Since its first reported case in the United States in January 2020, the ongoing COVID-19 pandemic has caused over 4 million deaths globally, and has severely disrupted global economies, educational and workplace practices, social gatherings, and daily behaviors [1]. To combat the spread of SARS-CoV-2, the virus that causes COVID-19, numerous vaccines targeting components of the virus have been rapidly developed. Since February 2021, three vaccines against SARS-CoV-2 have been granted Emergency Use Authorization (EUA) by the US Food and Drug Administration: BNT162b2 (Pfizer-BioNTech), mRNA-1273 (Moderna), and Ad26.COV2.S (Janssen/Johnson & Johnson) [2]. Although there is wide variability in vaccination rates among and within states, over 330 million total doses have been administered nationwide as of July 7, 2021, with 55.1% of adults having received one or more doses [3].

To support programs to increase vaccination, greater attention is now being paid to community perceptions of these vaccines and how they relate to vaccine uptake and hesitancy, particularly among racial and ethnic minorities [4]. Several studies have found sociodemographic differences in vaccine hesitancy across the population, with significantly higher rates of vaccine hesitancy among those who are non-White compared to Whites and those without a 4-year advanced degree compared to those with a 4-year advanced degree [5]. Many attribute this concentration of hesitancy among non-White groups, particularly among Black Americans, to centuries of structural and medical racism that have resulted in unequal treatment of minority populations in the American health care system [6]. Understanding the unequal distribution of COVID-19 vaccine uptake and hesitancy is important as vaccination campaigns across the United States aim to reach sufficient community coverage to surpass the herd immunity threshold, estimated to be between 80%-90% for COVID-19 [7].

Young adults, including college or university students, are more likely to be asymptomatic or paucisymptomatic carriers of SARS-CoV-2 compared to their older counterparts [8]. American college students also frequently live together with other students in congregate dormitory settings or off-campus housing, which has led to numerous outbreaks of COVID-19 among young adults on college campuses [9-11]. These outbreaks have had spillover effects into neighboring communities and act as super-spreader–like events [12]. Despite this increased potential for viral spread, young adults are among the least likely age group to receive vaccines against other respiratory pathogens, such as for seasonal influenza strains [13]. Seasonal influenza vaccination uptake, which has been suggested as a possible predictor of COVID-19 vaccination uptake [14], has historically been low on college campuses, estimated to be between 8%-39% based on a survey of college students [15] conducted at a time when many schools did not require seasonal influenza vaccination. Current national data reveal that 18- to 29-year-olds are the least likely age group to be vaccinated for COVID-19 [3]. Because of this, it is vital to understand perceptions of the COVID-19 vaccines and predictors of vaccine uptake and willingness among college student communities, overall and stratified by racial and ethnic minority groups. Understanding these patterns of uptake and willingness among college students will help public health officials and student health programs to better promote vaccination opportunities to increase the uptake of vaccines for young adults and college-aged persons.

In this study, we describe results of behavioral and perception surveys administered as part of a longitudinal cohort study of students, faculty, and staff at a small liberal arts college located in Milton, Massachusetts, a suburb of Boston. This college has approximately 2000 undergraduate students, about 1000 of which live on campus in congregate dormitory settings, as well as 300 faculty and 400 staff members. Data were collected at two time points during the Spring 2021 semester: in the first week students returned to campus in early February, and immediately prior to final exams in late April 2021. We report the perceptions and intentions of this population regarding the COVID-19 vaccine as well as vaccine uptake.

All students, faculty, and staff members of Curry College electronically received an invitation to learn more about the study and enroll via a HIPAA-compliant, online survey-hosting platform. Interested individuals completed the informed consent process online in either text or video format; we have previously demonstrated that video consent is associated with higher comprehension of consent elements [16]. Consent to participate was documented online. Eligibility criteria were as follows: aged ≥18 years, ability to read and understand English without assistance, being a member of the Curry College residential community during the Spring 2021 semester (February-May 2021); completing at least part of their instruction or job in-person on the Curry College campus in Milton, Massachusetts; intention to remain in the vicinity of Curry College for the entire study period, willingness to comply with Curry College COVID-19 weekly screening requirements, willingness to answer biweekly study surveys electronically sent via email, willingness to participant in venipuncture for blood sample collection, and having no bleeding disorder preventing the use of venipuncture. Eligible participants who did not complete consent before returning to campus were offered enrollment on-site during their first week of classes.

Enrolled participants completed an online baseline survey. The survey collected demographic and socioeconomic information, as well as perceptions regarding COVID-19 risk and the COVID-19 vaccines, vaccine hesitancy, and self-reported vaccine uptake, with individual questions adapted from a validated, national probability-sampled survey used in a larger study of SARS-CoV-2 seroprevalence [17]. Vaccine hesitancy and concerns about the vaccine were assessed with a single item asking about willingness to receive the vaccine when eligible. At the time of the baseline survey in February 2021, most states were only offering the vaccine to those aged >65 years, health care workers, and essential workers. By the time of the final survey in late April 2021, all US adults were eligible for the COVID-19 vaccine. Participants were also asked about their perception of the safety and efficacy of the vaccines and perceptions about the timing of the EUA approval for the vaccines. At the end of the Spring 2021 semester in late April, participants completed a final survey including the same questions about perceptions about COVID-19 vaccines and receipt of vaccination.

Participant status as a health care worker or student (HCW) was established after identifying the primary major or department with which the student, faculty, or staff member was primarily affiliated via school records. Students were categorized as HCWs if their major course of study was either nursing or exploratory health professions. Faculty and staff were categorized as HCWs if their primary department was either the Department of Nursing or the Student Health Center.

Selection fractions and ratios will be calculated for students as a whole as well as for on-campus residential and off-campus commuter students and to assess for possible selection bias among these student subpopulations.

All statistical analyses were conducted with SAS (version 9.4; SAS Institute). Descriptive statistics and frequencies among the study sample results were obtained for all categorical demographic, exposure, and outcome variables in the survey. Fisher exact test was used to determine if there were statistical differences in attitudes toward and willingness to receive the COVID-19 vaccine between several sociodemographic groups, including racial and ethnic groups. To determine whether there were statistical differences in sociodemographic variables and perception of/intention to receive vaccine between those who were vaccinated and unvaccinated in April, predicted prevalence ratios with marginal standardization and confidence intervals were calculated using logistic regression [18]. We also used Fisher exact test to determine if there were statistically significant differences in self-reported vaccine uptake at the final time point between those who reported at baseline that they were unwilling to receive the COVID-19 vaccine and those who reported they were willing.

This longitudinal cohort study was conducted with the approval of the Emory University (STUDY00002096) and Curry College Institutional Review Boards in accordance with all applicable regulations.

Between February 14-19, 2021, a total of 454 participants enrolled in the study and completed the baseline survey and venipuncture. Of these, 328 (72.8%) completed the second venipuncture and final survey in late April 2021. Most participants were female (333/454, 70.9%), White (366/433, 71.3%), non-Hispanic/Latinx (402/453, 69.2%), and students (308/450, 60.4%; Table 1). The median age of participants was 21 years. Most participants were not HCWs (313/454, 68.9%), as classified by department affiliation and student major (Table 1). In total, about 14% (308/2200) of the total student body participated in the study ulti(Table S1 in Multimedia Appendix 1).

Participants were asked about their willingness to receive a COVID-19 vaccine and their attitudes regarding COVID-19 vaccines at the baseline time point in February and at the final study survey in April 2021. At baseline, over two-thirds of those who reported they were unvaccinated indicated that they were willing or very willing to receive the COVID-19 vaccine once they became eligible (Figure 1, Table S2 in Multimedia Appendix 1). In comparison, in the final survey, among the 105 participants who reported not having received a dose of a COVID-19 vaccine, nearly 65% reported that they were willing or very willing to get vaccinated once they were able (Figure 1, Table S3 in Multimedia Appendix 1). All Massachusetts residents ≥16 years old have been eligible to receive the COVID-19 vaccine since April 19, 2021. However, in many areas, demand for vaccines exceeded supply, leading to delays in obtaining appointments [19]. Attitudes regarding the COVID-19 vaccine differed by race and ethnicity (Figure 1). In the baseline survey, 28% (8/28) of Black and 21% (6/29) of other non-White respondents reported they were unwilling or very unwilling to receive the COVID-19 vaccine, compared to only 13% (34/268) of White respondents. Among Hispanic/Latinx individuals, 40% (12/40) reported they were unwilling or very unwilling to receive the COVID-19 vaccine compared to 11% (39/300) of non-Hispanic/Latinx respondents.

Participants were also asked about their perceptions of the speed with which the COVID-19 vaccines were granted Emergency Use Authorization by the US Food and Drug Administration. In the baseline survey, 30.4% (137/451) of participants believed the COVID-19 vaccine was approved too quickly (Figure 2, Table S2 in Multimedia Appendix 1). These perceptions differed across racial and ethnic groups: 29% (104/363) of White, 50.0% (15/30) of Black, 37.8% (14/37) of other non-White respondents, and 53.8% (29/52) of Hispanic/Latinx participants believed the COVID-19 vaccine was approved too quickly. In the April survey, 25.1% (95/365) of respondents believed the COVID-19 vaccines were approved too quickly. By race and ethnicity, about 23.3% (74/318) of White, 43% (9/21) of Black, 34.6% (9/26) of other non-White, and 37.8% (14/37) of non-Hispanic/Latinx participants believed the COVID-19 vaccine was approved too quickly in the April survey.

At the final study assessment during late April 2021, about two-thirds (305/454) of all participants reported having received the COVID-19 vaccine (Table 1); this was similar to the Massachusetts statewide vaccination rate at the time [20]. However, in this study, 60.3% (186/308) of student participants reported having received the COVID-19 vaccine; this was much higher than the Massachusetts age-specific vaccination rate among 20- to 29-year-olds at that time, which was approximately 46% [20]. Participants who were natal sex women were about 10% more likely to self-report having received the COVID-19 vaccine compared to natal sex men (Table 1). Black and other non-White participants were 25% less likely to report vaccination compared to White participants. Overall Massachusetts data from the same point in time revealed a similar but weaker relationship between race and vaccination status [20]. However, there was not significant evidence of a relationship between self-reported vaccination uptake among Hispanic/Latinx participants when compared to non-Hispanic/Latinx participants. Taken together, these data indicate disparities in vaccine uptake among Black participants.

Other demographic variables were also found to be significantly associated with self-reported vaccination rate. Staff and faculty were nearly 50% more likely to report vaccination compared to students (Table 1). Of note, the average age among students was 21.5 years, while the average ages among faculty and staff were 50.7 years and 48.2 years, respectively; as such, faculty and staff had a longer window of time during which they could have received the COVID-19 vaccine by the time the survey was conducted due to the age-bracketed rollout in Massachusetts.

Further, we analyzed the relationship between work and/or study in health care settings and self-reported vaccination. Participants who identified as students or workers in health care settings were nearly 30% more likely to report COVID-19 vaccination compared to those who do not work or study in these settings (Table 1). Those who worked/studied in health care settings were given earlier eligibility to receive the COVID-19 vaccine; however, all residents of Massachusetts had been eligible to receive the vaccine since April 19, 2021, and the time of final survey collection was in late April. At the time, there were no workplace requirements for vaccination in the state of Massachusetts.

We examined the relationship between vaccine intention measured at baseline and vaccine uptake in the final survey. Those who responded at baseline that they were likely or very likely to receive the COVID-19 vaccine were significantly more likely to have received the vaccine by the final time point compared to those who said they were unlikely or very unlikely to receive the COVID-19 vaccine, which may indicate that vaccine perception and intentions were formed early in the vaccine rollout process (Figure 3).

Respondents who reported being unwilling to receive the COVID-19 vaccine at the final time point were asked to indicate possible reasons for being hesitant (Table 2). Although the plurality of respondents indicated “None of the above,” the most commonly selected prespecified reason was that the vaccine approval process was rushed. These results were consistent with results regarding questions about whether the vaccine approval timeline was rushed, suggesting that participants’ skepticism of the speed with which the COVID-19 vaccines were approved might have influenced their hesitancy in uptake of the vaccine.