“To Be Vaccinated or Not to Be Vaccinated”: Factors Influencing COVID-19 Vaccine Hesitancy and Future Vaccination Willingness Amongst US Women of Reproductive Age

Martina Anto-Ocrah,1,2 Michael Chen,3 Nabeeha Jabir Affan,2 Lindsey DeSplinter,4 Stefanie Hollenbach5 1Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; 2Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; 3JSI Research & Training Institute, Boston, MA, USA; 4McGovern Medical School, UT Health Houston, Houston, Texas, USA; 5Department of Obstetrics and Gynecology, University of Rochester, Rochester, NY, USACorrespondence: Martina Anto-Ocrah, Email [email protected] & Objectives: Growing data on the impact of herd immunity and susceptibility of unvaccinated persons to chronic COVID sequelae requires deeper understanding of vaccine stigma and hesitancy to facilitate population needs. Reproductive-aged women (18– 45 years) were at a “vaccine paradox” during COVID-19 – hesitant to receive the vaccine, yet at increased risk for COVID infection. In this study, we sought to: identify demographic predictors, reasons, geographic location of vaccine hesitancy, and COVID-specific attributes that predict future vaccination willingness. We hypothesized that high COVID risk perception and high COVID stress would be predictors of willingness.Methods: Study Design: Cross-sectional survey of women across the United States. Main Outcomes and Measures: Vaccine hesitancy was defined as responding “No/Not Sure” to the question “Have you received any of the COVID-19 vaccines?” The COVID-Risk scale evaluate perceived COVID Risk, and the COVID-19 Perceived Stress Scale (PSS-10-c) evaluated COVID stress. Open ended questions inquired about participants’ vaccine concerns.Results: Of the 1,037 women who accessed the survey, 948 (91%) consented and completed. Predictors of vaccine hesitancy included younger aged parents (p=0.005), non-white race (p=0.003), and having high school or lower educational attainment (p< 0.0001). Using smoking as a proxy measure of “health behavior”, we found long-term smokers or quitters were more hesitant than those who never smoked (p=0.03). Geographic analyses showed the most vaccine hesitant women resided in Southeast and Midwest US. Hesitancy reasons included side effects (21%) and fertility/pregnancy concerns (4%). High COVID risk perception (p=0.0004) and high COVID stress (p=0.01) significantly predicted future willingness to get vaccinated.Conclusions and Relevance: This research provides insights for managing the “vaccine paradox” in reproductive age women, and identifying factors that influence COVID-19 vaccine hesitancy and future vaccination willingness. Public health and policy advocates could target messaging around COVID risk and stress in Southeastern and Midwestern regions; as well as address women’s concerns around fertility and other side effects.Plain Language Summary: What do we already know about this topic?: During the COVID-19 pandemic, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) deemed women of reproductive age amongst “populations of high priority” for vaccination. However, these women were at a “vaccine paradox”- they were hesitant to receive the COVID vaccine, while concurrently at increased risk for severe COVID infections.What did our group do?: We surveyed a geographically representative sample of women across the United States to understand who the unvaccinated were, where they were geographically located, why they were vaccine hesitant, and what COVID-specific attributes predicted current, and future willingness to get vaccinated.What we found: Age, parenting status, race, education, and geography were predictors of vaccine hesitancy. Women’s vaccination decisions were also influenced by their household responsibilities, which increased during the pandemic. Future willingness to get vaccinated was higher if they had high COVID risk perception and high COVID stress.Implications of our findings: This research provides insights for promoting access, acceptance, and uptake of recommended vaccines amongst women of reproductive age to manage future pandemics. Our findings are even more paramount as reports show, that even though the pandemic has stabilized, COVID vaccination rates for women are lagging, compared to men’s.Keywords: women’s health, covid, vaccine hesitancy, covid stress, covid risk