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Vaccine hesitancy and reasons for refusing the COVID-19 vaccination among the U.S. public: A cross-sectional survey

02 Mar 2021-medRxiv (Cold Spring Harbor Laboratory Press)-
TL;DR: In a recent national survey, this article found that over one-third of respondents were vaccine hesitant (defined as nonacceptance or being unsure about acceptance of the COVID-19 vaccine) with respondent characteristics.
Abstract: ImportanceAlthough widespread vaccination will be the most important cornerstone of the public health response to the COVID-19 pandemic, a critical question remains as to how much of the United States population will accept it. ObjectiveDetermine: 1) rate of COVID-19 vaccine hesitancy in the United States public, 2) patient characteristics associated with hesitancy, 3) reasons for hesitancy, 4) healthcare sites where vaccine acceptors would prefer to be vaccinated. Design43-question cross-sectional survey conducted November 17-18, 2020, distributed on Amazon Mechanical Turk, an online labor marketplace where individuals receive a nominal fee (here, $1.80) for anonymously completing tasks. Eligible ParticipantsUnited States residents 18-88 years of age, excluding healthcare workers. A total 1,756 volunteer respondents completed the survey (median age 38 years, 53% female). Main Outcome MeasureMultivariable logistic regression modeled the primary outcome of COVID-19 vaccine hesitancy (defined as non-acceptance or being unsure about acceptance of the COVID-19 vaccine) with respondent characteristics. ResultsA total 663 respondents (37.8%) were COVID-19 vaccine hesitant (374 [21.3%] non-acceptors and 289 [16.5%] unsure about accepting). Vaccine hesitancy was associated with not receiving influenza vaccination in the past 5 years (odds ratio [OR] 4.07, 95% confidence interval [CI] 3.26-5.07, p<0.01), female gender (OR 2.12, 95%CI 1.70-2.65, p<0.01), Black race (OR 1.54, 95%CI 1.05-2.26, p=0.03), having a high school education or less (OR 1.46, 95%CI 1.03-2.07, p=0.03), and Republican party affiliation (OR 2.41, 95%CI 1.88-3.10, p<0.01). Primary reasons for hesitancy were concerns about side effects, need for more information, and doubts about vaccine efficacy. Preferred sites for vaccination for acceptors were primary doctors offices/clinics, pharmacies, and dedicated vaccination locations. ConclusionsIn this recent national survey, over one-third of respondents were COVID-19 vaccine hesitant. To increase vaccine acceptance, public health interventions should target vaccine hesitant populations with messaging that addresses their concerns about safety and efficacy.

Summary (2 min read)

Introduction

  • 1 Importance 17 Although widespread vaccination will be the most important cornerstone of the public health 18 response to the COVID-19 pandemic, a critical question remains as to how much of the United 19 States population will accept it.
  • 20 Objective 21 Determine: 1) rate of COVID-19 vaccine hesitancy in the United States public, 2) patient 22 characteristics associated with hesitancy, 3) reasons for hesitancy, 4) healthcare sites where 23 NOTE:.
  • This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
  • Vaccine acceptors would prefer to be vaccinated.
  • 24 Design 25 43-question cross-sectional survey conducted November 17-18, 2020, distributed on Amazon 26 Mechanical Turk, an online labor marketplace where individuals receive a nominal fee (here, 27 $1.80) for anonymously completing tasks.

Main Outcome Measure 32

  • Multivariable logistic regression modeled the primary outcome of COVID-19 vaccine hesitancy 33 (defined as non-acceptance or being unsure about acceptance of the COVID-19 vaccine) with 34 respondent characteristics.
  • Preferred sites for vaccination for acceptors were primary doctors’ 44 offices/clinics, pharmacies, and dedicated vaccination locations.
  • Over one-third of respondents were COVID-19 vaccine hesitant.
  • The three tenets of the public health 52 response to the pandemic remain social distancing, mask wearing, and vaccination (2,3).
  • 53 However, these mitigation measures are only as effective as their broad acceptance and 54 implementation.

Study Setting and Population 78

  • The authors distributed this cross-sectional survey from November 17 to November 18, 2020 on 79 Amazon Mechanical Turk (MTurk, https://www.mturk.com), an online labor marketplace in 80 which individuals anonymously complete tasks, including surveys, and in return receive a 81 nominal fee (in this case, $1.80).
  • MTurk is well-validated for behavioral experiments and 82 increasingly used to study healthcare questions, and data from MTurk are considered reliable 83 (13,14).
  • Because their goal was to assess vaccine hesitancy in a more medically naïve 86 population, the authors excluded respondents self-identifying as healthcare workers.
  • The survey included questions regarding demographic characteristics, 89 health insurance status, healthcare utilization, employment and housing status, and political 90 affiliation.
  • Respondents who responded that they would accept it were then 95 asked their preferred location to receive a COVID-19 vaccine.

Primary and Secondary Outcome Measures 99

  • The primary outcome measure was COVID-19 vaccine hesitancy - defined as either non-100 acceptance or being unsure about acceptance of the COVID-19 vaccine.
  • In terms of sample size calculation, the authors sought to power the primary outcome to 95% in 118 assessment of its association with four characteristics - gender, race, age, and political affiliation.
  • The authors found significant vaccine 172 hesitancy in the U.S. population that was more common in women, Blacks, and people with 173 lower education levels or who identified as Republicans.
  • To improve 236 efficient and equitable vaccine distribution, educational messaging campaigns should seek to 237 address non-acceptors’ primary concerns of safety and side effects of the vaccine.
  • Available from: 295 https://www.nih.gov/news-events/news-releases/promising-interim-results-clinical-trial-296 nih-moderna-covid-19-vaccine 297 22. CDC.

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1
Vaccine hesitancy and reasons for refusing the COVID-19 vaccination among the U.S. 1
public: A cross-sectional survey 2
3
Ali S. Raja, MD, MPH, MBA;
1*
Joshua D. Niforatos, MD, MTS;
2
Nancy Anaya, MD;
3
Joseph 4
Graterol, MD;
3
Robert M. Rodriguez, MD
3
5
6
1
Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical 7
School, Boston, Massachusetts, United States of America 8
2
Department of Emergency Medicine, The Johns Hopkins School of Medicine, Baltimore, 9
Maryland, United States of America 10
3
Department of Emergency Medicine, University of California, San Francisco, California, 11
United States of America 12
13
* Corresponding Author: 14
araja@mgh.harvard.edu (ASR)
15
Abstract 16
Importance 17
Although widespread vaccination will be the most important cornerstone of the public health 18
response to the COVID-19 pandemic, a critical question remains as to how much of the United 19
States population will accept it. 20
Objective 21
Determine: 1) rate of COVID-19 vaccine hesitancy in the United States public, 2) patient 22
characteristics associated with hesitancy, 3) reasons for hesitancy, 4) healthcare sites where 23
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted March 2, 2021. ; https://doi.org/10.1101/2021.02.28.21252610doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

2
vaccine acceptors would prefer to be vaccinated. 24
Design 25
43-question cross-sectional survey conducted November 17-18, 2020, distributed on Amazon 26
Mechanical Turk, an online labor marketplace where individuals receive a nominal fee (here, 27
$1.80) for anonymously completing tasks. 28
Eligible Participants 29
United States residents 18-88 years of age, excluding healthcare workers. A total 1,756 volunteer 30
respondents completed the survey (median age 38 years, 53% female). 31
Main Outcome Measure 32
Multivariable logistic regression modeled the primary outcome of COVID-19 vaccine hesitancy 33
(defined as non-acceptance or being unsure about acceptance of the COVID-19 vaccine) with 34
respondent characteristics. 35
Results 36
A total 663 respondents (37.8%) were COVID-19 vaccine hesitant (374 [21.3%] non-acceptors 37
and 289 [16.5%] unsure about accepting). Vaccine hesitancy was associated with not receiving 38
influenza vaccination in the past 5 years (odds ratio [OR] 4.07, 95% confidence interval [CI] 39
3.26-5.07, p<0.01), female gender (OR 2.12, 95%CI 1.70-2.65, p<0.01), Black race (OR 1.54, 40
95%CI 1.05-2.26, p=0.03), having a high school education or less (OR 1.46, 95%CI 1.03-2.07, 41
p=0.03), and Republican party affiliation (OR 2.41, 95%CI 1.88-3.10, p<0.01). Primary reasons 42
for hesitancy were concerns about side effects, need for more information, and doubts about 43
vaccine efficacy. Preferred sites for vaccination for acceptors were primary doctors’ 44
offices/clinics, pharmacies, and dedicated vaccination locations. 45
Conclusions 46
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted March 2, 2021. ; https://doi.org/10.1101/2021.02.28.21252610doi: medRxiv preprint

3
In this recent national survey, over one-third of respondents were COVID-19 vaccine hesitant. 47
To increase vaccine acceptance, public health interventions should target vaccine hesitant 48
populations with messaging that addresses their concerns about safety and efficacy.
49
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted March 2, 2021. ; https://doi.org/10.1101/2021.02.28.21252610doi: medRxiv preprint

4
INTRODUCTION 50
The greatest public health crisis of the past century, the COVID-19 pandemic has led to 51
over 1.8 million deaths globally as of January 3, 2021 (1). The three tenets of the public health 52
response to the pandemic remain social distancing, mask wearing, and vaccination (2,3). 53
However, these mitigation measures are only as effective as their broad acceptance and 54
implementation. 55
Along with research and development of therapeutics, the most anticipated control 56
measures are a series of COVID-19 vaccines, two of which - as of this writing - have received 57
United States (U.S.) Food and Drug Administration emergency use authorizations (4). As 58
COVID-19 vaccination is implemented across the U.S., a critical question remains as to how 59
much of the population will accept it. For COVID-19 vaccination to effectively confer herd 60
immunity, experts agree that at least 60-70% of the population will need to be vaccinated (5). 61
Vaccine hesitancy, a phenomenon which predates the pandemic, has been well studied with other 62
vaccinations, including the influenza and Measles/Mumps/Rubella vaccines. Recent influenza 63
vaccine vaccination hesitancy rates have hovered at approximately 40% (6–9). The traditionally 64
low rates of influenza vaccination in Black, Latinx, and Native American populations are of 65
particular concern since these groups have had disproportionately poor outcomes during the 66
COVID-19 pandemic (9–11). While a recent study found that COVID-19 vaccine hesitancy rates 67
have varied between 26-44% (with rates increasing throughout 2020), the reasons for vaccine 68
refusal in late 2020 have yet to be fully described (12). These reasons are especially relevant as 69
we begin public vaccination programs in early 2021. 70
With the need for widespread acceptance of COVID-19 vaccination in mind, the 71
objectives of this survey study were to determine: 1) the US population rate of COVID-19 72
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted March 2, 2021. ; https://doi.org/10.1101/2021.02.28.21252610doi: medRxiv preprint

5
vaccine hesitancy (defined as either non-acceptance or unsure about acceptance of the COVID-73
19 vaccine), 2) characteristics associated with hesitancy, 3) reasons for hesitancy, and 4) health 74
care sites where respondents would prefer to receive the vaccine. 75
76
MATERIALS AND METHODS 77
Study Setting and Population 78
We distributed this cross-sectional survey from November 17 to November 18, 2020 on 79
Amazon Mechanical Turk (MTurk, https://www.mturk.com
), an online labor marketplace in 80
which individuals anonymously complete tasks, including surveys, and in return receive a 81
nominal fee (in this case, $1.80). MTurk is well-validated for behavioral experiments and 82
increasingly used to study healthcare questions, and data from MTurk are considered reliable 83
(13,14). This study was approved by the Institutional Review Board at <redacted for review>. 84
We recruited U.S. residents between 18 and 88 years of age from MTurk to complete a 85
43-question survey. Because our goal was to assess vaccine hesitancy in a more medically naïve 86
population, we excluded respondents self-identifying as healthcare workers. 87
Survey Instrument 88
The survey (Supplement) included questions regarding demographic characteristics, 89
health insurance status, healthcare utilization, employment and housing status, and political 90
affiliation. Survey respondents were then asked a series of questions regarding self-reported 91
adherence to different COVID-19 mitigation measures and previous influenza vaccinations. 92
After a short descriptor about the COVID-19 vaccine including the statement that it would likely 93
be provided free of charge, participants were asked, “Would you accept the COVID-19 vaccine 94
when it becomes available?” Respondents who responded that they would accept it were then 95
. CC-BY-NC-ND 4.0 International licenseIt is made available under a
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
The copyright holder for this preprint this version posted March 2, 2021. ; https://doi.org/10.1101/2021.02.28.21252610doi: medRxiv preprint

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TL;DR: In response to the COVID-19 pandemic, US-based providers are forging new and innovative collaborations for delivering care to patients abroad that promise more efficient and higher quality of care which do not necessitate travel.
Abstract: Patients have historically travelled from across the world to the United States for medical care that is not accessible locally or not available at the same perceived quality. The COVID-19 pandemic has nearly frozen the cross-border buying and selling of healthcare services, referred to as medical tourism. Future medical travel to the United States may also be deterred by the combination of an initially uncoordinated public health response to the pandemic, an overall troubled atmosphere arising from widely publicized racial tensions and pandemic-related disruptions among medical services providers. American hospitals have shifted attention to domestic healthcare needs and risk mitigation to reduce and recover from financial losses. While both reforms to the US healthcare system under the Biden Presidency and expansion to the Affordable Care Act will influence inbound and outbound medical tourism for the country, new international competitors are also likely to have impacts on the medical tourism markets. In response to the COVID-19 pandemic, US-based providers are forging new and innovative collaborations for delivering care to patients abroad that promise more efficient and higher quality of care which do not necessitate travel.

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TL;DR: In this article , the authors investigate the relationship among political preferences, risk for COVID-19 complications, and complying with preventative behaviors, such as social distancing, quarantine, and vaccination, as they remain incompletely understood.
Abstract: We investigate the relationships among political preferences, risk for COVID-19 complications, and complying with preventative behaviors, such as social distancing, quarantine, and vaccination, as they remain incompletely understood. Since those with underlying health conditions have the highest mortality risk, prevention strategies targeting them and their caretakers effectively can save lives. Understanding caretakers' adherence is also crucial as their behavior affects the probability of transmission and quality of care, but is understudied. Examining the degree to which adherence to prevention measures within these populations is affected by their health status vs. voting preference, a key predictor of preventative behavior in the U. S, is imperative to improve targeted public health messaging. Knowledge of these associations could inform targeted COVID-19 campaigns to improve adherence for those at risk for severe consequences.We conducted a nationally-representative online survey of U.S. adults between May-June 2020 assessing: 1) attempts to socially-distance; 2) willingness/ability to self-quarantine; and 3) intention of COVID-19 vaccination. We estimated the relationships between 1) political preferences 2) underlying health status, and 3) being a caretaker to someone with high-risk conditions and each dependent variable. Sensitivity analyses examined the associations between political preference and dependent variables among participants with high-risk conditions and/or obesity.Among 908 participants, 75.2% engaged in social-distancing, 94.4% were willing/able to self-quarantine, and 60.1% intended to get vaccinated. Compared to participants intending to vote for Biden, participants who intended to vote for Trump were significantly less likely to have tried to socially-distance, self-quarantine, or intend to be vaccinated. We observed the same trends in analyses restricted to participants with underlying health conditions and their caretakers Underlying health status was independently associated with social distancing among individuals with obesity and another high-risk condition, but not other outcomes.Engagement in preventative behavior is associated with political voting preference and not individual risk of severe COVID-19 or being a caretaker of a high-risk individual. Community based strategies and public health messaging should be tailored to individuals based on political preferences especially for those with obesity and other high-risk conditions. Efforts must be accompanied by broader public policy.

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29 Mar 2021-medRxiv
TL;DR: In this article, a randomized controlled trial was conducted to investigate whether vaccination intention changes after viewing an animated YouTube video explaining how COVID-19 mRNA vaccines work, and they found that participants who watched the version of the video with a male narrator expressed statistically significant increased vaccination intention compared to the control group.
Abstract: Increasing acceptance of COVID–19 vaccines is imperative for public health, as unvaccinated individuals may impede the ability to reach herd immunity. Previous research on educational interventions to overcome vaccine hesitancy have shown mixed effects in increasing vaccination intention, although much of this work has focused on parental attitudes toward childhood vaccination. In this study, we conducted a randomized controlled trial to investigate whether vaccination intention changes after viewing an animated YouTube video explaining how COVID–19 mRNA vaccines work. We exposed participants to one of four interventions — watching the video with a male narrator, watching the same video with a female narrator, reading the text of the transcript of the video, or receiving no information (control group). We found that participants who watched the version of the video with a male narrator expressed statistically significant increased vaccination intention compared to the control group. The video with a female narrator had more variation in results. As a whole, there was a non–significant increased vaccination intention when analyzing all participants who saw the video with a female narrator; however, for politically conservative participants there was decreased vaccination intention for this intervention, particularly at a threshold between being currently undecided and expressing probable interest. These results are encouraging for the ability of interventions as simple as YouTube videos to increase vaccination propensity, although the inconsistent response to the video with a female narrator demonstrates the potential for bias to affect how certain groups respond to different messengers.

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TL;DR: The results show a variety of factors as being associated with vaccine hesitancy but they do not allow for a complete classification and confirmation of their independent and relative strength of influence.

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TL;DR: Many different psychological, contextual, sociodemographic and physical barriers that are specific to certain risk groups were identified and map knowledge gaps in understanding influenza vaccine hesitancy to derive directions for further research and inform interventions in this area.
Abstract: Background Influenza vaccine hesitancy is a significant threat to global efforts to reduce the burden of seasonal and pandemic influenza. Potential barriers of influenza vaccination need to be identified to inform interventions to raise awareness, influenza vaccine acceptance and uptake. Objective This review aims to (1) identify relevant studies and extract individual barriers of seasonal and pandemic influenza vaccination for risk groups and the general public; and (2) map knowledge gaps in understanding influenza vaccine hesitancy to derive directions for further research and inform interventions in this area. Methods Thirteen databases covering the areas of Medicine, Bioscience, Psychology, Sociology and Public Health were searched for peer-reviewed articles published between the years 2005 and 2016. Following the PRISMA approach, 470 articles were selected and analyzed for significant barriers to influenza vaccine uptake or intention. The barriers for different risk groups and flu types were clustered according to a conceptual framework based on the Theory of Planned Behavior and discussed using the 4C model of reasons for non-vaccination. Results Most studies were conducted in the American and European region. Health care personnel (HCP) and the general public were the most studied populations, while parental decisions for children at high risk were under-represented. This study also identifies understudied concepts. A lack of confidence, inconvenience, calculation and complacency were identified to different extents as barriers to influenza vaccine uptake in risk groups. Conclusion Many different psychological, contextual, sociodemographic and physical barriers that are specific to certain risk groups were identified. While most sociodemographic and physical variables may be significantly related to influenza vaccine hesitancy, they cannot be used to explain its emergence or intensity. Psychological determinants were meaningfully related to uptake and should therefore be measured in a valid and comparable way. A compendium of measurements for future use is suggested as supporting information.

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TL;DR: Overall, the results showed that multicomponent and dialogue-based interventions were most effective and identified strategies should be carefully tailored according to the target population, their reasons for hesitancy, and the specific context.

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TL;DR: Evidence from a natural experiment on effects of state government mandates in the US for face mask use in public issued by 15 states plus DC between April 8 and May 15 suggests that requiring face maskUse in public might help in mitigating COVID-19 spread.
Abstract: State policies mandating public or community use of face masks or covers in mitigating the spread of coronavirus disease 2019 (COVID-19) are hotly contested. This study provides evidence from a natural experiment on the effects of state government mandates for face mask use in public issued by fifteen states plus Washington, D.C., between April 8 and May 15, 2020. The research design is an event study examining changes in the daily county-level COVID-19 growth rates between March 31 and May 22, 2020. Mandating face mask use in public is associated with a decline in the daily COVID-19 growth rate by 0.9, 1.1, 1.4, 1.7, and 2.0 percentage points in 1-5, 6-10, 11-15, 16-20, and 21 or more days after state face mask orders were signed, respectively. Estimates suggest that as a result of the implementation of these mandates, more than 200,000 COVID-19 cases were averted by May 22, 2020. The findings suggest that requiring face mask use in public could help in mitigating the spread of COVID-19.

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Related Papers (5)
Frequently Asked Questions (15)
Q1. What are the contributions in this paper?

Vaccine hesitancy and reasons for refusing the COVID-19 vaccination among the U. S. 1 public: A cross-sectional survey 2 3 Ali S. Raja, MD, MPH, MBA ; Joshua D. Niforatos, MD, MTS ; Nancy Anaya, MD ; Joseph 4 Graterol, MD ; Robert M. Rodriguez, MD 5 6 1 Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical 7 School, Boston, Massachusetts, United States of America 8 2 Department of Emergency Medicine, The Johns Hopkins School of Medicine, Baltimore, 9 Maryland, United States of America 10 3 Department of Emergency Medicine, University of California, San Francisco, California, 11 United States of America 12 13 * Corresponding Author: 14 araja @ mgh. 

For COVID-19 vaccination to effectively confer herd 60 immunity, experts agree that at least 60-70% of the population will need to be vaccinated (5). 

When asked about acceptance of the COVID-19 vaccine, 37.8% (663) were COVID-19 142 vaccine hesitant: 374 (21.3%) non-acceptors and 289 (16.5%) unsure about accepting. 

98The primary outcome measure was COVID-19 vaccine hesitancy - defined as either non-100 acceptance or being unsure about acceptance of the COVID-19 vaccine. 

a framework of engaging community and religious leaders, 224 active messaging in various digital and non-digital media, education campaigns, targeted and 225 incentivized vaccine drives, and wide distribution of vaccine at trusted sites will likely be 226 required in order to decrease vaccine hesitancy. 

One of the potential ways to address vaccine hesitancy is to ensure that vaccines are 217 dispensed at locations where patients are most comfortable receiving them. 

55 Along with research and development of therapeutics, the most anticipated control 56 measures are a series of COVID-19 vaccines, two of which - as of this writing - have received 57 United States (U.S.) Food and Drug Administration emergency use authorizations (4). 

Because their goal was to assess vaccine hesitancy in a more medically naïve 86 population, the authors excluded respondents self-identifying as healthcare workers. 

Primary reasons 42 for hesitancy were concerns about side effects, need for more information, and doubts about 43 vaccine efficacy. 

192 Driven in part by popular perception of poor efficacy and fear of side effects, influenza 193 vaccine hesitancy is common (8–11,19). 

234 In conclusion, COVID-19 vaccine hesitancy is common in the U.S. population and more 235 prevalent in women, Blacks, people with lower education levels and Republicans. 

The authors transformed the primary outcome of 107 COVID-19 vaccine hesitancy from a nominal to a dichotomized (no/yes) categorical variable for 108 primary analysis and used the Chi-squared test with Bonferroni correction for multiple 109 comparisons to assess association of this outcome with characteristics of age, gender, race, 110 political affiliation, and receipt of influenza in previous years. 

35 Results 36 A total 663 respondents (37.8%) were COVID-19 vaccine hesitant (374 [21.3%] non-acceptors 37 and 289 [16.5%] unsure about accepting). 

61 Vaccine hesitancy, a phenomenon which predates the pandemic, has been well studied with other 62 vaccinations, including the influenza and Measles/Mumps/Rubella vaccines. 

vaccine 202 hesitancy may further exacerbate the disproportionate effects of the pandemic on Latinx, 203 African-American and Native American populations (22).