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Young Adult Perspectives on COVID-19 Vaccinations

  • Sally H. Adams
    Affiliations
    Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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  • Jason P. Schaub
    Correspondence
    Address correspondence to: Jason P. Schaub, M.P.H., UCSF Division of Adolescent and Young Adult Medicine, University of San Francisco, California, 3333 California Street, Suite 245, San Francisco, CA 94118.
    Affiliations
    Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California

    Philip R. Lee Institute For Health Policy, Studies, University of California San Francisco, San Francisco, California
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  • Jason M. Nagata
    Affiliations
    Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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  • M. Jane Park
    Affiliations
    Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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  • Claire D. Brindis
    Affiliations
    Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California

    Philip R. Lee Institute For Health Policy, Studies, University of California San Francisco, San Francisco, California
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  • Charles E. Irwin Jr.
    Affiliations
    Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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      Abstract

      Purpose

      Young adults have the highest cumulative incidence of COVID-19 infection in the country. Using March 2021 Household Pulse Survey data, an ongoing, cross-sectional nationally representative survey, we examined U.S. young adult intention to accept COVID-19 vaccines.

      Methods

      Young adult (ages 18–25 years) Household Pulse Survey participants were queried on intention to receive a COVID-19 vaccine and related perspectives (N = 5,082).

      Results

      Most unvaccinated respondents (76%) indicated an intention to become vaccinated. The most frequently cited reasons for potentially rejecting vaccination included desire to wait and see if the vaccine is safe (56%); concerns over side effects (53%); and believing others are in greater need of the vaccine (44%).

      Conclusions

      With 24% of young adults hesitant to accept a COVID-19 vaccine, public health interventions should target reasons for hesitancy, address concerns about safety and side effects, and underscore the importance of vaccinations for this population.

      Keywords

      Implications and Contribution
      In this nationally representative sample of U.S. young adults, one quarter indicated hesitancy to accept a COVID-19 vaccine. In an effort to achieve population-level immunity across the United States, targeted public health interventions addressing young adult hesitations to become vaccinated represent an important public health priority.
      As of June 30, 2021, U.S. young adults aged 18–29 years had the highest cumulative COVID-19 infection incidence nationally [
      Centers for Disease Control and Prevention
      Demographic trends of COVID-19 cases and deaths in the US reported to CDC web site.
      ]. Previous research indicates that a third of young adults are vulnerable to severe COVID-19 illness [
      • Adams S.H.
      • Park M.J.
      • Schaub J.P.
      • et al.
      Medical vulnerability of young adults to severe COVID-19 illness-data from the National Health Interview Survey.
      ]. However, March 2021 data from the Kaiser Family Foundation indicates that young adults ranked highest in intention to “wait and see” before accepting COVID-19 vaccination (25% vs. 17% for U.S. adults) [
      Kaiser Family Foundation
      KFF COVID-19 vaccine Monitor: March 2021 web site.
      ]. An October 2020 study mirrored this; 76% of youth (ages 14–22 years) indicated vaccination acceptance and 81% of the uncommitted indicated they would accept vaccination if it were proven safe by reliable scientists [
      • Brandt E.J.
      • Rosenberg J.
      • Waselewski M.E.
      • et al.
      National study of youth opinions on vaccination for COVID-19 in the U.S.
      ]. Currently, there is a gap in understanding underlying reasons for young adult vaccine hesitancy.
      The first vaccine achieved Food and Drug Administration Emergency Use Authorization in December 2020 [
      U.S. Food & Drug Administration
      Pfizer-BioNTech COVID-19 Vaccine web site.
      ]. However, COVID-19 vaccine acceptability concerns by the general population were noted at the pandemic's inception [
      • Malik A.A.
      • McFadden S.M.
      • Elharake J.
      • Omer S.B.
      Determinants of COVID-19 vaccine acceptance in the US.
      ,
      • Szilagyi P.G.
      • Thomas K.
      • Shah M.D.
      • et al.
      National trends in the US public’s likelihood of getting a COVID-19 vaccine—April 1 to December 8, 2020.
      ]. Numerous terms have been used to describe this phenomenon, such as “vaccine acceptance” or “vaccine hesitancy,” presently defined inclusively as COVID-19 vaccination intention. Given the importance of achieving population-level immunity, increasing intention to get vaccinated within all populations remains a public health priority.
      To increase understanding of young adults' vaccine perspectives, we used the Household Pulse Survey (HPS) data to examine COVID-19 vaccination rate, intentions, and reasons for not definitely planning to get vaccinated.

      Methods

      Sample

      We analyzed HPS data from March 3–29, 2021, for young adults of ages 18–25 years (N = 5,082). The HPS is an online, ongoing, cross-sectional, nationally representative survey conducted by the U.S. Census Bureau in collaboration with the National Center for Health Statistics and other agencies [
      Centers for Disease Control and Prevention
      Novel COVID-19 survey takes nation’s social, mental “Pulse” web site.
      ]. It aims to understand the effects of the COVID-19 pandemic on the U.S. population. Questions about COVID-19 vaccination, intentions, and a checklist of reasons for not getting vaccinated were recently added to the HPS. Data are released in 2-week batches for public use. The study was approved by the Internal Review Board of the University of California, San Francisco, with exempt status.

      Study objectives and outcomes

      Among 18- to 25-year-old adults, establish rates of (1) COVID-19 vaccination (yes/no); (2) intentions among the unvaccinated (definitely will, probably will, probably will not, and definitely will not get vaccine); (3) reasons for not definitely planning to get vaccinated among intention subgroups (recoded as “probably will” vs. “probably or definitely will not”); and (4) among those endorsing that they do not believe they need the COVID-19 vaccine, reasons for not believing they need the vaccine. An exploratory objective was to determine subgroup differences in reasons for intentions between the “probably will” and the “probably or definitely will not” get vaccine.

      Analyses

      We developed nationally representative estimates for aforementioned outcomes 1–4, using weighting variables in the HPS data set that adjust for nonresponse bias (person weight) and complex survey design (80 replicate weights). We examined differences in reasons for not getting vaccinated (outcomes 3 and 4) between “probably will” versus “probably or definitely will not get” subgroups by conducting chi square analyses. Analyses were conducted using SAS 9.4.

      Results

      Table 1 presents young adult sample demographic characteristics. Seventeen percent of young adults had received a COVID-19 vaccination, 83% had not and among the unvaccinated, 76% stated they would “probably” or “definitely” get a vaccine once available (Table 2).
      Table 1Demographic descriptors of young adults (ages 18–25): Household Pulse Survey (March, 2021)
      Young adult analytic sample (unweighted N = 5,082)Weighted %
      Sex
       Male53.3%
       Female46.7%
      Race/ethnicity
       Non-Hispanic white56.7%
       Non-Hispanic black7.8%
       Hispanic22.8%
       Non-Hispanic – Asian7.6%
       Non-Hispanic – Other, more than 1 race5.0%
      Insurance status
       Private70.4%
       Public8.6%
       Both private and public6.2%
       Other (not described enough to be categories into private/public categories)1.6%
       Uninsured13.2%
      Table 2COVID-19 vaccination status, intention and perspectives among young adults (ages 18-25): Household Pulse Survey (March, 2021)
      Have received a COVID-19 vaccine? (Full sample, n = 5,082)Young adults (18–25 years)

      Weighted %
      Yes ("vaccinated")17.0%
      No ("unvaccinated")83.0%
      If YES/vaccinated: Did you receive or plan to receive all needed doses?
       Yes (got or plan to get both)96.6%
       No3.4%
      If NO/unvaccinated: Once vaccine is available, would you get a vaccine?
       Definitely will50.8%
       Probably will25.5%
       Probably will not14.2%
       Definitely will not9.6%
      If not Definitely Will:

      What are reasons for not definitely planning to get vaccine?

      Checklist (check all that apply)
      All non “definitely will get” (49.2% of unvaccinated)Probably will get vaccine (25.5% of unvaccinated)Probably or definitely will not get vaccine (23.7% of unvaccinated)
       I plan to wait and see if it is safe and may get it later56.2%62.1%49.8%
       I am concerned about possible side effects of a COVID-19 vaccine53.4%52.8%54.0%
       I think other people need it more than I do right now44.0%57.0%30.1%
       I do not believe I need a COVID-19 vaccine22.8%9.8%36.7%
      Follow up for those who endorse "I do not believe I need a COVID-19 vaccine":

      Why do you believe you do not need a COVID-19 vaccine? Check all that apply
      Among 22.8% of all non “definitely will”Among 9.8% of the "probably will get vaccine"Among the 36.7% of the "probably or definitely not get vaccine"
      I am not a member of a high-risk group74.6%83.0%72.2%
      I do not believe COVID-19 is a serious illness49.5%39.0%52.5%
      I already had COVID-1930.9%34.0%30.0%
      I plan to use masks or other precautions instead25.4%19.7%27.0%
      I do not think vaccines are beneficial11.1%1.8%13.7%
      Other (unspecified)7.6%6.4%7.9%
       I do not trust the government22.3%11.5%33.9%
       I do not trust COVID-19 vaccines21.9%8.1%36.8%
      p < .05.
       I do not know if a COVID-19 vaccine will work21.4%17.6%25.5%
       I am concerned about the cost of a COVID-19 vaccine12.4%18.0%6.3%
       I do not like vaccines10.1%7.8%12.6%
       My doctor has not recommended it6.6%6.7%6.5%
       Other (unspecified)9.0%7.9%10.2%
      p < .05.
      Among the unvaccinated who did not “definitely” plan to get vaccinated, the most frequently cited reasons were “I plan to wait and see if it is safe and may get it later” (56%), “I am concerned about possible side effects of a COVID-19 vaccine” (53%), and “I think other people need it more than I do right now” (44%). Subgroup comparison between “probably will” versus “probably/definitely will not” get vaccinated differed significantly in one reason: “I do not trust COVID-19 vaccines (8% vs. 37%, p < .05.) In follow-up query of reasons for endorsing they did not believe they needed the vaccine (23%), the two most frequently endorsed reasons were “I am not a member of a high-risk group” (75%) and “I do not believe COVID-19 is a serious illness” (50%).

      Discussion

      Understanding COVID-19 vaccination intention is necessary to achieve population-level immunity and to end the pandemic. In this nationally representative young adult sample, 76% were “definitely” or “probably” planning on becoming vaccinated; however, 24% were unlikely to do so.
      This analysis confirms and extends the Kaiser Family Foundation results by identifying young adults' reasons for not definitely planning to become vaccinated [
      Kaiser Family Foundation
      KFF COVID-19 vaccine Monitor: March 2021 web site.
      ]. Among those not "definitely" planning to get vaccinated, the two top reasons indicated caution and safety concerns (1) wait and see if the vaccine is safe and (2) concern about side effects. Public education regarding vaccine testing, Food and Drug Administration Authorization and Approval processes, and research on side effects can address these concerns. Believing others were in greater need of the vaccine was frequently cited. This altruistic position may resolve as increasing numbers of higher-risk populations become fully vaccinated and vaccine availability expands. Further research exploring the higher levels of vaccine distrust among the “probably or definitely not” get vaccinated (37%) versus the “probably yes” (8%) can inform initiatives to increase vaccine uptake. Education and public health messaging encouraging young adult vaccination is needed, ideally harnessing social media and key influencers, including clinicians, who have a role in reducing COVID-19 vaccine hesitancy in youth and adult patients [
      • Brandt E.J.
      • Rosenberg J.
      • Waselewski M.E.
      • et al.
      National study of youth opinions on vaccination for COVID-19 in the U.S.
      ,
      • Finney-Rutten L.J.
      • Zhu X.
      • Leppin A.L.
      • et al.
      Evidence-based strategies for clinical organizations to address COVID-10 vaccine hesitancy.
      ].
      This analysis was limited to the data provided in the HPS, which did not query vaccine motivation, barriers to vaccine access, or factors that might mitigate hesitancy, such as recommendations from trusted sources to get vaccinated. Given demographic disparities in COVID-19 rates, further fine-grained examination of these motivation issues by demographic subgroups is needed.
      Addressing vaccine motivation and access is warranted, as it is unclear whether young adults intending to get vaccinated are motivated to take action. Initial efforts to encourage vaccination deemphasized young adults and reports in the general population highlighted barriers to getting vaccinated, including difficulty in understanding eligibility and accessing vaccine appointments [
      Kaiser Family Foundation
      KFF COVID-19 vaccine Monitor: March 2021 web site.
      ,
      Kaiser Family Foundation
      KFF COvid-19 Vaccine Monitor: Experiences with vaccine access and information needs web site.
      ]. These are relevant for young adults, who have experienced barriers in navigating health care systems when obtaining health insurance [
      • Wong C.A.
      • Asch D.A.
      • Vinoya C.M.
      • et al.
      The experience of young adults on HealthCare.gov: Suggestions for improvement.
      ]. Public health initiatives should provide guidance to reduce system barriers and barriers to COVID-19 vaccines, in recognition of young adults' low rates of health care utilization and lower uptake of annual influenza vaccine, compared with older adults [
      Institute of Medicine and National Research Council
      Investing in the health and well-being of young adults.
      ,
      Centers for Disease Control and Prevention
      Flu vaccine coverage, United States, 2019-20 Influenza season web site.
      ].
      Public health initiatives need to adapt rapidly as vaccine intentions and availability change, and research needs to close the knowledge gap regarding young adult vaccination motivation, barriers to vaccine access, and factors that might mitigate hesitancy, including vaccination recommendations by a clinician or other trusted source [
      • Finney-Rutten L.J.
      • Zhu X.
      • Leppin A.L.
      • et al.
      Evidence-based strategies for clinical organizations to address COVID-10 vaccine hesitancy.
      ]. Continued monitoring of vaccine intention, motivations, and barriers to access, with updated surveys reflecting real-time changes, can contribute to improved messaging and targeted outreach to increase young adult COVID-19 vaccination.

      Funding Sources

      This study was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) (under #U45MC27709, Adolescent and Young Adult Health Capacity Building Program), with supplemental support from HRSA grants #UA6MC27378 and T71MC0003, and the American Heart Association Career Development Award (CDA34760281). This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. The sponsors had no role in the preparation or submission of this article.

      References

        • Centers for Disease Control and Prevention
        Demographic trends of COVID-19 cases and deaths in the US reported to CDC web site.
        (Available at:)
        • Adams S.H.
        • Park M.J.
        • Schaub J.P.
        • et al.
        Medical vulnerability of young adults to severe COVID-19 illness-data from the National Health Interview Survey.
        J Adolesc Health. 2020; 67: 362-368
        • Kaiser Family Foundation
        KFF COVID-19 vaccine Monitor: March 2021 web site.
        (Available at:)
        • Brandt E.J.
        • Rosenberg J.
        • Waselewski M.E.
        • et al.
        National study of youth opinions on vaccination for COVID-19 in the U.S.
        J Adolesc Health. 2021; 68: 868-872
        • U.S. Food & Drug Administration
        Pfizer-BioNTech COVID-19 Vaccine web site.
        (Available at:)
        • Malik A.A.
        • McFadden S.M.
        • Elharake J.
        • Omer S.B.
        Determinants of COVID-19 vaccine acceptance in the US.
        EClinicalMedicine. 2020; 26: 100495
        • Szilagyi P.G.
        • Thomas K.
        • Shah M.D.
        • et al.
        National trends in the US public’s likelihood of getting a COVID-19 vaccine—April 1 to December 8, 2020.
        Jama. 2021; 325: 396-398
        • Centers for Disease Control and Prevention
        Novel COVID-19 survey takes nation’s social, mental “Pulse” web site.
        (Available at:)
        • Finney-Rutten L.J.
        • Zhu X.
        • Leppin A.L.
        • et al.
        Evidence-based strategies for clinical organizations to address COVID-10 vaccine hesitancy.
        Mayo Clin Proc. 2021; 96: 699-707
        • Kaiser Family Foundation
        KFF COvid-19 Vaccine Monitor: Experiences with vaccine access and information needs web site.
        (Available at:)
        • Wong C.A.
        • Asch D.A.
        • Vinoya C.M.
        • et al.
        The experience of young adults on HealthCare.gov: Suggestions for improvement.
        Ann Intern Med. 2014; 161: 231-232
        • Institute of Medicine and National Research Council
        Investing in the health and well-being of young adults.
        The National Academies Press, Washington, DC2014
        • Centers for Disease Control and Prevention
        Flu vaccine coverage, United States, 2019-20 Influenza season web site.
        (Available at:)