Racial/Ethnic Differences in COVID-19 Vaccine Hesitancy Among Health Care Workers in 2 Large Academic Hospitals

IMPORTANCE Significant differences in hesitancy to receive COVID-19 vaccination by race/ethnicity have been observed in several settings. Racial/ethnic differences in COVID-19 vaccine hesitancy among health care workers (HCWs), who face occupational and community exposure to COVID-19, have not been well described. OBJECTIVE To assess hesitancy to COVID-19 vaccination among HCWs across different racial/ethnic groups and assess factors associated with vaccine hesitancy. DESIGN, SETTING, AND PARTICIPANTS This survey study was conducted among HCWs from 2 large academic hospitals (ie, a children’s hospital and an adult hospital) over a 3-week period in November and December 2020. Eligible participants were HCWs with and without direct patient contact. A 3-step hierarchical multivariable logistic regression was used to evaluate associations between race/ethnicity and vaccine hesitancy controlling for demographic characteristics, employment characteristics, COVID-19 exposure risk, and being up to date with routine vaccinations. Data were analyzed from February through March 2021. MAIN not on, unsure about, or to delay vaccination, as the outcome. CONCLUSIONS AND RELEVANCE This study found that vaccine hesitancy before the authorization of the COVID-19 vaccine was increased among Black, Hispanic or Latino, and Asian HCWs compared with White HCWs. These findings suggest that interventions focused on addressing vaccine hesitancy among HCWs are needed.


Introduction
It has been more than a year since the first case of COVID-19 was reported in the US, and as of June 2021, more than 30 million diagnoses of COVID-19 and 590 000 deaths have been attributed to this outbreak. 1,2 Although the pandemic has impacted everyone, COVID-19 disease burden disproportionately falls on members of racial/ethnic minority groups. Black and Hispanic or Latino individuals are nearly 3-fold more likely to be hospitalized owing to COVID-19 and approximately 2-fold more likely to die from the disease compared with White non-Hispanic individuals. 3 With 3 authorized SARS-CoV-2 vaccines available for emergency use in the U.S, [4][5][6] it is important to increase access to COVID-19 vaccines and address COVID-19 vaccine hesitancy in communities where it is still high. 7,8 The vaccine allocation process in the US prioritized health care workers (HCWs) and residents of long-term care facilities, who were the first to be offered COVID-19 vaccines. As COVID-19 vaccination expands, it is important to continue to assess uptake of vaccination among HCWs across different racial/ethnic groups and ensure equitable allocation of vaccines. HCWs face occupational and community exposure to COVID-19, and they are essential to the public health response to this pandemic. Although the risk of occupational infection is low with proper use of personal protective equipment, studies have found that Black and Hispanic or Latino HCWs have a higher burden of infection, associated with increased community exposure to SARS-CoV-2. 9, 10 In a large study of 10 275 HCWs, 9 community exposure and living in areas with increased COVID-19 prevalence were associated with most infections among HCWs. The odds of being infected with COVID-19 were increased 2-fold among Black HCWs and HCWs with multiracial backgrounds compared with White HCWs. The differential risk for community acquisition of SARS-CoV-2 among HCWs from racial/ethnic minority groups likely stems from historical and systemic practices that have disadvantaged communities of color and led to residential segregation, which is associated with increased exposure to SARS-CoV-2. 11 Thus, uptake of COVID-19 vaccines is particularly crucial for HCWs living in communities with increased disease burden.
As an extension of our previous work, 12 we analyzed data from a large survey of HCWs at 2 hospitals in Philadelphia in the weeks prior to the launch of the COVID-19 vaccine for HCWs. The purpose of this study was to describe COVID-19 vaccine hesitancy, defined as intent to decline vaccination, being unsure about vaccination, or intent to delay vaccination, across different racial/ ethnic groups of HCWs and assess factors associated with vaccine hesitancy.

Methods
Institutional review boards at each hospital in this survey study reviewed the protocol and determined that the study was exempt from further review and informed consent because the identity of participants could not readily be ascertained directly or through identifiers linked to participants. This study is reported following the American Association for Public Opinion Research (AAPOR) reporting guideline.

Study Design and Participants
This was a cross-sectional survey study among HCWs. Eligible HCWs were asked to complete a confidential survey to assess their intention to receive a COVID-19 vaccine. HCWs with and without direct patient contact were eligible for this study if they were employees of hospital A (a children's hospital) or hospital B (an adult hospital) or contracted by a third party to work at either hospital.
Employees received an invitation to complete the survey using their work email. Reminders were sent via email once a week over a 3-week period in November and December 2020. HCWs who participated in COVID-19 vaccine clinical trials and those who did not report their race/ethnicity were excluded from our total sample in this analysis by race/ethnicity.

Survey
The survey focused on intention to receive a COVID-19 vaccine among HCWs and their family, when they planned to be vaccinated after being offered the vaccine (ie, immediately or 3 month, 6 months, or 12 months later), concerns about vaccine safety, level of vaccine efficacy desired, vaccination history and children's vaccination history, and demographic characteristics. When assessing intention to receive the COVID-19 vaccine, the following assumptions about the vaccine were presented: that it would be at least 50% effective and available at no cost and that vaccination would be voluntary.
Employment characteristics included hospital of employment, role in the hospital, and years of employment. We also assessed HCWs' exposure risk for COVID-19 in the hospital and in the community (ie, household and family exposure), as well as their history of COVID-19 infection. The surveys were developed and distributed using the Research Electronic Data Capture (REDCap) software version 10.9.4 (Vanderbilt University), and the data were stored in a secure server.

Outcome Variable
Vaccine hesitancy was the outcome. HCWs were classified as being hesitant if they reported that they did not plan to receive a vaccine or were unsure about receiving a COVID-19 vaccine or if they planned on delaying receipt of the vaccine for 3 months, 6 months, or 12 months. HCWs who reported that they were planning to receive the COVID-19 vaccine as soon as it was available to them were classified as not hesitant.

Covariates Demographic Characteristics
Demographic characteristics of HCWs included age, race/ethnicity, sex, education level, and residential area categorized as urban, suburban, or rural. Race/ethnicity was categorized as White, Black or African American, Asian, Hispanic or Latino, and other or mixed race/ethnicity. The other or mixed race/ethnicity category included American Indian or Alaska Native, Pacific Islander or Hawaiian, or mixed race/ethnicity categories.

Employment Characteristics
Employment characteristics included hospital of employment (ie, hospital A or B) and whether the role was clinical with direct patient contact (eg, roles as physicians, nurses, or physical therapists), nonclinical with direct patient contact (eg, roles in transport or food and cleaning services), or nonclinical with no patient contact (eg, roles as administrative and research staff). We also collected years of employment (ie, <1 year, 2-4 years, or Ն5 years).

Risk of COVID-19 Exposure
We assessed occupational risk of COVID-19 exposure by the area of work in the hospital. COVID-19 units, emergency departments (EDs), and intensive care units (ICUs) represented high-risk areas for household members with past COVID-19 infection. We also asked HCWs if they had a prior COVID-19 diagnosis.

Being Up to Date With Routine Vaccinations
We asked if HCWs or their children were up to date on routine vaccinations. We additionally asked HCWs if they had refused vaccination for themselves or their children in the past.

Statistical Analysis
We completed descriptive summary statistics (ie, frequencies and percentages) of COVID-19 vaccine hesitancy and HCW demographic and employment characteristics stratified by race/ethnicity. Differences in other variables across different racial/ethnic groups were evaluated by χ 2 tests with a significance level of P = .05. All tests were 2-sided. We reported the reasons for vaccine hesitancy among HCWs who were hesitant and reasons for vaccine acceptance among HCWs who were not hesitant. We then conducted a 3-step hierarchical multivariable logistic regression using the

Being Up to Date on Routine Vaccinations by Race/Ethnicity
We also asked HCWs if they were up to date with all or most routine vaccinations (

Reasons for COVID-19 Vaccine Hesitancy Among HCWs Who Were Hesitant
In Table 2, we report the frequency of reasons for vaccine hesitancy (from most to least common) by race/ethnicity and among 5440 individuals who indicated they were hesitant to receive the vaccine.

Reasons for COVID-19 Vaccine Acceptance Among HCWs Who Were Not Hesitant
Reasons for vaccination among 5431 HCWs who were not hesitant are listed in Table 3

Adjusted Associations Between Race/Ethnicity and COVID-19 Hesitancy
Model 1 shows the association between race/ethnicity and vaccine hesitancy adjusting for demographic characteristics, such as age, sex, education, and area of residence (   Table 4.

Discussion
According to the World Health Organization (WHO), vaccine hesitancy is defined as "the reluctance or refusal to vaccinate despite the availability of vaccines." 13 Vaccine hesitancy continues to be a considerable threat to global health and is among the top health priorities to tackle for WHO and the US. 13 This survey study found that vaccine hesitancy was high among HCWs and there were substantial differences in COVID-19 vaccine hesitancy by race/ethnicity among HCWs, a population with potentially more access to accurate information about vaccine science and limited barriers to vaccine access. We found that, compared with White HCWs, hesitancy was highest among Black and to what has been reported for HCWs of other racial/ethnic groups and center on safety concerns. 17 Interestingly, adjusting for employment characteristics and exposure to COVID-19 was not associated with much change in the aORs in our study, potentially suggesting that being in a health care   22 This approach may help accelerate vaccination for individuals who planned to delay or were contemplating vaccination; however, it will be important to monitor unintended outcomes associated with these mandates given that this approach may be associated with increased health and economic disparities if HCWs lose employment for refusing the vaccine. 23 Other strategies, such as positive and culturally responsive messaging on COVID-19 vaccines and using vaccinated HCWs as vaccine ambassadors, should also be tested.

Strengths and Limitations
Our study has several strengths. We conducted a large survey of HCWs before vaccine implementation in the US, and our findings highlight existing differences in COVID-19 vaccine hesitancy by race/ethnicity. Our sample represented HCWs from a broad range of backgrounds and roles. The 3-step hierarchal model we used allowed us to understand the relative associations of demographic characteristics, employment variables, COVID-19 risk exposure, and prior receipt of vaccines with COVID-19 vaccine hesitancy.
Our findings should be interpreted in the context of several important limitations. With a response rate of approximately 35%, there is a risk of selection bias and limited generalizability of the results. Although our sample was large, we surveyed respondents in 2 hospitals at 1 universityaffiliated academic institution. Furthermore, because we used a convenience sample, we were not able to compare demographic characteristics of respondents and nonrespondents. It is possible that survey respondents were more likely to be hesitant and wanted their voices known. Our study measured intention to vaccinate prior to vaccine availability. As more people have gotten vaccinated and the acceptability of COVID-19 vaccines has increased in the general public, 24 HCWs' attitudes toward vaccination may have changed. Additionally, our survey did not include specific questions on attitudes, beliefs, or mistrust concerning the vaccine. c Model 3 included Model 2 and adjusted for being up to date with routine vaccinations, ever refusing a vaccine, and ever refusing a vaccine for their children.