Beyond the shot: A framework of individual and external influences on U.S. young adults' COVID-19 vaccination decisions derived from thematic analysis.

Understanding vaccine decision-making among young adults is critical for shaping effective public health responses during and beyond the COVID-19 pandemic. This qualitative study investigates two key questions: (1) What are the reasons young adults choose to be vaccinated or remain unvaccinated against COVID-19? (2) What distinct attitudinal groups emerge based on these reasons? This cross-sectional online study assessed 1863 unique open-ended free-text responses provided by 1863 U.S. young adults between February 14 and June 15, 2022. The data originated from the COVID-19 Adult Resilience Experiences Study (CARES). Participants reported their vaccination status and then shared free-text explanations of their decision. Thematic analysis led to the development of the "COVID-19 Vaccination Attitudes Among Young Adults" model, illustrating how vaccination decisions were shaped by the dynamic interplay of individual and contextual factors. At the individual level, pro-vaccination, vaccine-hesitant, and anti-vaccination attitudes emerged. Pro-vaccination individuals emphasized motivations such as protecting health, trusting in science and institutions, and having a sense of collective responsibility. Vaccine-hesitant respondents were marked by uncertainty, including a fear of unknown risks and decision paralysis. Anti-vaccination individuals expressed distrust in governmental and scientific authorities, had a strong emphasis on personal autonomy, and expressed beliefs rooted in spiritual, naturalistic, or fatalistic frameworks. Beyond the individual level, three contextual influences shaped attitudes: government policies and mandates, social influence from other people around them, and vaccine accessibility. A key distinction across these groups was between collectivistic and individualistic motivations. Vaccine-hesitant individuals were characterized by ambivalence. COVID-19 vaccination attitudes among U.S. young adults reflect a complex intersection of personal beliefs and social context. Understanding these patterns can inform more nuanced public health strategies and communication efforts.