Time trends, factors associated with, and reasons for COVID-19 vaccine hesitancy: A massive online survey of US adults from January-May 2021

Abstract

Importance: COVID-19 vaccine hesitancy has become a leading barrier to increasing the US vaccination rate.

Objective: To evaluate time trends in COVID-19 vaccine intent during the US vaccine rollout, and identify key factors related to and self-reported reasons for COVID-19 vaccine hesitancy in May 2021.

Design, participants and setting: A COVID-19 survey was offered to US adult Facebook users in several languages yielding 5,088,772 qualifying responses from January 6 to May 31, 2021. Data was aggregated by month. Survey weights matched the sample to the age, gender, and state profile of the US population.

Exposure: Demographics, geographic factors, political/COVID-19 environment, health status, beliefs, and behaviors.

Main outcome measures: "If a vaccine to prevent COVID-19 were offered to you today, would you choose to get vaccinated." Hesitant was defined as responding probably or definitely would not choose to get vaccinated (versus probably or definitely would, or already vaccinated).

Results: COVID-19 vaccine hesitancy decreased by one-third from 25.4% (95%CI, 25.3, 25.5) in January to 16.6% (95% CI, 16.4, 16.7) in May, with relatively large decreases among participants with Black, Pacific Islander or Hispanic race/ethnicity and ≤high school education. Independent risk factors for vaccine hesitancy in May (N = 525,644) included younger age, non-Asian race, < 4 year college degree, living in a more rural county, living in a county with higher Trump vote share in the 2020 election, lack of worry about COVID-19, working outside the home, never intentionally avoiding contact with others, and no past-year flu vaccine. Differences in hesitancy by race/ethnicity varied by age (e.g., Black adults more hesitant than White adults <35 years old, but less hesitant among adults ≥45 years old). Differences in hesitancy by age varied by race/ethnicity. Almost half of vaccine hesitant respondents reported fear of side effects (49.2% [95%CI, 48.7, 49.7]) and not trusting the COVID-19 vaccine (48.4% [95%CI, 48.0, 48.9]); over one-third reported not trusting the government, not needing the vaccine, and waiting to see if safe. Reasons differed by degree of vaccine intent and by race/ethnicity.

Conclusion: COVID-19 vaccine hesitancy varied by demographics, geography, beliefs, and behaviors, indicating a need for a range of messaging and policy options to target high-hesitancy groups.

Fig 1. COVID-19 vaccine receipt and intent among US adults by month (January-May, 2021).

Vaccine hesitancy decreased among adults each month from January to May, mostly due to a decrease in the response, “probably not” (-7.1 percentage points (%) [95% CI -7.2, -6.9]) versus “definitely not” (-1.8% [95% CI -1.9, -1.7]).

Fig 2. COVID-19 vaccine hesitancy by race/ethnicity (ages 18–34 years^a), education level, US region and county Trump vote share in the 2020 presidential election among US adults by month (January-May, 2021).

Between January and May, the gap in percent hesitant between race/ethnicity groups among adults 18–34 years (panel A) and education levels among all ages (panel B) decreased, with the biggest decreases among the most hesitant groups (e.g., Black race and ≤high school education, respectively). Changes in percent hesitant over time were fairly similar across US regions (panel C); however, there was a slightly smaller decrease in the Mountain region and slightly larger decrease in the South versus other regions. The gap in percent hesitant by county political environment, quantified in quartiles of percent Trump vote share in the 2020 presidential election, increased slightly between January and May, with the most hesitant group (highest quartile) having the smallest decrease (panel D). ^a There was a significant interaction between race/ethnicity group and age group. Vaccine hesitancy for all race/ethnicity groups by all age groups is provided in S6 Table.

Fig 3. COVID-19 vaccine hesitancy by age group, stratified by race/ethnicity, among US adults, May 2021.

Differences in hesitancy by age (e.g., 18–24 year-olds versus 65–74 year-olds) were more pronounced in Blacks (RR = 7.26 [95%CI, 5.92, 8.61]) versus Whites (RR = 2.89 [95% CI 2.75, 3.04]) or other race/ethnicity groups. Asians had hesitancy <5% hesitancy in all age groups. Differences in hesitancy by race/ethnicity were more pronounced in younger adults and adults ≥75 years.