OBJECTIVES: Approximately 25% vaccine hesitancy was observed in the U.S. in 2022. This study assesses vaccine hesitancy attitudes and behavior for COVID-19 immunizations.

METHODS: We developed a one-time survey for adults ≥ 18 years who can read, write, and understand English, with approval from the West Virginia University IRB. Convenience sampling techniques were used to distribute the survey through social media and WVU list services. Participants were asked for demographic information in addition to the open-ended question to understand the vaccine hesitancy attitudes: "Please tell us what do you know about the COVID-19 vaccine?" Thematic analysis was performed for the open-ended question. Using the grounded theory approach, two independent researchers initially coded 75 responses to develop a coding framework based on health behavioral theory (HBT) and the Vaccine Attitudes Examination (VAX) scale. Participants' responses were coded over three rounds, totaling 65 responses, to assess inter-coder reliability using Cohen's Kappa (K = 0.85, 0.87, 0.89).

RESULTS: A total of 1,084 participants completed the survey, and the majority were young, female, White, and had at least some college education. 580(53.5%) participants gave substantive responses to the open-ended question. We identified two HBT constructs- outcome expectation from socio-cognitive theory and identity from self-regulatory theory. The themes observed in the outcome expectation were safety (186, 32.07%) and efficacy and benefits of vaccines (250, 43.10%). Themes for the identity included characteristics of vaccines (153, 26.38%) and mechanism of action (88, 15.17%). The VAX scale constructs, which include mistrust of vaccines and concerns about unforeseen future effects, were recorded alongside themes like the rapid development of vaccines, the risk of transmission to others, and the emergence of new COVID-19 variants.

CONCLUSIONS: With COVID-19 resurgence, this study's insights into vaccine hesitancy can be instrumental in developing public health strategies to promote COVID-19 immunizations in the US.