Leveraging 13 million responses to the U.S. COVID-19 Trends and Impact Survey to examine vaccine hesitancy, vaccination, and mask wearing, January 2021-February 2022

Study findings indicate that age was a major predictor for COVID-19 vaccine uptake, with higher odds of vaccine uptake increasing with age. Older age groups are likely to have more comorbidities, underlying health conditions, and physiological changes that accompany the aging process. The increased risk of severe illness from COVID-19 may incentivize older adults to take the COVID-19 vaccine as a preventative health measure, resulting in higher COVID-19 vaccine uptake and lower vaccine hesitancy [31]. Additionally, older adults were among the first groups eligible to receive the COVID-19 and thus early access may have assisted with vaccine uptake. According to a report by the CDC, individuals between the ages of 5 and 11 had the lowest rates of vaccinations, with 33.6% having received at least one dose and 26.6% having been fully vaccinated [32]. On the other hand, individuals older than 65 years presented the highest rates of vaccination. 95.0% of individuals between the ages of 65 and 74 have received at least one dose, 91.2% have been fully vaccinated and 65.2% have received the booster dose. Similarly, 95.0% of individuals ages 75 + have received at least one dose, 85.5% have been fully vaccinated and 68.9% have received the booster dose.

Consistent with previous studies’ findings [13], we also found that educational attainment was a significant positive predictor for COVID-19 vaccine uptake. Individuals with higher educational attainment may have better access to accurate vaccine information and the health literacy to understand that health information and navigate initially complex systems for obtaining the vaccine. In a survey done by the Census in December 2021, 49.6% of individuals were concerned with the vaccine side effects, 42.4% of individuals did not trust the vaccine and 35.4% of individuals did not trust the government [33]. Individuals with higher educational attainment may also be able to better understand how the vaccine works, which can reduce fear surrounding possible side effects of the vaccine. According to a Census report, the unvaccinated adults who were most hard to reach were more likely to be young adults under the age of 50, non-white, and unmarried [32]. These adults presented lower levels of education and economic stability, tending to manifest as increased difficulty meeting daily expenses. They were also more likely to report disabilities such as difficulty seeing, hearing, transporting, remembering, or having complete impairment, which made it harder for them to access the vaccine.

In our study, occupation was also a major predictor for COVID-19 vaccine uptake. Those who worked in the healthcare industry as a practitioner or supporter were significantly more likely to have received one or more doses of the COVID-19 vaccine than those who worked in other professional roles. Healthcare workers were on the front lines during the initial stages of the pandemic, and were in the highest priority group to receive the vaccine when it was first being distributed. The daily exposure to high-risk individuals and severe COVID-19 presentations may have pushed those working in healthcare to take the vaccine readily when it was offered to them [34]. Many hospitals and healthcare facilities also instituted a vaccine mandate for all employees, which may explain the significant association between those working in healthcare and vaccine uptake. As of September 21, 2021, at least 174 health systems required all of their employees to be vaccinated against COVID-19 [35], and a recent ruling by the Supreme Court enabled the Centers for Medicare and Medicaid Services to require all Medicare and Medicaid service providers to be vaccinated [36]. This may explain how the significant association between vaccination and working in healthcare is consistent in both from January 2021 to May 2021 and June 2021 to February 2022. Those who worked in arts, entertainment, and media also demonstrated a significant increase in vaccine uptake. As the pandemic waned and media production went back to in-person work, many large entertainment companies required that their employees be vaccinated and routinely tested to ensure worker safety, including The Walt Disney Company and NBC Universal [37]. This may have contributed to the associations observed between vaccine uptake and working in arts, entertainment, and media industries.

Those who worked in primarily blue-collar industries such as construction, installation & repair, and transportation & material moving demonstrated low rates of vaccine uptake and high rates of vaccine hesitancy across both time periods observed. A study by Carnegie Mellon University in collaboration with the University of Pittsburgh found that high-hesitancy occupations such as construction reported a lack of trust in both the COVID-19 vaccine and the U.S. government as a key driver for hesitancy. These individuals also expressed the belief that they do not need the vaccine, which may be due to the fact that much work in construction, repair, and transportation occurs either primarily outdoors or in uncrowded settings [38].

Moreover, our study found differential rates of vaccination and vaccine hesitancy across racial/ethnic groups. Whites and Asians were more likely to be vaccinated and have lower rates of vaccine hesitancy in comparison with blacks, multiracial individuals as well as Native American/Alaska Native, and Native Hawaiian/other Pacific Islanders. These differences could be due to differences in vaccination access and distribution. Initially neighborhoods with greater shares of whites and Asians had higher vaccination rates [39, 40]. Our results are in alignment with CDC published vaccination rates that report Asians having the highest rate of fully vaccinated (59.8%) and proportion of booster doses (65.4%), and Blacks having the lowest rate of fully vaccinated (40.6%), and the Hispanic/Latino population having the lowest proportion of booster doses (38.5%) [9].

Also, we found that individuals who identify as “other gender” had lower vaccination rates and higher rates of vaccine hesitancy than females and males. Individuals who identify with genders different than female and male had historically encountered challenges when accessing, trusting, and obtaining health care services. Thus, not trusting the COVID-19 vaccine and the system could be the reason why they presented lower rates of vaccination and higher rates of vaccine hesitancy. However, other studies have not found differences in vaccination or vaccine confidence by gender identity [39]. Exploring vaccination patterns among gender minorities is highly understudied and warrants further investigation.

As one of the most efficient ways of protecting ourselves and others from COVID-19, wearing masks was set as an outcome in our study. At the start of the COVID pandemic, besides isolation, mask-wearing was the widely recommended method of combating infection. However, the masking recommendation that was being encouraged by much of the scientific community was very quickly met with anti-masking resistance. Similar resistance was also expressed at the onset of the vaccine development. Our study highlighted an inverse correlation between mask-wearing and vaccine hesitancy, which has also been identified by other studies [25, 41]. This association might indicate that the faction of the community that is less likely to wear masks and more likely to express vaccine hesitancy also has have skepticism about the severity of the pandemic or mistrust of the government and the scientific community [42].

We found that older people were more likely to wear masks most or all the time in public compared to young adults. The higher chance of facing more severe health issues from COVID-19 could be one reason why older people valued mask wearing more than other age groups [43]. We also found that compared to male respondents, female respondents were more likely to wear masks most of the time or all the time. A previous study found that males were more likely to perceive face masks as infringing on their rights and independence compared to females [44]. Racial/ethnic minorities were more likely to wear masks most of the time or all the time compared whites, which aligns with previous literature [45]. Possible reason could be awareness of higher COVID-19 risk and severity of illness among racial/ethnic minorities [46]. According to data from the CDC, Black and Latina/o adults are more likely to become infected, be hospitalized due to severe illness, and die from COVID-19 complications when compared with White people. Asian Americans are also more likely to be become infected and be hospitalized when compared with White people. Lower mask wearing was also seen in protective service, construction, and installation and repair occupations. These groups also had lower vaccination rates and higher vaccine hesitancy. For many of them who worked outdoors, they might perceive lower transmission risk [47]. Additionally, political polarization around mask wearing [48] could further help explain patterns seen across occupations.

With the exception of bachelor’s degrees which were associated with higher vaccination rate and lower vaccine hesitancy, our study did not identify contextual factors at the ZIP code level that significantly predict COVID vaccination status or vaccine hesitancy. For mask wearing, percent Hispanic and sidewalks were associated with higher odds of wearing masks most or all the time. This is consistent with the finding that racial/ethnic minorities have higher mask wearing [45]. The presence of sidewalks may indicate greater opportunities for social interactions and hence contagion, which may lead individuals to wear masks. However, unexpectedly, civilian employment rate and mixed land use was associated with lower odds of mask wearing because a previous analysis linked these with more COVID cases [28]. Neighborhood data offers a granular geographical context and is known as a significant determinant of health outcomes. Future studies should expand upon our research by further investigating neighborhood level determinants that could influence behaviors around COVID-19 vaccines and mask-wearing.