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. Author manuscript; available in PMC: 2024 Sep 22.
Published in final edited form as: Vaccine. 2023 Sep 1;41(41):6120–6126. doi: 10.1016/j.vaccine.2023.08.075

Correlates of COVID-19 Vaccine Coverage in Arkansas: Results from a Weighted Random Sample Survey

Don E Willis 1, Ramey Moore 1, Jennifer A Andersen 1, Ji Li 2, James P Selig 2, Joshua C McKinnon 3, Morgan Gurel-Headley 4,5, Sharon Reece 6, Pearl A McElfish 1,*
PMCID: PMC10574122  NIHMSID: NIHMS1930422  PMID: 37661536

Abstract

We assessed COVID-19 vaccination (≥1 dose) status as influenced by sociodemographic factors (i.e., age, gender, race/ethnicity, education, income, and parent or guardian status), healthcare provider recommendation, and personal vaccine hesitancy among Arkansas residents in October 2022. We asked: did the likelihood of vaccination differ across sociodemographic groups of Arkansas during this period of the pandemic? Is COVID-19 vaccination associated with recommendations from healthcare providers and/or COVID-19 vaccine hesitancy? We analyzed data from a random sample survey of adults in Arkansas (N=2,201). Three in four adults self-reported vaccination against COVID-19 in October 2022. We found both positive and negative association between COVID-19 vaccination and age, gender, race/ethnicity, education, income, healthcare provider recommendation, and vaccine hesitancy. We highlight racial differences in COVID-19 coverage and the higher odds of COVID-19 vaccination among Black adults compared to White adults in particular, which has broad implications for the study of vaccine coverage and hesitancy. We also discuss implications of our findings regarding healthcare provider recommendations to be vaccinated against COVID-19.

Keywords: COVID-19, COVID-19 vaccine, COVID-19 vaccine correlates, vaccine coverage, vaccine hesitancy, healthcare provider reccomendations

INTRODUCTION

Loss of life due to COVID-19 has been both vast and unequal.1–3 Had minority communities experienced mortality rates equal to those of the college-educated, non-Hispanic White population, there would have been 71% fewer deaths due to COVID-19 among racial and ethnic minorities.3 Early reports of low vaccine acceptance4,5 and high vaccine hesitancy6 among Black Americans raised concerns about exacerbation of disparities in mortality after the availability of a COVID-19 vaccine. Two COVID-19 vaccines became available in the United States (US) in December 2020 and reduced hospitalization and death associated with COVID-19.7 By November 2021, vaccination against COVID-19 was estimated to have prevented over one million deaths and 10 million hospitalizations.8 National COVID-19 vaccination coverage (≥1 dose) by the end of 2021 remained at 79.3% with substantial geographic heterogeneity, and regional analysis suggests vaccination may have lessened mortality disadvantages for some minoritized racial groups and increased them for others.9 Given the differences in vaccination coverage by state, state-level data collection and analysis can offer further insight, particularly for states that have not consistently reported full demographic information.

Analysis of vaccine coverage by race/ethnicity is particularly valuable in states such as Arkansas that have been excluded from many national analyses due to a lack of reporting COVID-19 vaccination data by race/ethnicity.10,11 In 2021, the Arkansas Department of Health (ADH) reported that White, Black, and Hispanic residents made up 70.5%, 13.1%, and 7.34% of vaccinations administered in the state, respectively. Notably, these percentages are close to each group’s proportion within the state (68.2% non-Hispanic White, 14.7% non-Hispanic Black, and 8.2% Hispanic).12 However, the data presented by the ADH is not sufficient to determine COVID-19 vaccine coverage for each population or whether or not disparities exist after adjusting for other important covariates.

As the initial vaccines became available, researchers began noting issues related to incomplete data. Although data on sex were widely reported, race/ethnicity was being reported for only 51.9% of vaccine recipients.13,14 Given these gaps in state-level data, disparities in COVID-19 vaccine coverage have been determined primarily using national-level data. Significant racial disparities in COVID-19 vaccination coverage were documented in April of 2021 using the National Immunization Survey Adult COVID Module (NIS-ACM), after all adults became eligible for vaccination.15 These differences in coverage peaked during March-May of 2021 and gradually narrowed thereafter.15 Differences in COVID-19 vaccination coverage were no longer statistically significant between Black and Native Hawaiian or Pacific Islander (NHPI) adults compared with White adults by the end of November 2021.15 However, these trends were not consistent among all US regions.15 Vaccination coverage in general and across racial groups also appears to be dependent on proxies for political context (e.g., the share of votes for Trump within the state).16 Thus, state-level analysis can provide further nuance regarding sociodemographic differences in COVID-19 vaccine coverage. To our knowledge, this paper is the first to report COVID-19 vaccination disparities specific to the state of Arkansas.

The primary objective of this study was to assess COVID-19 vaccination (≥1 dose) disparities across sociodemographic factors (i.e., age, gender, race/ethnicity, education, income, and parent or guardian status) among Arkansas residents in October 2022. Given the racial disparities in COVID-19 mortality,17 we were particularly interested in coverage differences across race/ethnicity. We also assess associations between healthcare provider recommendation and COVID-19 vaccine hesitancy with COVID-19 vaccination status. We asked: did the likelihood of vaccination differ across sociodemographic groups of Arkansas during this period of the pandemic? Is COVID-19 vaccination associated with recommendations from healthcare providers and/or COVID-19 vaccine hesitancy? Assessing sociodemographic disparities in COVID-19 vaccination is critical for developing future vaccine campaigns, reducing the unequal burden of disease, and promoting equitable distribution of the vaccine in the US. Likewise, understanding how healthcare provider recommendations and COVID-19 vaccine hesitancy impact vaccine uptake can inform clinical and public health interventions.

METHODS

Procedures

Adults living in Arkansas were contacted using random digit dialing of both landline and cell phones. Black and Hispanic residents were oversampled to provide adequate representation in the sample. Arkansas residents aged 18 years or older were eligible to participate in the survey. Recruitment involved providing information about the study and what participation entailed, including the estimated time (15 minutes), potential risks and benefits, the voluntary nature of participation, and confidentiality of responses. Respondents consented by verbally agreeing to participate. Trained interviewers used computer-assisted telephone interviews to administer the survey. The survey was provided in both English and Spanish. Respondents completed the survey in an average of 16 minutes. Study procedures were approved as exempt by a review board for the protection of human subjects at the University of Arkansas for Medical Sciences. A total of 2,201 respondents completed the phone survey between October 3rd and October 24th, 2022.

Measures

COVID-19 Vaccination

The dependent variable was COVID-19 vaccination. Respondents were first asked the question, “Have you received a COVID-19 vaccine?” Response options included yes (1) and no (0). Although successful vaccination against COVID-19 is typically defined as completion of a dose series, we refer to individuals who responded “yes” to receiving a COVID-19 vaccine as vaccinated.

Sociodemographic Characteristics

We collected sociodemographic information including age, gender, race/ethnicity, education, income, and parent or guardian status. Age was measured in years and categorized. Gender was reported as either woman, man, non-binary, or self-described. Ten individuals reported themselves to be non-binary or self-described their gender—these individuals are not included in our analysis due to low frequency. Race/ethnicity was measured using the standard two items from the Behavioral Risk Factor Surveillance System. Answers were combined to identify individuals as non-Hispanic Black, Hispanic, non-Hispanic multiracial or other race (i.e., Asian, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander), and non-Hispanic White.18 Although it is problematic to combine such heterogeneous groups as those in the non-Hispanic multiracial and other race category, low frequencies among each of them do not allow us to analyze them separately.

To measure education, we asked respondents their highest degree or level of school completed. Response options were less than high school, some high school, high school graduate or equivalent (e.g., graduate equivalency degree), some college but no degree, associate degree, bachelor’s degree, and graduate or professional degree. Because of low frequency of responses, less than high school and only some high school were combined with high school to indicate education levels of high school or less. Respondents who reported some college or an associate degree were combined. Respondents with a bachelor’s degree were also combined with those who reported having a graduate or professional degree. Respondents were asked to report their annual household income from all sources. Response options ranged from $10,000 or less to $100,000 or more, increasing in intervals of $10,000. This variable was recoded to represent quartiles of responses ($29,000 or less, $30,000-$49,000, $50,000-$89,000, $90,000 or more). Parent or guardian status was assessed by asking respondents if they were the parent or guardian of a child under age 18, and response options included yes or no.

Provider Recommendation and Vaccine Hesitancy

We assessed whether respondents had a doctor or healthcare provider, if the healthcare provider recommended COVID-19 vaccination, and the respondent’s COVID-19 vaccine hesitancy. We asked respondents if they had one or more persons they thought of as their personal doctor or healthcare provider. If they responded “yes,” they were asked if any of their healthcare providers recommended they be vaccinated against COVID-19. These two items were combined to categorize respondents into three groups: 1) no healthcare provider, 2) healthcare provider, but no recommendation for the COVID-19 vaccine, and 3) healthcare provider who recommended the COVID-19 vaccine.

To assess COVID-19 vaccine hesitancy, we asked vaccinated adults, “Thinking specifically about the COVID-19 vaccines, how hesitant were you about getting vaccinated?” We asked unvaccinated adults, “Thinking specifically about the COVID-19 vaccines, how hesitant are you about getting vaccinated?” Response options for both questions included “not at all hesitant,” “a little hesitant,” “somewhat hesitant,” and “very hesitant.” Responses for both items were combined to indicate individuals’ feelings of hesitancy regardless of vaccination status. Accounting for COVID-19 vaccine hesitancy among both vaccinated and unvaccinated adults is important because hesitancy should not be conflated with the behavior of vaccination—prior studies have documented hesitancy among recently vaccinated individuals.19–22

Statistical Analyses

Our analysis included unweighted and weighted descriptive statistics of the data for both the total sample and by vaccination status, weighted bivariate logistic regressions, and a weighted multivariable logistic regression. Data were analyzed using SAS 9.4 (SAS Institute, Cary NC). No duplicate records were detected. Participants with incomplete responses (n=440; 20%) were omitted from the analyses of descriptive statistics and weighted bivariate logistic regressions. The most frequent pattern was missing only in income (N=298). Weights were generated using ranking ratio estimation to ensure the sample was representative of the Arkansas 2021 census estimates for age (18–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80+), sex (male, female), and race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic other or multiracial, and Hispanic or Latino any race). Full information maximum likelihood (FIML)23 were utilized for multivariable logistic regression with Mplus version 8 to minimize the limitations of missing data.24 We present results of weighted and unweighted descriptive statistics, weighted bivariate logistic regressions, and weighted multivariable logistic regression for COVID-19 vaccination.

RESULTS

We present the unweighted and weighted descriptive statistics for the total sample, and separated by COVID-19 vaccination status, in Table 1. Reported percentages are weighted unless otherwise noted. Approximately three fourths (76.73%, CI: [0.75, 0.79]) of Arkansas adults were vaccinated against COVID-19 (≥1 dose) in October of 2022. The unweighted sample was notably over-representative of respondents age 65 and older, women, and Black and Hispanic adults. Weighted sample descriptives match Arkansas’ population estimates across age, gender, race, and ethnicity.

Table 1.

Descriptive Statistics for Sample and by COVID-19 Vaccination Status

Total Sample Vaccinated Unvaccinated
Column Unweighted % (Freq) Column Weighted % Row Weighted % Row Weighted %
Age
18–24 8.72 (192) 11.30 70.90 29.10
25–34 10.81 (238) 16.65 66.81 33.19
35–44 12.54 (276) 17.03 69.33 30.67
45–54 14.63 (322) 16.08 77.97 22.03
55–64 17.26 (380) 16.20 83.75 16.25
65+ 36.03 (793) 22.72 86.64 13.36
Gender
Man 40.24 (876) 49.40 74.76 25.24
Woman 59.76 (1,301) 50.60 78.65 21.35
Race/Ethnicity
Black 20.44 (448) 14.70 84.66 15.34
Hispanic 14.37 (315) 8.20 80.94 19.06
Multiracial/other 4.20 (92) 8.90 70.97 29.03
White 60.99 (1,337) 68.20 75.27 24.73
Education
HS or less 30.88 (676) 29.64 69.21 30.79
Some college/associate degree 35.50 (777) 35.85 74.07 25.93
Bachelor’s/graduate degree 33.62 (736) 34.51 85.89 14.11
Income
$29k or less 31.97 (595) 27.69 72.31 27.69
$30–49,999 19.56 (364) 18.79 76.16 23.84
$50–89,999 25.95 (483) 27.86 74.25 25.75
$90–100,000 + 22.51 (419) 25.66 81.99 18.01
Parent/Guardian a
No 76.19 (1,677) 71.52 78.92 21.08
Yes 23.81 (524) 28.48 71.22 28.78
Provider Recommendation
No provider 14.84 (312) 19.52 59.73 40.27
Provider did not recommend 29.81 (627) 29.91 70.64 29.36
Provider did recommend 55.35 (1,164) 50.57 86.91 13.09
COVID-19 Vaccine Hesitancy
Not at all hesitant 42.47 (925) 38.45 93.45 6.55
A little hesitant 17.36 (378) 17.57 94.23 5.77
Somewhat hesitant 14.14 (308) 14.25 81.57 18.43
Very hesitant 26.03 (567) 29.72 43.06 56.94
Open in a new tab

HS=high school

a

Parents of children under age 18

In these descriptive results, vaccination coverage in October 2022 appears to have been highest among those age 65 or older (86.64%), women (78.65%), Black adults (84.66%), bachelor’s or graduate degree holders (85.89%), those with annual household incomes greater than $90,000 (81.99%), parents or guardians with children under age 18 (71.22%), those who had a provider who recommended COVID-19 vaccination (86.91%), and those who reported they were either “not at all hesitant” or “a little hesitant” to get the COVID-19 vaccine (93.45% and 94.23%, respectively).

In Table 2, we present odds ratios from weighted bivariate logistic regressions for COVID-19 vaccination. We find significantly higher odds of COVID-19 vaccination for respondents age 45–54 (OR=1.45; 95% CI: [1.00, 2.11]), 55–64 (OR=2.12; 95% CI: [1.43, 3.14]), and 65 or older (OR=2.66; 95% CI: [1.83, 3.88]), compared to those 18–24 years old. Odds of COVID-19 vaccination for women (OR=1.24; 95% CI: [1.02, 1.52]) were greater than for men. Odds of COVID-19 vaccination for respondents who identified as non-Hispanic Black (OR=1.81; 95% CI: [1.31, 2.51]) were greater than for those who identified as non-Hispanic White. Odds of COVID-19 vaccination for respondents who completed some college or an associate degree (OR=1.27; 95% CI: [1.01, 1.60]) and a bachelor’s degree or more (OR=2.71; 95% CI: [2.08, 3.52]) were greater than for those with a high school diploma or less education. Respondents who reported an income of $ $90,000 or more (OR=1.74; 95% CI: [1.29, 2.35]) had greater odds of COVID-19 vaccination than those who reported an income of $29,999 or less. Parents or guardians of children under age 18 (OR=0.66; 95% CI: [0.54, 0.82]) had lower odds of COVID-19 vaccination compared to those without children under age 18. Respondents with no healthcare provider (OR=0.62; 95% CI: [0.48, 0.80]) had decreased odds of COVID-19 vaccination compared to those with a healthcare provider who did not recommend vaccination. Respondents with a healthcare provider who did recommend COVID-19 vaccination (OR=2.76; 95% CI: [2.16, 3.54]) had greater odds of COVID-19 vaccination compared to those respondents with a healthcare provider who did not recommend vaccination. We find significantly lower odds of COVID-19 vaccination among respondents who reported they were “somewhat hesitant” (OR=0.31; 95% CI: [0.21, 0.46]) or “very hesitant” (OR=0.05; 95% CI: [0.04, 0.07]), rather than “not at all hesitant.”

Table 2.

Weighted Bivariate Logistic Regressions for COVID-19 Vaccination

OR 95% CI p-value Sig.
Age
18–24 - - - -
25–34 0.83 0.58 1.17 .285
35–44 0.93 0.65 1.32 .676
45–54 1.45 1.00 2.11 .050 *
55–64 2.12 1.43 3.14 <.001 ***
65+ 2.66 1.83 3.88 <.001 ***
Gender
Man - - - -
Woman 1.24 1.02 1.52 .031 *
Race/Ethnicity
Black 1.81 1.31 2.51 <.001 ***
Hispanic 1.40 0.94 2.06 .094
Multiracial/other 0.80 0.58 1.12 .194
White - - - -
Education
HS or less - - - -
Some college/associate degree 1.27 1.01 1.60 .042 *
Bachelor’s/graduate degree 2.71 2.08 3.52 <.001 ***
Income
$29k or less - - - -
$30–49,999 1.22 0.90 1.67 .200
$50–89,999 1.10 0.84 1.45 .474
$90–100,000 + 1.74 1.29 2.35 <.001 ***
Parent/Guardiana
No - - - -
Yes 0.66 0.54 0.82 <.001 ***
Provider Recommendation
Provider did not recommend - - - -
No provider 0.62 0.48 0.80 <.001 ***
Provider did recommend 2.76 2.16 3.54 <.001 ***
COVID-19 Vaccine Hesitancy
Not at all hesitant - - - -
A little hesitant 1.15 0.69 1.91 .601
Somewhat hesitant 0.31 0.21 0.46 <.001 ***
Very hesitant 0.05 0.04 0.07 <.001 ***
Open in a new tab
***

p<.001

**

p<.01

*

p<.05

CI=confidence interval; HS=high school; OR=odds ratio

a

Parents of children under age 18

We present results from a weighted FIML multivariable logistic regression for COVID-19 vaccination in Table 3. After adjusting for covariates, all independent variables were significantly associated with COVID-19 vaccination except for being a parent or guardian of a child under age 18. We find significantly higher adjusted odds of COVID-19 vaccination for respondents age 55–64 (aOR=2.53; 95% CI: [1.33, 4.79]) and 65 or older (aOR=2.26; 95% CI: [1.23, 4.15]), compared to those 18–24 years old. Respondents who were women (aOR=1.40; 95% CI: [1.01, 1.92]) had greater odds of COVID-19 vaccination than men. Respondents who identified as Black (aOR=1.97; 95% CI: [1.25, 3.10]) or Hispanic (aOR=2.18; 95% CI: [1.34, 3.53]) had greater odds of COVID-19 vaccination than non-Hispanic White respondents. Those who completed some college or an associate degree (aOR=1.46; 95% CI: [1.01, 2.12]) or a bachelor’s degree or more (aOR=1.71; 95% CI: [1.10, 2.65]) had greater odds of COVID-19 vaccination compared to those with a high school education or less. Respondents who reported an income of $30,000 to $49,999 (aOR=1.64; 95% CI: [1.01, 2.68]) or $90,000 or more (aOR=2.13; 95% CI: [1.27, 3.59]) had greater odds of COVID-19 vaccination compared to those with an income of $29,999 or less. People with a healthcare provider who recommended COVID-19 vaccination (aOR=1.97; 95% CI: [1.40, 2.77]) had greater odds of COVID-19 vaccination compared to those with a healthcare provider who did not recommend COVID-19 vaccination. We find no statistically significant difference in the odds of COVID-19 vaccination between respondents who reported having no healthcare provider and those whose healthcare provider did not recommend vaccination. We find significantly lower adjusted odds of COVID-19 vaccination among respondents who reported they were “somewhat hesitant” (aOR=0.38; 95% CI: [0.23, 0.63]) or “very hesitant” (aOR=0.06; 95% CI: [0.04, 0.09]), rather than “not at all hesitant” to be vaccinated.

Table 3.

Weighted Multivariable Logistic Regression for COVID-19 Vaccination

aOR 95% CI p-value Sig.
Age
18–24 - - - -
25–34 1.18 0.61 2.31 .625
35–44 1.41 0.73 2.73 .310
45–54 1.82 0.96 3.46 .066
55–64 2.53 1.33 4.79 .004 **
65+ 2.26 1.23 4.15 .009 **
Gender
Man - - - -
Woman 1.40 1.01 1.92 .041 *
Race/Ethnicity
Black 1.97 1.25 3.10 .003 **
Hispanic 2.18 1.34 3.53 .002 **
Multiracial/other 1.23 0.62 2.44 .549
White - - - -
Education
HS or less - - - -
Some college/associate degree 1.46 1.01 2.12 .047 *
Bachelor’s/graduate degree 1.71 1.10 2.65 .017 *
Income
$29k or less - - - -
$30–49,999 1.64 1.01 2.68 .048 *
$50–89,999 1.40 0.87 2.24 .169
$90–100,000 + 2.13 1.27 3.59 .004 **
Parent/Guardian a
No - - - -
Yes 1.03 0.70 1.53 .867
Provider Recommendation
Provider did not recommend - - - -
No provider 0.76 0.48 1.21 .247
Provider did recommend 1.97 1.40 2.77 <.001 ***
COVID-19 Vaccine Hesitancy
Not at all hesitant - - - -
A little hesitant 1.34 0.71 2.51 .370
Somewhat hesitant 0.38 0.23 0.63 <.001 ***
Very hesitant 0.06 0.04 0.09 <.001 ***
Open in a new tab
***

p<.001

**

p<.01

*

p<.05

aOR=adjusted odds ratio; CI=confidence interval; HS=high school

a

Parents of children under age 18

DISCUSSION

We find that three in four respondents said they were vaccinated against COVID-19 in October 2022. This is lower than the vaccination coverage (≥1 dose) reported for the US (87.3%) by the Centers for Disease Control and Prevention as of October 2021.25 We also find COVID-19 vaccination coverage was not equal across the population. Our descriptive analyses suggested differences across sociodemographic groups, and this was supported further by unadjusted bivariate regressions, as well as an adjusted multivariable regression. In particular, odds of COVID-19 vaccination were higher among Black and Hispanic respondents even after adjusting for covariates. Further, odds of COVID-19 vaccination were higher among respondents in the oldest three age groups (45–54, 55–64, 65+), women, those with higher educational attainment, and those with higher annual household incomes after adjusting for covariates. Most of these associations are consistent with prior COVID-19 vaccine research. For example, a study from early 2021 has also demonstrated higher COVID-19 vaccine coverage among women and those age 65+ or older compared to men and those age 18–29.26 Our findings are similar to prior work demonstrating that vaccine coverage among non-Hispanic Black and Hispanic adults has increased, that previously identified disparities in vaccination rates have narrowed, and that Hispanic coverage has surpassed non-Hispanic White adults.15 Notably, our results showed that COVID-19 vaccine coverage among non-Hispanic Black adults surpassed that of non-Hispanic White adults. Importantly, though, racial disparities in COVID-19 vaccine coverage vary by geographic region, and prior studies were each at the national-level.9,16 The present paper is the first to our knowledge to report COVID-19 vaccine coverage disparities specific to the state of Arkansas.

Existing evidence specific to the state of Arkansas has demonstrated low levels of COVID-19 vaccine acceptance (not vaccination status) and high levels of COVID-19 vaccine hesitancy among Black adults,5,6 which was associated with experiences of discrimination with police or in courts.27 This evidence would reasonably lead researchers to expect lower levels of COVID-19 vaccine coverage among Black adults in Arkansas; however, additional evidence from the state revealed those who have been vaccinated frequently did so despite hesitancy.19 Over three quarters of recently vaccinated Black adults in Arkansas reported some level of vaccine hesitancy—the highest of any racial/ethnic group.19 In sum, our finding of high vaccine coverage among Black adults in Arkansas is less surprising after recognizing that hesitancy is a state of indecision that does not always result in vaccine refusal and that overlap between hesitancy and vaccination appears to differ across racial and ethnic populations.19 The higher vaccination coverage among Black and Hispanic adults may also be informed by differences in risk appraisal for COVID-19 infection. Given the disproportionate risks of exposure, hospitalization, and death from COVID-19 experienced by Black and Hispanic populations,1–3,28,29 individuals who identify as Black and Hispanic may be appraising the risks associated with an infection higher than White individuals, leading to higher uptake of the vaccination even when feelings of hesitancy remain.19 Finally, the lower COVID-19 vaccination we observe among non-Hispanic White adults should be considered within the context of prior findings showing that racial/ethnic vaccination rates are associated with state political context.16

The higher vaccination coverage among Black and Hispanic respondents could be due to public health efforts in Arkansas to reach minority populations. Arkansas’ medical school, department of health, and healthcare providers collaborated with community-based organizations across the state to implement outreach programs aimed at equitable vaccine distribution for minority populations. Specific programs include working with faith-based organizations, integrating community health workers into community-based and clinical settings to facilitate vaccinations, and conducting multi-lingual vaccine education campaigns.30–32 The efforts were funded by the Community Engagement Alliance (CEAL) Against COVID-19 Disparities (NIH 10T2HL156812-01), Rapid Acceleration of Diagnostics (RADx) (NIH 3 R01MD013852-03S2), and the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (6 U3UHS45467-01-01). More information about the funders can be found at the following websites: https://covid19community.nih.gov/; https://www.nih.gov/research-training/medical-research-initiatives/radx; and https://www.hrsa.gov/.

Over half (55.35%) of Arkansas adults reported having a healthcare provider who recommended COVID-19 vaccination. However, substantial proportions reported having no healthcare provider (14.84%) or a provider who did not recommend the vaccine (29.81%). After adjusting for covariates, only individuals whose healthcare provider recommended vaccination were significantly more likely to be vaccinated against COVID-19 than those whose provider did not recommend the vaccine. Equally important is our finding that there was statistically no difference in the odds of being vaccinated against COVID-19 between respondents who had no personal healthcare provider and those who had a provider that did not recommend COVID-19 vaccination. This finding is consistent with prior research that healthcare provider recommendations matter for vaccinations generally,33,34 as well as for COVID-19 vaccine uptake.35 Respondents who reported having no personal healthcare provider or received no recommendation from their healthcare provider are important groups to focus on as public health officials work towards improving COVID-19 vaccine coverage. Encouraging and supporting healthcare providers in methods of effective vaccine counseling could be a fruitful point of intervention.

COVID-19 vaccine hesitancy varied widely among Arkansas adults in October 2022, with the most common response being “not at all hesitant.” Although COVID-19 vaccination was more commonly reported among those who were “not at all hesitant” or “a little hesitant,” it is important to note there was not perfect overlap between hesitancy and vaccination status. Among the “very hesitant,” more than two fifths were vaccinated. Nearly 7% of the “not at all hesitant” remained unvaccinated. Of note, only the “somewhat hesitant” and “very hesitant” had statistically significantly higher odds of vaccination than the “not at all hesitant” in unadjusted and adjusted analyses. In sum, as past research has suggested, the attitude or motivational state of vaccine hesitancy should not be conflated with vaccination status.19,36–38 Although many researchers have categorized the vaccinated as non-hesitant, this practice could lead to inaccurate estimates of hesitancy within the population as well as muddle the conceptual clarity needed to communicate findings appropriately. This point is particularly salient when it comes to understanding racial disparities in COVID-19 vaccine hesitancy and coverage, where early reports of high vaccine hesitancy among Black populations ignored justifiable reasons for such hesitancy27,39–42 and often conflated hesitancy with refusal of the vaccine, which contributed to a narrative of victim-blaming.43,44

Limitations

There are several limitations to be considered when interpreting these results. We analyzed cross-sectional data and, therefore, cannot establish causal relationships. The cross-sectional nature of our data also means results should be interpreted as specific to the time-point during which they were collected—estimates and assocations often change over time. We believe our results are generalizable to the state of Arkansas, which fills an important gap in the literature. However, given prior research demonstrating geographic heterogeneity in COVID-19 vaccine coverage and its correlates, we do not advise generalizing these findings outside of Arkansas. We have relied on self-reported survey measurement to operationalize our independent and dependent variables. This type of measurement may be subject to some differences when compared to studies that utilized vaccination health records. Furthermore, our study is limited to assessing correlates of receiving one or more doses of the vaccine, rather than series completion. Simultaneously, this study has many strengths, including random sampling with oversampling of Black and Hispanic residents to provide a representative sample. We did not, however, oversample for other racial and ethnic groups (Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and multiracial), which led to the problematic practice of aggregating heterogeneous groups. Moreover, this study is the first to provide state-level estimates of COVID-19 vaccine coverage by race/ethnicity in Arkansas while adjusting for a wide set of covariates.

CONCLUSIONS

Our research supports three primary conclusions. First, our results suggest that three in four Arkansans were vaccinated against COVID-19 as of October 2022, indicating that areas for improving vaccine coverage remain. For example, many adults have not had the vaccine recommended to them by their healthcare provider or do not have a healthcare provider at all. Encouraging and supporting healthcare providers with resources to recommend the vaccine is an action that can be taken immediately by public health officials in the state.

Second, vaccine coverage was uneven across the population. Of particular importance, given racial disparities in COVID-19 morbidity and mortality, are racial differences in COVID-19 vaccination. Early in the COVID-19 pandemic, high mortality rates and high vaccine hesitancy among Black Americans was frequently noted in popular media. Reports of racial disparities in mortality that lacked discussion of social conditions such as racism, as well as the assumption that reports of hesitancy would translate to low vaccination, combined to produce a widespread public narrative that effectively blamed Black people for dying of COVID-1943 and perpetuated stereotypes and myths of biological race.44 This narrative also ignored evidence of associations between COVID-19 vaccine hesitancy and experiences of racial discrimination both nationally42,45 and among Black adults in Arkansas specifically.27 Our findings suggest that despite earlier evidence of high fear of infection, low acceptance, and high vaccine hesitancy even on the same day as being vaccinated, non-Hispanic Black adults have nearly double the odds of being vaccinated against COVID-19 compared to non-Hispanic White adults in Arkansas. In short, despite justifiable fears and concerns, Black respondents have the highest vaccine coverage in the state.

Our results provide further support for measuring vaccine hesitancy among both the vaccinated and unvaccinated rather than assuming hesitancy is equivalent to refusal, or vice-versa. Finally, vaccine coverage remains unequal across several other sociodemographic factors, such as age, gender, education, and income, that were not the primary focus of this paper. These disparities are important and should be examined further.

Acknowledgments

Funding:

Support was provided by the Community Engagement Alliance (CEAL) Against COVID-19 Disparities (NIH 10T2HL156812-01); Rapid Acceleration of Diagnostics (RADx) (NIH 3 R01MD013852-03S2); and University of Arkansas for Medical Sciences Translational Research Institute funding awarded through the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) (UL1 TR003107). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. This project was also supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) (6 U3UHS45467-01-01). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the US Government. For more information, please visit HRSA.gov. Support was also provide by the Rural Research Award Program (RRAP) of the Winthrop P. Rockefeller Cancer Institute of the University of Arkansas for Medical Sciences (AWD00055587).

Footnotes

Conflict of Interest: The authors declared no conflicts of interest.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Ethical Approval: Study procedures were approved by a review board for the protection of human subjects at the University of Arkansas for Medical Sciences.

Informed Consent: Respondents consented by verbally agreeing to participate.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Data Availability:

The deidentified data underlying the results presented in this study may be made available upon reasonable request from the corresponding author, Pearl A. McElfish, at pamcelfish@uams.edu.

REFERENCES

  • 1.Andrasfay T, Goldman N. Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. Proc Natl Acad Sci U S A. 2021;118(5):e2014746118. doi: 10.1073/pnas.2014746118 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Donovan D U.S. Officially Surpasses 1 Million COVID-19 Deaths. Johns Hopkins Coronavirus Resource Center. Published 2022. Accessed May 23, 2022. https://coronavirus.jhu.edu/from-our-experts/u-s-officially-surpasses-1-million-covid-19-deaths [Google Scholar]
  • 3.Feldman JM, Bassett MT. Variation in COVID-19 Mortality in the US by Race and Ethnicity and Educational Attainment. JAMA Netw Open. 2021;4(11):e2135967. doi: 10.1001/jamanetworkopen.2021.35967 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Malik AA, McFadden SM, Elharake J, Omer SB. Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine. 2020;26:100495. doi: 10.1016/j.eclinm.2020.100495. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Amick BC, Allen JL, Brown CC, Goudie A, Tilford M, Williams M. Racial differences in vaccine acceptance in a rural southern US state. medRxiv. 2022:2022.05.12.22274953. doi: 10.1101/2022.05.12.22274953. [DOI] [Google Scholar]
  • 6.Willis DE, Andersen JA, Bryant-Moore K, et al. COVID-19 vaccine hesitancy: Race/ethnicity, trust, and fear. Clin Transl Sci. 2021;14(6):2200–2207. doi: 10.1111/cts.13077. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Cerqueira-Silva T, Andrews JR, Boaventura VS, et al. Effectiveness of CoronaVac, ChAdOx1 nCoV-19, BNT162b2, and Ad26.COV2.S among individuals with previous SARS-CoV-2 infection in Brazil: a test-negative, case-control study. Lancet Infect Dis. 2022;22(6):791–801. doi: 10.1016/S1473-3099(22)00140-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Schneider EC, Shah A, Sah P, Moghadas SM, Vilches T, Galvani A. The U.S. COVID-19 Vaccination Program at One Year: How Many Deaths and Hospitalizations Were Averted? Commonwealth Fund 2021. doi: 10.26099/3542-5n54. [DOI] [Google Scholar]
  • 9.Masters NB, Zhou T, Meng L, et al. Geographic Heterogeneity in Behavioral and Social Drivers of COVID-19 Vaccination. Am J Prev Med. 2022;63(6):883–893. doi: 10.1016/j.amepre.2022.06.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Dottle R, Tartar A. Half of U.S. States Have Big Racial Vaccine Gaps Heading Into Omicron. Bloomberg. Published 2021. Accessed January 10, 2023. https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/us-vaccine-demographics.html.
  • 11.Johns Hopkins Coronavirus Resource Center. Arkansas - COVID-19 Overview - Johns Hopkins. Published 2021. Accessed January 9, 2023. https://coronavirus.jhu.edu/region/arkansas.
  • 12.Arkansas Department of Health. Arkansas Department of Health COVID-19 Case Update. Published 2023. Accessed January 10, 2023. https://experience.arcgis.com/experience/633006d0782b4544bd5113a314f6268a/
  • 13.Painter EM. Demographic characteristics of persons vaccinated during the first month of the COVID-19 vaccination program — United States, December 14, 2020–January 14, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(5):174–177. doi: 10.15585/mmwr.mm7005e170 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Krieger N, Waterman PD, Chen JT, Testa C, Hanage WP. Missing again: US racial and ethnic data for COVID-19 vaccination. The Lancet. 2021;397(10281):1259–1260. doi: 10.1016/S0140-6736(21)00465-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Kriss JL. COVID-19 vaccination coverage, by race and ethnicity — national immunization survey adult COVID module, United States, December 2020–November 2021. MMWR Morb Mortal Wkly Rep. 2022;71(23):757–763. doi: 10.15585/mmwr.mm7123a2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Wrigley-Field E, Berry KM, Persad G. Race-specific, state-specific COVID-19 vaccination rates adjusted for age. Socius Sociol Res Dyn World. 2022;8:10.1177/23780231221082401. doi: 10.1177/23780231221082401. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Gross CP, Essien UR, Pasha S, Gross JR, Wang S yi, Nunez-Smith M Racial and Ethnic Disparities in Population-Level Covid-19 Mortality. J Gen Intern Med. 2020;35(10):3097–3099. doi: 10.1007/s11606-020-06081-w [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.CDC. Behavioral Risk Factor Surveillance System Survey Questionnaire. Published 2020. Accessed January 10, 2023. http://www.cdc.gov/brfss/
  • 19.Willis DE, Selig JP, Andersen JA, et al. Hesitant but vaccinated: assessing COVID-19 vaccine hesitancy among the recently vaccinated. J Behav Med. 2023;46(1–2):15–24. doi: 10.1007/s10865-021-00270-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Moore R, Purvis RS, Hallgren E, et al. Motivations to vaccinate among hesitant adopters of the COVID-19 vaccine. J Community Health. 2022;47(2):237–245. doi: 10.1007/s10900-021-01037-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Hallgren E, Moore R, Purvis RS, et al. Facilitators to vaccination among hesitant adopters. Hum Vaccines Immunother. 2021;17(12):5168–5175. doi: 10.1080/21645515.2021.2010427 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Purvis RS, Hallgren E, Moore RA, et al. Trusted Sources of COVID-19 Vaccine Information among Hesitant Adopters in the United States. Vaccines. 2021;9(12):1418. doi: 10.3390/vaccines9121418 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Enders CK. The Performance of the Full Information Maximum Likelihood Estimator in Multiple Regression Models with Missing Data. Educ Psychol Meas. 2001;61(5):713–740. doi: 10.1177/0013164401615001 [DOI] [Google Scholar]
  • 24.Muthén LK, Muthén BO. Mplus: Statistical Analysis with Latent Variables: User’s Guide. 8th ed.; 1998.
  • 25.CDC. COVID-19 Vaccination Coverage and Vaccine Confidence Among Adults. Published November 14, 2022. Accessed January 26, 2023. https://www.cdc.gov/vaccines/imz-managers/coverage/covidvaxview/interactive/adults.html
  • 26.Diesel J, Sterrett N, Dasgupta S, et al. COVID-19 Vaccination coverage among adults —United States, December 14, 2020–May 22, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(25):922–927. doi: 10.15585/mmwr.mm7025e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Willis DE, Andersen JA, Montgomery BEE, et al. COVID-19 vaccine hesitancy and experiences of discrimination among black adults. J Racial Ethn Health Disparities. 2022;10(3)1025–1034. doi: 10.1007/s40615-022-01290-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Feldman J Coronavirus Is an Occupational Disease That Spreads at Work. Published 2021. Accessed April 5, 2021. https://jacobinmag.com/2021/01/covid-19-business-work-public-health.
  • 29.Acosta AM, Garg S, Pham H, et al. Racial and Ethnic Disparities in Rates of COVID-19–Associated Hospitalization, Intensive Care Unit Admission, and In-Hospital Death in the United States From March 2020 to February 2021. JAMA Netw Open. 2021;4(10):e2130479. doi: 10.1001/jamanetworkopen.2021.30479 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.McElfish PA, Rowland B, Hall S, et al. Comparing community-driven COVID-19 vaccine distribution methods: Faith-based organizations vs. outpatient clinics. J Fam Med Prim Care. 2022;11(10):6081–6086. doi: 10.4103/jfmpc.jfmpc_327_22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.McElfish PA. Use of Community-Based Participatory Research Partnerships to Reduce COVID-19 Disparities Among Marshallese Pacific Islander and Latino Communities – Benton and Washington Counties, Arkansas, April–December 2020. Prev Chronic Dis. 2021;18:E91. doi: 10.5888/pcd18.210124 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Willis DE, McElfish PA. Racial disparities in the COVID-19 response affecting the Marshall Islands diaspora, United States of America. Bull World Health Organ. 2021;99(9):680–681. doi: 10.2471/BLT.20.277855 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.DeRoo SS, Pudalov NJ, Fu LY. Planning for a COVID-19 Vaccination Program. JAMA. 2020;323(24):2458–2459. doi: 10.1001/jama.2020.8711 [DOI] [PubMed] [Google Scholar]
  • 34.Edwards KM, Hackell JM, THE COMMITTEE ON INFECTIOUS DISEASES TCOPAAM. Countering Vaccine Hesitancy. Pediatrics. 2016;138(3):e20162146. doi: 10.1542/peds.2016-2146 [DOI] [PubMed] [Google Scholar]
  • 35.Nguyen KH, Yankey D, jun Lu P, et al. Report of Health Care Provider Recommendation for COVID-19 Vaccination Among Adults, by Recipient COVID-19 Vaccination Status and Attitudes — United States, April–September 2021. Morb Mortal Wkly Rep. 2021;70(50):1723–1730. doi: 10.15585/mmwr.mm7050a1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Moore R, Purvis RS, Willis DE, et al. The vaccine hesitancy continuum among hesitant adopters of the COVID-19 vaccine. Clin Transl Sci. 2022;15(12):2844–2857. doi: 10.1111/cts.13385 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Lloyd R People are getting COVID shots despite hesitation. Scientific American. Published 2022. Accessed July 5, 2022. https://www.scientificamerican.com/article/people-are-getting-covid-shots-despite-hesitation/.
  • 38.Larson HJ. Defining and measuring vaccine hesitancy. Nat Hum Behav. 2022;6:1609–1610. doi: 10.1038/s41562-022-01484-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Corbie-Smith G Vaccine Hesitancy Is a Scapegoat for Structural Racism. JAMA Health Forum. 2021;2(3):e210434. doi: 10.1001/jamahealthforum.2021.0434 [DOI] [PubMed] [Google Scholar]
  • 40.Bajaj SS, Stanford FC. Beyond Tuskegee — Vaccine distrust and everyday racism. N Engl J Med. 2021;384(5):e12. doi: 10.1056/NEJMpv2035827 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Quinn SC, Andrasik MP. Addressing Vaccine Hesitancy in BIPOC Communities — Toward Trustworthiness, Partnership, and Reciprocity. N Engl J Med. 2021;385(2):97–100. doi: 10.1056/NEJMp2103104 [DOI] [PubMed] [Google Scholar]
  • 42.Willis DE, Montgomery BEE, Selig JP, et al. COVID-19 Vaccine Hesitancy and Racial Discrimination among US Adults. Prev Med Rep. 2022;31:102074. doi: 10.1016/j.pmedr.2022.102074. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Kendi IX. Stop blaming black people for dying of the coronavirus. Published 2020. Accessed July 30, 2020. https://www.ibramxkendi.com/blog/2018/10-cy55m-ms393-tsa64-9kb7c-hbd5j-wryfa-h8682-58mc4-wzce3-z8yxy-emcsr-f686c-sskx9-cmef8-5n8mj-a3s9r-f8rw5
  • 44.Chowkwanyun M, Reed AL. Racial health disparities and Covid-19 — caution and context. N Engl J Med. 2020;383(3):201–203. doi: 10.1056/NEJMp2012910 [DOI] [PubMed] [Google Scholar]
  • 45.Savoia E, Piltch-Loeb R, Goldberg B, et al. Predictors of COVID-19 vaccine hesitancy: socio-demographics, co-morbidity and past experience of racial discrimination. medRxiv. 2021;2021.01.12.21249152. doi: 10.1101/2021.01.12.21249152. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The deidentified data underlying the results presented in this study may be made available upon reasonable request from the corresponding author, Pearl A. McElfish, at pamcelfish@uams.edu.

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