key: cord-1052462-vaxhb7xx
authors: Thorpe, Alistair; Fagerlin, Angela; Drews, Frank A.; Shoemaker, Holly; Scherer, Laura D.
title: Self-reported health behaviors and risk perceptions following the COVID-19 vaccination rollout in the US: An online survey study.
date: 2022-05-18
journal: Public Health
DOI: 10.1016/j.puhe.2022.05.007
sha: 0852a3b677a292bd96541b744585fcc54b80888f
doc_id: 1052462
cord_uid: vaxhb7xx

Objectives Concerns have been raised that mass-vaccination campaigns might lead to reduced engagement with other recommended health behaviors. We assessed self-reported behaviors and risk perceptions following the COVID-19 vaccine rollout in the US. Study design Between December-2, 2020 and March-23 2021 we conducted three online survey studies with US adult respondents. Methods Respondents self-reported their COVID-19 vaccination status, their frequency of engaging in risk-increasing behaviors and wearing a mask when in public places., and their COVID-19 risk perceptions (i.e., perceived likelihood of getting COVID-19 and of being hospitalized if they got COVID-19). Results Our analytical sample included 832 respondents who had completed the first and final surveys and had received either 0 or 2 doses of a COVID-19 vaccine. Most respondents were non-Hispanic White (75%), male (77%) and US Veterans (64%), with the median age between 55 and 74 years. Overall, respondents reported frequently wearing masks when in public and rarely engaging in risk-increasing behaviors. Regardless of vaccination status, respondents reported more frequently engaging in risk-increasing behaviors and lower risk perceptions in March-2021 than December-2020. Mask wearing did not change over the study period with vaccinated respondents consistently reporting more frequent mask wearing than unvaccinated respondents. Conclusions Taken together, our findings indicate that the COVID-19 vaccine rollout in the US did not result in the rapid abandonment of protective behaviors or dramatic uptake of risk-increasing behaviors. Additional studies are needed to monitor how mass-vaccination might impact public behaviors and risk perceptions as coverage widens.

Efforts to limit the impact of the COVID-19 pandemic have relied heavily on people making substantive changes to the way they live and interact with one another. Most people have been diligent in adopting and adhering to recommended health behaviors despite the high costs and difficulty of doing so. 1 However, signs of decreasing engagement, particularly to less habitual and more burdensome health behaviors (e.g., physical distancing), have emerged during the pandemic. 2, 3 Concerns have been raised that the rollout of COVID-19 vaccines would exacerbate decreasing public engagement to health behaviors. 4, 5 Misconceptions about the protection offered by vaccines among those fully-or-partially vaccinated 6 and overconfidence in the protection of people who are vaccinated among unvaccinated people 4 have been noted as potential drivers of increased complacency towards health behaviors, which could undermine the public health impact of the COVID-19 vaccines. However, current evidence on the impact of the COVID-19 vaccine rollout on public engagement with other health behaviors remains limited and inconclusive, 7, 8 particularly in the US.

The aim of this study was to better understand the impact of the COVID-19 vaccine rollout on reported frequency of engaging in risk-increasing behaviors, wearing a mask when in public, and risk perceptions across the early vaccine rollout period in the US (December-2020 to March-2021). In order to identify potential differences in the reported behaviors and perceptions of 

Respondents answered a series of questions about their current behaviors, well-being, healthcare experiences, and attitudes regarding the COVID-19 pandemic. Although not relevant to the present findings, it is worth noting that at the start of the March-2021 survey, respondents were randomly assigned to a control group or to view one of two messages about COVID-19 vaccines as part of a separate experiment about communications regarding COVID-19 vaccine development and safety. 9 As the messages had no effect on respondents' vaccine intentions, safety perceptions, or worries about side effects we report data across all respondents.

Vaccination status (measured March-2021): "Have you received the COVID-19 vaccine?" with responses "No", "Yes, 1-dose" and "Yes, 2-doses". As we could not differentiate between those vaccinated with a 1-dose vaccine (Johnson & Johnson) and those who received the first of a 2dose vaccine (e.g., Pfizer or Moderna), respondents who answered "Yes, 1-dose" were not J o u r n a l P r e -p r o o f included in these analyses. However, analyses including these respondents are available in the Appendix. Mask wearing (measured December-2020 and March-2021): How frequently, if at all, respondents were "Wearing a mask over your nose and mouth when you are in a public place (e.g., a store)". The risk-increasing behavior and mask wearing questions were answered using a 6-point scale (1="Never", 2="Very rarely", 3="Rarely", 4="Occasionally", 5="Frequently", 6="Very frequently").

Risk perceptions (measured December-2020 and March-2021): Two questions ("In your opinion, how likely is it that you will get COVID-19 during the next month?", and "If you were to get COVID-19, how likely do you think it is that you would need to be hospitalized?") answered using a 5-point scale (1="Not at all likely" to 5="Very likely"). Analyses were conducted using R-Studio Version-1.4.1106. We conducted linear mixed effects models with lme4 for each outcome measure with survey time (December-2020; March-2021) as the within-subjects factor and vaccination status as the between-subjects factor. For follow-up comparisons, we used rstatix to conduct Welch's independent t-tests and paired-samples t-tests.

These analyses were not pre-registered. Although we pre-registered the research question, we realized the proposed analyses were not the most appropriate for answering the research question. Thus, we present the pre-registered analyses in the Appendix. Most respondents were non-Hispanic White (621, 75%), male (641, 77%) and US Veterans (529, 64%), with a median age between 55-74 years (Appendix Table 1a ).

On average, respondents reported very rarely engaging in risk-increasing behaviors both before and after the COVID-19 vaccine rollout (Figure 1 and Appendix: Table 2 ). In December-2020, Taken together, our findings indicate that the COVID-19 vaccine rollout in the US did not result in the rapid abandonment of protective behaviors or dramatic uptake of risk-increasing behaviors. Overall, respondents reported very rarely engaging in risk-increasing behaviors both before and after the vaccine rollout. Thus, despite respondents engaging slightly more frequently in risk-increasing behaviors after the vaccine rollout, with a steeper change among vaccinated respondents, both vaccinated and unvaccinated respondents continued to predominantly avoid engaging in risky behaviors and situations. Engagement with protective health behaviors also remained high following the COVID-19 vaccine rollout with the vast majority of respondents in our sample consistently reporting that they frequently-to-very frequently wore masks when in public. Notably, vaccinated respondents reported more frequent mask wearing than unvaccinated respondents, which further highlights the scope for promoting mask use by unvaccinated individuals. While engagement with risk-increasing behaviors and mask wearing did not change dramatically, risk perceptions did vary with vaccinated respondents in particular thinking it was less likely they would get COVID-19 or be hospitalized if they did get COVID-19 following the COVID-19 vaccine rollout.

Limitations of the present study include reliance on the accuracy of self-reported vaccination status and behavior. Self-report data provides valuable public health insights given the high correspondence with actual health behaviors 10, 11 and medical records (e.g., for vaccination status). 12 However, it is important to consider that there are many reasons why respondent's answers may have been inaccurate or inconsistent (e.g., social desirability). Observational data for the same period would therefore provide greater confidence in the present findings. In J o u r n a l P r e -p r o o f addition, our sample is not representative of the general population. Nonetheless, these findings provide important insights into the behaviors and perceptions of US adults, some of whom were eligible and received COVID-19 vaccines in the early stages of the rollout.

Continued assessment of public behavior remains important given changing recommendations (e.g., revised CDC guidance for fully-vaccinated individuals announced in April and May-2021), 13 easing of public health measures, and the emergence of variants of concern (e.g., Delta/Omicron).

The present findings do not support concerns that the COVID-19 vaccine rollout resulted in complacency towards other health behaviors by either vaccinated or unvaccinated individuals.

Conversely, vaccinated respondents continued to avoid risk-increasing behaviors and very frequently wore masks when in public even in light of their reduced risk following vaccination, which these respondents acknowledged in updating their risk perceptions. Unvaccinated respondents also continued to refrain from risk-increasing behaviors, frequently wore masks in public, and reported only moderate changes in their risk-perceptions. These findings suggest that, at least in this study, the COVID-19 vaccine rollout did not appear to result in widespread complacency towards other health behaviors. Results of mixed effects models main effects and interactions shown in each panel.

COVID-19 Stress, Coping, and Adherence to CDC Guidelines

A worldwide assessment of COVID-19 pandemic-policy fatigue. Available at SSRN 3774252

Change in Reported Adherence to Nonpharmaceutical Interventions During the COVID-19 Pandemic

Risk Compensation and COVID-19 Vaccines

Are people letting down their guard too soon after covid-19 vaccination? The BMJ

Beyond the First Dose -Covid-19 Vaccine Follow-through and Continued Protective Measures

Thinking beyond behavioural change as an explanation for increased COVID post vaccination

Do people reduce compliance with COVID-19 guidelines following vaccination? A longitudinal analysis of matched UK adults

Communicating about COVID-19 vaccine development and safety. medRxiv

Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence

Predictors of COVID-19 vaccine uptake: An online longitudinal study of US Veterans and non-Veterans. medRxiv

Validation of self-reported influenza vaccination in the current and prior season. Influenza and other respiratory viruses

Conflicts of interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.