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COVID-19 Vaccination in the United States, August–November 2021

Published:January 25, 2023DOI:https://doi.org/10.1016/j.amepre.2023.01.014

      Abstract

      Introduction

      COVID-19 vaccines are safe, effective, and widely available, but many adults in the United States have not been vaccinated for COVID-19. This study examined the associations between behavioral and social drivers of vaccination with COVID-19 vaccine uptake in U.S. adults and their prevalence by region.

      Methods

      A nationally-representative sample of US adults participated in a crosssectional telephone survey August–November 2021; the analysis was conducted January 2022. Survey questions assessed self-reported COVID-19 vaccine initiation, demographics, and behavioral and social drivers of vaccination.

      Results

      Among the 255,763 respondents, 76% received their first dose of COVID-19 vaccine. Vaccine uptake was higher among respondents aged 75 years and above (94%), females (78%), and Asian non-Hispanic people (94%). The drivers of vaccination most strongly associated with uptake included higher anticipated regret from non-vaccination, risk perception, and confidence in vaccine safety and importance, followed by work- or school-related vaccination requirements, social norms, and provider recommendation (all p<.05). The direction of association with uptake varied by reported level of difficulty accessing vaccines. The prevalence of all of these behavioral and social drivers of vaccination was highest in the Northeast region and lowest in the Midwest and South.

      Conclusions

      This nationally-representative survey found that COVID-19 vaccine uptake was most strongly associated with greater anticipated regret, risk perception, and confidence in vaccine safety and importance, followed by vaccination requirements and social norms. Interventions that leverage these social and behavioural drivers of vaccination have potential to increase COVID-19 vaccine uptake and could be considered for other vaccine introductions.

      Keywords

      Introduction

      Vaccines are a crucial tool to mitigate both individual and community impacts of the COVID-19 pandemic. The Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices first recommended use of COVID-19 vaccines for priority groups in December 2020. Vaccine eligibility in the United States (U.S.) expanded to all persons aged ≥5 years by October 2021.1 While overall COVID-19 vaccine initiation exceeds 80% in adults, uptake differs by age, race, insurance status, income, region, and rurality.2,3 Vaccine hesitancy, defined as a motivational state of being conflicted about, or opposed to, getting vaccinated, has been identified as a barrier to vaccine uptake. 4-8 To address hesitancy and increase COVID-19 vaccine uptake, it is important to identify the behavioral and social drivers of vaccination and implement interventions that address these drivers in diverse populations and regions in the U.S.
      The Behavioral and Social Drivers of vaccination (BeSD) framework, 9,10 built on the Increasing Vaccination Model, identifies thinking and feeling, social processes, and practical issues as the key domains associated with vaccine uptake (Appendix 1). 10 The social processes domain includes constructs such as a recommendation from a healthcare provider, which is consistently associated with higher vaccine uptake across age, racial, and ethnic groups for both COVID-19 vaccine and other vaccines.11,12 Within the practical issues domain, difficulty of access has been identified as a barrier to COVID-19 vaccine uptake, whereas vaccination requirements have been suggested to increase uptake. 13-15
      The National Immunization Survey Adult COVID Module (NIS-ACM) complements other COVID-19 vaccination surveys, 16-18 providing nationally and regionally-representative weekly estimates of the behavioral and social drivers of COVID-19 vaccination. 19,20 Data from the NIS-ACM were analyzed to assess: 1) the proportion of respondents who initiated COVID-19 vaccination overall, by population subgroups, and by behavioral and social drivers; 2) demographic characteristics of access barriers by vaccination status; 3) prevalence of behavioral and social drivers in four regions of the United States; and 4) associations between each level increase in behavioral and social drivers of vaccination and COVID-19 vaccine uptake.

      Methods

      Study Sample

      The NIS-ACM generated a nationally representative sample of U.S. adults using random-digit-dialing of cell phone numbers.20 Participants were from the 50 U.S. states, the District of Columbia, and U.S. territories. 20 The overall survey response rate ranged from 20.9% in September to 23.4% in November 2021.
      The NIS-ACM conducted a telephone survey in English and Spanish during August 1—November 27, 2021. 21 Respondents indicated their consent verbally; they could withdraw their consent by hanging up the phone. Respondents did not receive incentives for participation. The dataset for this cross-sectional study was de-identified; access to this dataset can be obtained through the NCHS Research Data Centers. 22 This activity was reviewed by CDC and conducted consistent with applicable federal law and CDC policy
      § See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.
      . This study followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines. 23

      Measures

      The survey assessed self-reported COVID-19 vaccine uptake or initiation with the question, “Have you received at least one dose of a COVID-19 vaccine?” with binary responses categorized as “Yes” and “No.” Self-reported demographic factors included age (categorized as 18-29; 30-39; 40-49; 50-64; 65-74; and 75 years and above), gender (male or female), race and ethnicity (White non-Hispanic; Black non-Hispanic; Hispanic; Asian non-Hispanic; American Indian/Alaska Native non-Hispanic; Native Hawaiian/Pacific Islander non-Hispanic; or other/multiple races), annual household income (below Federal Poverty Level for 2021 24; above Federal Poverty Level but under $75,000; $75,000 and above; or unknown), health insurance (not insured or insured), essential/frontline worker status (essential healthcare; school and childcare; other frontline worker; other essential worker; or not a frontline or essential worker), metropolitan statistical area (MSA) (MSA principal city, MSA non-principal city, and non-MSA); and U.S. Census region (Northeast, South, Midwest, and West). These demographic factors were selected due to disparities in vaccine uptake between these subgroups.
      In the thinking and feeling domain, four questions assessed risk perception, anticipated regret, confidence in vaccine importance, and confidence in vaccine safety. Risk perception was assessed with the question “How concerned are you about getting COVID-19?” with ordinal responses categorized as “Very concerned,” “Moderately concerned,” “A little concerned,” and “Not at all concerned.” Anticipated regret if not vaccinated was assessed with the statement: “If I [do not get/had not gotten] a COVID-19 vaccine, I [will/would] regret it,” with response options of “Very strongly agree,” “Strongly agree,” “Somewhat agree,” and “Do not agree.” Confidence in vaccine importance was assessed with the question, “How important do you think getting a COVID-19 vaccine is to protect yourself against COVID-19?” with response options of “Very important,” “Somewhat important,” “A little important,” and “Not at all important.” Similarly, confidence in vaccine safety was assessed with the question, “How safe do you think a COVID-19 vaccine is for you?” with response options of as “Completely safe,” “Very safe,” “Somewhat safe,” and “Not at all safe.”
      In the domain of social processes, one question assessed provider recommendation, “Has a doctor, nurse, or other health professional ever recommended that you get a COVID-19 vaccine?” with responses of “Yes” or “No,” and another question assessed social norms: “If you had to guess, about how many of your family and friends have received a COVID-19 vaccine?” with response options of “Almost all,” “Many,” “Some,” or “None.”
      In the domain of practical issues, two questions assessed difficulty of access and vaccine requirements. Difficulty of access was assessed with the question “How difficult [would it be for you/was it for you] to get a COVID-19 vaccine?” with ordinal responses options of “Not at all difficult,” “A little difficult,” “Somewhat difficult,” and “Very difficult.” Vaccine requirement was assessed with the question “Does your work or school require you to get a COVID-19 vaccine?” with responses categorized as “Yes,” “No,” or “Unemployed/not applicable.”

      Statistical Analysis

      Vaccine uptake was weighted to represent the noninstitutionalized U.S. population aged ≥18 years using population control totals for age group, gender, MSA, and race/ethnicity, with further calibration to cumulative COVID-19 vaccine administration in September 2021 by gender and age group for each jurisdiction. The unweighted number and weighted proportion of respondents who self-reported COVID-19 vaccine uptake was assessed by demographic characteristics and by responses to the behavioral and social questions. The weighted proportion of respondents who reported that it was very or somewhat difficult to get a COVID-19 vaccine was calculated and stratified by vaccination status. To examine geographic variability, the number and weighted proportion of respondents was calculated in each of the four Census regions (Northeast, Midwest, South, and West). For each region, the weighted proportion of respondents who were very or moderately concerned about getting COVID-19; strongly or very strongly agreed that they would regret not getting a COVID-19 vaccine; were confident that COVID-19 vaccines are completely or very safe; were confident that COVID-19 vaccines are very or somewhat important; had all or almost all friends and family members who were vaccinated against COVID-19; had received a provider recommendation to get a COVID-19 vaccine; believed it was very or somewhat difficult to get a COVID-19 vaccine; and were subject to a work or school COVID-19 vaccination requirement was reported.
      Last, the associations of COVID-19 vaccine initiation with each behavioral and social driver of COVID-19 were evaluated using separate ordinal logistic regressions and predictive marginals for each driver, controlling for demographic characteristics, including age, gender, race, ethnicity, household income, health insurance status, rurality, frontline/essential worker status, and census region. The unadjusted prevalence differences were reported in results because these models assume no interactions. The analyses used staircase coding for the predictors that compared each level to the next higher level (i.e., for a 4-level predictor: 1 vs. 2, 2 vs. 3, and 3 vs. 4). Analyses used t-tests to determine differences between groups with statistical significance at p<0.05. Analyses were performed using SAS (version 9.4)25 and SUDAAN (version 11.0.3). 26

      Results

      Among the 255,763 survey respondents, 20.9% were aged 18–29 years; 21.4% were 65 years and above; 51.6% were female; and 62.2% were White non-Hispanic, 11.9% were Black non-Hispanic, and 17.2% were Hispanic (Table 1). Self-reported vaccine uptake (≥1 dose of COVID-19 vaccine) was 76.1%. Over 75% of respondents in the following categories reported receiving at least one dose of a COVID-19 vaccine: respondents aged 50 years and above (82.2%-94.1% by age band), females (78.2%), White non-Hispanic persons (76.6%), Asian non-Hispanic persons (93.7%), Hispanic persons (76.9%), persons with insurance (78.5%), college graduates (85.2%), persons with advanced degrees (92.5%), school and childcare workers (87.2%), health care workers (84.0%), and non-essential workers (77.8%). The proportion of unvaccinated respondents who reported difficulty accessing COVID-19 vaccines was greater among the younger age groups (49.1%), Black non-Hispanic persons (34.6%), American Indian or Alaska Native non-Hispanic persons (51.3%), those with incomes below the Federal Poverty Level (46.3%), and rural residents (37.6%) (Table 2).
      Table 1Demographics and COVID-19 vaccination (≥1 dose) overall and among those vaccinated, National Immunization Survey Adult COVID Module, August—November 27, 2021.
      OverallReceived ≥1 dose of COVID-19 vaccine
      Demographicsn% (95% CI)n% (95% CI)
      Overall255,763100.0218,52176.1 (75.7-76.5)
      Age (years)
      18-2943,17620.9 (20.5-21.2)33,66161.6 (60.7-62.5)
      30-3941,31217.4 (17.1-17.7)33,60967.5 (66.6-68.5)
      40-4938,81716.0 (15.7-16.3)32,33573.2 (72.2-74.1)
      50-6470,52924.4 (24.0-24.7)61,90882.2 (81.5-82.8)
      65-7439,54112.6 (12.3-12.8)36,93191.9 (91.3-92.5)
      75+17,9938.8 (8.5-9.0)16,84594.1 (93.4-94.8)
      Gender
      Male123,51248.4 (48.0-48.8)103,50174.1 (73.6-74.7)
      Female130,14251.6 (51.2-52.0)113,63678.2 (77.7-78.7)
      Race/Ethnicity
      White, non-Hispanic161,50662.2 (61.8-62.6)139,03876.6 (76.1-77.0)
      Black, non-Hispanic29,12311.9 (11.7-12.2)24,49873.0 (71.9-74.1)
      Hispanic32,06217.2 (16.8-17.5)27,60676.9 (75.9-77.8)
      Asian, non-Hispanic11,6304.2 (4.1-4.4)11,21193.7 (92.5-94.7)
      American Indian/Alaska Native, non-Hispanic3,2331.0 (0.9-1.0)2,40058.9 (54.5-63.1)
      Native Hawaiian/Pacific Islander, non-Hispanic1,3760.4 (0.3-0.4)1,08873.6 (67.9-78.6)
      Other/multiracial9,2293.1 (3.0-3.3)7,00464.3 (62.0-66.5)
      Household Income
      Below Federal Poverty Level23,08710.7 (10.5-11.0)17,74865.6 (64.3-66.8)
      Above Federal Poverty Level, < $75k annual income79,88532.1 (31.7-32.4)67,33974.4 (73.7-75.1)
      Above Federal Poverty Level, ≥ $75k annual income96,80733.0 (32.6-33.3)87,25882.7 (82.1-83.2)
      Unknown income55,98424.3 (23.9-24.6)46,17674.0 (73.2-74.8)
      Health insurance
      No19,43910.0 (9.7-10.2)13,56857.4 (56.0-58.7)
      Yes228,70990.0 (89.8-90.3)199,18978.5 (78.1-78.9)
      Education
      High school or less62,37839.0 (38.6-39.4)47,41469.0 (68.3-69.7)
      Some college71,18330.5 (30.2-30.9)58,53774.1 (73.5-74.8)
      College graduate63,98019.2 (18.9-19.5)58,38985.2 (84.5-85.9)
      Advanced degree50,57111.2 (11.0-11.4)48,27492.5 (91.9-93.1)
      Frontline and essential worker status
      Essential healthcare27,1839.3 (9.1-9.5)24,75584.0 (83.0-85.0)
      School and childcare9,5262.9 (2.8-3.0)8,86587.2 (85.6-88.7)
      Other frontline worker16,5507.4 (7.1-7.6)12,97466.3 (64.8-67.8)
      Other essential worker29,33612.5 (12.2-12.7)22,90966.2 (65.0-67.3)
      Not a frontline or essential worker171,44668.0 (67.6-68.3)148,11077.8 (77.4-78.2)
      Rurality
      MSA, principal city89,93133.0 (32.6-33.3)78,93278.2 (77.5-78.8)
      MSA, non-principal city117,84553.2 (52.8-53.6)102,00277.3 (76.8-77.8)
      Non-MSA47,98713.8 (13.6-14.1)37,58766.6 (65.5-67.6)
      Census Region
      Northeast51,69817.4 (17.2-17.6)46,45784.5 (83.8-85.1)
      Midwest45,89920.8 (20.5-21.0)38,53570.4 (69.5-71.3)
      South91,71538.0 (37.7-38.3)77,00572.1 (71.5-72.7)
      West55,27723.8 (23.5-24.0)46,48980.8 (80.1-81.5)
      Note: Table reports weighted percentages. NIS-ACM= National Immunization Survey Adult COVID Module. MSA = Metropolitan Statistical Area.
      Census regions: West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Washington, and Wyoming. South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Maryland, Mississippi, North Carolina, Louisiana, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia; Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont; Midwest: Indiana, Illinois, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin.
      Table 2Self-reported difficulty getting a COVID-19 vaccine overall and among those unvaccinated, National Immunization Survey Adult COVID Module, August 1-November 27, 2021.
      It was very or somewhat difficult to get a COVID-19 vaccine
      OverallNot vaccinated
      Demographicsn% (95% CI)% (95% CI)
      Age (years)
      18-294,62711.5 (10.9-12.1)49.1 (46.5-51.8)
      30-395,35312.1 (11.5-12.7)31.6 (28.9-34.3)
      40-495,07613.9 (13.2-14.6)22.7 (20.5-25.2)
      50-649,86714.8 (14.2-15.3)14.3 (12.8-15.9)
      65-747,35920.6 (19.7-21.4)5.5 (4.3-6.9)
      75+3,03520.3 (19.1-21.5)4.9 (3.7-6.4)
      Gender
      Male15,68713.3 (13.0-13.7)24.2 (22.8-25.7)
      Female20,02116.0 (15.6-16.4)18.2 (17.0-19.4)
      Race/ethnicity
      White, non-Hispanic3,90315.8 (15.4-16.1)17.0 (16.0-18.1)
      Black, non-Hispanic24,00812.4 (11.6-13.1)34.6 (31.3-38.1)
      Hispanic3,48612.3 (11.6-13.0)27.6 (24.8-30.7)
      Asian, non-Hispanic1,69215.3 (14.0-16.7)6.0 (3.8-9.4)
      American Indian/Alaska Native, non-Hispanic41012.3 (10.1-14.9)51.3 (41.4-61.1)
      Native Hawaiian/Pacific Islander non-Hispanic16213.2 (9.7-17.8)28.3 (17.3-42.9)
      Other/multiracial1,23716.1 (14.4-17.8)37.0 (31.2-43.1)
      Income
      Below Federal Poverty Level2,91313.8 (13.0-14.7)46.3 (42.9-49.8)
      Above Federal Poverty Level, <$75K annual income9,90113.2 (12.7-13.7)23.7 (22.0-25.6)
      Above Federal Poverty Level, >=$75K annual income15,06915.9 (15.5-16.4)9.3 (8.3-10.4)
      Unknown income8,14715.7 (15.1-16.3)24.2 (22.3-26.2)
      Health insurance
      No2,20012.2 (11.3-13.1)17.9 (17.0-18.8)
      Yes32,84715.0 (14.7-15.3)51.1 (47.2-55.0)
      Education
      High school or less7,10612.7 (12.2-13.2)27.1 (25.2-29.1)
      Some college8,77913.7 (13.2-14.3)18.2 (17.2-19.3)
      College graduate9,45616.9 (16.3-17.5)36.4 (34.5-38.4)
      Advanced degree9,62920.5 (19.8-21.3)21.8 (20.2-23.6)
      Essential/frontline worker
      No26,26915.7 (15.4-16.1)6.9 (5.9-8.1)
      Yes9,23412.6 (12.1-13.1)4.0 (3.0-5.3)
      Rurality
      MSA, principal city13,10114.5 (14.0-14.9)21.5 (20.0-23.2)
      MSA, non-principal city18,12815.8 (15.4-16.2)17.6 (16.4-18.8)
      Non-MSA4,80111.3 (10.6-11.9)37.6 (34.7-40.6)
      Census region
      Northeast8,49818.7 (18.1-19.4)10.7 (9.4-12.2)
      Midwest5,95413.8 (13.2-14.4)26.3 (24.1-28.6)
      South13,55313.8 (13.4-14.3)26.1 (24.5-27.8)
      West7,12614.4 (13.8-15.1)18.3 (16.4-20.4)
      Risk perception varied by region, with 41.1% of respondents in the Midwest and 49.1% of respondents in the Northeast reporting being very or moderately concerned about getting COVID-19 (Figure 1). In the Midwest, 75.7% reported confidence that COVID-19 vaccines are very or somewhat important, in contrast with the Northeast, where 86.4% reported confidence that COVID-19 vaccines are very or somewhat important. The proportion of respondents reporting confidence that COVID-19 vaccines are completely or very safe ranged from 60.0% in the South to 69.7% in the Northeast. Only 39.6% of respondents in the West reported receiving a provider recommendation compared to 45.5% in the Northeast. The proportions of respondents who reported having almost all or many vaccinated family and friends ranged from 64.7% in the Midwest to 79.3% in the Northeast. In the Midwest, 14.2% reported COVID-19 vaccine requirements for work or school, whereas 25.5% of respondents in the Northeast reported these requirements. In the Northeast, 81.3% reported that it was a little or not at all difficult to get a COVID-19 vaccine compared to 86.2% of respondents in the South and Midwest.
      Figure 1
      Figure 1Prevalence (and 95% CI) of behavioral and social drivers (BeSD) of vaccination among adults by Census region, August 1-November 27, 2021
      Each higher level of the BeSD constructs was associated with a higher likelihood of vaccine uptake, reported in marginal prevalence differences, where each level was compared to the level preceding (Table 3). In the thinking and feeling domain, anticipated regret of not receiving a vaccine and then getting infected with COVID-19, confidence in vaccine safety, and confidence in vaccine importance were most strongly associated with receiving a COVID-19 vaccine. Confidence that COVID-19 vaccines are somewhat safe was associated with an unadjusted 57.0 percentage point (95% CI 55.9-58.1) higher uptake, compared to those who responded that the vaccines were not at all safe (Table 3). For each level of confidence in vaccine importance, the likelihood of vaccine uptake was 25.2 (95% CI 23.2-27.1) to 29.8 (95% CI 28.0-31.6) percentage points higher. For the social norms construct, reporting some family and friends vaccinated was associated with a 28.1 (95% CI 26.2-30.0) percentage point higher likelihood of uptake than reporting having no family or friends who were vaccinated. Provider recommendation and vaccination requirements were associated with 11.6 (95% CI 10.9-12.3) percentage points and 21.8 (95% CI 21.1-22.6) percentage points higher vaccination likelihood, respectively. Those who reported that it was a little difficult to get a vaccine were 12.9 (95% CI 12.0-13.9) percentage points more likely to be vaccinated than those who reported that it was not at all difficult. Adjusted rates were similar to the likelihood of vaccine uptake in the unadjusted model.
      Table 3Association between behavioral and social drivers and COVID-19 vaccination (≥1 dose), National Immunization Survey Adult COVID Module, August 1—November 27, 2021.
      UnadjustedAdjusted for demographics
      Behavioral and Social Drivers of VaccinationVaccinated%
      Unadjusted frequencies and weighted percentages and marginal prevalence differences.
      (95% CI)
      Marginal prevalence difference
      The marginal preference difference consecutively adds the difference in uptake between each ordinal level of the Behavioral and Social Drivers of Vaccination constructs (e.g. compared to those who are not at all concerned about getting COVID-19, those who are a little concerned about getting COVID-19 are 21.6 (95% CI 20.5-22.6) percentage points more likely to have at least one dose of COVID-19 vaccine).
      (95% CI)Marginal prevalence difference
      The marginal preference difference consecutively adds the difference in uptake between each ordinal level of the Behavioral and Social Drivers of Vaccination constructs (e.g. compared to those who are not at all concerned about getting COVID-19, those who are a little concerned about getting COVID-19 are 21.6 (95% CI 20.5-22.6) percentage points more likely to have at least one dose of COVID-19 vaccine).
      (95% CI)
      Thinking and Feeling
      Concerned about getting COVID-19
      Not at all concerned53.5 (52.7-54.4)
      A little concerned78.9 (78.2-79.6)25.2
      p< 0.001;
      (24.1-26.3)21.6
      p< 0.001;
      (20.5-22.6)
      Moderately concerned85.5 (84.9-86.1)6.6
      p< 0.001;
      (5.7-7.5)5.5
      p< 0.001;
      (4.6-6.4)
      Very concerned89.5 (88.9-90.1)4.0
      p< 0.001;
      (3.1-4.9)3.1
      p< 0.001;
      (2.2-4.0)
      Anticipated regret if not vaccinated
      Do not agree32.0 (31.2-32.7)
      Somewhat agree79.2 (78.3-80.0)47.2
      p< 0.001;
      (46.0-48.3)42.3
      p< 0.001;
      (41.1-43.5)
      Strongly agree95.2 (94.8-95.6)16.0
      p< 0.001;
      (15.1-16.9)14.0
      p< 0.001;
      (13.0-14.9)
      Very strongly agree97.3 (97.0-97.6)2.0
      p< 0.001;
      (1.6-2.5)2.1
      p< 0.001;
      (1.7-2.7)
      Thinks a COVID-19 vaccine is important
      Not at all important11.1 (10.4-11.8)
      A little important40.8 (39.2-42.5)29.8
      p< 0.001;
      (28.0-31.6)31.8
      p< 0.001;
      (30.0-33.7)
      Somewhat important65.9 (64.8-67.0)25.2
      p< 0.001;
      (23.2-27.1)23.5
      p< 0.001;
      (21.6-25.5)
      Very important95.3 (95.1-95.6)29.3
      p< 0.001;
      (28.2-30.4)24.5
      p< 0.001;
      (23.5-25.6)
      Thinks a COVID-19 vaccine is safe
      Not at all safe10.2 (9.5-10.9)
      Somewhat safe67.1 (66.3-68.0)57.0
      p< 0.001;
      (55.9-58.1)55.1
      p< 0.001;
      (53.8-56.4)
      Very safe94.9 (94.5-95.2)27.7
      p< 0.001;
      (26.7-28.6)24.6
      p< 0.001;
      (23.7-25.5)
      Completely safe96.8 (96.5-97.1)1.9
      p< 0.001;
      (1.5-2.3)2.2
      p< 0.001;
      (1.7-2.7)
      Social Processes
      Health care provider recommended vaccine
      No71.1 (70.6-71.6)
      Yes82.9 (82.4-83.4)11.6
      p< 0.001;
      (10.9-12.3)8.6
      p< 0.001;
      (7.9-9.3)
      Friends and family vaccinated
      None18.5 (16.8-20.3)
      Some46.5 (45.7-47.3)28.1
      p< 0.001;
      (26.2-30.0)26.5
      p< 0.001;
      (24.2-28.8)
      Many82.0 (81.3-82.7)35.5
      p< 0.001;
      (34.4-36.6)30.5
      p< 0.001;
      (29.4-31.6)
      Almost all94.1 (93.8-94.4)12.0
      p< 0.001;
      (11.2-12.8)10.2
      p< 0.001;
      (9.4-11.0)
      Practical Issues
      Difficulty getting a COVID-19 vaccine
      Not at all difficult74.3 (73.8-74.7)
      A little difficult87.3 (86.4-88.1)12.9
      p< 0.001;
      (12.0-13.9)10.7
      p< 0.001;
      (9.7- 11.6)
      Somewhat difficult84.9 (83.9-85.9)-2.3
      p< 0.001;
      (-1.0–3.6)-3.8
      p< 0.001;
      (-2.4–5.2)
      Very difficult66.8 (64.9-68.5)-18.3
      p< 0.001;
      (-16.2–20.4)-17.8
      p< 0.001;
      (-15.7–19.9)
      Work or school requires you to get a COVID-19 vaccine
      No69.6 (69.1-70.1)RefRef
      Yes91.4 (90.8-92.0)21.8
      p< 0.001;
      (21.1-22.6)19.7
      p< 0.001;
      (19.0-20.4)
      Unemployed/not applicable85.2 (84.4-86.0)15.5
      p< 0.001;
      (14.6-16.5)1.5
      p< 0.05. Adjusted for age, gender, race/ethnicity, income, insurance status, essential/frontline worker status, rurality, Census region
      (0.1-2.9)
      Note. Overall n = 218,521
      low asterisklow asterisk p< 0.001;
      low asterisk p< 0.05. Adjusted for age, gender, race/ethnicity, income, insurance status, essential/frontline worker status, rurality, Census region
      a Unadjusted frequencies and weighted percentages and marginal prevalence differences.
      b The marginal preference difference consecutively adds the difference in uptake between each ordinal level of the Behavioral and Social Drivers of Vaccination constructs (e.g. compared to those who are not at all concerned about getting COVID-19, those who are a little concerned about getting COVID-19 are 21.6 (95% CI 20.5-22.6) percentage points more likely to have at least one dose of COVID-19 vaccine).

      Discussion

      This nationally representative survey of over 200,000 U.S. adults identified behavioral and social drivers associated with COVID-19 vaccination nationally and regionally. Vaccine uptake was most strongly associated with anticipated regret if not vaccinated, risk perception, confidence in vaccine safety, and confidence in vaccine importance, followed by a smaller magnitude of association with social norms, vaccination requirements, ease of access, and provider recommendation. In contrast to reports from earlier in the COVID-19 vaccination roll-out, 27,28 the analysis did not find self-reported difficulty uniformly associated with lower receipt of vaccine. This unexpected finding might be attributable to extensive efforts to reduce access barriers, including mobile vaccination sites, removing an insurance or identification requirement, and substantial community-led outreach. 29-31 Alternatively, the impact of access barriers on uptake could be modified by other contextual or community-level environmental factors.32,33,34 In addition, this finding might be ascribed to a limitation in the survey question, given the heterogeneity between overall rates of difficulty accessing the vaccine and those rates among the unvaccinated between demographic strata.
      Respondents in the Northeast reported the highest prevalence of confidence in vaccine safety and importance, risk perception, social norms, and provider recommendations, while respondents in the Midwest and South consistently reported the lowest prevalence of these drivers. The lower prevalence of these behavioral and social drivers in the Midwest and South might contribute to the lower COVID-19 vaccine uptake in these regions, compared with the Northeast and West.
      While the thinking and feeling constructs were associated with uptake, few effective, evidence-based interventions that act upon these constructs to increase vaccination rates have been identified.10 That is, although anticipated regret in not being vaccinated, confidence in vaccine safety, and confidence in vaccine importance are associated with vaccine uptake, it is not clear how to use persuasive or educational techniques to reliably change these perceptions. More innovative approaches are needed to improve vaccine confidence in a manner that achieves improvements in vaccine uptake.
      In the social processes domain, strong associations were identified between the proportion of family and friends vaccinated (social norms) and vaccination uptake. These findings underscore the critical role of social processes for increasing vaccination, particularly as individuals tend to underestimate the proportion of their social networks that are vaccinated. 27,35,36 However, it is also important to note that simply communicating descriptive norms has not been effective in increasing vaccine uptake.37 Tailored and community-led interventions, including ZIP code-level vaccination access planning and community engagement, have been shown to reduce inequities in COVID-19 vaccination by race and ethnicity.38-40 One particularly promising intervention could be encouraging vaccinated people to be peer ambassadors and disclose their vaccination status to family and friends. Following one vaccine ambassador training in Los Angeles County, California, 83% of community vaccine ambassadors reported motivating at least one person and 19% reported motivating at least six unvaccinated people to get a COVID-19 vaccine.41 Given the disparities in vaccination rates by race and ethnicity as well as the disproportionate burden of COVID-19 in these communities,42,43 it is important to strengthen community-led interventions from trusted individuals among these groups.44,45
      Provider recommendation remains a key component to increasing vaccine uptake, even for those who describe themselves as vaccine hesitant.46 Providers, pharmacists, and nurses are consistently listed as one of the most trusted sources of health information28,47 and are frequently cited as the reason their patients opt to receive a vaccine.48,49 The impact of provider recommendation extends to health professionals in other contexts, including mental health.50 The association of provider recommendation and vaccine uptake might be somewhat attenuated in these findings due to the underuse of primary care services during the COVID-19 pandemic and high proportion of adults in the United States without a primary care provider, 51 limiting opportunities for providers to convey recommendations. Actions should be taken to encourage providers to actively reach out to patients and encourage vaccination and to ensure the quality of providers’ recommendations.52-55
      Interventions in the practical issues domain have consistently been associated with increased uptake, even without trying to change risk perception or vaccine confidence.14,56,57 While practical issues encompass an array of challenges, including patient experiences, transport costs, and overall difficulty accessing vaccination,4 this survey explores only two facets: self-reported access difficulties and vaccination requirements. These findings illustrate a strong and positive association between vaccination requirements and vaccine uptake. Vaccination requirements have been associated with reductions in ethnic and racial disparities in vaccination coverage 41 and higher levels of vaccine confidence among healthcare workers.58 That said, the implementation of vaccination requirements requires care. Because the effectiveness of vaccination requirements depends on the context in which requirements are implemented, best practices include provisions for stable access to vaccines, multiple interventions in addition to requirements that encourage uptake, and fair and equitable administration of vaccination requirements.59 Other promising interventions in the practical issues domain include vaccination incentives (when incentives are delivered immediately, with certainty, and valued by recipients), onsite vaccination, and reminders.60

      Limitations

      This study has four main limitations. First, as a random-digit dial survey, institutionalized individuals or those without a phone or only a landline telephone would not be eligible for inclusion in this survey. Second, the response rate ranged from 20.9% in September to 23.4% in November, although it is consistent with other nationally representative surveys 20. To address potential bias from incomplete sample frame and nonresponse, the NIS surveys weigh responses to the non-institutionalized U.S. adult population.61 Third, vaccine status was self-reported, rather than verified. While a limitation, assessments have found self-report to be 98% accurate when compared to vaccination attestation.62 Additionally, the NIS-ACM survey weights included calibration to regional COVID-19 vaccine administration data, mitigating systematic errors in vaccine uptake from incomplete sample frame, nonresponse, and errors in self-reported vaccination status. Fourth, it was assumed that the relationships between behavioral and social drivers and COVID-19 vaccine uptake remained constant over the four-month data collection period, as reported elsewhere.63

      Conclusions

      This study identifies risk perception, confidence in vaccine safety and importance, and anticipated regret as the leading behavioral and social drivers associated with COVID-19 vaccine uptake, followed by smaller associations between social norms, vaccination requirements, and provider recommendations on vaccine uptake. The findings from this study provide data that can be used to design interventions to increase COVID-19 vaccine uptake: leveraging social norms to equip individuals to be vaccine ambassadors to family and friends; supporting healthcare workers to make effective vaccine recommendations; researching ways to change risk perceptions and confidence in vaccine safety and importance; and implementing vaccination requirements in an equitable manner.

      Acknowledgements

      All authors declare no conflicts of interested pertinent to this manuscript; all have provided their conflict of interest disclosures. The co-authors are CDC government employees who did not receive funding specific to this work. The academic co-authors received funding from the CDC to support the engagement in the COVID-19 vaccination response. No other funding source was involved in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit this manuscript for publication. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention.
      No financial disclosures were reported by the authors of this paper.

      CRediT authorship contribution statement

      Kimberly E. Bonner: Conceptualization; Investigation; Methodology; Roles/Writing - original draft. Kushagra Vashist: Data curation; Formal analysis; Investigation; Methodology; Writing - review & editing. Neetu S. Abad: Conceptualization; Investigation; Methodology; Resources; Writing - review & editing, Supervision. Jennifer L. Kriss: Data curation; Formal analysis; Investigation; Methodology; Resources; Writing - review & editing. Lu Meng: Conceptualization; Data curation; Formal analysis, Validation, Methodology. James T. Lee: Data curation; Investigation; Methodology; Resources; Writing - review & editing. Elisabeth Wilhelm: Conceptualization, Writing - review & editing. Peng-Jun Lu: Data curation; Formal analysis; Investigation; Methodology; Writing - review & editing. Rosalind J. Carter: Writing - review & editing. Kwanza Boone: Methodology; Writing - review & editing. Brittney Baack: Conceptualization; Writing - review & editing. Nina B. Masters: Writing - review & editing, Debora Weiss: Writing - review & editing. Carla Black: Writing - review & editing. Qian Huang: Writing - review & editing. Sitaram Vangala: Writing - review & editing. Christina Albertin: Writing - review & editing. Peter G. Szilagyi: Conceptualization, Methodology; Writing - review & editing, Supervision. Noel T. Brewer: Conceptualization; Investigation; Methodology; Resources; Writing - review & editing, Supervision. James A. Singleton: Data curation; Investigation; Methodology; Resources; Writing - review & editing, Supervision.

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      Appendix. SUPPLEMENTAL MATERIAL