The Association of Reported Experiences of Racial and Ethnic Discrimination in Health Care with COVID-19 Vaccination Status and Intent — United States, April 22, 2021–November 26, 2022

In 2021, the CDC Director declared that racism is a serious threat to public health,* reflecting a growing awareness of racism as a cause of health inequities, health disparities, and disease. Racial and ethnic disparities in COVID-19–related hospitalization and death (1,2) illustrate the need to examine root causes, including experiences of discrimination. This report describes the association between reported experiences of discrimination in U.S. health care settings and COVID-19 vaccination status and intent to be vaccinated by race and ethnicity during April 22, 2021–November 26, 2022, based on the analysis of interview data collected from 1,154,347 respondents to the National Immunization Survey–Adult COVID Module (NIS–ACM). Overall, 3.5% of adults aged ≥18 years reported having worse health care experiences compared with persons of other races and ethnicities (i.e., they experienced discrimination), with significantly higher percentages reported by persons who identified as non-Hispanic Black or African American (Black) (10.7%), non-Hispanic American Indian or Alaska Native (AI/AN) (7.2%), non-Hispanic multiple or other race (multiple or other race) (6.7%), Hispanic or Latino (Hispanic) (4.5%), non-Hispanic Native Hawaiian or other Pacific Islander (NHOPI) (3.9%), and non-Hispanic Asian (Asian) (2.8%) than by non-Hispanic White (White) persons (1.6%). Unadjusted differences in prevalence of being unvaccinated against COVID-19 among respondents reporting worse health care experiences than persons of other races and ethnicities compared with those who reported that their health care experiences were the same as those of persons of other races and ethnicities were statistically significant overall (5.3) and for NHOPI (19.2), White (10.5), multiple or other race (5.7), Black (4.6), Asian (4.3), and Hispanic (2.6) adults. Findings were similar for vaccination intent. Eliminating inequitable experiences in health care settings might help reduce some disparities in receipt of a COVID-19 vaccine.

NIS–ACM is a random-digit–dialed mobile telephone survey of adults aged ≥18 years in the 50 states, the District of Columbia, selected local areas, and selected U.S. territories.^† During the data collection period for this report, monthly survey response rates ranged from 17% to 23%. Reported experiences of racial and ethnic discrimination were assessed by the question, “When seeking health care in the last 2 years, do you feel your experiences were worse than, the same as, or better than (those of) persons of other races or ethnicities?” (hereafter worse, same, and better). “Don’t know” was also a valid response option. This question was adapted from CDC’s Behavioral Risk Factor Surveillance System (BRFSS) Reactions to Race module.^§ The question was field tested, cognitively tested, and approved by the Office of Management and Budget, then slightly modified for NIS-ACM by adding ethnicities and expanding the time frame to 2 years because of COVID-19. Because of the interest in examining reported inequitable experiences in health care and the association of these experiences with COVID-19 vaccination behaviors, the focus for the analysis of discrimination was a comparison of worse experiences with same experiences. COVID-19 vaccination status^¶ was assessed by three questions: “Have you received at least one dose of a COVID-19 vaccine?,” “Which brand of COVID-19 vaccine did you receive for your first dose?,” and “How many doses of a COVID-19 vaccine have you received?” The last two questions assessed completion of the primary series or partial vaccination. Among persons who had not received any COVID-19 vaccine doses, vaccination intent** was assessed by the question, “How likely are you to get a COVID-19 vaccine?” The outcomes of interest in this study were 1) being unvaccinated against COVID-19 and 2) among unvaccinated persons, definitely not intending to get vaccinated. Unadjusted and adjusted prevalence differences compared those reporting experiences that were worse than and the same as those of persons of other races and ethnicities. T-tests were used to assess statistical significance of unadjusted prevalence differences. Adjusted prevalence differences were based on multivariable logistic regression and predictive marginals assessing the association of reported discrimination with vaccination status and vaccination intent, overall and by race and ethnicity, controlling for age, sex, education, poverty status, metropolitan statistical area (urban, suburban, or rural residence), U.S. Census Bureau region, and health insurance status. Adjusted and unadjusted prevalence differences were considered statistically significant at p<0.05. Analyses were conducted for respondents overall and separately for AI/AN, Asian, Black, Hispanic, NHOPI, White, and multiple or other race respondents. Data were weighted to represent the noninstitutionalized U.S. adult population and to adjust for nonresponse and households without a telephone. Data were calibrated to state vaccine administration data reported to CDC.^†† SAS (version 9.4; SAS Institute) and SUDAAN (version 11; RTI International) were used for statistical analyses. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^§§

Overall, 3.5% of respondents reported that their experiences in health care were worse than those of persons of other races and ethnicities (Supplementary Table; https://stacks.cdc.gov/view/cdc/127243) (Supplementary Figure 1; https://stacks.cdc.gov/view/cdc/127237). Significantly higher percentages of having worse experiences were reported by Black (10.7%), AI/AN (7.2%), multiple or other race (6.7%), Hispanic (4.5%), NHOPI (3.9%) and Asian (2.8%) adults than by White (1.6%) adults. The prevalence of being unvaccinated against COVID-19 was significantly higher among respondents reporting worse experiences in health care than among those reporting the same experiences, with unadjusted prevalence differences of 5.3 overall, and 19.2 among NHOPI, 10.5 among White, 5.7 among multiple and other race, 4.6 among Black, 4.3 among Asian, and 2.6 among Hispanic adults (Table 1) (Figure). After adjustment, the prevalence differences associated with being unvaccinated were attenuated but remained statistically significant overall (3.2) as well as for NHOPI (14.6), White (6.1), Black (2.7), Asian, (3.8), and Hispanic (3.0) adults (Table 1) (Supplementary Figure 2; https://stacks.cdc.gov/view/cdc/127242).

Among unvaccinated respondents, the prevalence of those who stated that they were definitely not intending to get vaccinated was significantly higher among those who reported worse experiences in health care than among those who reported that their experiences were the same as those of persons of other races and ethnicities, with unadjusted prevalence differences of 3.7 overall, and 10.6 among NHOPI, 9.8 among White persons, 6.3 among multiple and other race, 3.5 among Black, and 3.0 among Hispanic (Table 2) (Figure). After adjustment, the prevalence differences were attenuated but remained statistically significant overall (2.9) and for White (6.4), multiple and other race (4.9), Black (2.6), and Hispanic (3.3) adults (Table 2) (Supplementary Figure 2; https://stacks.cdc.gov/view/cdc/127242).

Acknowledgment

Madeleine R. Valier.

Corresponding author: Laurie D. Elam-Evans, lxe1@cdc.gov.

¹Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC; ²School of Global Affairs, King’s College London, London, England; ³Rollins School of Public Health, Emory University, Atlanta, Georgia; ⁴Division of Global HIV and TB, Center for Global Health, CDC; ⁵Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.

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Abbreviations: MSA = metropolitan statistical area; PD = prevalence difference; Ref = referent group.
* Reported experiences of racial and ethnic discrimination were assessed by the question, “When seeking health care in the last 2 years, do you feel your experiences were worse than, the same as, or better than (those of) persons of other races or ethnicities?” Persons who reported “worse” experiences were considered to have experienced discrimination.
^† Received 1 dose of the Pfizer-BioNTech vaccine or 1 dose of the Moderna vaccine.
^§ Received 2 doses of the Pfizer-BioNTech vaccine, 2 doses of the Moderna vaccine, 1 dose of the Janssen (Johnson & Johnson) vaccine, or 2 doses of the Novavax vaccine (starting with August 2022 data).
^¶ Adjusted prevalence differences were those adjusted for age (18–29, 30–39, 40–49, 50–64, 65–74, or ≥75 years), sex (female or male), education (high school diploma or less, some college, college graduate, or advanced degree), poverty status (below poverty, at or above poverty and <$75,000 annually, or at or above poverty and ≥$75,000 annually), MSA status (MSA principal city, MSA nonprincipal city, or non-MSA), U. S. Census Bureau region (Northeast, Midwest, South, or West), and health insurance status (insured or not insured).
** Statistically significant difference compared with Ref (“same as”) (p<0.05).
^†† 95% CI >20 might not be reliable.

FIGURE. Unadjusted association* between experience with racial and ethnic discrimination^† while seeking health care and being (A) unvaccinated and (B) unvaccinated and definitely not intending to get vaccinated, overall and by race and ethnicity^§— National Immunization Survey – Adult COVID Module, April 22, 2021–November 26, 2022

Abbreviations: AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or other Pacific Islander; NH = non-Hispanic

* 95% CIs indicated by error bars; 95% CIs that exclude zero are statistically significant.

^† Reported experiences of racial and ethnic discrimination were assessed by the question, “When seeking health care in the last 2 years, do you feel your experiences were worse than, the same as, or better than (those of) persons of other races or ethnicities?” Persons who reported “worse” experiences were considered to have experienced discrimination.

^§ Hispanic persons could be of any race.

Abbreviations: MSA = metropolitan statistical area; PD = prevalence difference; Ref = referent group.
* Reported experiences of racial and ethnic discrimination were assessed by the question, “When seeking health care in the last 2 years, do you feel your experiences were worse than, the same as, or better than (those of) persons of other races or ethnicities?” Persons who reported “worse” experiences were considered to have experienced discrimination.
^† The unadjusted row percentages for the five categories of vaccination intent add to the unadjusted percentages of unvaccinated adults.
^§ Adjusted prevalence differences were those adjusted for age (18–29, 30–39, 40–49, 50–64, 65–74, or ≥75 years), sex (female or male), education (high school diploma or less, some college, college graduate, or advanced degree), poverty status (below poverty, at or above poverty and <$75,000 annually, or at or above poverty and ≥$75,000 annually), MSA status (MSA principal city, MSA nonprincipal city, or non–MSA), U.S. Census Bureau region (Northeast, Midwest, South, or West), and health insurance status (insured or not insured).
^¶ Statistically significant difference compared with Ref (“same as”) (p<0.05). ** 95% CI >20 might not be reliable.