Background Despite the availability of safe and efficacious COVID-19 vaccines, a significant proportion of the American public remains unvaccinated and does not appear immediately interested in receiving the vaccine. Methods In this study, we analyzed data from the U.S. Census Bureau’s Household Pulse Survey, a biweekly cross-sectional survey of U.S. households. We estimated the prevalence of vaccine hesitancy across states and nationally and assessed the predictors of vaccine hesitancy and vaccine rejection. Additionally, we examined the underlying reasons for vaccine hesitancy, grouped into thematic categories. Results A total of 459,235 participants were surveyed from January 6 to March 29, 2021. While vaccine uptake increased from 7.7 to 47 percent, vaccine hesitancy rates remained relatively fixed: overall, 10.2 percent reported that they would probably not get a vaccine, and 8.2 percent would definitely not get a vaccine. Income, education, and state political leaning strongly predicted vaccine hesitancy. However, while both female sex and Black race were factors predicting hesitancy, among those who were hesitant, these same characteristics predicted vaccine reluctance rather than rejection. Those who expressed reluctance invoked mostly “deliberative” reasons while those who rejected the vaccine were also likely to invoke reasons of “dissent” and “distrust”. Conclusion Vaccine hesitancy comprises a sizable proportion of the population and is large enough to threaten achieving herd immunity. Distinct subgroups of hesitancy have distinctive socio-demographic associations as well as cognitive and affective predilections. Segmented public health solutions are needed to target interventions and optimize vaccine uptake.

Background Disparities in COVID-19 testing—the pandemic’s most critical but limited resource—may be an important but modifiable driver of COVID-19 inequities. Methods We analyzed data from the Missouri State Department Health and Senior Services on all COVID-19 tests conducted in the St. Louis and Kansas City regions. We adapted a well-established tool for measuring inequity—the Lorenz curve—to compare COVID-19 testing rates per diagnosed case among Black and White populations. Results Between 3/14/2020 and 9/15/2020, 606,725 and 328,204 COVID-19 tests were conducted in the St. Louis and Kansas City regions, respectively. Over time, Black individuals consistently had approximately half the rate of testing per case compared to White individuals. In the early period (3/14/2020 to 6/15/2020), zip codes in the lowest quartile of testing rates accounted for only 12.1% and 8.8% of all tests in the St. Louis and Kansas City regions, respectively, even though they accounted for 25% of all cases each region. These zip codes had higher proportions of residents who were Black, without insurance, and with lower median incomes. These disparities were reduced but still persisted during later phases of the pandemic (6/16/2020 to 9/15/2020). Lastly, even within the same zip code, Black residents had lower rates of tests per case compared to White residents. Conclusions Black populations had consistently lower COVID-19 testing rates per diagnosed case compared to White populations in two Missouri regions. Public health strategies should proactively focus on addressing equity gaps in COVID-19 testing to improve equity of the overall response.

Background The COVID-19 vaccination campaign in the US has been immensely successful in vaccinating those who are receptive, further increases in vaccination rates however will require more innovative approaches to reach those who remain hesitant. Developing vaccination strategies that are modelled on what people want could further increase uptake. Methods and findings To inform COVID-19 vaccine distribution strategies that are aligned with public preferences we conducted a discrete choice experiment among the US public (N = 2,895) between March 15 to March 22, 2021. We applied sampling weights, evaluated mean preferences using mixed logit models, and identified latent class preference subgroups. On average, the public prioritized ease, preferring single to two dose vaccinations (mean preference: -0.29; 95%CI: -0.37 to -0.20), vaccinating once rather than annually (mean preference: -0.79; 95%CI: -0.89 to -0.70) and reducing waiting times at vaccination sites. Vaccine enforcement reduced overall vaccine acceptance (mean preference -0.20; 95%CI: -0.30 to -0.10), with a trend of increasing resistance to enforcement with increasing vaccine hesitancy. Latent class analysis identified four distinct preference phenotypes: the first prioritized inherent “vaccine features” (46.1%), the second were concerned about vaccine “service delivery” (8.8%), a third group desired “social proof” of vaccine safety and were susceptible to enforcement (13.2%), and the fourth group were “indifferent” to vaccine and service delivery features and resisted enforcement (31.9%). Conclusions This study identifies several critical insights for the COVID-19 public health response. First, identifying preference segments is essential to ensure that vaccination services meet the needs of diverse population subgroups. Second, making vaccination easy and promoting autonomy by simplifying services and offering the public choices (where feasible) may increase uptake in those who remain deliberative. And, third vaccine mandates have the potential to increase vaccination rates in susceptible groups but may simultaneously promote control aversion and resistance in those who are most hesitant.

Although sexual stigma has been linked to decreased HIV testing among men who have sex with men (MSM), mechanisms for this association are unclear. We evaluated the role of psychosocial well-being in connecting sexual stigma and HIV testing using an explanatory sequential mixed methods analysis of 25 qualitative and 1480 quantitative interviews with MSM enrolled in a prospective cohort study in Nigeria from March/2013-February/2016. Utilizing structural equation modeling, we found a synergistic negative association between sexual stigma and suicidal ideation on HIV testing. Qualitatively, prior stigma experiences often generated psychological distress and perceptions of feeling unsafe, which decreased willingness to seek services at general health facilities. MSM reported feeling safe at the MSM-friendly study clinic but still described a need for psychosocial support services. Addressing stigma and unmet mental health needs among Nigerian MSM has the potential to improve HIV testing uptake.

Background Equity in vaccination coverage is a cornerstone for a successful public health response to COVID-19. To deepen understanding of the extent to which vaccination coverage compares with initial strategies for equitable vaccination, we explore primary vaccine series and booster rollout over time and by race/ethnicity, social vulnerability, and geography. Methods and findings We analyzed data from the Missouri Department of Health and Senior Services on all COVID-19 vaccinations administered across 7 counties in the St. Louis region and 4 counties in the Kansas City region. We compared rates of receiving the primary COVID-19 vaccine series and boosters relative to time, race/ethnicity, zip-code-level Social Vulnerability Index (SVI), vaccine location type, and COVID-19 disease burden. We adapted a well-established tool for measuring inequity—the Lorenz curve—to quantify inequities in COVID-19 vaccination relative to these key metrics. Between 15 December 2020 and 15 February 2022, 1,763,036 individuals completed the primary series and 872,324 received a booster. During early phases of the primary series rollout, Black and Hispanic individuals from high SVI zip codes were vaccinated at less than half the rate of White individuals from low SVI zip codes, but rates increased over time until they were higher than rates in White individuals after June 2021; Asian individuals maintained high levels of vaccination throughout. Increasing vaccination rates in Black and Hispanic communities corresponded with periods when more vaccinations were offered at small community-based sites such as pharmacies rather than larger health systems and mass vaccination sites. Using Lorenz curves, zip codes in the quartile with the lowest rates of primary series completion accounted for 19.3%, 18.1%, 10.8%, and 8.8% of vaccinations while representing 25% of the total population, cases, deaths, or population-level SVI, respectively. When tracking Gini coefficients, these disparities were greatest earlier during rollout, but improvements were slow and modest and vaccine disparities remained across all metrics even after 1 year. Patterns of disparities for boosters were similar but often of much greater magnitude during rollout in fall 2021. Study limitations include inherent limitations in the vaccine registry dataset such as missing and misclassified race/ethnicity and zip code variables and potential changes in zip code population sizes since census enumeration. Conclusions Inequities in the initial COVID-19 vaccination and booster rollout in 2 large US metropolitan areas were apparent across racial/ethnic communities, across levels of social vulnerability, over time, and across types of vaccination administration sites. Disparities in receipt of the primary vaccine series attenuated over time during a period in which sites of vaccination administration diversified, but were recapitulated during booster rollout. These findings highlight how public health strategies from the outset must directly target these deeply embedded structural and systemic determinants of disparities and track equity metrics over time to avoid perpetuating inequities in healthcare access.