Views about vaccines and how views changed during the COVID-19 pandemic among a national sample of young gay, bisexual, and other men who have sex with men

ABSTRACT

We examined perceptions of vaccines and changes during the coronavirus disease 2019 (COVID-19) pandemic. From 2019 to 2021, a national sample of young gay, bisexual, and other men who have sex with men completed an open-ended survey item about vaccine perceptions. Analyses identified themes and polarity (negative, neutral, or positive) within responses and determined temporal changes across phases of the pandemic (“pre-pandemic,” “pandemic,” “initial vaccine availability,” or “widespread vaccine availability”). Themes included health benefits of vaccines (53.9%), fear of shots (23.7%), COVID-19 (10.3%), vaccines being safe (5.6%), and vaccine hesitancy/misinformation (5.5%). Temporal changes existed for multiple themes (p < .05). Overall, 53.0% of responses were positive, 31.2% were negative, and 15.8% were neutral. Compared to the pre-pandemic phase, polarity was less positive for the widespread vaccine availability phase (odds ratio = 0.64, 95% confidence interval: 0.42–0.96). The findings provide insight into how vaccine perceptions change in concert with a public health emergency.

KEYWORDS:

• Vaccine
• vaccination
• young adult
• immunization
• gay men
• bisexual men

Introduction

Vaccination is one of the greatest public health achievements of the 20^th century,¹ yet many people in the United States (US) still do not receive their recommended doses.^2,3 Several vaccines have been surrounded by controversy (e.g., measles, mumps, and rubella [MMR] vaccine⁴; human papillomavirus [HPV] vaccine,^5,6 which has contributed to a growing vaccine hesitancy movement in the US.⁷ Indeed, nonmedical exemptions for vaccination have increased meaningfully over the last decade, and there are nearly 500 websites that feature content against vaccination.^8,9 This public health concern has likely been exacerbated by the coronavirus disease 2019 (COVID-19) pandemic, as COVID-19 vaccination has been met with a great deal of misinformation, controversy, and opposition.¹⁰

Given the evolving vaccine landscape in the US, it is important to continue to examine people’s thoughts and cognitions about vaccination, as these are key correlates of vaccine acceptability and hesitancy.¹¹ We sought to examine perceptions of vaccines among a national sample of young adult gay, bisexual, and other men who have sex with men (YGBMSM) and temporal patterns in these perceptions during the COVID-19 pandemic. YGBMSM often face challenges in accessing and receiving preventive healthcare, so the results will provide key insight into this public health issue.^12,13 This information can then help inform future interventions and communication efforts about vaccination.

Methods

Participants

Data were collected as part of a randomized controlled trial of an HPV vaccination intervention for YGBMSM. Details about this trial have been described previously.¹⁴ Briefly, we recruited a convenience sample of YGBMSM in the US through advertisements on social media sites, existing research panels, and university-based health organizations. Interested individuals were directed to a mobile-friendly project website to complete an eligibility screener.

Eligibility criteria included: (a) cisgender male; (b) 18–25 years of age; (c) either self-identifying as gay, bisexual, or queer; reporting ever having oral or anal sex with a male; or reporting being sexually attracted to males; (d) living in the US; (e) no doses of HPV vaccine received; and (f) no previous participation in the study. After providing informed consent, participants completed a baseline survey prior to receiving any content about HPV vaccination. Participants received $40 for completing baseline activities. The Institutional Review Board at The Ohio State University approved this study.

Measures

Data for the current analysis are from the baseline survey of participants who enrolled in the study between December 2019 and June 2021 and answered an open-ended question about vaccine perceptions: “What is the first thing you think about when you hear the word ‘vaccine’?” (n = 1,069). Two research team members first independently reviewed a subset of responses to inductively identify initial qualitative codes and met to compare codes and develop a coding scheme. The coders then applied the scheme to all responses for this survey item, after which they compared codes, resolved any discrepancies, made any needed adaptations, and identified themes. For each theme, each participant’s response was categorized as having the theme (given a value of “1”) or not having the theme (given a value of “0”). A response could be categorized as having multiple themes.

We also examined the polarity of responses and its timing in relation to the COVID-19 pandemic. For polarity, we categorized each response as being either negative (contained language not supportive of vaccination), neutral (contained language that was conflicting about or ambiguous toward vaccination), or positive (contained language supportive of vaccination). For timing, we used a participant’s date of enrollment into the study to categorize their response as having occurred during one of four phases of the COVID-19 pandemic.¹⁵

The phases represent important pandemic-related events that occurred in the US and included: “pre-pandemic” for participants who enrolled prior to March 11, 2020 (the day the World Health Organization designated COVID-19 a pandemic)¹⁶; “pandemic” for those who enrolled between March 11, 2020 and December 13, 2020, during which time period no COVID-19 vaccines were available in the US outside of clinical trials; “initial vaccine availability” for participants who enrolled between December 14, 2020 (the day the COVID-19 vaccine was first given outside of a clinical trial in the US) and April 18, 2021¹⁷; and “widespread vaccine availability” for participants who enrolled on or after April 19, 2021 (the first day the vaccine was available to all individuals ages 16 and older in all 50 states and the District of Columbia).¹⁸

Data analysis

For quantitative data analysis, we first described participant characteristics, themes, and polarity. We then used logistic regression to assess differences in the prevalence of each theme across the four phases of the COVID-19 pandemic and used ordinal logistic regression to determine temporal changes in polarity of responses. The ordinal logistic regression model dinal logistic regression model met the assumption of proportional odds according to the Brant test.¹⁹ Regression models produced odds ratios (ORs) and 95% confidence intervals (CIs). All statistical tests were two-tailed with a critical alpha of 0.05. Data were analyzed with R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria) and Stata version 15.0 (Statacorp, College Station, TX).

Results

Most participants were ages 22–25 (64.5%), were single and having sex or casually dating (65.4%), had at least some college education (67.4%), and self-identified as gay (64.8%) (Table 1). Just over half of participants indicated a minoritized racial/ethnic identity (54.1%). Overall, 119 (11.1%) participants were recruited during the pre-pandemic phase, 154 (14.4%) during the pandemic phase, 507 (47.4%) during the initial vaccine availability phase, and 289 (27.0%) during the widespread vaccine availability.

Table 1. Demographic and health-related characteristics of participants (n = 1,069).

	n (%)
Age (years)
18–21	380 (35.5)
22–25	689 (64.5)
Race/ethnicity
Non-Hispanic white	491 (45.9)
Non-Hispanic black	116 (10.9)
Hispanic	312 (29.2)
Non-Hispanic other	150 (14.0)
Relationship status
Single and not having sex	157 (14.7)
Single and having sex or casually dating	699 (65.4)
In a relationship	213 (19.9)
Education level
High school or less	348 (32.6)
Some college or more	721 (67.4)
Employment status
Employed full time or part time	772 (72.2)
Other	297 (27.8)
Sexual identity
Gay	693 (64.8)
Bisexual	289 (27.0)
Some other identity	87 (8.1)
Ever had sex with a man
No	73 (6.8)
Yes	996 (93.2)
Sexually attracted to males
No	38 (3.6)
Yes	1031 (96.4)
Region of residence
Northeast	194 (18.1)
Midwest	193 (18.1)
South	368 (34.4)
West	314 (29.4)
Health insurance
Private insurance	655 (61.3)
Public insurance	189 (17.7)
None/don’t know	225 (21.0)
Last preventative health visit
Within last year	489 (45.7)
More than a year ago	580 (54.3)

Percents may not sum to 100% due to rounding.

Themes

Table 2 shows the nine themes about vaccines that were identified, along with example terms/responses that demonstrate each theme. The most common themes were the health benefits of vaccines (53.9%), fear of shots (23.7%), COVID-19 (10.3%), vaccines being safe (5.6%), and vaccine hesitancy/misinformation (5.5%). The remaining themes were present in less than 5% of responses and included vaccine side effects (4.3%), other (non-COVID-19) diseases (3.7%), vaccine enthusiasm (2.0%), and other barriers to vaccination (i.e., not involving a fear of shots or vaccine side effects) (1.7%).

Table 2. Themes about vaccination across the phases of the COVID-19 pandemic (n = 1,069).

	Example Terms	Pre-Pandemic (n = 119)	Pandemic (n = 154)	Initial Vaccine Availability (n = 507)	Widespread Vaccine Availability (n = 289)
		n (%)	n (%)	n (%)	n (%)
Health benefits	prevention; keep from getting sick	71 (59.7)	94 (61.0)	276 (54.4)	135 (46.7)*
Fear of shots	needles; injections	30 (25.2)	43 (27.9)	117 (23.1)	63 (21.8)
COVID-19	COVID-19; COVID	0 (0.0)	5 (3.2)	68 (13.4)**	37 (12.8)**
Vaccines being safe	safe; safety	4 (3.4)	8 (5.2)	32 (6.3)	16 (5.5)
Vaccine hesitancy and misinformation	unsure; controversial	9 (7.6)	10 (6.5)	19 (3.7)	21 (7.3)
Vaccine side effects	pain; sickness	5 (4.2)	7 (4.5)	17 (3.4)	17 (5.9)
Other diseases (non-COVID-19)	flu; influenza	9 (7.6)	7 (4.5)	17 (3.4)*	7 (2.4)*
Vaccine enthusiasm	hope; enthusiasm	1 (0.8)	2 (1.3)	8 (1.6)	10 (3.5)
Other barriers to vaccination	cost; health insurance	3 (2.5)	3 (1.9)	6 (1.2)	6 (2.1)

p-values are from logistic regression models examining temporal changes in each theme. The pre-pandemic phase was the referent group in these models, except for the theme of COVID-19. For the COVID-19 theme, the pandemic phase was the referent group since COVID-19 was not mentioned during the pre-pandemic phase. COVID-19 = coronavirus disease 2019. *p < .05, **p < .01.

Responses from the widespread vaccine availability phase were less likely to mention the health benefits of vaccines compared to the pre-pandemic phase (46.7% vs. 59.7%; OR = 0.59, 95% CI: 0.38–0.91). Compared to the pandemic phase, responses from the initial vaccine availability phase (13.4% vs. 3.2%; OR = 4.62, 95% CI: 1.83–11.66) and widespread vaccine availability phase (12.8% vs. 3.2%; OR = 4.38, 95% CI: 1.68–11.38) were more likely to mention COVID-19. Pandemic phase served as the referent group for the COVID-19 theme. Compared to the pre-pandemic phase, responses from the initial vaccine availability phase (3.4% vs. 7.6%; OR = 0.42, 95% CI: 0.18–0.98) and widespread vaccine availability phase (2.4% vs. 7.6%; OR = 0.30, 95% CI: 0.11–0.83) were less likely to mention other (non-COVID-19) diseases. There were no other temporal changes in themes (all other p > .05).

Polarity

Overall, about half (53.0%) of responses were categorized as positive with fewer being negative or neutral (31.2%, and 15.8%, respectively). Compared to the pre-pandemic phase, responses from the widespread vaccine availability phase were less positive in polarity (OR = 0.64, 95% CI: 0.42–0.96). This reflects that positive polarity decreased from 58.8% during the pre-pandemic phase to 47.8% during the widespread vaccine availability phase, while the negative polarity increased from 26.1% during the pre-pandemic phase to 36.0% during the widespread vaccine availability phase (Figure 1). The polarity of responses during the pandemic phase and the initial vaccine availability phase did not differ from the pre-pandemic phase (both p > .05).

Figure 1. Polarity across phases of the COVID-19 pandemic (n = 1,069). Error bars indicate standard errors.

Discussion

Vaccine hesitancy is an increasing public health concern in the US.^8,9 The current study offered a unique opportunity to examine sentiments toward vaccines among a national sample of YGBMSM and identify potential temporal changes in these sentiments. The most prevalent themes identified in this study (health benefits of vaccines, fear of shots, vaccines being safe, vaccine hesitancy/misinformation) are consistent with past research qualitatively examining vaccine perceptions.^20,21 However, one notable difference is that these past studies also identified autonomy as a common theme.^20,21 This difference could be due to these studies focusing on parents and healthcare providers, whereas our study included only young adults (who may perceive autonomy as a less salient issue).^20,21 For polarity, over half of the responses in our study were positive, which also aligns with past research on people’s thoughts about vaccines.²²

We also found temporal changes in both themes and polarity. The increase in responses related to COVID-19 over time likely reflects the large increase in media coverage and attention around COVID-19 vaccination that occurred during our study.^23,24 The decrease in responses related to the health benefits of vaccines may be attributable to evolving concerns about the efficacy of COVID-19 vaccines that occurred during this time. For example, there may have been concerns about vaccine efficacy against different COVID-19 variants or that two of the original COVID-19 vaccine series were the first messenger ribonucleic acid (mRNA) vaccines to be approved by the Food and Drug Administration.²⁵ Future efforts should explore how people’s perceptions of vaccines may be affected by the emergence of new types of vaccines. Interestingly, we did not find temporal changes in the prevalence of comments related to vaccine misinformation and hesitancy, despite its presence on social media and other avenues.^26,27 This suggests that the observed decrease in positive polarity and increase in negative polarity over time was not driven by increases in vaccine misinformation and hesitancy, but rather other vaccine-related concerns (e.g., vaccine efficacy) or potentially recent negative experiences with vaccination (e.g., experiencing an adverse event after COVID-19 vaccination or another vaccination).

Future implications

The results of our study have implications for future vaccine communication efforts for young adults. The identified themes represent topics that are likely salient to young adults concerning vaccination and should therefore be highlighted in future communication efforts for these ages. Further, our results concerning temporal patterns in themes and polarity show how views on vaccines change in concert with a public health emergency. People’s cognitions change during such crises,²⁸ and our results provide novel insight into how vaccine perceptions changed during the COVID-19 pandemic. Such information can help future efforts promoting vaccination anticipate such temporal changes and be prepared to provide timely content.

Limitations

Study limitations include assessing participants’ perceptions about vaccines with a single open-ended survey item, though participants could provide as much information as they wanted to for this item. Data collection for the baseline survey concluded in June 2021, and it is likely that perceptions about vaccines have continued to evolve in response to vaccine-related developments since then (e.g., the availability of additional COVID-19 doses.²⁹ Related, the survey item was only included on a baseline survey, so we were not able to measure within-person changes over time. Participants were a convenience sample of YGBMSM that were participating in an HPV vaccination intervention and who were recruited via online avenues, which may limit the generalizability of our findings. However, participants were from throughout the US, where most young adults use the internet (about 99%)³⁰ and social media (over 80%)³¹; and past research has shown that vaccine-related attitudes of YGBMSM are similar to those of other young men.³² Lastly, we were not able to examine how temporal changes in our outcomes may have differed by participants’ characteristics due to small sample sizes. Future research is needed to examine such subgroup differences.

Conclusion

We examined perceptions of vaccines among a national sample of YGBMSM in the US. Most participants had positive views about vaccines (i.e., polarity), and we identified several key themes within their responses. Importantly, we also determined that how themes and polarity changed in concert with the COVID-19 pandemic. Results can help guide future interventions and communication efforts about vaccination by informing the content and timeliness of such efforts.

Author’s contributions

Conception and Design: Daniel Marshall, Annie-Laurie McRee, Amy L. Gower, and Paul L. Reiter

Analysis and Interpretation of the Data: Daniel Marshall and Paul Reiter

Manuscript Drafting: Daniel Marshall, Annie-Laurie McRee, Amy L. Gower, and Paul L. Reiter

Critical Revision: Daniel Marshall, Annie-Laurie McRee, Amy L. Gower, and Paul L. Reiter

All authors approve the final version to be published and agree to be accountable for all aspects of the work.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R37CA226682. Additional support was provided from the Center for Health Communications Research at the University of Michigan [P30CA046592] and the Recruitment, Intervention, and Survey Shared Resource at The Ohio State University Comprehensive Cancer Center [P30CA016058]. This work was prepared while Dr. McRee was employed at the University of Minnesota. The opinions expressed in this article are the authors’ own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.