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: Young adult, COVID-19, Vaccine, COVID-19 vaccine, COVID-19 vaccine hesitancy, Vaccine intention, Vaccine hesitancy
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 [1]. Previous research indicates that a third of young adults are vulnerable to severe COVID-19 illness [2]. 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) [3]. 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 [4]. 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 [5]. However, COVID-19 vaccine acceptability concerns by the general population were noted at the pandemic's inception [6,7]. 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 [8]. 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 1.
Demographic descriptors of young adults (ages 18–25): Household Pulse Survey (March, 2021)
| Young adult analytic sample (unweighted N = 5,082) | Weighted % |
|---|---|
| Sex | |
| Male | 53.3% |
| Female | 46.7% |
| Race/ethnicity | |
| Non-Hispanic white | 56.7% |
| Non-Hispanic black | 7.8% |
| Hispanic | 22.8% |
| Non-Hispanic – Asian | 7.6% |
| Non-Hispanic – Other, more than 1 race | 5.0% |
| Insurance status | |
| Private | 70.4% |
| Public | 8.6% |
| Both private and public | 6.2% |
| Other (not described enough to be categories into private/public categories) | 1.6% |
| Uninsured | 13.2% |
Table 2.
COVID-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% | ||
| No | 3.4% | ||
| If NO/unvaccinated: Once vaccine is available, would you get a vaccine? | |||
| Definitely will | 50.8% | ||
| Probably will | 25.5% | ||
| Probably will not | 14.2% | ||
| Definitely will not | 9.6% | ||
| 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 later | 56.2% | 62.1% | 49.8% |
| I am concerned about possible side effects of a COVID-19 vaccine | 53.4% | 52.8% | 54.0% |
| I think other people need it more than I do right now | 44.0% | 57.0% | 30.1% |
| I do not believe I need a COVID-19 vaccine | 22.8% | 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 group | 74.6% | 83.0% | 72.2% |
| I do not believe COVID-19 is a serious illness | 49.5% | 39.0% | 52.5% |
| I already had COVID-19 | 30.9% | 34.0% | 30.0% |
| I plan to use masks or other precautions instead | 25.4% | 19.7% | 27.0% |
| I do not think vaccines are beneficial | 11.1% | 1.8% | 13.7% |
| Other (unspecified) | 7.6% | 6.4% | 7.9% |
| I do not trust the government | 22.3% | 11.5% | 33.9% |
| I do not trust COVID-19 vaccines | 21.9% | 8.1% | 36.8%∗ |
| I do not know if a COVID-19 vaccine will work | 21.4% | 17.6% | 25.5% |
| I am concerned about the cost of a COVID-19 vaccine | 12.4% | 18.0% | 6.3% |
| I do not like vaccines | 10.1% | 7.8% | 12.6% |
| My doctor has not recommended it | 6.6% | 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 [3]. 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 [4,9].
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 [3,10]. These are relevant for young adults, who have experienced barriers in navigating health care systems when obtaining health insurance [11]. 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 [12,13].
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 [9]. 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.
Footnotes
Conflicts of interest: The authors have no conflicts of interest to disclose.
This manuscript has been approved by all authors, is not under review at any other journal, and if accepted, will not be published in any other venue.
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
- 1.Centers for Disease Control and Prevention Demographic trends of COVID-19 cases and deaths in the US reported to CDC web site. https://covid.cdc.gov/covid-data-tracker/#demographics Available at:
- 2.Adams S.H., Park M.J., Schaub J.P. Medical vulnerability of young adults to severe COVID-19 illness-data from the National Health Interview Survey. J Adolesc Health. 2020;67:362–368. doi: 10.1016/j.jadohealth.2020.06.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kaiser Family Foundation KFF COVID-19 vaccine Monitor: March 2021 web site. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-march-2021/ Available at:
- 4.Brandt E.J., Rosenberg J., Waselewski M.E. National study of youth opinions on vaccination for COVID-19 in the U.S. J Adolesc Health. 2021;68:868–872. doi: 10.1016/j.jadohealth.2021.02.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.U.S. Food & Drug Administration Pfizer-BioNTech COVID-19 Vaccine web site. https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine Available at:
- 6.Malik A.A., McFadden S.M., Elharake J., Omer S.B. 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]
- 7.Szilagyi P.G., Thomas K., Shah M.D. 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. doi: 10.1001/jama.2020.26419. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Centers for Disease Control and Prevention Novel COVID-19 survey takes nation’s social, mental “Pulse” web site. https://www.cdc.gov/coronavirus/2019-ncov/communication/accomplishments/pulse-survey.html Available at:
- 9.Finney-Rutten L.J., Zhu X., Leppin A.L. Evidence-based strategies for clinical organizations to address COVID-10 vaccine hesitancy. Mayo Clin Proc. 2021;96:699–707. doi: 10.1016/j.mayocp.2020.12.024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Kaiser Family Foundation KFF COvid-19 Vaccine Monitor: Experiences with vaccine access and information needs web site. https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-experiences-vaccine-access-information-needs/ Available at:
- 11.Wong C.A., Asch D.A., Vinoya C.M. The experience of young adults on HealthCare.gov: Suggestions for improvement. Ann Intern Med. 2014;161:231–232. doi: 10.7326/L14-0287. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Institute of Medicine and National Research Council . The National Academies Press; Washington, DC: 2014. Investing in the health and well-being of young adults. [PubMed] [Google Scholar]
- 13.Centers for Disease Control and Prevention Flu vaccine coverage, United States, 2019-20 Influenza season web site. https://www.cdc.gov/flu/fluvaxview/coverage-1920estimates.htm Available at: