Public Willingness to Mask and Vaccinate in the Future: Results From a 2023 Nationally Representative Survey of US Adults

Abstract

The enduring spread of COVID-19 and other respiratory viruses highlights a need for greater focus on long-term public willingness to perform protective behaviors. Although COVID-19 is no longer considered a public health emergency of international concern, it is unknown whether people in the United States plan to continue protective behaviors to protect themselves and others against infection. To inform planning and communications, we used a nationally representative survey of 1,936 US adults to examine attitudes and intentions toward future vaccination and mask-wearing. A majority believed COVID-19 vaccines were safe (73%) and effective in protecting against serious illness (72%). One-third (33%) had strong intentions to get an updated COVID-19 vaccine most years in the future. Among those with weaker intentions (n=1,287), many cited concerns about safety (71%) and efficacy (64%), lack of trust in institutions (64%), or beliefs that prior vaccination or infection protected them (62%). Approximately two-thirds (69%) of respondents believed masks were effective in protecting the wearer from getting COVID-19, and a majority appeared moderately receptive to future public mask-wearing, particularly when there was proximate risk of infection from COVID-19 (67%) or other respiratory viruses (59%). Men, non-Hispanic White adults, younger adults, rural residents, and adults with higher incomes, without college degrees, and without serious medical conditions or physical limitations were more likely to indicate resistance toward future COVID-19 vaccination and/or mask-wearing. Findings support tailored messaging to address concerns and opportunities among different populations, as well as support for communications programs and community engagement to motivate future uptake.

Introduction

As public health leaders prepare for future seasonal and emergency infectious disease outbreaks, the enduring community spread of COVID-19 and other respiratory viruses highlights the need to focus on public willingness to perform protective behaviors over the long term.¹ This is especially important given the risks that COVID-19, seasonal influenza, and respiratory syncytial virus (RSV) could spread simultaneously in coming years to create a more deadly respiratory illness season in many parts of the United States and around the world.^2,3 At the same time, the risk of additional novel circulating infectious diseases continues.⁴ Vaccination and mask-wearing have been effective approaches to limiting the impact of COVID-19, and the protection that masks confer extends to other upper respiratory viruses.^5–8 Increasing public willingness to stay up to date on COVID-19 vaccination and to wear masks if viral spread is high is a critical public health goal. Although COVID-19 is no longer considered a public health emergency of international concern,⁹ it is unknown whether people in the United States plan to continue protective behaviors to protect themselves and others against infection and, if so, under what circumstances.^10–13

There is a dearth of research on the US public's attitudes and intentions toward protective behaviors after the first years of the pandemic and oriented toward the future. Most studies on this topic were conducted early in the pandemic, before the widespread availability of COVID-19 vaccines (ie, in 2020 or 2021);^11–24 were focused on past behaviors (eg, vaccination hesitancy or vaccine coverage);^{13–15,20–22,24,25} or used broad metrics, such as indicating whether people wore a mask at all, rather than more specific measures of different circumstances under which people wore masks (eg, seasonally, when they had been exposed to COVID-19 even if asymptomatic, or when there were COVID-19 outbreaks).^14,18,19 There is a gap in the literature on attitudes and future intentions to perform protective behaviors in an ongoing way and in the face of possible pandemic fatigue. For example, it is important to understand whether vaccination intention near the formal end of a pandemic differs from intention at the beginning, and the reasons why people may hesitate to vaccinate against COVID-19 annually when it is recommended.^{10–17,21–25} It is also not known whether mask-wearing might persist as a strategy for preventing the spread of COVID-19 and other infectious diseases in the wake of a pandemic, especially when the behavior was largely new to the US public.^5,14,18,19 In addition to these broad questions, it is not clear whether past patterns of sociodemographic variability in vaccination and mask-wearing behaviors or intentions (eg, by race and ethnicity, age, rurality) will persist when future practices are considered.^{13–15,17–20,22–24}

The purpose of this 2023 study was to examine US adults’ current attitudes toward COVID-19 vaccines and wearing masks in public, and their intentions to perform these protective behaviors in the future. We explored whether differences in intentions to get vaccinated and wear masks in the future varied by social and demographic characteristics, as well as whether people were likely to be motivated by their own health risks or the health risks of other people in their household.

Methods

Study Population and Survey Design

Data used in this study were obtained from a nationally representative online and telephone survey conducted among 1,936 US adults ages 18 years and older. The survey was designed and analyzed by researchers at Harvard T.H. Chan School of Public Health (HSPH) as part of technical assistance provided to inform rapid response communication efforts by state and local public health departments through the Association of State and Territorial Health Officials and the National Public Health Information Coalition. This study was determined to be exempt by the HSPH Institutional Review Board.

Data Collection

Surveys were conducted from February 14 to March 6, 2023, which was 2 months before the end of the COVID-19 public health emergency of international concern was announced in May 2023.⁹ Data were collected by SSRS, an independent polling firm, following reporting guidelines from the American Association for Public Opinion Research. SSRS contacted participants through 2 nationally representative, high-quality, probability-based web panels: the SSRS Opinion Panel and the Ipsos KnowledgePanel. Panel members were recruited by mail using address-based sampling and by telephone using random-digit dialing. Most participants completed the survey online; to ensure a fully representative sample, 150 interviews were completed by telephone among adults who did not regularly use the internet. Questions were administered in English and Spanish, according to respondents’ preferences. Among all adults invited to participate, 49% completed the survey.

Survey Instrument and Measures

We developed the survey instrument using the American Association for Public Opinion Research Best Practices for Survey Research.²⁶ The survey included questions about current attitudes and future intentions toward COVID-19 vaccination and mask-wearing, some of which were adapted or influenced by prior surveys on COVID-19 vaccination and mask-wearing.^{14,19,22,23,27,28} We incorporated input from public health department staff on content, question wording, response options, and flow. The survey was pretested via telephone with respondents from a range of demographic backgrounds to help ensure that the questions were understandable and minimized bias.

Attitudinal questions assessed respondent views on COVID-19 vaccines’ effectiveness and safety, based on evidence that these views influence vaccine acceptance,^11,12 as well as their views on masks’ effectiveness, convenience, comfort, and interference with communication. Wearing masks was specified as wearing “masks that cover both the nose and mouth while fitting snugly against the sides of the face and the bridge of the nose,” reflecting language used by public health officials at the time of questionnaire development.²⁹

Intention questions regarding vaccines assessed participants’ likelihood of getting an updated COVID-19 vaccine most years beyond 2023, if it were recommended by public health officials in the future. For respondents who were only somewhat likely, not too likely, or not at all likely to get an updated COVID-19 vaccine most years, follow-up questions assessed reasons why not (by supplying a list of 12 reasons and asking for each to be ranked as a major reason, minor reason, or not a reason). Intention questions regarding mask-wearing asked respondents’ likelihood of wearing a mask in public places across 7 different circumstances (as part of normal routines, seasonally in the fall/winter, before major events, with upper respiratory virus symptoms, during COVID-19 outbreaks, during other upper respiratory illness outbreaks, or if asymptomatic but exposed to COVID-19). The questions about different circumstances aimed to reflect the variation among public health agencies’ and leaders’ discussions about future mask-wearing guidance, which may range from very consistent mask-wearing to more tailored approaches that account for proximate risk of exposure or of spreading illness.^5,8,30,31 The timeframe for the future-oriented questions on mask-wearing was “through the rest of this year,” because a year is an understandable timeframe for most people, whereas estimates for frequent behaviors beyond a year into the future might be more difficult for people to anticipate.³² Likelihood was measured on a 4-point Likert scale. Full wording of all questions is available in the Appendix (see , www.liebertpub.com/doi/suppl/10.1089/hs.2023.0136).

Analysis

The sample was weighted using a multistage design to account for panel recruitment methods and the resultant probability of selection into the study. Data were weighted by gender, race and ethnicity, education, age, metropolitan status, US Census region, population density quintile, and civic engagement, using population parameters drawn from US Census data. After weighting, differences between the survey sample and national sources were within 1.5 percentage points for all demographic characteristics (see the Appendix for details). The weighted sample data were then analyzed as follows.

First, we examined weighted percentages of attitudes and intentions using univariate analysis across all measures. For mask-wearing questions, we looked at intentions in each of the 7 defined circumstances, and also generated a composite measure to assess for those “very likely” to wear a mask under at least 1 circumstance.

Second, we generated weighted percentages of attitudes and intentions to assess whether having strong vaccine and mask-wearing intentions (defined as being “very likely” to get updated vaccines or wear masks in the future) varied by selected demographic and health characteristics. To assess for strong intentions, we dichotomized the variable to isolate those “very likely” compared with all others. Analyzing the top-end category of a scale has been shown to better predict future behaviors, such as vaccination, compared with other response combinations (eg, when combined with those “somewhat likely”).^16,33,34 We examined differences between groups defined by demographic and health characteristics using 2-tailed t tests. Demographic and socioeconomic characteristics examined were gender, age, race and ethnicity, education, metropolitan status, and household income. Health characteristics examined included smoking and physical limitations or serious medical conditions, and were selected because they are related to risk of severe illness from COVID-19. We also examined whether respondents lived with any “high-risk household members,” defined as those at high risk for serious illness from COVID-19 because of age, smoking, physical limitations, or serious medical conditions.

Finally, we conducted parallel logistic regression models and reported the adjusted odds ratios of reporting strong future COVID-19 vaccination and mask-wearing intentions, with 95% confidence intervals. Models were run to determine whether the observed bivariate differences in vaccine and mask-wearing intentions across demographic and health characteristics persisted after controlling for the other demographic and health characteristics. As described previously, we chose a dichotomized outcome based on prior literature showing that the top-end category of a scale better predicts future behaviors than other response combinations.^16,33,34 Based on Wald tests conducted to determine whether each variable significantly contributed to each model, we excluded smoking status and household income from the final models.

All analyses used weighted data and were conducted in Stata version 15.0 (StataCorp LLC, College Station, TX). Statistically significant differences below P < .05 are shown in the tables. However, only differences of 10 percentage points or higher were deemed to have practical implications for policy or communications, and only these differences are considered meaningful for discussion in the text that follows.³⁴

Results

Attitudes and Intentions Toward COVID-19 Vaccination

A large majority (72%) of surveyed adults said they believed current COVID-19 vaccines and boosters were “very” (40%) or “somewhat” (32%) effective at protecting the person getting vaccinated from serious illness or hospitalization from COVID-19 (Table 1). However, respondents did not perceive other dimensions of vaccine effectiveness—namely, protection against COVID-19 infection or spread—equivalently. Only about a quarter thought COVID-19 vaccines were “very effective” at protecting the person who gets vaccinated from getting COVID-19 (26%) or in keeping the person who gets vaccinated from spreading COVID-19 to other people (22%). In terms of vaccine safety, a large majority (73%) thought current vaccines and boosters were safe, including 37% who said they were “very safe.”

Table 1.

US Adults' Attitudes and Intentions Toward Vaccination Against COVID-19

Category/Question	Response %
Attitudes
Effectiveness	Very	Somewhat	Not too	Not at all
In general, how effective do you think current vaccines and booster shots are for most adults in…
…protecting the person getting vaccinated from getting seriously ill or having to be hospitalized with COVID-19?	40	32	15	13
…protecting the person who gets vaccinated from getting COVID-19?	26	35	20	19
…keeping the person who gets vaccinated from spreading COVID-19 to other people?	22	34	23	21
Safety	Very	Somewhat	Not very	Not at all
In general, how safe do you think current vaccines and booster shots are for most adults?	37	36	13	14
Intentions	Very	Somewhat	Not too	Not at all
Thinking beyond 2023, how likely would you be to get an updated COVID-19 vaccine most years?	33	19	18	29
Reasons why not likely to get updated COVID-19 vaccine most years	Yes, a (major or minor) reason	Major reason	Minor reason	Not a reason
Are each of the following a major reason, a minor reason, or not a reason at all that you are not [very] likely to get an updated COVID-19 vaccine most years?^a
I would want to see more research done on getting the updated COVID-19 vaccines every year.	74	49	25	26
I would be worried about the safety of updated COVID-19 vaccines.	71	45	27	29
I don’t trust the government agencies that would promote the updated COVID-19 vaccines.	64	39	25	36
I don’t think an updated COVID-19 vaccine would be very effective in protecting against COVID-19.	64	35	29	36
I don’t trust the companies that would make updated COVID-19 vaccines.	63	34	29	37
I think the previous COVID-19 vaccines or boosters I have already gotten would be enough protection.^b	62	22	40	37
I would rather get natural immunity from getting COVID-19.	58	30	28	42
I don’t think I would be likely to get very sick if I got COVID-19.	56	20	35	44
I think getting an annual vaccine is too much for my immune system.	49	26	23	51
I already had COVID-19 and I think that would be enough protection.	48	21	27	52
I wouldn’t have the time to get it or schedule around possible side effects like a fever.	34	12	22	66
I had a bad reaction to a previous COVID-19 vaccine or booster.^b	32	13	19	68

Question asked only among 1,287 respondents who answered they were “somewhat likely,” “not too likely,” or “not at all likely” to get an updated COVID-19 vaccine most years.

Question asked only among 827 adults who had been vaccinated against COVID-19.

For future COVID-19 vaccination intentions, 33% of adults surveyed reported that they would be “very likely” to get an updated COVID-19 vaccine most years beyond 2023, while 19% were “somewhat likely,” 18% were “not too likely,” and 29% were “not at all likely” to do this. Among the subset of adults who were not “very likely” to get an annual COVID-19 vaccine, a majority reported 8 different reasons why: 74% said they would want to see more research done on updated vaccines, 71% were worried about safety, 64% did not trust the government agencies promoting vaccines, 64% did not think an updated vaccine would be very effective, 63% did not trust the companies that make the vaccines, 62% thought the previous vaccines gave enough protection, 58% would rather get immunity from contracting COVID-19, and 56% did not think they would be likely to get very sick if they got COVID-19.

Attitudes and Intentions Toward Mask-Wearing Under Different Circumstances

About a quarter (27%) of surveyed adults said masks were “very effective” in protecting the wearer from getting COVID-19, and an additional 42% said they were “somewhat effective.” A similar share said that masks were either “very” (29%) or “somewhat” (42%) effective in keeping the person wearing the mask from spreading COVID-19 to other people (Table 2). Respondents widely reported that it was “very” (48%) or “somewhat” (31%) easy to make sure they had a mask on hand when they needed or wanted one. At the same time, a majority (66%) thought masks were uncomfortable, including 22% who said they were “very uncomfortable.” Further, a majority (71%) thought masks interfered with communicating with other people “a lot” (32%) or “some” (39%).

Table 2.

US Adults’ Attitudes and Intentions Toward Mask-Wearing Under Different Circumstances

Category/Question	Response %
Attitudes
Effectiveness	Very	Somewhat	Not too	Not at all
In general, how effective do you think a mask like this is in…
…protecting the person wearing the mask from getting COVID-19?	27	42	18	13
… keeping the person wearing the mask from spreading COVID-19 to other people?	29	42	16	12
Convenience	Very easy	Somewhat easy	Somewhat difficult	Very difficult
In general, how easy or difficult is it for you to make sure you have a mask like this when you need or want one?^a	48	31	8	3
Comfort	Very comfortable	Somewhat comfortable	Somewhat uncomfortable	Very uncomfortable
How physically comfortable or uncomfortable do you think it is to wear a mask like this?	9	25	44	22
Interference with communication	A lot	Some	Not very much	Not at all
For you personally, how much do you feel masks interfere with communicating with other people?^b	32	39	21	8
Intentions	Very likely	Somewhat likely	Not too likely	Not at all likely
How likely are you to wear a mask in public places under each of the following circumstances through the rest of 2023?
Percent “very likely” to mask under at least 1 of the listed circumstances^c	56	NA	NA	NA
If there are a lot of people in your area sick with COVID-19	44	23	13	21
If you have been exposed to COVID-19 but do not have symptoms	41	23	14	22
If there are a lot of people in your area sick with upper respiratory illnesses other than COVID-19	37	22	17	24
If you have mild symptoms, like coughing, sneezing, or a sore throat, but you do not have COVID-19	34	25	16	25
Before you go on a trip or other big events	24	19	22	34
During the fall and winter, when more people get sick generally	23	21	23	33
As part of your normal routine	15	16	24	45

Notes: Data come from a February to March 2023 nationally representative online and telephone survey of 1,936 US adults ages 18 years and older. Weighted percentages are displayed. Results may not add up to 100% due to rounding. Respondents were given context that mask-wearing questions were "about masks that cover both the nose and mouth while fitting snugly against the sides of the face and the bridge of the nose."

10% indicated not applicable - they did not need/want a mask.

Respondents were given the following additional context about interference with communication: “Some people feel that masks like this can interfere with communication by making it hard to hear someone or read their facial expressions. Other people don’t feel that masks interfere with communication.”

Composite measure of adults reporting they were “very likely” to wear a mask under at least 1 of the 7 circumstances listed.

When it comes to future mask-wearing intentions, survey respondents were somewhat divided, with just over half (56%) reporting that they would be “very likely” to wear a mask in the future under at least 1 of the circumstances given (per the composite measure). The reported likelihood of wearing masks across these different circumstances varied, with a majority likely to wear masks when there was a more proximate risk of getting or spreading COVID-19 infection. A majority said they would be “very” (44%) or “somewhat” (23%) likely to wear a mask in public places if a lot of people in their area were sick with COVID-19, or if they were exposed to COVID-19 themselves but were asymptomatic (41% “very likely,” 23% “somewhat likely”). Further, willingness to wear masks extended beyond COVID-19, as majorities also said they would wear a mask if a lot of people in their area were sick with upper respiratory illnesses other than COVID-19 (37% “very likely,” 22% “somewhat likely”) or if they had mild symptoms like coughing, sneezing, or a sore throat but did not have COVID-19 (34% “very likely,” 25% “somewhat likely”). Lower shares of adults said they would wear a mask in public before they went on a trip or to other big events (24% “very likely,” 19% “somewhat likely”) or during the fall and winter (23% “very likely,” 21% “somewhat likely”), and few said they would do this as part of their normal routine (15% “very likely,” 16% “somewhat likely”).

Subgroup Differences in Future Intentions

Results of unadjusted comparisons suggest that characteristics associated with weaker vaccine intentions (that is, not being “very likely” to get an updated COVID-19 vaccine most years) included being younger, not having a college degree, living in a rural area, and not having any serious medical conditions or physical limitations (Table 3). For example, only about 1 in 5 adults ages 18 to 24 years had strong intentions (were “very likely”) to get a COVID-19 vaccine most years, compared with more than half of adults ages 65 years and older. Living with household members at high risk for severe illness from COVID-19 was not meaningfully associated with stronger vaccine intentions, as differences were statistically significant but were only 6 percentage points apart.

Table 3.

Percentage of US Adults “Very Likely” to Adopt Protective Behaviors in the Future, by Selected Demographic, Socioeconomic, and Health Characteristics

Characteristic	Get updated COVID-19 vaccine most years	Mask in public if people in the area are sick with COVID-19	Mask in public if exposed to COVID-19 but asymptomatic	Mask in public if people in the area are sick with upper respiratory illnesses	Mask in public if you have mild symptoms (eg, coughing) but not COVID-19	Mask in public before you go on a trip/other big events	During the fall/winter, mask in public when more people get sick generally	Mask in public as part of your normal routine
Total (N=1,936)	33	44	41	37	34	24	23	15
Gender
Men^a (n=889)	31	37	35	31	29	19	18	12
Women^b (n=1,025)	35	49^a	45^a	42^a	39^a	29^a	26^a	17^a
Age, years
18-24^a (n=278)	19	41	37	32	31	18	18	15
25-34^b (n=313)	24	41	42	36	37^e	24	25	14
35-44^c (n=296)	27	43	41	36	38^e	27^a	22	15
45-54^d (n=238)	30^a	42	41	40	37^e	22	28^ae	14
55-64^e (n=299)	37^abc	39	39	32	28	20	18	13
65+^f (n=512)	54^abcde	52^abcde	44	43^ae	34	30^ae	24	19
Race/ethnicity
White^a (n=1,290)	34	34	33	26	27	18	14	9
Black (n=234)	32	64^a	56^a	57^a	54^a	43^a	43^a	30^a
Hispanic (n=255)	33	54^a	50^a	51^a	45^a	31^a	36^a	23^a
AAPI (n=93)	36	69^a	60^a	56^a	43^a	34^a	27^a	23^a
Education
High school or less^a (n=807)	29	47	39	40^c	36	27	27^c	19^c
Some college^b (n=545)	27	43	40	37	35	23	23	15
College or more^c (n=582)	44^ab	41	44	33	33	22	18	11
Metropolitan status
Urban^a (n=512)	34^c	48^c	48^bc	42^c	41^bc	27^c	26^c	16
Suburban^b (n=931)	35^c	44^c	40^c	37^c	34^c	26^c	23^c	16^c
Rural^c (n=486)	25	32	29	26	23	15	15	11
Household income
<$25k^a (n=321)	33	56^bcd	49^d	53^bcd	46^cd	37^cd	39^bcd	30^bcd
$25k-<$50k^b (n=452)	30	47^d	45^d	40^d	37^d	29^d	28^cd	17^d
$50k-<$75k^c (n=343)	38^b	46^d	41	37^d	34	22	20	13
$75k+^d (n=786)	33	37	36	29	29	19	16	10
Smoker
Yes (n=603)	31	44	41	37	33	24	20	14
No (n=1,332)	34	43	41	37	35	25	24	16
Serious medical conditions/physical limitations
Yes^a (n=831)	44^b	54^b	50^b	45^b	41^b	30^b	27^b	19^b
No^b (n=1,105)	26	36	34	31	29	20	20	13
High-risk household members
Yes^a (n=1,009)	36^b	47^b	43	39	35	24	24	15
No^b (n=927)	30	40	38	35	33	24	22	15

Notes: Data come from a February to March 2023 nationally representative online and telephone survey of 1,936 US adults ages 18 years and older. Weighted percentages are displayed. Race/ethnicity defined as non-Hispanic White, non-Hispanic Black, Hispanic or Latino, and AAPI (Asian American or Pacific Islander). For race/ethnicity, statistical comparisons were only made between non-White vs. White respondents. Adults with other racial/ethnic identities and other gender identities are included in the total but not shown. Smoker defined as a current or former smoker. Serious medical conditions/physical limitations defined as having a serious heart, lung, kidney, or brain condition; mental health condition; substance use disorder; cancer; diabetes; obesity or overweight; sickle cell disease; tuberculosis; or decreased immunity; or are very limited in physical movement/have a disability. High-risk household members defined as household members are at high risk for serious illness from COVID-19 because of age, certain health conditions, physical limitations/ disabilities, or smoking.

a-f

Within each demographic and health characteristic, percentage is statistically significantly greater than the category denoted using superscript letters (a through f) at P<.05. Analyses were conducted using 2-tailed t-tests.

Abbreviation: AAPI, Asian American or Pacific Islander.

Compared with adults from US racial and ethnic minority populations (Black, Hispanic/Latino, or Asian American/Pacific Islander) and those earning less than $25,000 per year, White (non-Hispanic) adults and those earning at least $75,000 per year were less likely to indicate strong intentions to wear a mask across all 7 future circumstances (Table 3). Men had significantly weaker intentions than women (≥10 percentage points) to wear a mask across all circumstances except routinely and seasonally, where differences between groups were statistically significant but were within 10 percentage points. Similarly, compared with people living in urban and suburban areas, those in rural areas were significantly less likely (≥10 percentage points) to have strong intentions to wear a mask across circumstances except routinely and seasonally, where some differences between groups were statistically significant but were within 10 percentage points. In addition, people without serious medical conditions or physical limitations had significantly weaker intentions (≥10 percentage points) to wear a mask than those with such conditions, again except routinely and seasonally, where differences between groups were statistically significant but were within 10 percentage points. Younger age was inconsistently associated with mask-wearing intentions, though the oldest group (ages 65 years and older) was more likely than younger age groups to have strong mask-wearing intentions during times of high rates of COVID-19 locally. Smoking status, education, and having high-risk household members did not make a meaningful difference (≥10 percentage points) in mask-wearing intentions under any identified circumstance.

After controlling for socioeconomic, demographic, and relevant health-related characteristics in logistic regression models, most of the bivariate differences from Table 3 persisted. Table 4 shows adjusted odds ratios with 95% confidence intervals of reporting strong future intentions of COVID-19 vaccination and mask-wearing.

Table 4.

Adjusted Odds Ratios (95% CI) of US Adults “Very Likely” to Adopt Protective Behaviors in the Future, by Selected Demographic, Socioeconomic, and Health Characteristics

Characteristic/Reference	Get updated COVID-19 vaccine most years(n=1,907)	Mask in public if people in the area are sick with COVID-19(n=1,913)	Mask in public if exposed to COVID-19 but asymptomatic(n=1,910)	Mask in public if people in the area are sick with upper respiratory illnesses (n=1,910)	Mask in public if you have mild symptoms (eg, coughing) but not COVID-19(n=1,911)	Mask in public before you go on a trip/other big events (n=1,904)	Mask in public during the fall/winter, when more people get sick generally (n=1,911)	Mask in public as part of your normal routine (n=1,913)
Gender: Men (ref)
Women	1.18 (0.92-1.51)	1.63^a (1.29-2.07)	1.55^a (1.23-1.96)	1.67^a (1.31-2.14)	1.62^a (1.26-2.06)	1.74^a (1.32-2.31)	1.65^a (1.23-2.21)	1.51^a (1.08-2.12)
Age, years: 18-24 (ref)
25-34	0.92 (0.58-1.45)	0.96 (0.64-1.44)	1.10 (0.74-1.65)	1.28 (0.83-1.96)	1.19 (0.78-1.80)	1.49 (0.91-2.44)	1.83^a (1.11-3.02)	0.97 (0.54-1.74)
35-44	1.11 (0.69-1.80)	1.08 (0.70-1.67)	1.12 (0.73-1.73)	1.33 (0.83-2.11)	1.37 (0.88-2.13)	1.87^a (1.11-3.14)	1.67 (0.96-2.88)	1.20 (0.65-2.24)
45-54	1.32 (0.80-2.19)	1.03 (0.66-1.60)	1.10 (0.71-1.73)	1.60^a (1.01-2.55)	1.25 (0.79-1.99)	1.36 (0.77-2.39)	2.35^a (1.34-4.11)	1.14 (0.57-2.26)
55-64	1.92^a (1.20-3.06)	1.03 (0.67-1.58)	1.11 (0.72-1.70)	1.30 (0.83-2.05)	0.85 (0.54-1.35)	1.39 (0.82-2.37)	1.48 (0.86-2.55)	1.25 (0.68-2.32)
65+	4.03^a (2.63-6.17)	1.88^a (1.26-2.79)	1.45 (0.98-2.16)	2.26^a (1.48-3.47)	1.23 (0.81-1.88)	2.57^a (1.57-4.20)	2.28^a (1.36-3.84)	2.11^a (1.19-3.76)
Race/ethnicity: White (ref)
Black	1.20 (0.81-1.76)	4.09^a (2.79-6.00)	2.87^a (2.02-4.07)	4.15^a (2.85-6.04)	3.21^a (2.24-4.61)	3.69^a (2.51-5.43)	4.79^a (3.24-7.09)	4.88^a (3.16-7.53)
Hispanic	1.48^a (1.03-2.13)	2.70^a (1.89-3.86)	2.42^a (1.68-3.49)	3.42^a (2.41-4.86)	2.15^a (1.51-3.05)	2.23^a (1.50-3.31)	3.60^a (2.42-5.35)	3.70^a (2.33-5.88)
AAPI	1.32 (0.72-2.46)	6.02^a (3.37-10.77)	3.44^a (1.95-6.08)	4.88^a (2.75-8.65)	2.22^a (1.29-3.83)	3.01^a (1.63-5.59)	2.88^a (1.51-5.47)	4.82^a (2.36-9.84)
Education: High school or less (ref)
Some college	0.98 (0.72-1.32)	0.84 (0.63-1.11)	1.03 (0.78-1.37)	0.93 (0.70-1.24)	0.94 (0.70-1.26)	0.82 (0.58-1.13)	0.81 (0.57-1.14)	0.77 (0.52-1.14)
College or more	2.30^a (1.70-3.11)	0.88 (0.65-1.18)	1.38^a (1.03-1.85)	0.85 (0.63-1.14)	0.95 (0.71-1.29)	0.79 (0.56-1.12)	0.68^a (0.48-0.97)	0.60^a (0.40-0.90)
Metropolitan status: Rural (ref)
Urban	1.53^a (1.07-2.18)	1.61^a (1.14-2.28)	1.76^a (1.25-2.48)	1.65^a (1.15-2.36)	1.85^a (1.30-2.63)	1.65^a (1.07-2.54)	1.46 (0.93-2.27)	1.10 (0.67-1.81)
Suburban	1.56^a (1.15-2.12)	1.53^a (1.13-2.06)	1.44^a (1.07-1.94)	1.51^a (1.11-2.05)	1.55^a (1.13-2.11)	1.79^a (1.23-2.61)	1.50^a (1.01-2.24)	1.38 (0.88-2.17)
Chronic illness/physical limitations: No (ref)
Yes	1.99^a (1.54-2.57)	2.07^a (1.61-2.66)	1.95^a (1.52-2.49)	1.76^a (1.36-2.27)	1.76^a (1.36-2.28)	1.73^a (1.30-2.30)	1.52^a (1.13-2.04)	1.63^a (1.17-2.27)
High-risk household members: No (ref)
Yes	1.03 (0.81-1.32)	1.10 (0.86-1.41)	1.12 (0.88-1.42)	1.04 (0.81-1.33)	0.99 (0.77-1.27)	0.85 (0.64-1.12)	0.98 (0.74-1.30)	0.79 (0.57-1.09)

Notes: Data come from a February to March 2023 nationally representative online and telephone survey of 1,936 US adults ages 18 years and older. Sample sizes vary across models because “don’t know”/“refused” responses were coded as missing. In addition, adults identifying as “other” for race/ethnicity and as “nonbinary” or “other” for gender were included in the models but results are not reported due to low sample size. Race/ethnicity defined as non-Hispanic White, non-Hispanic Black, Hispanic or Latino, and AAPI (Asian American or Pacific Islander). Serious medical conditions/physical limitations defined as having a serious heart, lung, kidney, or brain condition; a mental health condition; substance use disorder; cancer; diabetes; obesity or overweight; sickle cell disease; tuberculosis; or decreased immunity; or are very limited in physical movement/have a disability. High-risk household members defined as having household members at high risk for serious illness from COVID-19 because of age, certain health conditions, physical limitations/disabilities, or smoking.

Statistically significant at P<.05.

Abbreviation: Ref, reference.

Discussion

This study provides new insights into US adults’ attitudes and intentions toward future mask-wearing and COVID-19 vaccination after 3 years of the COVID-19 pandemic. Our central findings suggest that the US public is moderately receptive to future vaccination and mask-wearing, both when there is proximate risk of COVID-19 infection and also extending beyond COVID-19 when other upper respiratory infection rates are high. Communications that leverage this willingness without overreaching will be crucial in motivating public response over time as needed. We highlight 3 specific findings with implications for preparedness planning and communication.

First, while we found that one-third of US adults have strong intentions to get vaccinated against COVID-19 in the future if recommended by public health officials, this appears to indicate relatively low interest in repeated future vaccination.²⁵ This is in contrast to the high share of the population (81% of US adults) who have already received at least 1 dose of the vaccine.³⁵ This suggests a lower receptivity to COVID-19 vaccination as a protective behavior in a nonpandemic context that is transitioning into routine vaccination, despite ongoing community spread and unclear data about the longevity of prior vaccine protection. As a possible contributor to lower receptivity, it seems that US adults are considerably underestimating COVID-19 vaccines’ effectiveness and safety.^36,37 In addition, large shares of adults with weaker vaccine intentions report that they do not have high trust in the government or in the pharmaceutical companies that make COVID-19 vaccines; they also believe they are already well-protected, would rather get natural immunity from COVID-19 infection, or do not believe getting COVID-19 will make them seriously ill. Accordingly, future communications should continue to emphasize the safety of COVID-19 vaccines, while clarifying messaging around effectiveness.

During the pandemic, public understanding of vaccine effectiveness has been challenged by reduced estimates of effectiveness at preventing infection compared with effectiveness at mitigating serious illness and death.⁷ Setting public expectations around what the vaccine does and where it excels is critical in the goal of transparency and also in ensuring that the public fully appreciates the benefits of the vaccine, even as they continue to see people who are vaccinated nonetheless get infected with the virus. Enhancing trust—which can foster greater receptivity to messages—is a longer-term and more challenging enterprise that needs to be addressed in ways that go beyond messaging and relate more broadly to effective community engagement across topics even beyond vaccines.^16,37,38 Enhancing trust will require greater funding for improvements to the communication and broader infrastructure of public health, including staffing and training.

Second, there is higher interest in future mask-wearing than in getting updated COVID-19 vaccines most years, but willingness to mask varies widely under different circumstances. People are more willing to mask in situations where there is proximate risk to COVID-19 infection, as well as in situations where there is risk of infection from other upper respiratory viruses. This suggests that receptivity to mask-wearing as a protective behavior has expanded beyond the specific COVID-19 pandemic context, which is where it was introduced for many US adults. However, receptivity to mask-wearing has not extended to adopting the behavior as part of people’s normal or even seasonal routines. With this in mind, US planning and communications efforts may consider that there are limits to public acceptance of mask-wearing outside of a pandemic context. Efforts may therefore focus on providing targeted guidance for the specific situations in which masks are most useful. Communication should also address mask effectiveness because, despite what current research suggests,^39,40 a smaller than expected share of adults believe masks are effective at protecting the wearer from COVID-19. Further, public health leaders and communicators could reinforce other positive beliefs about masks, emphasizing how easy it is to have masks on hand, explaining how to increase comfort when using an appropriate mask, and acknowledging that masks can interfere with communication.

Third, our findings suggest some clear patterns of sociodemographic variability related to intentions toward future behaviors. In particular, our study provides new insights about differences in intention among US racial and ethnic groups. Although some prior research has noted racial or ethnic gaps in COVID-19 vaccination and vaccination intentions,^{13,15,17,22–24,41,42} our study did not find significant gaps in future vaccine intentions. This finding may reflect less resistance to vaccination among racially and ethnically minoritized adults than previously understood and also deepening awareness of the greater risk of exposure to COVID-19 derived from, for example, housing, work, or other structural disparities. These considerations are reinforced by our findings related to mask-wearing intentions, where racial and ethnic minority adults were more likely than White adults to have strong intentions to wear masks. In this way, these findings suggest opportunities for public health leaders to address persistent racial and ethnic disparities in vaccination rates by leveraging existing receptivity and enhancing access.⁴² The absence of racial and ethnic disparities in future vaccination intentions, as well as the greater receptivity to masks among adults from minoritized communities, may also reflect increased resistance to protective measures among White adults over the course of the pandemic. In many cases, such perceptions are inconsistent with the true risks of exposure and health impacts, and this should also be addressed.

It is notable that we found greater resistance to future vaccination and mask-wearing among adults younger than 65 years, men, higher-income adults, and adults living in rural areas, which is consistent with research from earlier in the COVID-19 pandemic that reported these groups to have been less likely to wear masks and get vaccinated in the past.^13–24 In our data, these patterns held both in cases of proximate COVID-19 risk and proximate risk of other (non-COVID-19) upper respiratory illnesses, suggesting a deeper resistance to mask-wearing that may go beyond views of COVID-19 and/or the pandemic specifically. Addressing underlying resistance to adopting protective behaviors will require more than traditional messaging and should account more fully for tailored community engagement. This may include programs to address public health issues beyond respiratory illness in order to build stronger connections and trust more broadly. More research about public views of these additional areas will be critical to developing robust public health communication strategies for the future.

Finally, consideration of personal health risks was evident in that adults reporting serious medical conditions or physical limitations were more likely to have strong vaccination or mask-wearing intentions. However, adults were not as likely to consider their prior smoking status. In addition, people were less likely to consider the COVID-19 health risk profile of their household members, as it was not meaningfully associated with higher vaccination or mask-wearing intentions. These findings suggest a complex relationship between US adults’ understanding of risk for severe illness and intention to adopt protective behaviors. It seems likely that people may not appreciate the full range of medical considerations that put them or their family members at higher risk, and we believe future research should explore the relationship between objective and self-perceived measures of risk.^13,21,25

This study has several limitations common to probability-based surveys. First, the study is cross-sectional, and thus there cannot be any formal causal interpretation of the relationships between variables, such as attitudes and intentions. Second, the data were self-reported, and there is a risk of nonresponse bias beyond what has been addressed through weighting. Third, there may be additional attitudes about these behaviors that are important to consider in the future, such as convenience for getting the COVID-19 vaccine annually. Fourth, though we found moderate receptivity to individual adoption of protective behaviors, intentions may be different from follow-through. Finally, we asked about intentions for behaviors through the rest of the year, but these intentions may not align with future behaviors across a longer time period, particularly if future threats differ substantially from COVID-19. Future research could examine intentions to adopt protective behaviors under additional scenarios (eg, is vaccination intention stronger ahead of seasonal surges?). Notably, this survey was conducted at a time when many Americans were already well-protected against COVID-19, having been offered multiple rounds of vaccination and, for much of the US population, having already gotten infected with COVID-19 itself as well. When people are well-protected, future intentions toward vaccination may depend in part on vaccination efficacy over time. In addition, after we conducted the survey, additional research about mask effectiveness was published that could have changed public views.^40,43

Conclusion

The results reported here identify US adults’ willingness to get vaccinated and wear masks in the future, in different scenarios and among different segments of the population. This information can inform future seasonal and emergency infectious disease planning and communications efforts. Although the US public appears moderately receptive to future vaccination and mask-wearing, planning and communications efforts should consider that public acceptance of these behaviors is limited and does not extend to routine adoption. Given the notable resistance toward vaccination and public mask-wearing among some subsets of US adults, even in the case of proximate risk of COVID-19 and other respiratory illnesses, the existing limits to protective behaviors may be expected to persist beyond the current pandemic and need to be anticipated in future outbreaks of other respiratory illnesses. Our findings support the need for not only enhanced messaging that is tailored to address concerns and opportunities among different populations, but stronger support for public health communications programs, with greater community engagement.

Supplementary Material

Supplemental Material

Footnotes

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention (CDC), any other portion of the government of the United States, the Association of State and Territorial Health Officials (ASTHO), the National Public Health Information Coalition, Harvard TH Chan School of Public Health (HSPH), or SSRS. This study was funded through a cooperative agreement between CDC and ASTHO, who subcontracted to HSPH.

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Supplementary Material

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