Article Correlates of COVID-19 Vaccine Acceptance, Hesitancy and Refusal among Employees of a Safety Net California County Health System with an Early and Aggressive Vaccination Program: Results from a Cross-Sectional Survey Nicole M. Gatto 1, *, Jerusha E. Lee 2 , Donatella Massai 1 , Susanna Zamarripa 3 , Bijan Sasaninia 3 , Dhruv Khurana 3 , Kelsey Michaels 3 , Deborah Freund 1,2 , Judi Nightingale 3 and Anthony Firek 3 on behalf of the Riverside University Health System (RUHS) Comparative Effectiveness and Clinical Outcomes Research Center (CECORC)-Claremont Graduate University (CGU) COVID-19 Research Group   Citation: Gatto, N.M.; Lee, J.E.; Massai, D.; Zamarripa, S.; Sasaninia, B.; Khurana, D.; Michaels, K.; Freund, D.; Nightingale, J.; Firek, A.; et al. Correlates of COVID-19 Vaccine Acceptance, Hesitancy and Refusal among Employees of a Safety Net California County Health System with an Early and Aggressive Vaccination Program: Results from a Cross-Sectional Survey. Vaccines 2021, 9, 1152. https://doi.org/10.3390/ vaccines9101152 Academic Editor: Brian D. Poole Received: 12 September 2021 Accepted: 5 October 2021 Published: 9 October 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1 School of Community and Global Health, Claremont Graduate University, 150 E 10th St, Claremont, CA 91711, USA; donatella.massai@cgu.edu (D.M.); debbie.freund@cgu.edu (D.F.) 2 Department of Economic Sciences, Claremont Graduate University, 150 E 10th St, Claremont, CA 91711, USA; jerusha.lee@cgu.edu 3 Riverside University Health System, Comparative Effectiveness and Clinical Outcomes Research Center, 26520 Cactus Avenue, Moreno Valley, CA 92555, USA; szamarripa@ruhealth.org (S.Z.); bsasaninia@ruhealth.org (B.S.); d.khurana@ruhealth.org (D.K.); kmich004@ucr.edu (K.M.); j.nightingale@ruhealth.org (J.N.); a.firek@ruhealth.org (A.F.) * Correspondence: nicole.gatto@cgu.edu Abstract: Since health professionals provide frontline care to COVID-19 patients, information on vaccine acceptance among healthcare workers is needed. We developed and implemented an anony- mous internet-based cross-sectional survey with direct solicitation among employees of a safety net health system. Items queried demographic and health-related characteristics, experience with and knowledge of COVID-19, and determinants of decisions to vaccinate. COVID-19 vaccine accep- tance groups (acceptors, hesitant, refusers) were defined; an adapted version of the WHO vaccine hesitancy scale was included. The survey demonstrated good reliability (Cronbach’s alpha = 0.92 for vaccine hesitancy scale; 0.93 for determinants). General linear and logistic regression methods examined factors which were univariately associated with vaccine hesitancy and vaccine acceptance, respectively. Multivariable models were constructed with stepwise model-building procedures. Race/ethnicity, marital status, job classification, immunocompromised status, flu vaccination and childhood vaccination opinions independently predicted hesitancy scale scores. Gender, education, job classification and BMI independently predicted acceptance, hesitancy, and refusal groups. Among hesitant employees, uncertainty was reflected in reports of motivating factors influencing their inde- cision. Despite a strong employee-support environment and job protection, respondents reported physical and mental health effects. The appreciation of varied reasons for refusing vaccination should lead to culturally sensitive interventions to increase vaccination rates amongst healthcare workers. Keywords: vaccine hesitancy; COVID-19; pandemic; SARS-CoV-2; healthcare workers; vaccine acceptance; physicians; nurses; determinants 1. Introduction The success of any vaccination program is dependent on a number of interconnected and interdependent actions. These include development of vaccine, testing for efficacy and safety, rapid distribution to the population and acceptance by recipients. The latter issue of vaccine uptake [1] is critical, and can be characterized as vaccine acceptance, refusal, or hesitancy. Vaccine hesitancy is formally defined as a “delay in acceptance or refusal of vaccines despite availability of vaccine services” [2] and is acknowledged as complex and Vaccines 2021, 9, 1152. https://doi.org/10.3390/vaccines9101152 https://www.mdpi.com/journal/vaccines