wearing, vaccine acceptance, and the infodemic, various COVID-19 vaccines have emerged. Several studies have addressed the rationing of the COVID-19 vaccine as well as acceptance rates. In a 2020 survey of over 13,000 individuals in 19 countries, 71.5% of participants reported they would be very or somewhat likely to get a COVID-19 vaccine, with differences in acceptance rates ranging from almost 90% (China) to less than 55% (Russia).(16) A European survey reported that 73.9% of 7664 participants would be willing to get a COVID-19 vaccine, with 18.9% of respondents being unsure and 7.2% stating they would not want a vaccine.(17) In May of 2020, another survey of 2006 adults was conducted in the United States. In that survey, 69% of participants were willing to get a COVID-19 vaccine, and increased willingness was noted if the respondent was moderate or liberal in their political leaning, if they believed that their healthcare provider would recommend vaccination, and if they reported higher levels of perceived likelihood of being infected with COVID-19 in the future.(18) A survey by the Pew Research Center reported that about 50% of individuals surveyed in August of 2020 would consider getting the COVID-19 vaccine if it was available, which was a decline from the 72% who were willing to receive it when surveyed in May of 2020; additionally, there was lower willingness to get the vaccine among Blacks (32%) compared with whites (52%).(19)

Understanding and gauging levels of vaccine acceptance and hesitancy is only one part of the larger picture. Because the vaccine is currently available, the rationing and prioritization of individuals to receive the vaccine has been under scrutiny of the public eye. Various groups have proposed ethical frameworks with regard to rationing life-saving resources, often focusing on the principles of treating individuals equally, giving priority to the worst off, maximizing benefits, and rewarding instrumental value.(20) The CDC has provided recommendations to federal, state, and local governments as to who should be given the COVID-19 vaccine first, starting with healthcare personnel and residents of long-term care facilities (Phase 1a), followed by frontline essential workers and people aged 75 years and older (Phase 1b), and, subsequently people aged 65 to 74 years, people aged 16 to 64 years with underlying health conditions, and other essential workers (Phase 1c).(6)

With the distribution and administration of vaccines already underway, gauging the levels of vaccine acceptance in our communities is essential in order to better understand how to reach those who may be hesitant and to increase trust in public health. The purpose of this study was to gauge perceptions of individuals among the general public, as well as healthcare workers, on matters related to COVID-19, including vaccine acceptance, face mask acceptance, and prioritization of who should receive the COVID-19 vaccine first and last.

Methods

Cross-sectional, anonymous, online, voluntary surveys were distributed to the general public via email, social media, and word-of-mouth. Data were collected between August 1, 2020 and November 1, 2020 via Qualtrics (Qualtrics, Provo, UT). The protocol was approved by the institutional review board of Florida Atlantic University (IRB Net ID 1620495-1). Participants had to be 18 years of age or older. The survey included 35 items to determine demographics and individual perceptions regarding matters related to COVID-19, such as vaccination and the wearing of face masks.

This survey sought to explore views regarding face mask wearing, vaccine hesitancy, and prioritization of vaccine distribution among individuals in the United States prior to the release of the COVID- 19 vaccines to gauge the willingness to get the vaccine, with the ultimate goal of helping provide public health officials with a timely overview of issues that might arise in the uptake of the vaccine. It sought to answer the following questions:

• If an FDA-approved vaccine for COVID-19 was available to you, would you get the vaccine today?

• Are there any correlations between face-mask wearing and willingness to get the vaccine?

• Which groups of individuals should receive the COVID-19 vaccine(s) first and last?

Of the original 3367 subjects who completed the survey, 340 were removed for lack of data and 41 were not from the United States, leaving a total of 2986 in the sample. Demographic information collected included age, gender, race, relationship status, parenthood status, state of residence, employment status, and occupation, including healthcare worker status. Participants also were asked about direct physical contact with individuals who tested positive for COVID-19, whether they get the influenza vaccine, whether they allow their children to receive vaccines, and whether they believe the government should require individuals to get the COVID-19 vaccine. Data were analyzed using SPSS v 26 for both descriptive and inferential analysis.

Results

Demographic Characteristics of the Sample

There was a significant over-sampling of females (73.0%) compared with the United States average of 50.8%. There was also over-sampling of white individuals (80.7%) compared with the United States average of 76.3% and an under-sampling of Black individuals (2.5% compared with the United States average of 13.4%) and Hispanics (7.2% compared with the United States average of 18.5%). The majority of those sampled were married (59.9%), and, due to sampling strategies, the majority were in the South Atlantic region of the United States (69.7%). Finally, most subjects in the sample were either employed full-time (48.5%) or retired (15.3%) (Table 1). The average age of all respondents was 48.4 years (range, 18–85 years). Of those who answered the question of whether they had been in direct physical contact with anyone who tested positive for COVID-19, 50% said they had not been in contact with a COVID-19 patient. Of those who reported contact with known COVID-19 cases, “friends” was the most commonly chosen answer (7.8%), followed closely by “family” (6.7%) and “coworkers” (6.8%) (Table 2).

Would you get the COVID-19 vaccine?

When asked if they would get an FDA-approved COVID-19 vaccine today if it was available to them, 44% of participants reported that they would get it today, 36.3% reported that they would want to wait, 8.5% were unsure, and 8.0% would never get the vaccine (Table 3). Those who reported “other” had their qualitative answers analyzed as to whether they would never get it, would wait, or said “yes,” and their responses were coded accordingly. Of those who originally said “other,” many wanted to wait until they were either assured that the vaccine was safe or until they consulted their doctor; they were given a score of “wait.” If they reported that their physician would recommend it, they were coded as a “yes” due to lack of hesitancy. Several individuals also reported that they would want to know if they had antibodies first and would get the vaccine if they did not– they were coded as “yes” because they would get the vaccine. Of those who reported that they would wait, 30.1% reported that they would wait for more than 12 months, 26.3% said they would between 6 and 12 months, 20.6% would wait 3 to 6 months, and 13.6% would wait 1 to 3 months (Table 4).

Factors Related to COVID-19 Vaccine Acceptance

Gender, Age, Race: There was a significant relationship between gender and vaccine acceptance, X(squared)(6) = 64.78, p < .001, N = 2975 (Table 5). Men were more likely to be willing to get the COVID-19 vaccine (56.8%) compared with women (42.2%) and other genders (32.2%). Women and other genders were more likely to wait to get the vaccine compared to men. There also was a significant relationship between age and COVID-19 vaccine acceptance, X(squared)(9) = 59.03, p < .001 (Table 5). Those who were born between 1997 and 2012 (Generation Z) were more likely to be willing to get the vaccine (57.7%) compared with those born between 1946 and 1964 (baby boomers, 49.1%), those born between 1965 and 1980 (generation X, 40.3%), and those born between 1981 and 1996 (millennials, 43.5%). Finally, there was a significant relationship between race and vaccine acceptance, X(squared)(6) = 80.79, p < .001 (Table 5). Those who identified as Asian (57.1%) and white (47.0%) were more likely to be willing to get the vaccine compared with other groups. Blacks were more likely to wait (48%) or not get the vaccine (24%) compared with other groups, although Hispanics were close (46.3%) in terms of waiting to receive the vaccine.

Contact with COVID-19–positive Individuals: We found no significant relationship between direct contact with a COVID-19–positive individual and willingness to get the COVID-19 vaccine, X(squared)(3) = 17.33, p = .101 (Table 5), with those who reported direct contact being just as likely to get the COVID-19 vaccine (41.5%) compared with those who lacked direct contact (46.5%). Furthermore, there was not a significant relationship between working in healthcare and COVID-19 vaccine acceptance, X(squared)(3) = 6.24, p = .101 (Table 5). Those who identified as healthcare workers were just as likely to get the COVID-19 vaccine (46.6%) compared with those who identified as nonhealthcare workers (44.7%).

Face Masks and Vaccine Acceptance: There is a significant relationship between believing face masks prevent the spread of COVID-19 and willingness to get the COVID-19 vaccine, X(squared)(6) = 770.7, p < .001 (Table 5). Those who would never get the vaccine were less likely to believe masks were effective (46.6%) compared with those who would wait (91.7%), those who were unsure (93.3%), and those who reported that they would get the vaccine (98.1%). Additionally, those who would never get the vaccine were also much more likely to disagree that face masks were effective at reducing the transmission of COVID-19 (27.1%). More specifically, wearing a face mask in public was found to be significantly related to willingness to get the COVID-19 vaccine, X(squared)(6) = 340.9, p < .001, (Table 5). Those who would never get the vaccine were less likely to wear a mask in public (79.7%) compared with those who would wait (98.4%), those who were unsure (99.2%), and those who would get the vaccine (99.4%). Additionally, those who would never get the vaccine were much more likely to disagree with wearing a mask in public (17.5%) (Table 5).

Belief that the government should make face masks mandatory was significantly related to willingness to receive the COVID-19 vaccine, X(squared)(6) = 770.7, p < .001 (Table 5). Those who reported that they would never get the vaccine were less likely to believe that there should be a government mask mandate (46.6%) compared with those who would wait to receive the vaccine (82.2%), those who were unsure (86.2%), and those that would receive the vaccine (92.7%). Additionally, those who would never get the vaccine were also much more likely to disagree with a mask mandate (57.1%), with under 10% of respondents in the other three groups disagreeing with a mask mandate. Those who believed that mask-wearers should receive medical treatment before those who do not wear masks were significantly more likely to accept a COVID-19 vaccine, X(squared)(6) = 92.4, p < .001 (Table 5). Only 13% of those who would never get the vaccine agreed with the statement that those who wear face masks should receive medical treatments for COVID-19 before those who do not wear face masks, compared with 26.7% of those who would wait to receive the vaccine, 26.7% of those who are unsure about getting the vaccine, and 30.4% of those who would receive the vaccine. Of those who would not get the vaccine, 73.7% disagreed that mask-wearers should receive medical treatment first, compared with under 50% for the other three groups. Finally, there was a significant relationship between believing that the government should require the COVID-19 vaccine and willingness to get the vaccine, X(squared)(6) = 569.35, p < .001 (Table 5). Those who believed the government should require the vaccine were more willing to get the vaccine (61.9%) compared with those who were unsure (39.7%) and those who disagreed with a government mandate (29.6%).

Flu Vaccine Acceptance and COVID-19 Acceptance: Acceptance of the influenza vaccine was significantly associated with willingness to receive the COVID-19 vaccine, with those who get the influenza vaccine on a yearly basis being more willing to accept the COVID-19 vaccine (58%) compared with those who get the influenza vaccine some years (40.1%), and those who never get the influenza vaccine (19.1%), X(squared)(6) = 614.61, p < .001 (Table 5).

Opinions on COVID-19 Vaccine Distribution: Overwhelmingly, the sample reported that healthcare workers should receive the vaccine first (62.5%), followed by those at higher risk (13%), which includes those with health issues and those in nursing homes (10.1%) (Table 6). The sample was more divided as to who should receive the vaccine last, with 36.3% selecting children under the age of 18 and 26.1% selecting the government (e.g., President, Congress) (Table 7).

Feeling Safer with Vaccines: When asked if they would feel safer sitting next to someone who has received the COVID-19 vaccine over someone who did not receive the vaccine, 66.1% reported they would feel safer, 21.6% reported that they would not feel more or less safe, and 9.4% were unsure (Table 8).

Discussion

We disseminated a survey to 3367 adults in the United States to better understand public perceptions on matters related to COVID-19, including face mask usage, vaccine acceptance, and prioritization of groups of individuals to receive the first and last COVID-19 vaccine(s). Our findings suggest that acceptance of a COVID-19 vaccine is related to a number of factors, including gender, race, age, and belief that face masks help reduce the transmission of COVID-19.

Of the sample, a majority were willing to receive the COVID-19 vaccine today if it was available to them. A substantial portion of the sample, however, would want to wait to receive the vaccine. Of those who would wait to receive the COVID-19 vaccine, a majority would wait over 12 months. The most common reason for waiting to get the vaccine was wanting to ensure that the vaccine was safe, but other reasons reported included ensuring the efficacy of the vaccine, cost of the vaccine, coverage of the vaccine by insurance, prioritizing higher-risk individuals, fear of long-term adverse effects, distrust of the current data from the trials, distrust of the government, fear that the clinical trials were rushed, having antibodies, personal health issues, and the personal choice of not receiving any vaccines. Of the individuals who would never receive the COVID-19 vaccine, the most common reason reported was their belief that the vaccine would be unsafe or not efficacious. Other reported reasons included already having COVID-19, inability to receive vaccinations for medical reasons, believing COVID-19 is a hoax, spiritual and religious beliefs, belief that they are in good health and would not be symptomatic from COVID-19, and distrust of vaccines or the government.

Further, the results of the study indicate that a majority of respondents believed that healthcare workers should receive the COVID-19 vaccine first, which was in accordance with the initial distribution schedule. A majority of the sample also reported that children under the age of 18 years should be the last to receive the COVID-19 vaccine(s). Many individuals left optional comments regarding the difficulty of answering the questions of who should receive the COVID-19 vaccines first and last, highlighting the ethical challenges surrounding rationing and distribution of limited resources. Although the CDC outlined guidelines as to the distribution schedule of the vaccine(s), final distribution decisions are being made at the local and state levels, which led to substantial criticism from the public.

The results of our study indicate that although many individuals believe in vaccination and would be willing to receive the COVID-19 vaccine(s), a growing number of individuals distrust vaccines, public health measures and policies, and the government. The politicization of face mask-wearing and vaccine acceptance are evident, because many individuals left optional comments on the survey outlining their personal opinions on why they do or do not wear face masks, why they would or would not receive the vaccine, and the effects the pandemic has had on them and their loved ones. In light of this information, we hope that the results of our study help elucidate some of the ongoing and incoming public health challenges posed by the COVID-19 pandemic and serve to guide policy-making and education of the general public as to vaccine safety and scientific literacy.

Limitations of the Study

This study was limited by its sample size and demographics. The majority of the respondents were female, white, married Florida residents. Additionally, our results may be biased in that respondents needed to have Internet access and a smartphone or computer to participate. Because the study was survey-based, there is no way to validate whether the participants’ responses were accurate; an individual’s willingness to get vaccinated may change over time, especially as local and global events unfold and more data become available to the public. Further, although the survey was anonymous, there may have been a degree of social desirability bias with regards to the participants’ responses. The strengths of this study include the stratification of demographics and that it was one of the first studies to address, in detail, perceptions of the general public on face mask usage, vaccine acceptance and reasons for or against it, as well as opinions on which groups of individuals should receive the vaccines first and last.

Future Directions

Within the months since our study was initiated, several major events have occurred, including the FDA approval, distribution, and administration of COVID-19 vaccines in the United States. Because our study was a snapshot of public perception at one moment in time, we seek to continue monitoring how these perceptions towards vaccination and face mask usage evolve in the context of these recent developments and the ongoing and upcoming spikes of the pandemic.

Conclusions

Our study found that a majority of our sample (44%) would accept a COVID-19 vaccine if available to them. Factors related to vaccine acceptance included race, age, gender, personal contact with COVID-19–positive individuals, and the belief that face masks help reduce the transmission of COVID-19. Further, a majority of the sample believed that healthcare workers should be given the COVID-19 vaccine(s) first and children under the age of 18 years should receive the vaccine(s) last. These findings should be taken into account in the development of vaccine distribution schema and in the movement to decrease vaccine hesitancy and improve vaccine acceptance rates in the general population.

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