Vaccine 40 (2022) 562–567

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Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Short communication

Underserved population acceptance of combination influenza-COVID-19

booster vaccines
Robert P. Lennon a,⇑, Ray Block Jr b, Eric C. Schneider c, Laurie Zephrin d, Arnav Shah e,
The African American Research Collaborative 2021 COVID Group 1
a
Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA
b
Penn State, Departments of Political Science and African American Studies, 308 Pond Laboratory, University Park, PA 16802, USA
c
Senior Vice President for Policy and Research, The Commonwealth Fund, 1 East 75th Street, New York, NY 10021, USA
d
Health System Equity, The Commonwealth Fund, 1 East 75th Street, New York, NY 10021, USA
e
Senior Research Associate, Policy and Research, The Commonwealth Fund, 1 East 75th Street, New York, NY 10021, USA

a r t i c l e i n f o a b s t r a c t

Article history: Recent data indicates increasing hesitancy towards both COVID-19 and influenza vaccination. We studied
Received 9 July 2021 attitudes towards COVID-19 booster, influenza, and combination influenza-COVID-19 booster vaccines in
Received in revised form 26 November 2021 a nationally representative sample of US adults between May and June 2021 (n = 12,887). We used pre-
Accepted 30 November 2021
qualification quotes to ensure adequate sample sizes for minority populations. Overall vaccine accep-
Available online 7 December 2021
tance was 45% for a COVID-19 booster alone, 58% for an influenza vaccine alone, and 50% for a combina-
tion vaccine. Logistic regression showed lower acceptance among female, Black/African American, Native
Keywords:
American/American Indian, and rural respondents. Higher acceptance was found among those with col-
COVID-19
Vaccine confidence
lege and post-graduate degrees. Despite these differences, our results suggest that a combination vaccine
Influenza may provide a convenient method of dual vaccination that may increase COVID-19 vaccination coverage.
Health disparities Ó 2021 Elsevier Ltd. All rights reserved.

1. Introduction nonetheless suggest racial and ethnic disparities, with proportions

COVID-19 vaccine acceptance has varied over time in the
months prior to authorization of a vaccine. In June 2020, 75.5% of
U.S. adults reported being ‘‘very or somewhat likely” to accept a
COVID-19 vaccine, [1] but in September 2020, only 51% of U.S.
adults would ‘‘definitely or probably” get a vaccine to prevent
COVID-19 [2]. There are significant disparities in vaccine accep-
tance by race and ethnicity. Early in the pandemic, 65% of White
U.S. respondents were likely to get a COVID-19 vaccine when avail-
able, compared to only 22% of Black or African Americans [3].
After six months of vaccination efforts, actual uptake falls in the
middle of prior estimates of acceptance, and uptake among racial
and ethnic groups varies. As of June 3, 2021, the U.S. Centers for
Disease Control and Prevention (CDC) reported that 52% of U.S.
adults (
18 years of age) were fully vaccinated, with 63% having
received at least one dose [4]. The limited data on smaller minority
populations (i.e., Pacific Islander, Native American/Alaska Native)
⇑ Corresponding author.
E-mail addresses: rlennon@pennstatehealth.psu.edu (R.P. Lennon), rblock@psu.
edu (R. Block Jr), es@cmwf.org (E.C. Schneider), lz@cmwf.org (L. Zephrin), as@cmwf.
org (A. Shah), henry@africanamericanresearch.us.
1
African American Research Collaborative, USA.
of vaccinated population higher than their population proportion
among Non-Hispanic White, Non-Hispanic American Indian/Alaska
Native and Asian groups, and the opposite among Non-Hispanic
Black and Hispanic/Latino groups [5]. Further, over the first six
months of the pandemic, there was a decrease in COVID-19 and
influenza vaccination [6]. In that study, decreased vaccine inten-
tion correlated with lower trust in media, [6] which is very con-
cerning given low trust in media by minority groups [7]. For
these reasons, although influenza vaccination rates have been
much higher over the past two years, [8] and influenza infections
have been low (in part from higher vaccination, and in part from
COVID-19 public health precautions [9,10]), there is concern that
influenza vaccination rates will decrease over the this season.
Additional concerns related to disparities in COVID vaccine accep-
tance pertain to disparities in disease risk: the groups experiencing
the severest consequences from the disease are typically less likely
to accept vaccination [11].
Combination influenza-COVID-19 vaccines are being developed,
[12,13] but to date public acceptance of such a vaccine is unknown.
Given the relatively low acceptance rate of the influenza vaccine,
and flattening acceptance of COVID-19 vaccines, it may be combi-
nation vaccines are less acceptable than either vaccine alone. In
that event, it will be important to give the public a choice of vacci-

https://doi.org/10.1016/j.vaccine.2021.11.097
0264-410X/Ó 2021 Elsevier Ltd. All rights reserved.
R.P. Lennon, R. Block Jr, E.C. Schneider et al.
nations to avoid driving down rate. Alternatively, it may be that
higher familiarity with the influenza vaccine, combined with
potentially higher urgency of a COVID-19 booster, leads to higher
acceptance of a combination vaccine. In that event, combination
vaccines may offer a synergistic benefit, increase uptake of each.
The objective of this study is to determine the acceptability of a
combination influenza-COVID-19 vaccine (combination) compared
to influenza or COVID-19 vaccines alone, in a nationally
representative sample of U.S. adults that includes large oversam-
ples of racial and ethnic groups often underrepresented in such
surveys.
2. Material and methods
The African American Research Collaborative (AARC) is an orga-
nization dedicated to bringing an accurate understanding of Afri-
can American civic engagement to the public discourse. AARC
developed a survey and conducted a national mixed-mode (tele-
phone and online) poll of U.S. minority adults from May 7 – June
7, 2021. Unlike other widely-used public opinion surveys about
COVID-19 vaccine attitudes (e.g., the Kaiser Family Foundation’s
COVID-19 Vaccine Monitor, the Centers for Disease Control and
Prevention’s National Immunization Surveys, etc.), the AARC poll
included large and nationally representative samples of racial
and ethnic minorities using sampling techniques designed to
recruit minority respondents from all parts of the country and liv-
ing in diverse geographic contexts. Survey methodology is
described in detail elsewhere (www.covidvaccinepoll.com). Briefly,
pre-stratification randomized quota sampling was used as a start-
ing point to generate nationally representative samples of White
and minority-group populations, and post-stratification weights
were added to bring the resulting sample into balance with known
census demographic estimates for each racial and ethnic group in
the sample. BSP Research (https://bspresearch.com/) conducted
the surveys, asking respondents about their vaccine intentions.
Acceptance of the flu vaccine was measured by asking partici-
pants, ‘‘Do you plan to get the flu vaccine this year?” (yes, no, don’t
know/unsure). Acceptance of an annual COVID-19 vaccine was
measured by asking participants, ‘‘Some medical professionals think
COVID-19 vaccines may need to be taken annually, similar to the sea-
sonal flu vaccine. Would you say. . .” (I would definitely take an
updated COVID-19 vaccine once per year, I might take an updated
COVID-19 vaccine each year [it depends], I would NOT take an
updated COVID-19 vaccine each year). Acceptance of a combination
COVID-19 – flu vaccine was measured by asking participants,
‘‘Would you be willing to take a combination COVID-Flu vaccine as
one shot every year to protect yourself from both COVID-19 and
influenza?” (yes, no, don’t know/unsure). We patterned these survey
items after those used in other polls (see, e.g., the Kaiser Family
Foundation COVID-19 Vaccine Monitor Dashboard: https://www.
kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-
monitor-dashboard/). Comparing survey items that have different
response categories is very common in the social sciences. That
said, to aid with cross-item comparability, we use only the extreme
‘‘affirmative” response categories as unambiguous indicators of
vaccine acceptance.
Reaching demographic minority populations is difficulty, lead-
ing to low and unequal response rates in modern survey research
[14,15]. To overcome this challenge, we relied on pre-
stratification quotas to achieve large and representative subsam-
ples of demographic minority groups [16]. This sampling approach
requires random selection within strata, but ensures large and near
representative sample sizes for key demographics, including gen-
der; race/ethnicity; age; geography (urban, suburban, rural); immi-
grant status (native born, foreign born, undocumented); education;
563
Vaccine 40 (2022) 562–567
and political ideology. To further encourage diverse participation,
the study was offered in English, Spanish, Chinese, Korean, and
Vietnamese. Survey responses were powered to ensure a margin
of error under 4%. Statistical analysis was completed to 95% confi-
dence using Stata (version 16) software.
Descriptive statistics were used to describe the dependent vari-
ables, theoretically-central predictors, and control variables. Logis-
tic regression analysis was used to evaluate characteristic traits of
those likely to accept a given vaccination, and we derived odds
ratios as the ‘‘quantities of interest” in these models. There is a
table for each dependent variable (influenza vs. COVID vs. combo
vaccine acceptance). The first column records the independent
variables, and the table entries tell us the impact of a given predic-
tor on a particular dependent variable, holding other variables
constant.
Some of the predictors are organized so that readers can see the
specific categories comprising them. For example, the race/ethnic-
ity variable has five categories: Latino/a/X, Black/African American,
Asian American or Pacific Islander, Native American/American
Indian, and White. Each category is its own separate predictor (in
this case, we display the non-White categories and ‘‘White” is
omitted, making it the reference category to which the other
groups are compared).
We added the predictors incrementally. The first model only
has race and ethnicity. The second model adds socio-
demographic variables, all of which have been suggested to influ-
ence vaccine acceptance (partisanship, [17] gender, [18] income,
[19] education, [18] and geography/residency [20]). Likewise, the
third model includes a person’s age [18] and their baseline willing-
ness to receive vaccines [21] – predictors that are not only relevant
to a person’s health and wellness overall but are also risk factors
for COVID-19 severity. Below, we focus on the results from the ‘‘full
models” (i.e., the models in the third column, with all the predic-
tors added).
3. Results
Of the 12,887 respondents to the 2021 COVID-19 Vaccine Poll,
more than half of the respondents are women, and the median
age group is 35 to 59 years old (Table 1). The weighted demo-
graphic data are consistent with national demographic data
reported from the Pew Research Center and the U.S. Census, within
a margin of error of ± 4.0% for each racial and ethnic subgroup.
Among respondents in our survey, the total percentage of those
who have, will certainly, or will most likely take a COVID-19 vac-
cine alone is 45%, with a range of 37–53% across demographic sub-
groups. For an influenza vaccine alone, overall acceptance was 58%,
with a demographic range of 52–69%. For a combination influenza-
COVID-19 vaccine, overall acceptance was 50%, with a range of 44–
61%, regardless of race or ethnicity. Table 1 also shows variation in
respondents’ intent to take the COVID-19 vaccine, an influenza
vaccine, and a hypothetical combination influenza-COVID-19 boos-
ter. Generally, acceptance is highest for and influenza vaccine and
lowest for a COVID vaccine, with willingness to receive a combina-
tion vaccine falling between the others.
Tables 2 through 4 show the logistic regression models for our
measures of vaccine acceptance. In all the models, the coefficients
we report are odds ratios (ORs), accompanied by z-statistics in
parentheses and using superscript symbols to denote statistical
significance. The estimates are clustered by a respondent’s state
of residence, in keeping with common survey sampling strategies
and because geography introduces heteroskedasticity [22]. The
models demonstrate racial and ethnic differences in people’s will-
ingness to receive vaccine. Because we are primarily concerned
with these group differences, we focus the discussion below on
 Vaccine 40 (2022) 562–567

Table 1
Weighted Respondent Demographics (N = 12,287) and vaccine acceptance.

Demographic characteristic % of US Censusy or Gallup % accepting vaccination§

sample* Pollà
Influenza COVID-19 booster Combination influenza-COVID-19
alone alone booster
Overall 100% 100% 58% 45% 50%
Gender
y
Female 51.1% 50.8% 48.5% 47.4% 45.7%
Male 48.9% 49.2%y 51.5% 52.6% 54.3%
Race/Ethnicity
Black/African Am. 13.4% 13.4%y 52% 39% 42%
Asian Am. and Pacific Islander 6.7% 6.1%y 69% 53% 60%
Latino/a 15.2% 18.5%y 54% 46% 51%
Native Am. /Am. Indian 1.0% 1.3%y 52% 37% 44%
White (only) 63.7% 60.1%y 60% 45% 50%
Education Level
High school or less 40.0% n/a 52.5% 36.6% 42.6%
Some college, not graduate 30.2% n/a 53.2% 41.4% 44.7%
College graduate/ post graduate 30.0% 32.1%y 71.6% 59.3% 65.1%
degree
Median Income ($67521) y
% Above median 71.2% n/a 65.10 65.69 63.82
% Below median 28.9% n/a 34.90 34.31 36.18
Party Identification
Democrat 38.4% 30%à 43.7% 49.4% 48.1%
Independent 25.5% 39%à 23.5% 21.9% 22.5%
Republican 30.6% 29%à 28.9% 24.8% 25.8%
Geography/Urbanicity
Large city or urban area 31.6% n/a 64.1% 50.3% 57.1%
Suburb near large city 29.7% n/a 60.7% 46.9% 53.4%
Small town or small city 18.2% n/a 54.4% 43.5% 44.9%
Suburb near small town/city 7.5% n/a 54.0% 39.9% 46.6%
Rural area 13.1% n/a 47.5% 31.7% 33.6%

Am. = American.
*
Margins of error: ± 0.9% for full sample (n = 12,887), ± 2.1% for African Americans (n = 2,281), ± 1.8 for Latino/a (n = 2,944), ±, 2.1 for Asian Americans and Pacific Islanders
(n = 2,281), and ± 2.2 for American Indians/Native Americans (n = 1,921).
y
US Census, 2020. https://www.census.gov/quickfacts/fact/table/US/PST045219
à
Average responses of May and June 2021 (same as survey months), Gallup. https://news.gallup.com/poll/15370/party-affiliation.aspx.
§
Vaccine acceptance measured as follows:
 For influenza only: % ‘‘yes (I plan to get the flu vaccine this year)”.
 For COVID-19 only vaccine: % ‘‘I would definitely take an updated COVID-19 vaccine once per year”.
 For combination vaccine: % ‘‘yes (I would be willing to take every year)”.

results in the ‘‘full” models of each table (third column), which dis-
play the impact of race and ethnicity on vaccine acceptance, con-
trolling for other factors.
For example, the odds ratios in third column of Table 2 for the
predictor variables for Latino/a/X, African American, and Native
American respondents are 0.67, 0.51, and 0.80, respectively and
they are all statistically significant at the p < .10 level of lower.
Since ratios below the value of 1 suggest a negative relationship
between independent and dependent variables, Table 2 confirms
that, taking other factors into account, these respondents are less
acceptant of an influenza vaccine. However, respondents who are
Asian American/Pacific Islander are no different than their White
colleagues when it comes to vaccine acceptance (OR = 0.86,
p > .10).
In full model in Table 3, we evaluate racial/ethnic differences in
the acceptance of a COVID-19 vaccine. Here, the only statistically
significant difference is between White and African American
respondents (the odds ratio for the Black respondents’ predictor
variable is 0.67, with a p-value of < 0.05). This demonstrates that,
controlling for other factors, the African Americans who took our
survey are less willing than their White colleagues to receive the
COVID vaccine.
Table 4 contains the results for a hypothetical combination
influenza + COVID-19 vaccine. Once again, African Americans are
less accepting when compared to White respondents (OR = 0.60,
p < .05).
4. Discussion
Our results suggest that COVID-19 vaccine acceptance among
racial and ethnic groups is higher than reported in polling from
May 24, 2021, [23] and consistent with CDC reports of actual vac-
cination percentage across all US adults [4]. While offering some
hope for wider coverage, the persistence of demographic dispari-
ties in uptake speaks to the need for changing vaccination
messaging.
Influenza vaccine acceptance is generally higher than pre-
COVID influenza coverage, [24] and similar to the rates of the
2020–2021 flu season, which enjoyed much higher coverage than
usual [8]. This is encouraging in the face of early indications that
influenza vaccination intentions were declining [6]. However,
given historic low acceptance of influenza vaccination, [25] it is
important to remain vigilant with pro-vaccination health messag-
ing, as pandemic-vaccination intentions may not persist into post-
pandemic seasons.
Acceptance of a combination vaccine among minorities is
higher than for COVID-19 alone, but lower than influenza alone.
While no historical data are available for comparison, the fact that
approximately half of the population is willing to accept a novel
combination vaccine suggests that bundling new vaccines or
boosters (like COVID-19) with highly accepted vaccines (like
influenza) may be a convenient option to increase uptake of future
novel vaccines among minorities.

564
 Vaccine 40 (2022) 562–567

Table 2
Odds ratios from logistic regression models of influenza vaccine acceptance.

Willing to take influenza vaccination Model Odds ratios (z-statistic)

First Model: Second Model: Third Model: Health- Related Predictors Added
Racial/Ethnic Groups Socio- Demographic Factors Added
Latino/a/X 0.81* (-2.16) 0.73** (-3.02) 0.67** (-3.00)
Black/African American 0.73** (-2.93) 0.55*** (-7.88) 0.51*** (-4.57)
Asian Am. or Pacific Islander 1.49*** (4.42) 1.08 (0.86) 0.86 (-1.46)
Native American/Am. Indian 0.73*** (-3.49) 0.74** (-3.05) 0.80+ (-1.76)
Respondent identifies as Democrat 1.89*** (8.00) 1.45*** (3.52)
Respondent identifies as Republican 1.03 (0.24) 0.93 (-0.41)
Gender (1 = Woman, 0 = Man) 0.84+ (-1.88) 0.80* (-2.17)
Earns more than the median income 1.60*** (6.14) 1.38** (2.72)
Some college 0.97 (-0.34) 0.95 (-0.36)
College graduate and beyond 1.48*** (4.13) 1.48** (3.14)
Resides in suburb near large city 0.84 (-1.53) 0.94 (-0.33)
Resides in small town/city 0.65** (-2.83) 0.65** (-2.68)
Resides in suburb near small town/city 0.68** (-2.75) 0.82 (-0.60)
Resides in rural area 0.61* (-2.57) 0.98 (-0.074)
Between 35 and 59 years old 1.03 (0.21)
60 years old and above 1.18 (0.94)
Always get flu shot every year 694.7*** (29.7)
Gets flu shot some, but not all, years 36.3*** (16.2)
Usually does not get the flu shot 4.86*** (7.24)
Observations 12,287 10,896 10,896
Pseudo R2 0.0050 0.054 0.59

Exponentiated coefficients, clustered by state; z statistics in parentheses

Source: 2021 American COVID-19 Vaccine Poll. (We drop the constant terms from each model.)
*
p < 0.05, **p < .01, ***p < .001. Bold number are statistically significant at the p < .05 level. Marginally significant differences are identified by +, where 0.50  p < 0.10, in
order to identify relationships of interest for future studies.

Table 3
Odds ratios from logistic regression models of COVID-19 vaccine booster acceptance.

Willing to take COVID-19 booster Model Odds ratios (z-statistic)

First Model: Second Model: Third Model: Health- Related Predictors Added
Racial/Ethnic Groups Socio- demographic Factors Added
Latino/a/X 1.02 (0.24) 0.90 (-1.23) 1.09 (1.07)
Black/African American 0.77** (-2.68) 0.59*** (-6.07) 0.67*** (-5.09)
Asian Am. or Pacific Islander 1.39*** (3.72) 1.05 (0.72) 1.05 (0.46)
Native American/Am. Indian 0.73*** (-3.44) 0.82+ (-1.94) 1.02 (0.21)
Respondent identifies as Democrat 2.39*** (14.7) 2.13*** (10.5)
Respondent identifies as Republican 0.83 (-1.28) 0.65** (-3.07)
Gender (1 = Woman, 0 = Man) 0.81** (-3.24) 0.79** (-3.24)
Earns more than the median income 1.19+ (1.75) 1.05 (0.46)
Some college 1.22* (2.33) 1.31** (2.61)
College graduate and beyond 1.88*** (5.80) 1.95*** (6.06)
Resides in suburb near large city 0.98 (-0.21) 1.00 (0.051)
Resides in small town/city 0.87 (-1.19) 0.92 (-0.70)
Resides in suburb near small town/city 0.77+ (-1.91) 0.77 (-1.55)
Resides in rural area 0.67* (-2.44) 0.73+ (-1.81)
Between 35 and 59 years old 1.06 (0.50)
60 years old and above 2.11*** (5.79)
Always get flu shot every year 12.8*** (20.4)
Gets flu shot some, but not all, years 3.26*** (10.5)
Usually does not get the flu shot 1.83*** (3.75)
Observations 12,287 10,896 10,896
Pseudo R2 0.0031 0.069 0.24

Exponentiated coefficients, clustered by state; z statistics in parentheses

Source: 2021 American COVID-19 Vaccine Poll. (We drop the constant terms from each model.)
*
p < 0.05, **p < .01, ***p < .001. Bold number are statistically significant at the p < .05 level. Marginally significant differences are identified by +, where 0.50  p < 0.10, in
order to identify relationships of interest for future studies.

Further study is warranted to investigate why combination
vaccine acceptance falls between influenza and COVID-19. As
some of those not accepting of a COVID-19 booster would accept
a combination vaccine, presumably the long history of influenza
vaccine safety allayed trepidations stemming from the newness
of the COVID-19 booster. Similarly, it appears that fears about
the COVID-19 booster drove some otherwise accepting of an
influenza vaccine to not accept a combination vaccine. To avoid
565
decreasing influenza vaccination in that group, it may be impor-
tant to offer both the combination vaccine and the influenza vac-
cine alone.
For influenza, COVID-19 booster, and a combination vaccines,
highest acceptance was among those with a college education
(similar to previous reports on influenza [26] and COVID-19 vacci-
nation [20]) and those living in urban areas (similar to previous
reports on influenza [27] and COVID-19 [28]).
 Vaccine 40 (2022) 562–567

Table 4
Odds ratios from logistic regression models of a combination influenza plus COVID-19 vaccine booster acceptance.

Willing to take influenza / COVID-19 combination vaccine Model Odds ratios (z-statistic)
First Model: Second Model: Third Model: Health- Related Predictors
Racial/Ethnic Socio- demographic Factors Added
Groups Added
Latino/a/X 1.01 (0.099) 0.84+ (-1.82) 0.93 (-0.80)
Black/African American 0.72** (-3.15) 0.54*** (-7.27) 0.60*** (-5.11)
Asian Am. or Pacific Islander 1.50*** (4.93) 1.10 (1.50) 1.04 (0.30)
Native American/Am. Indian 0.78** (-2.89) 0.87 (-1.49) 1.00 (0.041)
Respondent identifies as Democrat 2.36*** (10.2) 2.04*** (7.59)
Respondent identifies as Republican 0.86 (-1.01) 0.77+ (-1.65)
Gender (1 = Woman, 0 = Man) 0.68*** (-5.81) 0.65*** (-5.00)
Earns more than the median income 1.49*** (5.22) 1.29** (3.05)
Some college 1.05 (0.41) 1.07 (0.55)
College graduate and beyond 1.78*** (4.71) 1.74*** (4.33)
Resides in suburb near large city 0.94 (-0.70) 1.02 (0.24)
Resides in small town/city 0.71** (-2.84) 0.78* (-2.10)
Resides in suburb near small town/city 0.77+ (-1.83) 0.89 (-0.62)
Resides in rural area 0.53*** (-3.67) 0.63* (-2.35)
Between 35 and 59 years old 1.20+ (1.92)
60 years old and above 1.37** (2.96)
Always get flu shot every year 18.7*** (22.6)
Gets flu shot some, but not all, years 7.03*** (17.3)
Usually does not get the flu shot 2.58*** (5.47)
Observations 12,287 10,896 10,896
Pseudo R2 0.0045 0.086 0.26

Exponentiated coefficients, clustered by state; z statistics in parentheses.

Source: 2021 American COVID-19 Vaccine Poll. (We drop the constant terms from each model.).
*
p < 0.05, **p < .01, ***p < .001. Bold number are statistically significant at the p < .05 level. Marginally significant differences are identified by +, where 0.50  p < 0.10, in
order to identify relationships of interest for future studies.

As a cross-sectional survey, our data may not be generalizable
over time. Further, our data does not include reasons behind high
and low intent; hence, other attitudes or beliefs may underlay dis-
parities observed. Moreover, the non-experimental nature of this
data source limits our ability to establish causal relationships the
highlighted factors and outcomes. Strengths of our study include
robust sampling, offering a 4% margin of error for minority groups
that have limited data to date. By offering the survey in multiple
languages, we increased the likelihood of generalizability to non-
native English-speaking adults.
Because our goal was to examine the presence of racial and eth-
nic group differences in vaccine acceptance, while additional anal-
yses that explain why racial/ethnic group differences exist in
vaccine acceptance and that consider the potential role of race
and ethnicity as moderator variables have merit, such explorations
are beyond the scope of the current paper.
5. Conclusions
The rapid development and wide distribution of vaccines for
COVID-19 has been impressive. However, millions of people are
still unvaccinated because of lack of access or persistent vaccine
hesitancy, undermining the effectiveness of vaccines in controlling
the pandemic. As mitigation efforts like masks, social distancing,
and school and business closures are relaxed or retired, widespread
vaccination is particularly important to minimize the emergence of
COVID-19 mutations. As more contagious viral variants emerge,
hospitalizations and deaths will continue to have a disproportion-
ate impact on people of color given historic disparities in health
care access and quality. Further, vaccination among low-income
workers and workers of color – who were disproportionately
impacted by COVID-19 related job losses – is needed to facilitate
their return to employment.
Despite previously documented COVID-19 and influenza vac-
cine hesitancy, combination influenza-COVID-19 booster vaccines
would be moderately acceptable, and this approach could mod-
566
estly increase COVID-19 vaccine uptake, but may also decrease
influence vaccine uptake. An optimal approach may therefore be
to off a combination vaccine first, and if refused offer individual
influenza or COVID-19 boosters to accommodate those who will
accept only one.
Author Contributions
RB conceived of the study. Authors RPL, RB, ECS, LZ, and AS
designed the study. Authors RPL and RB analyzed and interpreted
the data. RPL drafted the article. Authors RPL, RB, ECS, LZ, and AS
critically revised the article for intellectual content, and gave final
approval of the version submitted.
Funding
This work was supported by the Commonwealth Fund, the
Robert Wood Johnson Foundation, and the WK Kellogg Foundation.
Members of RWJF and WKKF funding organization provided con-
sultation on survey development, but otherwise were not involved
in research design, data collection, analysis, or interpretation. Com-
monwealth Fund staff named as co-authors participated in survey
development and critical revision of the work, but were not
involved in data collection, analysis, or interpretation. Funders
were not involved in the decision to submit the article for
publication.
Declaration of Competing Interest
The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
to influence the work reported in this paper.
Acknowledgements
The authors are grateful to the members of the African Ameri-
can Research Collaborative 2021 COVID group. Listed in alphabet-
ical order by last name, the group includes Matt Barreto, Erica
Bernal-Martinez, Ray Block Jr., Gayle Chacon, Annabelle De St.
Maurice, Henry Fernandez, Ray Foxworth, Matt Hildreth, Robert

P. Lennon, Marcella Nunez-Smith, Gabriel Sanchez, Eric C. Schnei-
der, Arnav Shah, Peter Szilagyi, Janelle Wong, and Laurie Zephrin.
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