COVID-19 Vaccination Requirements, Encouragement and Hesitancy among Non-Healthcare, Non-Congregate Workers in Chicago: Results from the WEVax Survey

doi:10.21203/rs.3.rs-2492932/v1

Background

While frontline and essential workers were prioritized for COVID-19 vaccination in the United States, coverage rates and encouragement strategies among non-healthcare workers have not been well-described. The Chicago Department of Public Health surveyed non-healthcare businesses to fill these knowledge gaps and identify potential mechanisms for improving vaccine uptake.

Methods

The Workplace Encouragement for COVID-19 Vaccination in Chicago survey (WEVax Chicago) was administered, using REDCap from July 11 to September 12, 2022, to businesses previously contacted for COVID-19 surveillance and vaccine-related outreach. Stratified random sampling by industry was used to select businesses for phone follow-up; zip codes with low COVID-19 vaccine coverage were oversampled. Business and workforce characteristics including employee vaccination rates were reported. Frequencies of requirement, verification, and eight other strategies to encourage employee vaccination were assessed, along with barriers to uptake. Fisher’s exact test compared business characteristics, and Kruskal-Wallis test compared numbers of encouragement strategies reported among businesses with high (> 75%) vs. lower or missing vaccination rates.

Results

Forty-nine businesses completed the survey, with 86% having 500 or fewer employees and 35% in frontline essential industries. More than half (59%) reported high COVID-19 vaccination rates among full-time employees; most (75%) workplaces reporting lower coverage were manufacturing businesses with fewer than 100 employees. Verifying vaccination was more common than requiring vaccination (51% vs. 28%). The most frequently reported encouragement strategies aimed to improve convenience of vaccination (e.g., offering leave to be vaccinated (67%) or to recover from side effects (71%)), while most barriers to uptake were related to vaccine confidence (concerns of safety, side effects, and other skepticism). More high-coverage workplaces reported requiring (p=0.03) or verifying vaccination (p=0.07), though the mean and median numbers of strategies used were slightly greater among lower-coverage versus higher-coverage businesses.

Conclusions

Many WEVax respondents reported high COVID-19 vaccine coverage among employees. Vaccine requirement, verification and addressing vaccine mistrust may have more potential to improve coverage among working-age Chicagoans than increasing convenience of vaccination. Vaccine promotion strategies among non-healthcare workers should target low-coverage businesses and assess motivators in addition to barriers among workers and businesses.

As the COVID-19 pandemic has continued, vaccinations have proven critical to prevention of severe illness, hospitalization, and death. Recognizing the associations between workplace exposure and likelihood of contracting COVID-19, the Advisory Committee on Immunization Practices (ACIP) recommended that employees in critical infrastructure and highest-risk industries be prioritized for vaccination (1). In March 2021, the U.S. Cybersecurity & Infrastructure Security Agency (CISA) cited vaccine hesitancy among these workers as detrimental to both the nationwide vaccine rollout and the continued functioning of the U.S. critical infrastructure (2).

The World Health Organization has defined vaccine hesitancy as “a delay or refusal to accept vaccines” despite their availability (3), with a “3’C’s” framework characterizing reasons as related to 1) a lack of confidence in vaccines 2) inconvenience of being vaccinated, and 3) complacency about needing vaccination. While most studies of COVID-19 vaccine hesitancy by occupation have focused on healthcare workers, nationally-representative surveys conducted during early vaccine availability (March through June 2021) measured vaccine coverage and intent specifically among frontline essential and other non-healthcare workers (4–6). Overall, these studies identified a lack of vaccine confidence (concerns of side effects, safety, and vaccine ineffectiveness) as an overarching reason for vaccine hesitancy; they cited that strategies to increase convenience of vaccination (providing on-site vaccination, or PTO for vaccination and recovery) have potential to increase vaccination. At the time of this report, coverage rates remain sub-optimal among working-age Americans, despite broad availability of three FDA-approved COVID-19 vaccines, and updated evaluations of strategies to increase coverage are needed.

Given the continuing need to inform vaccine promotion initiatives, the Chicago Department of Public Health (CDPH) conducted a study of workplace encouragement for COVID-19 vaccination (“WEVax Chicago”) from July - September of 2022. The survey aimed to describe frequency of vaccination requirements, encouragement strategies and persisting challenges to uptake among non-healthcare workplaces of varying sizes and industries throughout Chicago. This report summarizes the survey’s findings and implications for future research to improve vaccination coverage among non-healthcare workers.

Study design and population

The Workplace Encouragement for COVID-19 Vaccination in Chicago (WEVax Chicago) survey was a cross-sectional survey administered through REDCap (7) from July 11 through September 12, 2022, among businesses with at least one location in Chicago. The study excluded businesses classified as healthcare-related, government, or based in congregate settings (e.g., long-term care facilities, educational and childcare settings, shelters, and correctional facilities), given vaccination requirements and rollout strategies specific to these (8–11). Survey respondents are thus described as non-healthcare, non-congregate workplaces (NHNCW) for the remainder of this report. NHNCW were categorized into thirteen industry sectors for sampling, consistent with those used to summarize Chicago’s workplace COVID-19 surveillance data. These included four early eligibility (“1b”) (Food Production & Processing, Factory & Manufacturing, Warehousing & Distribution, Grocery) and nine others (Bars & Restaurants, Construction, Retail, Hotel, Office Settings, Personal Care & Service, Janitorial, Transportation and Other) (12). The sample included 537 businesses that had been previously contacted by CDPH for COVID-19 surveillance and vaccine-related outreach (e.g., follow-up on reported cases or potential workplace-related transmission among employees, or mobile vaccination efforts during early-phase vaccine rollout in Chicago in 2021).

To improve response rate, two CDPH interviewers conducted active recruitment by calling just over one-third (35%, 186/537) of businesses from the initial contact list, chosen through random sampling stratified by industry group for representativeness. Businesses in zip codes with first-dose coverage rates below the citywide average according to CDPH's vaccine dashboards (13) were oversampled for phone outreach. These comprised 38% of all businesses called, and at least two per industry strata except for janitorial and hotel (each with one contact in a low-coverage zip code). Within factory/manufacturing, bars and restaurants, food production/processing, and transportation/warehousing strata, at least half (≥50%) of workplaces called were in low-coverage zip codes. The survey (Additional file 1) was sent to five businesses during a pilot period the week before deployment for feedback on length, clarity, feasibility, and ease of answering questions. This study was determined to be exempt from review by the Institutional Review Board (IRB) at CDPH (Protocol #22-03).

Workplace (business) and workforce (employee) characteristics

Questions assessing business characteristics mirrored those included in routine COVID-19 workplace assessments administered by CDPH, for comparability. Industry was collected as free-text, per NIOSH recommendations (14)(“How would you describe your primary type of business or industry?”). With closed-ended response categories, respondents were asked to indicate whether describing employees of multi-location businesses, or a single-location business (in which case zip code was also collected).Total full-time and part-time staff, proportion working off-site at time of survey, primary languages spoken, and availability of employer-sponsored health insurance were collected. (In this report, part-time or other temporary/contract staff are referred to collectively as “part-time staff’.) Workforce race and ethnicity data are not included, due to concerns around inaccuracies and missingness in reported data, potentially stemming from reluctance of businesses to disclose in relation to COVID.

Estimation of COVID-19 vaccine coverage among employees

A definition of terms preceded the vaccination requirements section of the survey. “Primary series” of COVID-19 vaccination was defined as “the doses recommended for individuals to be considered "fully vaccinated" against COVID-19”. During the survey period, this included: 1) 2 doses of Pfizer-BioNTech given 3–8 weeks apart, 2) 2 doses of Moderna given 4–8 weeks apart, or 3) 1 dose of Johnson & Johnson’s Janssen vaccine. This survey was conducted before the availability of updated (“bivalent”) boosters, so did not distinguish between original and newer-formulation booster doses when assessing proportions of boosted employees. Businesses were asked to report employee vaccination and booster rates or the number of employees who had received their primary series and any booster doses. Among businesses that specified numbers instead of proportions of employees who were fully vaccinated and boosted, vaccination rates were calculated from reported total numbers of employees. Due to the small sample and degrees of missingness, rates were maintained as a categorical variable (lower vaccination coverage (≤75%), higher vaccination coverage (>75%), missing).

Vaccine requirement, encouragement strategies and barriers

Businesses were asked if they required employees to be 1) fully vaccinated and/or 2) boosted as eligible, and if vaccination status was verified. The survey also assessed any use of eight other strategies derived from CISA guidance for vaccine encouragement among essential workers (offering on-site vaccination, paid time off for vaccination or side effects, monetary or other incentive for vaccination, use of workplace signage or other communication tools to promote vaccination, training for staff to serve as vaccine ambassadors, and townhalls or information sessions to promote vaccination among workers) (2). Free-text sections allowed respondents to describe other strategies and challenges to vaccine encouragement among employees.

Analytic and Statistical Methods

Business characteristics

Vaccine eligibility was defined dichotomously by City-designated industry group, as frontline essential/early eligibility for vaccine (“1b”, beginning January 25, 2021) (12) or other. While essential workers not included in 1b may have been vaccinated in the 1c phase preceding broad (“Phase 2”) eligibility in Chicago, most 1c and Phase 2 workers were vaccinated in the same period (April through June 2021), compared to 1b workers (February and March 2021). To aid comparison with findings from other jurisdictions, NIOSH’s Industry and Occupation Computerized Coding System (NIOCCS) was also used to categorize free-text industry descriptions into one of 27 major groupings per the North American Industry Classification System (NAICS)(15). Business size was defined categorically from total number of staff. Zip codes were used to classify single-location businesses by city region, consistent with the conventions used by other City departments for planning purposes and resource allocation.

Vaccine Requirement, Encouragement Strategies and Barriers

Use of each encouragement strategy was dichotomized (any or never) for primary series and/or boosters, and among full-time and part-time employees separately. Mean (with standard deviation, SD) and median (with interquartile range, IQR) numbers of strategies reported per workplace were calculated. Bivariate analyses with Fisher’s exact test compared coverage rates (higher versus lower) among workplaces reporting and not reporting use of each strategy. The Kruskal-Wallis test compared distributions of the number of strategies reported by workplaces in each coverage group. The hypotheses for these comparisons were 1) that businesses reporting use of encouragement strategies would also report higher coverage, and 2) that high-coverage workplaces would report using a greater number of vaccine encouragement strategies.

Thematic analyses of barriers to vaccine encouragement reported in free text responses utilized a deductive approach: descriptions of encouragement practices and barriers were classified using the “3C’s” model of factors of vaccine hesitancy (complacency, confidence, and convenience)(3). Potential factors related to confidence included safety (side effects), medical conditions or provider advice, other mistrust or anxiety (e.g., related to efficacy, government mistrust, philosophical or religious objections). Factors related to convenience included being too busy or lacking access (perceived cost, transportation, difficulty finding vaccine providers). Factors of complacency included workers not feeling the vaccine was necessary or perceiving that prior infection would be sufficiently protective against future COVID-19 infection.

Characteristics of WEVax Survey Respondents and Workforce

From July 11 through September 12, 2022, survey response rates were 9% (49/537) among all e-mailed contacts, and 11% (21/186) among those called directly by CDPH; 1 additional respondent was recruited through social media. Among 50 total respondents, 1 out-of-jurisdiction business was excluded. The 49 included in the final sample are described by workplace type and rate of full vaccination in Figure 1, and by other characteristics in Table 1. Most were in manufacturing and office settings (n=11 or 22% each). Just over one-third (n=17, 35%) were in 1b industries. Classifications by major NAICS code are shown in supplemental material (Additional file 2, table). Most businesses were in Central Chicago (n=15, 31%) or West Chicago (n=14, 29%). Half had fewer than 100 employees (n=25, 51%). Almost all represented a single-location business (n=27, 56%) or employees working across multiple locations (n=13, 27%). Three quarters (n=36, 73%) said most of their staff were on-site. Spanish was the second most frequently reported primary language among employees (n=24, 49%) after English (n=46, 94%). Almost all (n=46, 94%) reported sponsoring health insurance for full-time employees).

TABLE 1. DEMOGRAPHICS OF WEVAX CHICAGO SURVEY RESPONDENTS (n=49),
OVERALL AND BY ESTIMATED COVERAGE RATE AMONG FULL-TIME EMPLOYEES

			% Full-time employees fully vaccinated
	All (N=49)		<=75% (n=8)		>75% (n=29)		Missing (n=12)
	n	(%)	n	(%)	n	(%)	n	(%)
Eligibility phase
1b (early)	17	(34.6)	6	(75.0)	6	(20.6)	5	(41.6)
Other	32	(65.3)	2	(25.0)	23	(79.3)	7	(58.3)
City region
Central	15	(30.6)	2	(25.0)	10	(34.4)	3	(25.0)
West	14	(28.5)	2	(25.0)	10	(34.4)	2	(16.6)
Northwest	7	(14.2)	2	(25.0)	4	(13.7)	1	(8.3)
North	5	(10.2)	1	(12.5)	3	(10.3)	1	(8.3)
Southwest	4	(8.1)	0	(–)	1	(3.4)	3	(25.0)
Far South	2	(4.0)	1	(12.5)	1	(3.4)	0	(–)
Multiple	1	(2.0)	0	(–)	0	(–)	1	(8.3)
Unknown	1	(2.0)	0	(–)	0	(–)	1	(8.3)
Workplace size
Fewer than 100	25	(51.0)	5	(62.5)	15	(51.7)	5	(41.6)
100-500	17	(34.6)	2	(25.0)	12	(41.3)	3	(25.0)
Over 500 employees	5	(10.2)	1	(12.5)	2	(6.8)	2	(16.6)
Unknown	2	(4.0)	0	(–)	0	(–)	2	(16.6)
% of full-time employees teleworking
0	21	(42.8)	5	(62.5)	10	(34.4)	6	(50.0)
1-25%	15	(30.6)	1	(12.5)	10	(34.4)	4	(33.3)
26-50%	1	(2.0)	0	(–)	1	(3.4)	0	(–)
51-75%	2	(4.0)	0	(–)	2	(6.8)	0	(–)
76-99%	4	(8.1)	1	(12.5)	3	(10.3)	0	(–)
100% (all employees)	4	(8.1)	1	(12.5)	3	(10.3)	0	(–)
NA or do not know	2	(4.0)	0	(–)	0	0.0	2	(16.6)
Primary languages spoken in workplace
English	46	(93.8)	8	(100.0)	29	(100.0)	9	(75.0)
Spanish	24	(48.9)	3	(37.5)	13	(44.8)	8	(66.6)
Polish	4	(8.1)	1	(12.5)	3	(10.3)	0	(–)
Arabic	3	(6.1)	1	(12.5)	1	(3.4)	1	(8.3)
Chinese (including Mandarin and Cantonese)	4	(8.1)	0	(–)	3	(10.3)	1	(8.3)
Tagalog	1	(2.0)	0	(–)	1	(3.4)	0	(–)
Employer-sponsored health insurance
For full-time employees	42	(85.7)	8	(90)	26	(89.6)	10	(83.3)
For both full-time and part-time employees	2	(4.0)	0	(–)	2	(6.8)	0	(–)
No	1	(2.0)	0	(–)	1	(3.4)	0	(–)
Unknown	2	(4.0)	1	(12.5)	1	(3.4)	2	(16.6)
Location types
Single (only) location	27	(55.1)	5	(62.5)	16	(55.1)	6	(50.0)
Multiple locations, combined	13	(26.5)	1	(12.5)	6	(20.6)	6	(50.0)
One of multiple	9	(18.3)	2	(25.0)	7	(24.1)	0	(–)

Employee Vaccination Requirements and Coverage

Distributions of COVID-19 vaccine coverage estimates are shown in Table 2. Most businesses (n=29/49, 59%) reported high rates of full vaccination among full-time staff. The 8 workplaces reporting that 75% or fewer full-time staff were fully vaccinated were geographically diverse (Table 1); most were (non-food) manufacturing facilities (n=6, 75%) and had fewer than 100 full-time employees (n=5, 63%). Due to high levels of missing data, subsequent sections of this report focus on full vaccination and encouragement among full-time employees only; data on part-time employees are described in supplemental content (Additional file 3, table).

TABLE 2. ESTIMATED COVID-19 VACCINATION COVERAGE AMONG FULL-TIME AND PART-TIME WORKERS AMONG WEVAX CHICAGO SURVEY RESPONDENTS (n=49)

			Full-time (n=49)^a	Part-time or other (n=37)^b
			n (% of non-missing)	n (% of non-missing)
Primary series	0%		0 (-)	1 (4.2)
	1-25%		0 (-)	0 (-)
	26-50%		6 (16.2)	2 (8.3)
	51-75%		2 (5.4)	1 (4.2)
	76-99%		21 (56.8)	10 (41.7)
	100%		8 (21.6)	10 (41.7)
Any boosters	0%		1 (3.4)	1 (5.9)
	1-25%		3 (10.3)	0 (-)
	26-50%		8 (27.6)	5 (29.4)
	51-75%		7 (24.1)	1 (5.9)
	76-99%		5 (17.2)	3 (17.6)
		100%	5 (17.2)	7 (41.2)
^aNumber of businesses missing COVID-19 vaccination rate estimates for full-time employees: n=12 for primary series (24.5%), n=20 for boosters (40.8%)
^bNumber of businesses missing COVID-19 vaccination rate estimates for part-time or other employees: n=13 for primary series (35.1%), n=20 for boosters (54.1%)

Vaccination Requirement and Encouragement Strategies

Frequencies of vaccine encouragement strategies are summarized in Figure 2. Less than one third (n=14, 28%) of businesses reported ever requiring employees to be vaccinated against COVID-19. Verifying vaccination was more common (n=25, 51%). All 14 businesses requiring vaccination and 11 others ever verified vaccination. Of those, 5 (20%) reported still doing so at the time of the survey. Providing time off to recover from side effects (n=35, 71%), or to get vaccinated (n=34, 69%) were the most frequently reported strategies, followed by use of promotional signage and communication (n=31, 63%). Fifteen businesses (30%) reported offering vaccine on-site; 12 (24%) reported organizing informational townhalls, 7 (14%) offered monetary incentives, 5 (10%) reported training staff as vaccine ambassadors. Eleven (22%) described other strategies aimed at convenience (sign-up or transportation, vaccine events with neighboring companies and at city-run sites). Non-monetary incentives included access to work-related social events and prioritization for job openings. Some respondents said employees got vaccinated to comply with requirements at client sites, or to protect coworkers.

Bivariate analyses of strategies reported among high versus lower-coverage workplaces are shown in Table 3. Thirteen of 14 (93%) businesses requiring full vaccination also reported high coverage, compared to 16 of 33 (49%) without this requirement (p=0.03; 1 business requiring full vaccination did not provide any coverage estimates). Among businesses that reported verifying vaccination, almost all had high coverage rates (n=21/25, 84%), compared to 8/21 (38%) among businesses that never verified vaccination (p=0.07). Most businesses missing coverage data (8/12 missing rates of vaccination among full-time employees) reported not verifying vaccination. Lower-coverage workplaces reported a slightly higher median number of encouragement strategies compared to higher-coverage and those missing data (p=0.12).

TABLE 3. STRATEGIES TO ENCOURAGE EMPLOYEE COVID-19 VACCINATION AMONG WEVAX CHICAGO SURVEY RESPONDENTS, OVERALL AND BY COVERAGE RATE (n=49)

	% Full-time staff fully vaccinated
	<=75% (n=8)	>75% (n=29)	Missing (n=12)	p value*
	n, (%)	n, (%)	n, (%)
Require vaccination
Yes	0 (-)	13 (92.9)	1 (7.1)	0.03
No	8 (24.2)	16 (48.5)	9 (27.3)
Unknown	0 (-)	0 (-)	2 (100)
Verify vaccination status
Yes	2 (8.0)	21 (84)	2 (8.0)	0.07
No	5 (23.8)	8 (38.1)	8 (38.1)
Unknown	1 (33.3)	0 (-)	2 (66.7)
On-site vaccine
Yes	4 (26.7)	7 (46.7)	4 (26.7)	0.23
No	4 (12.9)	20 (64.5)	7 (22.6)
Paid time off to vaccinate
Yes	6 (18.2)	19 (57.6)	8 (24.2)	1.0
No	2 (13.3)	10 (66.7)	3 (20)
Paid time off to recover
Yes	8 (22.9)	21 (60)	6 (17.1)	0.31
No	0 (-)	7 (63.6)	4 (36.3)
Monetary
Yes	1 (14.3)	5 (71.4)	1 (14.3)	1.0
No	7 (17.5)	24 (60)	9 (22.5)
Workplace signage
Yes	6 (19.4)	19 (61.3)	6 (19.4)	1.0
No	2(13.3)	9 (60)	4 (26.7)
Vaccine ambassadors
Yes	1 (20)	3 (60)	1 (20)	1.0
No	7 (17.5)	25 (62.5)	8 (20)
Townhalls
Yes	4 (33.3)	7 (58.3)	1 (8.3)	0.20
No	4 (11.8)	22 (64.7)	8 (23.5)
Other incentives^a
Yes	0 (10.0)	7 (70.0)	2 (20.0)	0.31
No	8 (21.6)	21 (56.8)	8 (21.6)
Unknown	0 (-)	1 (33.3)	2 (66.7)
Number strategies
Mean (SD)	3.75 (1.7)	3.0 (1.5)	2.4 (0.9)	0.12
Median (IQR)	4 (2-5)	3 (2-4)	2 (2-3)
*p-values from Fisher’s exact test comparing workplaces with high and low vaccination rates, except in comparison of number of strategies reported (Kruskal-Wallis p-value for workplaces reporting high vs. low vs. missing coverage). ^aData were missing on any use of on-site vaccine, promotional signage, townhalls (n=3, 6% each), time off to be vaccinated (n=1, 2%) or recover (n=3, 6%), monetary incentive (n=2, 4%), vaccine ambassadors (n=4, 8%) or other incentives (n=3, 6%). ^bOther incentives reported included (among highly-vaccinated business): conversations, access to work-sponsored social events, (missing coverage levels): hiring preference for vaccinated candidates; 1 missing more information

Vaccination Barriers, Challenges and Hesitancy

From free text responses, multiple businesses reported that requiring vaccination was a challenge given already-existing difficulties with employee retention and unwillingness to end teleworking. Among descriptions of other barriers to encouragement of employee vaccination (Table 4), the primary theme was a lack of confidence in vaccines. One company cited complacency among employees who had already recovered from COVID-19 infection.

TABLE 4. REASONS FOR COVID-19 VACCINE HESISTANCY AMONG NHNCW,

AS REPORTED BY BUSINESSES RESPONDING TO WEVAX CHICAGO SURVEY (n=49)

Theme	Subcategories	Examples
Confidence	Safety	Fear of side effects Perceptions of mRNA vaccines as unsafe compared to older vaccines Claims that family members died soon after receiving vaccine
Confidence	Other mistrust, skepticism, or anxiety	Feeling that vaccination is too politicized (government mistrust) Hesitancy to work at a company that requires vaccination Misinformation about life insurance policy cancellation Conspiracies of vaccines containing implanted devices Religious objections Disbelief that COVID-19 is real Skepticism of frequently-changing CDC guidance
Complacency	Already had COVID-19	Belief that natural immunity obviates need to vaccinate

The WEVax survey had three major findings regarding 1) vaccine requirements, 2) encouragement strategies, and 3) persisting barriers to workforce vaccination. Having a requirement for employee vaccination appeared to be associated with greater likelihood of achieving high vaccination coverage rates. Almost all respondents indicated use of multiple strategies for encouragement of vaccination, usually to increase the convenience of vaccination (offering time off to be vaccinated or recover, providing transportation, facilitating appointments). While themes of reported vaccine hesitancy centered around low vaccine confidence (personal concerns of vaccine safety, misinformation, and other skepticism among workers), initiatives to improve confidence and reduce complacency (vaccine ambassador training, informational town halls) were the least-frequently reported by WEVax survey respondents. Respondents did not indicate reasons for not employing these strategies, and barriers to their use have not been widely reported. In their summary of six virtual town halls encouraging COVID-19 vaccination among racial and ethnic minority groups in South Florida, Wagner et al noted that these efforts were resource intensive and may have resulted in only small increases in likelihood to vaccinate among an highly-vaccinated populations (16).

Though not collected concomitantly with the WEVax survey, individual-level CICT data collected by CDPH from June 2021 -May 2022 (Additional file 4, figure) echo our findings. Vaccine confidence and misinformation about vaccine safety were identified as primary reasons for hesitancy, while inconvenience was reported far less frequently and decreasingly over time. This is important because it suggests that the encouragement strategies reported by workplaces may not directly address prevailing reasons for hesitancy as described by both workplaces and working-age Chicagoans. Furthermore, 41% of unvaccinated working-age Chicagoans refused to specify reasons for not vaccinating, suggesting that assessment of potential motivators
(e.g. – “what would it take for you to change your mind about being vaccinated for COVID-19”?) instead of barriers alone may generate more actionable data for increasing coverage rates among NHNCW. For example, the longitudinal HEROES RECOVER study conducted in 2020 found that increases in COVID-19 vaccine knowledge, safety and effectiveness were positively associated with intent to vaccinate among essential workers (17). In their 2021 report, Nguyen et al. also described top motivators for COVID-19 vaccination by worker group (4). Among non-healthcare frontline workers, the most frequently specified motivators were more data on vaccine effectiveness (29%) and safety (37%), workplace vaccination requirements (27%), and prevention of transmission to family and friends (31%) or in the community (21%), with similar findings among other non-healthcare workers. COVID-19 vaccines have received FDA approval since these studies have been conducted, and hospitalization and mortality rates have decreased substantially. Updated assessments could elucidate whether vaccine effectiveness, safety, and desire to protect others should still be considered key motivators for vaccination, or whether other messaging may be more effective at this phase of the pandemic.

The WEVax study was limited by low response rate, though direct outreach by phone increased responsiveness. Low-coverage regions were underrepresented despite oversampling. The regional coverage data used to inform this sampling, representative of residents, may not have been representative of workplaces in those regions. It is also possible that workplaces that are less promotive of workplace vaccination (whether by requirement or incentivization) or with poor coverage rates were less likely to participate. In addition, selection bias may have resulted in overestimates of high vaccine coverage and encouragement strategies used, since contact lists were comprised of businesses already willing to engage with CDPH for COVID-19 vaccination and prevention efforts. Survey data were subject to recall limitation, in that respondents may not have remembered (or been present for) encouragement strategies practiced by their workplaces previously. Differential misclassification may have occurred among businesses that reported never verifying vaccination status; these had greater missingness of coverage data (n=8 or 38% compared to n=2 or 8% among those who checked vaccination status). Incomplete data on workforce demographics prevented identification of demographic groups that would benefit from targeted workplace-based messaging and outreach to improve vaccination.

Though limited, results from the WEVax survey may be useful in informing larger studies, and among small business outreach organizations like BACP in Chicago: 85% of respondents were small businesses (500 or fewer employees). The finding that higher-coverage workplaces reported a lower median number of encouragement strategies suggests that specific types of strategies, such as vaccine requirement and verification, are more strongly associated with increased coverage than others; use of more strategies is not necessarily associated with higher coverage. However, the temporality of encouragement strategies and vaccine coverage cannot be established given the cross-sectional nature of the survey. Larger prospective studies including a greater proportion of under-vaccinated workplaces could provide insights into approaches that have been differentially successful in highly vaccinated settings. These and future efforts to describe vaccine hesitancy at the individual level should include standardized collection of industry and occupation information, to facilitate classification (e.g., using NIOCCS) and stratification to describe NHNCW specifically.

Frequent allotment of time off to be vaccinated or recover from vaccination is unsurprising, given Chicago’s Vaccine Anti-Retaliation Ordinance passed in March 2021 (18): businesses must allow workers to use allotted sick time or paid time off to be vaccinated against COVID-19, and those requiring employee vaccination must provide paid time off for employees to be vaccinated. Infrequent vaccination requirement is consistent with updated data from the KFF Vaccine Monitor Survey (April 13-26, 2022), indicating that only 40% of respondents said their workplaces required vaccines after withdrawal of federal vaccine mandates in January 2022. The WEVax survey did not ask respondents to specify the amount of any monetary incentives offered. A 2021 study conducted at a large manufacturing company in Minnesota found that from August through September 2021, a substantial ($1000) financial incentive increased employee vaccination rates from 76% to 86%, citing the limitations of no control group, and FDA-approval of the Pfizer vaccine during the study period (19). Such incentives are not likely to be sustainable among smaller workplaces, or to outweigh all skepticism about safety and intention of vaccination efforts to combat COVID-19. A lack of other available data evaluating encouragement among non-healthcare workplaces in the U.S. highlights the need for future studies in these areas.

While the Center for Medicare and Medicaid Services vaccine mandate for healthcare workers was upheld by court challenges, the U.S. Supreme Court overturned OSHA’s emergency temporary standard for healthcare which required not only vaccines, but also masking and regular testing; the Supreme Court also disallowed these requirements for nonhealthcare workers. This study demonstrates the practices of, likely, the most compliant companies in Chicago, and is instructive of what to expect without a national mandate for employers.

Most workplaces that responded to the WEVax survey reported high vaccination coverage against COVID-19, use of workplace communication to promote vaccination, and multiple strategies to increase convenience of getting vaccinated. Persisting vaccine mistrust and safety concerns were found to be greater barriers to vaccination than convenience among working-age Chicagoans in both workplace and individual-level analyses. Requirement and verification of vaccination were more common among high-coverage workplaces. Future studies to identify mechanisms for increasing vaccination among workers should include, at minimum, increased recruitment of low-coverage workplaces and assessment of potential motivators (in addition to barriers) among unvaccinated workers.

KFF – Kaiser Family Foundation

CDPH – Chicago Department of Public Health

CICT – Case Investigation and Contact Tracing

WEVax Chicago – Workplace Encouragement for COVID-19 Vaccination in Chicago

NHNCW – Non-Healthcare, Non-Congregate Workplaces

IRB – Institutional Review Board

NIOSH – National Institute for Occupational Safety & Health

CISA – U.S. Cybersecurity & Infrastructure Security Agency

NIOCCS – NIOSH Industry and Occupation Computerized Coding System

NAICS – North American Industry Classification System

SD – Standard Deviation

IQR – Interquartile Range

BACP – Business Affairs and Consumer Protection

FDA – Food and Drug Administration

Conflict of Interest for ALL Authors: None declared

Ethics approval and consent to participate:

This research protocol involved gathering information from human subjects. Methods were carried out in accordance with relevant guidelines and regulations: this study protocol was reviewed by the Institutional Review Board at the Chicago Department of Public Health (Protocol #22-03). It was determined to meet the revised Common Rule [45 CFR 46.104(d)(2)(ii)] category for exemption from further review, such that informed consent processes were not required:

“Research only includes interactions involving educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures, or observation of public behavior (including visual or auditory recording).” Specifically,
“any disclosure of the human subjects' responses outside the research would not reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, educational advancement, or reputation”.

Consent for publication:

Not applicable, manuscript does not contain data from any individual person

Availability of data and materials
Datasets generated during the current study are not publicly available as these contain identifying information for responding businesses.
De-identified data are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
The study has no funding sources to declare.

Authors' contributions

FL conceived of study, created and disseminated survey, analyzed data, drafted manuscript, and designed figures. All other authors provided survey feedback. LF, SM and JK contributed to manuscript revisions with SM and JK providing project oversight.

Acknowledgements
Unaiza Seedat, Janice Turner, Emma Weber

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No competing interests reported.

COVID-19 Vaccination Requirements, Encouragement and Hesitancy among Non-Healthcare, Non-Congregate Workers in Chicago: Results from the WEVax Survey

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Journal Publication

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Abstract

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Background

Methods

Results

Discussion

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Abbreviations

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References

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Supplementary Files

Status:

Journal Publication

Version 1