
==== Front
Ann Med
Ann Med
Annals of Medicine
0785-3890
1365-2060
Taylor & Francis

39239845
10.1080/07853890.2024.2399318
2399318
Version of Record
Research Article
Public Health
COVID-19 vaccination receipt and intention to vaccinate among adults with disabilities and functional limitations, United States
K. H. Nguyen et al.
https://orcid.org/0000-0002-3558-6983
Nguyen Kimberly H. a
Nguyen Kimchi b
Allen Jennifer D. c
a Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
b Department of Medicine, Children’s Hospital, Boston, Massachusetts, USA
c Department of Community Health, Tufts University, Medford, Massachusetts, USA
CONTACT Kimberly H. Nguyen kimberly.nguyen@emory.edu Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA 30322, USA
6 9 2024
2024
6 9 2024
56 1 239931823 2 2024
8 5 2024
27 5 2024
KnowledgeWorks Global Ltd.5 9 2024
published online in a building issue5 9 2024
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
2024
The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

Abstract

Background

People with disabilities are at increased risk for severe COVID-19 health outcomes and face barriers accessing COVID-19 vaccines. The aim of this study is to examine receipt of ≥ 1 dose of the COVID-19 vaccine, intention to vaccinate in the future, and reasons for not vaccinating among people with disabilities and functional limitations using a large, nationally representative dataset of adults in the United States.

Methods

Data were analyzed from the Census Bureau’s Household Pulse Survey (14–26 April 2021, n = 68,913). Separate logistic regression models were conducted to examine the association between each disability (vision, hearing, cognition and mobility), overall disability status, and functional status on ≥1 dose COVID-19 vaccination receipt and intention to vaccinate. Furthermore, reasons for not getting vaccinated were examined among those with disabilities or functional limitations.

Results

Approximately 13% of adults reported having a disability, and almost 60% reported having some or a lot of functional limitations. Over 65% of adults with disabilities had received ≥1 dose of COVID-19 vaccines, compared to 73% among adults without disabilities (adjusted prevalence ratio = 0.94). Among adults with disabilities, those who were younger, had lower educational attainment and income, did not have insurance and had a prior history of COVID-19 were less likely to get vaccinated or intend to get vaccinated than their respective counterparts. The main reasons for not getting vaccinated were concerns about possible side effects (52.1%), lack of trust in COVID-19 vaccines (45.4%) and lack of trust in the government (38.6%).

Discussion and conclusion

Efforts to ensure high and equitable vaccination coverage include working with communities to strengthen the message that the vaccine is safe and effective, educating health professionals about the need to recommend and promote vaccines, and making vaccination sites more accessible for people who need additional accommodations.

Keywords

COVID-19
vaccination coverage
vaccine hesitancy
vaccine confidence
disability
disparities
functional limitation
adults
Jennifer D. Allen was supported by the Tufts University Office of the Vice Provost for Research (OVPR) Research and Scholarship Strategic Plan. The other authors received no external funding.
==== Body
pmcIntroduction

According to the International Classification of Functioning, Disability and Health (ICF), people with disabilities are defined as a diverse group of people with a wide range of needs: (1) impairment in a person’s body structure or function or mental functioning; (2) activity limitation, such as difficulty seeing, hearing, walking or problem solving; or (3) participation restrictions in normal daily activities [1,2]. Approximately 26% of US adults (61 million) live with some form of disability and experience disparities in health outcomes that can be linked to demographic, social, economic or environmental characteristics [3,4]. In 2021, 31 states reported 111,000 cases and over 6,500 deaths attributable to COVID-19 among people with disabilities who use long-term services and supports [5]. People with disabilities may be at greater risk of COVID-19 infection due to living in group settings (e.g. overcrowding, inadequate mitigation practices), and are more likely to have socioeconomic disadvantages and chronic health conditions that may increase the risk for COVID-19 infection and mortality [6–12]. For example, people with disabilities may have chronic health conditions, including obesity, diabetes, acute and chronic respiratory diseases and cardiovascular disease, which further compound the risk of severe consequences of COVID-19 infection [10–12]. Moreover, people with disabilities may have limited or no health insurance, which leads to unmet health care needs [13,14]. The prevalence of disability and associated poorer health outcomes are higher among minority racial/ethnic groups, such as Blacks/African Americans, Latinx and American Indians/Alaska Natives, who also experience a disproportionately high rates of COVID-19 infection and mortality [15,16].

In addition to greater COVID-19 risk and severe health outcomes, some people with disabilities encounter challenges in protecting themselves from COVID-19, such as adopting prevention measures and getting vaccinated [13–16]. For example, some people with disabilities are often unable to engage in social distancing practices due to their reliance on caregivers for communication and daily needs, have reduced ability to communicate with face masks (both speaking and hearing others) or have difficulty understanding information or communicating symptoms of illness [17]. In addition to these challenges, people with disabilities may face barriers accessing vaccination sites, such as transportation and scheduling appointments [18,19]. Altogether, these issues present challenges for people with disabilities to receive lifesaving COVID-19 vaccines, which would protect not only themselves but also those whom they are in close contact with.

In December 2020, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommended that healthcare personnel and residents in long-term care facilities, defined as nursing homes, skilled nursing facilities and assisted living facilities, be prioritized for COVID-19 vaccine distribution [20,21]. However, states have discretion about which groups to prioritize in their vaccine distribution plans, and few states specifically prioritize people with disabilities [5]. Those with disabilities may still be able to receive the vaccine as early as December 2020 if they have employment or other characteristics that fall into one of the Advisory Committee on Immunization Practices (ACIP) recommendations for priority COVID-19 vaccine allocation: health care personnel and residents of long-term care facilities, frontline essential workers and persons aged ≥75 years and persons aged 65–74 years, persons aged 16–64 years at high risk for severe COVID-19 illness because of underlying medical conditions and other workers in essential and critical infrastructure sectors [20]. Although there was no specific prioritization for people with disabilities at the national level, those with mental, physical or developmental disabilities were prioritized for the vaccine in 10 States [22]. If people with disabilities were not able to get the vaccine under the prioritization groups above, and their state did not prioritize vaccines for those with disabilities, they were able to get the vaccine in April 2021 when the vaccine became available to everyone aged 16 and older [23]. Further understanding is needed about COVID-19 vaccination receipt and intention to vaccinate among people with disabilities. The aim of this study is to examine receipt of ≥ 1 dose of the COVID-19 vaccine, intention to vaccinate and reasons for not vaccinating among people with disabilities and functional limitations using data from the Census Bureau’s Household Pulse Survey (HPS). This is a large, nationally representative survey that collects data on COVID-19 vaccination coverage and intentions, and provides important insights to help understand barriers to vaccination and efforts to achieve high and equitable vaccination coverage which are critical to curbing the transmission of COVID-19.

Methods

Survey design

The Household Pulse Survey (HPS) is a large, nationally representative household survey conducted by the US Census Bureau since April 2020 to help understand household experiences during the COVID-19 pandemic [24]. The HPS utilizes the Census Bureau’s Master Address File (MAF), which has approximately 140,000,000 valid housing units, to create a systematic sample of all eligible housing units. These addresses were matched to a unique email or cell-phone from the Census Contact Frame, and those with a match (over 80% of addresses in the MAF) were selected as the final eligible housing unit for the HPS. For the data collection from 14–26 April 2021, households were selected from a systematic sample of approximately 1,035,000 housing units from the sampling frame, and one respondent from each household was contacted via email and/or text to complete a 20-minute survey online using Qualtrics as a data collection platform. The final sample size for the data collection was 68,913; however, for this study, only participants who answered questions about disability and functional status in the survey were included in the analysis (n = 54,328). The response rate of 6.6% was based on the methodology found in this Census report and is similar to other HPS survey waves [25]. This study was considered not to be human subjects research by Emory University and Tufts University Health Sciences Institutional Review Board (STUDY00001672).

COVID-19 questions

The HPS asks questions on COVID-19 vaccination coverage, intent and reasons for not vaccinating. COVID-19 vaccination receipt (≥1 dose) was assessed by the following question: ‘Have you received a COVID-19 vaccine?’ Among unvaccinated adults, intent to be vaccinated was assessed with the following question: ‘Once a vaccine to prevent COVID-19 is available to you, would you…definitely, probably, be unsure about, probably not or definitely not get a vaccine’. Because the vaccination intent questions were only asked of those who were not vaccinated, assessing intent over time would show bias as more people got vaccinated (decreasing the sample size of those who are asked about intent) [26]. To reduce this potential for bias, vaccination coverage and intent were assessed among everyone in the sample, and responses were combined to create overarching categories. Respondents were categorized as (1)vaccine endorsers if they received or definitely will get the vaccine, (2) reachable if they probably will or are unsure about getting a vaccine or (3) reluctant if they probably or definitely will not get a vaccine. Among non-vaccinated individuals who did not definitely intend to get vaccinated, respondents were asked reasons for not getting vaccinated: ‘“Which of the following, if any, are reasons that you [probably will/probably won’t/definitely won’t] get a COVID-19 vaccine’. Response options, in which respondents could select all that apply, were: (1) I am concerned about possible side effects of a COVID-19 vaccine, (2) I don’t know if a COVID-19 vaccine will work, (3) I don’t believe I need a COVID-19 vaccine, (4) I don’t like vaccines, (5) My doctor has not recommended it, (6) I plan to wait and see if it is safe and may get it later, (7) I think other people need it more than I do right now, (8) I am concerned about the cost of a COVID-19 vaccine, (9) I don’t trust COVID-19 vaccines, (10) I don’t trust the government and (11) Other. These questions underwent expert review at the Census Bureau and federal partner agencies, as well as cognitive testing in labs at the CDC’s National Center for Health Statistics [24].

Disability and functional status

To assess COVID-19 vaccination among adults with disabilities and those with different levels of functional limitations, questions on disability and functional status were assessed using previously established measures [1,27–29]: (1) Do you have difficulty seeing, even when wearing glasses? (2) Do you have difficulty hearing, even when using a hearing aid? (3) Do you have difficulty remembering or concentrating? and (4) Do you have difficulty walking or climbing stairs? Response options were (1) no difficulty, (2) some difficulty, (3) a lot of difficulty and (4) cannot do at all. Those who answered ‘a lot of difficulty’ or ‘cannot do at all’ were categorized as having the specific disability pertaining to that question (e.g. hearing disability). This produced four non-mutually exclusive groups for disability. An overall disability status variable was created for those who reported any of the four categories of disability. Functional status was also determined based on the four questions. If respondents answered ‘a lot of difficulty’ or ‘cannot do it all’ to any of the four questions, they were categorized as having a lot of functional limitations. For remaining respondents, if they answered ‘some difficulty’ to any of the four questions, they were categorized as having some functional limitations. Finally, remaining respondents who answered ‘no difficulty’ to any of the four questions were categorized as having no functional limitations.

Sociodemographic variables

Sociodemographic variables assessed were: age group, sex, race/ethnicity, educational status, annual household income, insurance status and previous COVID-19 diagnosis. Age was categorized as 18–49, 50–64 and ≥65 years. Race/ethnicity was categorized as non-Hispanic (NH)white, NH black, Hispanic, NH Asian and NH other/multiple races. Annual household income was categorized as <$35,000, $35,000–$49,999, $50,000–$74,999, ≥ $75,000 or not reported. Insurance status was defined as having or not having insurance. Previous COVID-19 diagnosis was defined as a ‘yes’ response to the following question: ‘Has a doctor or other healthcare provider ever told you that you have COVID-19?’ Respondents were also asked about delays in getting medical care at any time in the last 4 weeks because of the coronavirus pandemic.

Analysis

Socioeconomic characteristics and receipt of medical services by disability or functional status were analyzed. Separate logistic regression models were conducted to examine the association between each disability (vision, hearing, cognition and mobility), overall disability status, and functional status on ≥1 dose COVID-19 vaccination receipt and intention to vaccinate, after controlling for age group, sex, race/ethnicity, educational status, annual household income, insurance status and previous COVID-19 diagnosis. Variables included in this model were derived from directed acyclic graphs and previous literature showing factors which are likely to be associated with disability status and COVID-19 vaccination [28,29]. Proportions and 95% confidence intervals (CI) for reasons for not getting vaccinated were examined by disability and functional status and stratified by vaccination intent. Contrast tests for the differences in proportions, comparing each category to the referent category were conducted with a 0.05 significance level (α = 0.05). Analyses accounted for the survey design and replicate weights using balanced replicate weighting procedures in SAS 11.0. Unless noted otherwise, all results reported in the text are statistically significant at p < 0.05 level.

Results

From 14–26 April 2021, more than 13% of the sample had some form of disability and over 50% had some or a lot of functional limitations (Table 1). Almost 14% of people with disabilities had a previous diagnosis of COVID-19. A higher proportion of adults with disabilities were aged 65 years or older (27.3%), Hispanic (18.9%) or NH other race (4.8%) compared to adults with no disabilities (23.7%, 14.9% and 3.3%, respectively). Adults with disabilities also had less education and less income than adults without disabilities. In addition, adults with disabilities compared to those without disabilities were more likely to have a delay in getting medical care in the last 4 weeks due to the coronavirus pandemic (34.3% compared to 18.2%) (Table 1).

Table 1. Characteristics of people with disabilities and functional limitations, United States, April 16–26, 2021.

 	Disability status	Functional status	
 	With disability (n = 6,198)	Without disability (reference)(n = 48,130)	A lot of limitations (n = 6,198)	Some limitations (n = 24,994)	No limitations (reference)(n = 23,136)	
 	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	
Overall	13.3 (12.6, 14.0)*	86.7 (86.1, 87.4)	13.3 (12.6, 14.0)*	45.8 (44.9, 46.7)*	40.9 (40.1, 41.7)	
Age Groups (in years)	 	 	 	 	 	
18-49	46.2 (43.4, 49.0)	49.0 (48.4, 49.7)	46.2 (43.4, 49.0)*	44.3 (43.2, 45.4)*	54.4 (53.2, 55.6)	
50-64	26.5 (24.3, 28.9)	27.2 (26.7, 27.8)	26.5 (24.3, 28.9)	28.4 (27.5, 29.4)*	25.9 (25.0, 26.8)	
≥65	27.3 (25.5, 29.1)*	23.7 (23.3, 24.1)	27.3 (25.5, 29.1)*	27.3 (26.4, 28.1)*	19.7 (18.9, 20.6)	
Sex	 	 	 	 	 	
Male	40.3 (37.8, 42.9)*	48.3 (47.8, 48.9)	40.3 (37.8, 42.9)*	45.2 (44.2, 46.3)*	51.8 (50.8, 52.8)	
Female	59.7 (57.1, 62.2)*	51.7 (51.1, 52.2)	59.7 (57.1, 62.2)*	54.8 (53.7, 55.8)*	48.2 (47.2, 49.2)	
Race/Ethnicity	 	 	 	 	 	
Non-Hispanic white	62.3 (60.0, 64.5)*	66.1 (65.5, 66.7)	62.3 (60.0, 64.5)*	67.2 (66.1, 68.3)*	64.8 (63.8, 65.8)	
Non-Hispanic black	9.9 (8.2, 11.9)	10.5 (10.1, 10.9)	9.9 (8.2, 11.9)	10.5 (9.9, 11.2)	10.6 (10.0, 11.2)	
Hispanic	18.9 (17.0, 21.0)*	14.9 (14.4, 15.4)	19.0 (17.0, 21.0)*	15.1 (14.2, 16.1)	14.6 (13.7, 15.6)	
Non-Hispanic Asian	4.1 (3.2, 5.2)*	5.2 (4.9, 5.5)	4.1 (3.2, 5.2)*	3.9 (3.5, 4.3)*	6.7 (6.3, 7.2)	
Non-Hispanic other/multiple races	4.8 (4.1, 5.6)*	3.3 (3.0, 3.6)	4.8 (4.1, 5.6)*	3.3 (2.9, 3.7)	3.3 (2.8, 3.7)	
Educational Status	 	 	 	 	 	
High school or less	45.1 (42.7, 47.4)*	34.4 (33.7, 35.1)	45.1 (42.7, 47.4)*	36.5 (35.2, 37.8)*	32.0 (30.7, 33.4)	
Some college or college graduate	46.0 (43.7, 48.4)*	49.0 (48.4, 49.6)	46.0 (43.7, 48.4)	49.7 (48.6, 50.8)	48.2 (47.1, 49.3)	
Above college graduate	8.9 (8.1, 9.8)*	16.6 (16.2, 17.0)	8.9 (8.1, 9.7)*	13.8 (13.3, 14.4)*	19.8 (19.1, 20.5)	
Annual Household Income	 	 	 	 	 	
<$35,000	38.7 (36.1, 41.4)*	20.8 (20.1, 21.5)	38.7 (36.1, 41.4)*	24.2 (23.2, 25.3)*	16.9 (15.8, 18.0)	
$35,000-$49,999	13.8 (12.3, 15.5)*	10.7 (10.0, 11.4)	13.8 (12.3, 15.5)*	11.9 (11.1, 12.8)*	9.2 (8.3, 10.2)	
$50,000-$74,999	14.3 (12.4, 16.4)	16.3 (15.7, 16.9)	14.3 (12.4, 16.4)	17.3 (16.4, 18.2)*	15.1 (14.3, 16.0)	
≥$75,000	23.9 (21.6, 26.2)*	43.3 (42.4, 44.1)	23.9 (21.6, 26.2)*	37.7 (36.6, 38.9)*	49.5 (48.1, 50.8)	
Did not report	9.3 (7.6, 11.4)	9.0 (8.5, 9.6)	9.3 (7.6, 11.4)	8.8 (8.0, 9.7)	9.3 (8.5, 10.1)	
Insurance Status	 	 	 	 	 	
Insured	88.8 (86.9, 90.4)*	91.3 (90.7, 91.9)	88.8 (86.9, 90.4)	91.9 (91.0, 92.7)	90.7 (89.6, 91.7)	
Not insured	11.2 (9.6, 13.1)*	8.7 (8.1, 9.3)	11.2 (9.6, 13.1)	8.1 (7.3, 9.0)	9.3 (8.3, 10.4)	
Previous COVID-19 diagnosis	 	 	 	 	 	
Yes	13.9 (12.5, 15.4)	13.3 (12.6, 14.0)	13.9 (12.5, 15.4)	13.9 (12.9, 15.0)	12.7 (11.8, 13.6)	
No	84.0 (82.3, 85.6)*	86.0 (85.3, 86.7)	84.0 (82.3, 85.6)*	85.4 (84.4, 86.4)	86.7 (85.7, 87.6)	
Delay getting medical care because of the coronavirus pandemic in the last 4 weeks	34.3 (32.1, 36.6)*	18.2 (17.6, 18.7)	34.3 (32.1, 36.6)*	23.0 (22.1, 24.0)*	12.8 (12.0, 13.7)	
Note: All percentages and adjusted prevalence ratios are weighted to the U.S. adult population.

*Significant differences in proportions comparing each group to the referent group.

CI: confidence intervals.

Only 65.1% of adults with disabilities had received at least one dose of COVID-19 vaccines, compared to 73.0% among adults without disabilities (Table 2 and Figure 1). Vaccination receipt was lower for adults with a vision, cognition or mobility disability compared to adults without the respective disability (Table 2). In multivariable regression analyses, people with any disability had lower rates of vaccination (adjusted prevalence ratio (aPR) = 0.94, 95%CI: 0.91–0.98) compared to those without disabilities. By disability type, people with a vision disability (aPR = 0.94, 95%CI: 0.89–0.99) and people with a mobility disability (aPR = 0.90, 95%CI: 0.85–0.96) were less likely to get vaccinated; people with a mobility disability were also less likely to intend to get vaccinated (aPR = 0.92, 95%CI: 0.87–0.98) (Table 2).

Figure 1. COVID-19 vaccination receipt (≥1 dose) and intent by disability status and disability type, United States, April 14-26, 2021.

Table 2. COVID-19 vaccination receipt and intent by disability and functional status, United States, April 14–26, 2021.

 	Total	COVID-19 vaccination (≥1 dose)	COVID-19 vaccination intent*	
 	Unweighted n	% (95%CI)	% (95%CI)	aPR (95%CI)†	% (95%CI)	aPR (95%CI)†	
Disability Status	 	 	 	 	 	 	
Yes	6179	13.3 (12.6, 13.9)	65.1 (62.1, 68.0)‡	0.94 (0.91, 0.98)	75.2 (72.3, 77.9)‡	0.98 (.95, 1.01)	
No (reference)	48049	86.7 (86.1, 87.4)	73.0 (72.2, 73.8)	reference	80.0 (79.3, 80.8)	reference	
Functional status	 	 	 	 	 	 	
A lot of limitations	6179	13.3 (12.6, 13.9)	65.1 (62.1, 68.0)‡	0.95 (0.92, 0.99)	75.2 (72.3, 77.9)‡	1.00 (0.96, 1.04)	
Some limitations	24944	45.8 (44.9, 46.7)	73.7 (72.5, 74.9)	1.02 (0.99, 1.04)	81.1 (80.0, 82.2)‡	1.04 (1.01, 1.06)	
No limitations (reference)	23105	40.9 (40.1, 41.8)	72.3 (71.1, 73.6)	reference	78.8 (77.7, 79.9)‡	reference	
Type of Disability	 	 	 	 	 	 	
Vision	 	 	 	 	 	 	
Yes	1587	3.6 (3.3, 3.9)	61.8 (57.2, 66.3)‡	0.94 (0.89-0.99)	72.2 (67.8, 76.6)‡	0.96 (0.91-1.01)	
No (reference)	52582	96.4 (96.1, 96.7)	72.4 (71.5, 73.2)	reference	79.7 (79.0, 80.4)	reference	
Hearing	 	 	 	 	 	 	
Yes	1137	2.4 (2.2, 2.7)	70.4 (64.9, 75.9)	0.95 (0.88-1.03)	76.1 (70.7, 81.4)	0.93 (0.86-1.01)	
No (reference)	52955	97.6 (97.3, 97.8)	72.0 (71.1, 72.9)	reference	79.5 (78.7, 80.3)	reference	
Cognition	 	 	 	 	 	 	
Yes	2485	6.0 (5.5, 6.5)	58.7 (53.9, 63.4)‡	0.96 (0.91-1.01)	71.4 (67.5, 75.3)‡	1.00 (0.96-1.03)	
No (reference)	51635	94.0 (93.5, 94.5)	72.8 (72.0, 73.6)	reference	79.9 (79.2, 80.7)	reference	
Mobility	 	 	 	 	 	 	
Yes	2524	5.2 (4.8, 5.6)	65.9 (61.4, 70.4)‡	0.90 (0.85-0.96)	73.8 (68.9, 78.6)‡	0.92 (0.87-0.98)	
No (reference)	51649	94.8 (94.4, 95.2)	72.3 (71.5, 73.1)	reference	79.7 (79.1, 80.4)	reference	
Note: All percentages and adjusted prevalence ratios are weighted to the U.S. adult population.

*Vaccination intent defined as those who were vaccinated (≥1 dose)and definitely intend to get vaccinated.

†Separate logistic regression models examined the association between each disability and functional status and disability type on COVID-19 vaccination receipt and intent, adjusting for age group, sex, race/ethnicity, educational status, annual household income, insurance status, and previous COVID-19 diagnosis.

‡Significant differences in proportions comparing each group to the referent group.

CI: confidence intervals; aPR: adjusted prevalence ratio.

Vaccination receipt (≥1 dose)and intent among people with disabilities was highest among adults who are aged 65 years and older, had a higher than college education, had incomes ≥75,000, and never had a previous COVID-19 diagnosis compared to their respective counterparts (Table 3). Adults who were not insured were less likely to get vaccinated (aPR = 0.85, 95%CI: 0.74–0.98) than adults with health insurance. Furthermore, vaccination intent was lower among NH Black adults (aPR = 0.90, 95%CI: 0.84–0.96), Hispanic (aPR = 0.89, 95%CI: 0.81–0.99)and NH other racial groups (aPR = 0.84, 95%CI: 0.73–0.97)compared to NH White adults (Table 3).

Table 3. Factors associated with vaccination receipt and intent among adults with disabilities, United States, April 14–26, 2021.

 	COVID-19 vaccination (≥1 dose)	COVID-19 vaccination intent*	
 	% (95%CI)	aPR (95%CI)†	% (95%CI)	aPR (95%CI)†	
Overall	65.1 (62.1, 68.0)	–	75.2 (72.3, 77.9)	–	
Age Groups (in years)	 	 	 	 	
18-49 (reference)	52.6 (47.4, 57.8)	reference	67.0 (62.4, 71.6)	reference	
50-64	71.5 (68.2, 74.8)‡	1.41 (1.26-1.57)	80.1 (77.2, 82.9)‡	1.21 (1.13-1.31)	
≥65	80.1 (75.8, 84.5)‡	1.55 (1.38-1.74)	84.7 (80.3, 89.2)‡	1.27 (1.17-1.38)	
Sex	 	 	 	 	
Male (reference)	64.6 (59.9, 69.3)	reference	79.1 (75.2, 83.0)	reference	
Female	65.4 (62.0, 68.9)	1.04 (0.97-1.11)	72.8 (69.1, 76.4)‡	0.95 (0.89-1.01)	
Race/Ethnicity	 	 	 	 	
Non-Hispanic white (reference)	67.0 (63.4, 70.6)	reference	75.7 (72.5, 78.8)	reference	
Non-Hispanic black	63.5 (55.2, 71.8)	0.92 (0.83-1.03)	72.7 (64.9, 80.4)	0.90 (0.84-0.96)	
Hispanic	60.0 (51.3, 68.8)	0.92 (0.82-1.05)	76.9 (70.9, 82.8)	0.89 (0.81-0.99)	
Non-Hispanic Asian	73.1 (56.2, 90.1)	1.05 (0.79-1.39)	80.8 (63.2, 98.5)	0.97 (0.76-1.23)	
Non-Hispanic other/multiple races	56.9 (48.8, 65.0)‡	0.88 (0.73-1.05)	65.4 (57.4, 73.4)‡	0.84 (0.73-0.97)	
Educational Status	 	 	 	 	
High school or less (reference)	57.0 (51.5, 62.5)	reference	72.2 (67.0, 77.5)	reference	
Some college or college graduate	69.9 (66.9, 72.9)‡	1.23 (1.13-1.35)	76.2 (73.3, 79.2)	1.07 (1.00-1.14)	
Above college graduate	81.2 (77.3, 85.1)‡	1.36 (1.22-1.52)	86.0 (82.4, 89.6)‡	1.16 (1.06-1.27)	
Annual Household Income	 	 	 	 	
<$35,000 (reference)	56.5 (52.0, 61.0)	reference	69.0 (64.1, 73.9)	reference	
$35,000-$49,999	70.2 (64.6, 75.8)‡	1.19 (1.07-1.32)	77.0 (72.3, 81.8)‡	1.09 (0.99-1.20)	
$50,000-$74,999	73.5 (66.8, 80.1)‡	1.18 (1.04-1.34)	78.7 (71.7, 85.8)‡	1.08 (0.97-1.21)	
≥$75,000	74.5 (68.6, 80.5)‡	1.23 (1.12-1.36)	82.8 (79.8, 85.8)‡	1.16 (1.08-1.24)	
Did not report	56.4 (45.5, 67.2)	1.03 (0.88-1.20)	74.6 (65.1, 84.0)	1.10 (0.98-1.23)	
Insurance Status	 	 	 	 	
Insured (reference)	68.1 (65.3, 70.9)	reference	77.5 (74.8, 80.3)	reference	
Not insured	42.1 (33.2, 50.9)‡	0.85 (0.74-0.98)	59.3 (49.4, 69.1)‡	0.89 (0.78-1.02)	
Previous COVID-19 diagnosis	 	 	 	 	
Yes (reference)	58.8 (54.0, 63.5)	reference	70.4 (65.8, 75.1)	reference	
No	67.1 (63.8, 70.4)‡	1.11 (1.02-1.22)	77.2 (74.2, 80.1)‡	1.09 (1.01-1.18)	
Abbreviations: CI = confidence intervals; aPR = adjusted prevalence ratio.

Note: All percentages and adjusted prevalence ratios are weighted to the U.S. adult population.

*Vaccination intent defined as those who were vaccinated (≥1 dose)and definitely intend to get vaccinated.

†Adjusted for age group, sex, race/ethnicity, educational status, annual household income, insurance status, and previous COVID-19 diagnosis.

‡Significant differences in proportions comparing each group to the referent group.

Among adults with disabilities in the reachable group, the most commonly reported reason was concerns about possible side effects (61.6%), which is higher among this group compared to people without disabilities (53.2%) (Table 4). Other reasons for not getting vaccinated among this group were the desire to wait and see if it is safe (53.6%), uncertainty if a vaccine will work (19.8%), and lack of trust in COVID-19 vaccines (19.3%). Among adults in the reluctant group, the main reasons were concerns about possible side effects (52.1%), lack of trust in COVID-19 vaccines (45.4%) and lack of trust in the government (38.6%). Among adults with some or a lot of functional limitations in the reachable group, a higher proportion said they did not trust the government (13.9% and 14.7%, respectively) or did not receive a recommendation from their doctor (7.7% and 10.6%, respectively)compared to people with no functional limitations (9.1% and 4.4%). Among adults with some functional limitations in the reluctant group, a higher proportion said that they planned to wait and see and may get it later (34.3%)compared to adults without any functional limitations (26.5%) (Table 4).

Table 4. Reasons for not getting vaccinated by vaccination intent and stratified by disability and functional status, United States, April 14–26, 2021.

 	Disability status	Functional status	
 	With disability	Without disability (reference)	A lot of limitations	Some limitations	No limitations (reference)	
 	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	% (95%CI)	
Reachable (Probably/Unsure)	 	 	 	 	 	
Concerned about possible side effects	61.6 (54.2, 68.4)*	53.2 (49.8, 56.7)	61.6 (54.2, 68.4)*	55.5 (51.0, 60.0)	50.5 (45.2, 55.7)	
Don’t know if a vaccine will work	19.8 (13.9, 27.5)	18.7 (15.9, 21.9)	19.8 (13.9, 27.5)	20.9 (17.7, 24.6)	16.0 (11.9, 21.3)	
Don’t believe I need a vaccine	5.6 (3.2, 9.6)	8.0 (6.3, 10.2)	5.6 (3.2, 9.6)	8.2 (5.8, 11.4)	7.8 (5.6, 10.8)	
Don’t like vaccines	9.6 (4.6, 19.2)	6.1 (4.7, 7.8)	9.6 (4.6, 19.2)	6.7 (4.7, 9.6)	5.3 (3.6, 7.6)	
Doctor has not recommended it	10.6 (6.9, 15.9)	6.2 (4.8, 7.9)	10.6 (6.9, 15.9)*	7.7 (5.8, 10.2)*	4.4 (2.8, 6.7)	
Plan to wait and see if it is safe and may get it later	53.6 (46.1, 61.0)	59.3 (55.6, 62.9)	53.6 (46.1, 61.0)	59.7 (55.2, 64.1)	58.8 (53.4, 64.0)	
Other people need it more right now	17.8 (12.9, 23.9)*	27.2 (24.2, 30.3)	17.8 (12.9, 23.9)*	26.6 (22.5, 31.1)	27.8 (22.8, 33.4)	
Concerned about the cost	5.4 (3.1, 9.2)	4.5 (3.0, 6.6)	5.4 (3.1, 9.2)	5.6 (3.7, 8.4)	3.1 (1.2, 7.8)	
Don’t trust COVID-19 vaccines	19.3 (13.1, 27.4)	14.9 (12.4, 17.8)	19.3 (13.1, 27.4)	16.0 (12.9, 19.7)	13.5 (9.8, 18.2)	
Don’t trust the government	14.7 (11.1, 19.2)	11.7 (9.9, 13.9)	14.7 (11.1, 19.2)*	13.9 (10.9, 17.7)*	9.1 (7.2, 11.4)	
Other reason for not getting vaccine	14.4 (10.3, 19.9)	9.3 (7.7, 11.2)	14.4 (10.3, 19.9)*	9.9 (7.8, 12.5)	8.7 (6.6, 11.2)	
Reluctant (Probably not/Definitely not)	 	 	 	 	 	
Concerned about possible side effects	52.1 (45.7, 58.4)	50.4 (47.5, 53.3)	52.1 (45.7, 58.4)	52.4 (47.7, 57.0)	48.7 (45.2, 52.2)	
Don’t know if a vaccine will work	24.8 (18.7, 32.1)	23.1 (20.7, 25.6)	24.8 (18.7, 32.1)	23.1 (19.4, 27.4)	23.0 (19.9, 26.5)	
Don’t believe I need a vaccine	26.3 (21.0, 32.4)*	34.8 (32.3, 37.5)	26.3 (21.0, 32.4)*	26.4 (22.6, 30.6)*	42.0 (38.1, 45.9)	
Don’t like vaccines	16.5 (10.5, 24.9)	15.9 (13.9, 18.2)	16.5 (10.5, 24.9)	15.9 (12.7, 19.7)	16.0 (13.1, 19.3)	
Doctor has not recommended it	4.9 (3.0, 7.9)	5.4 (4.5, 6.6)	4.9 (3.0, 7.9)	5.4 (4.2, 6.8)	5.5 (4.0, 7.5)	
Plan to wait and see if it is safe and may get it later	31.2 (24.6, 38.7)	30.1 (27.5, 32.8)	31.2 (24.6, 38.7)	34.3 (30.5, 38.4)*	26.5 (23.0, 30.4)	
Other people need it more right now	10.7 (6.7, 16.7)	10.2 (8.5, 12.2)	10.7 (6.7, 16.7)	8.5 (6.7, 10.8)	11.6 (9.0, 14.7)	
Concerned about the cost	2.3 (1.0, 5.0)	2.0 (1.3, 3.0)	2.3 (1.0, 5.0)	2.1 (1.3, 3.4)	1.9 (1.0, 3.6)	
Don’t trust COVID-19 vaccines	45.4 (38.1, 52.9)	48.8 (45.9, 51.6)	45.4 (38.1, 52.9)	49.0 (44.5, 53.6)	48.6 (44.5, 52.6)	
Don’t trust the government	38.6 (31.7, 46.0)	34.2 (31.6, 36.9)	38.6 (31.7, 46.0)	31.8 (28.0, 36.0)	36.2 (32.7, 39.8)	
Other reason for not getting vaccine	19.9 (14.5, 26.7)	15.6 (13.6, 17.8)	19.9 (14.5, 26.7)	13.9 (11.8, 16.3)	17 (14.2, 20.2)	
Note: All percentages and adjusted prevalence ratios are weighted to the U.S. adult population.

* Significant differences in proportions comparing each group to the referent group.

CI: confidence intervals.

Discussion and conclusion

This is among the earliest and largest nationally representative studies on COVID-19 vaccination coverage, intent and reasons for not vaccinating among people with disabilities and functional limitations, a group that comprises more than one quarter of the population [4]. Given that some people with disabilities have greater risk of severe and long COVID [11], it is critical that greater efforts are made to protect this vulnerable group from harmful health consequences of COVID-19. We found that people with disabilities or functional limitations were less likely to receive COVID-19 vaccination or intend to get vaccinated compared to those without disabilities or functional limitations. In particular, those with vision, cognition or mobility disabilities were less likely to get vaccinated against COVID-19, indicating that there may be physical and mental barriers that prevents some people with disabilities from getting the vaccine. In addition, vaccination receipt and intent among adults with disabilities was lower among younger adults, those with less education and income, those without health insurance, and those with a previous COVID-19 diagnosis. Since concerns about side effects are the most commonly reported reason for non-vaccination, targeted messages and strategies to address concerns and misinformation and provider recommendations can improve vaccine confidence. Furthermore, lower vaccination among those with physical or cognitive limitations highlights the importance of removing barriers to access to COVID-19 vaccines. These findings also highlight disparities and underscores the importance of reducing gaps in coverage by strengthening confidence in vaccine safety and efficacy and removing barriers to access to advance health equities.

In this study, people with disabilities reported delaying getting medical care which may be due to similar access barriers that may have contributed to lower COVID-19 vaccination receipt among this population [3]. Given that people with disabilities often have difficulty with mobility, they may experience additional challenges like transportation getting to a vaccination site; for example, people with a visual or mobility disability were less likely to get vaccinated in this study compared to their peers without disability, and a higher percentage (14.4%) of people with a lot of functional limitations reported other reasons for not getting vaccinated than those among people with no limitations (8.7%). Ensuring that vaccination sites are easily accessible, convenient and available in places where these populations live and work could also improve vaccine acceptance and coverage.

These results are consistent with other studies on COVID-19 vaccination among adults with disabilities. Similar to this study, Ryerson et al. found that adults with a disability were less likely than were those without a disability to be vaccinated [28]. In addition, studies found that people with disabilities were more report that it was difficult to get vaccinated, and more likely to avoid or postpone medical care and less likely to get COVID-19 testing than adults without a disability [28,30]. Another study found that concern about vaccines was the most significant predictor of hesitancy towards COVID-19 vaccines, even after adjusting for demographic, economic and geographic factors [31]. These studies indicate that people with disabilities face barriers to access and vaccine hesitancy, and efforts are needed to promote vaccination uptake and confidence in this population.

Efforts are needed to increase vaccine uptake among people with disabilities. These include working with partner organizations that serve people with disabilities, tailoring messages to specific disabilities (i.e. physical, mental, sensory), making information available in a variety of accessible formats (such as for people with vision, hearing or cognitive disabilities), using a range of media channels to communicate about COVID-19 vaccines, and enlisting trusted messengers from communities with high rates of under- or non-vaccination [32]. Healthcare providers should address concerns about the COVID-19 vaccine, such as potential side effects, and make a strong recommendation or discuss the importance of getting vaccinated for COVID-19. Vaccination sites can help people with disabilities by addressing reasonable accommodation needs for people with disabilities, providing help with scheduling for those who need it, providing other scheduling options in addition to web-based forms, and providing information for scheduling accessible transportation appointments. Personal care attendants and family members can also help people with disabilities by assisting with scheduling vaccinations, arranging transportation, being present during the vaccination process if needed, and offering support and encouragement. Together, these efforts can make vaccinations more easily accessible for people with disabilities, as well as increase their confidence and trust in vaccines and the public health officials who distribute them.

The findings in this study are subject to several limitations. First, although sampling methods and data weighting were designed to produce nationally representative results, respondents might not be fully representative of the general US adult population. Second, the HPS has a low response rate (<10%); however, non-response bias assessment conducted by the Census Bureau found that the survey weights adjusted for most of this bias, even though some bias may remain [33]. Third, the survey was fielded 14–26 April 2021, during the same month when COVID-19 vaccines were available to all adults. As a result, those with disabilities may not have had a chance to get vaccinated at the time of the survey if they were not prioritized for the vaccine through other criteria or were prioritized in their state, which may have reduced vaccination coverage found in this study. However, the study serves as a baseline for understanding intentions and reasons for not vaccinating among a vulnerable population where efforts are still needed to protect this group from severe health consequences of COVID-19. Finally, the HPS does not include institutionalized adults, and many people with disabilities are likely to live in long-term, congregate care settings, including nursing homes, psychiatric institutions, residential group homes and private institutions [17]. As a result, the proportion of people with a disability in this study may be lower than reported in previous studies. This indicates that the actual magnitude of disparities in vaccine access could be greater than what is reported.

Lower vaccination receipt and intent among people with disabilities and functional limitations underscore the need for enhanced efforts to reach these vulnerable and marginalized populations, many of whom are experiencing a disproportionate burden of COVID-19 infections and deaths and may face discrimination in accessing health services [34]. This study provides a baseline of vaccination coverage, intent and reasons for non-vaccination among adults with disabilities and functional limitations, which may be used to assess changes in this group in future studies. This is important given that COVID-19 related hospitalizations and long and severe symptoms are increasing in this population in recent months [11], and further efforts are needed to protect this population from harmful COVID-19 consequences and advance health equities. Efforts needed include outreach to those with disabilities, working with communities to strengthen the message that the vaccine is safe and effective, educating health professionals about the need to recommend and promote vaccines, and making vaccination sites more accessible for people who need special accommodations. Since the vaccine is currently available to everyone nationally, directing vaccines to vulnerable populations and tailoring messages to boost confidence in vaccines are needed to achieve the goal of herd immunity. Ensuring high and equitable vaccination coverage in all populations is critical to preventing the spread of COVID-19, protecting the most vulnerable members of society.

Authors contributions

Kimberly Nguyen was involved in the conception and design of the study, interpretation of the data, drafting of the paper and critical revision for intellectual content. Kimchi Nguyen was involved in the conception and design, analysis and interpretation of the data and revising it critically for intellectual content. Jennifer Allen was involved in the conception and design of the study, interpretation of the data and critical revision for intellectual content. All authors provided final approval for the version to be published and agreed to be accountable for all aspects of the work.

Disclosure statement

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

Data availability statement

The data that support the findings of this study are openly available at https://www.census.gov/programs-surveys/household-pulse-survey/datasets.html.
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