Older Adults’ Intentions and Attitudes Toward the Updated Bivalent COVID-19 Booster 2023

Survey, United States, July 2023
By Kelsey Costa, MS, RDN -
Medically Reviewed by Dr G. Michael DiLeo, MD

A new survey reveals older adults’ plans for the updated bivalent booster shots. This article presents a review of the results and their implications.


Survey results showed that most vaccinated older adults would likely get the updated booster.

Those likely to receive the shots want to protect themselves from the new variants, protect others, and prevent severe illness due to COVID-19.

Those unlikely to take the updated bivalent booster shots cite concerns surrounding the updated boosters’ safety, effectiveness, and side effects.

The impact of the COVID-19 pandemic has been felt worldwide and continues to affect older adults disproportionately.

In April 2023, the U.S. FDA updated its vaccine guidelines regarding bivalent booster shots, including special indications for older adults and people with compromised immune systems.

According to the FDA, adults aged 65 and older can now receive an additional dose of the “updated” bivalent booster shots four months after the first, and immunocompromised can receive an additional dose after two months.

The new booster shots are intended to better protect against COVID-19 caused by the omicron variant, which is still the predominant variant in the U.S.

Following this update, Health Canal conducted an anonymous survey to investigate older adults’ intentions and attitudes toward the updated bivalent boosters.

This survey, which aimed to uncover what might affect older adults’ decisions to take the updated shots, found that most vaccinated people aged 65 and older plan to take the additional dose when available.


Health Canal surveyed over 1,000 U.S. adults online on April 22, 2023. Survey responses were collected from individuals ages 65 and older previously vaccinated for COVID-19.

All survey responses were anonymous, and participants were asked to answer questions about their plans and motivations in their decisions regarding the updated bivalent boosters.

Likert scale questions were used to measure the importance of each factor in individuals’ decision-making process.

The current post-pandemic landscape

Today, 95.0 percent of adults 65 and older in the United States have received at least one dose of the original COVID-19 vaccine.

The number who have received an updated bivalent booster dose is less than half at 42.4 percent.

This discrepancy can be explained by the current prevalence of misinformation, according to Shiv Pillai MD, PhD, a professor of medicine at Harvard Medical School and director of the Autoimmune Center of Excellence at Massachusetts General Hospital and the Ragon Institute of Mass General, MIT, and Harvard.

“We are in an era where we have many ‘influencers’ who are either unable to accept that they do not have enough information to communicate on certain issues or do not care if what they communicate is factual or not. Large segments of the population do not know what to believe. It is clear that with the evolution of the virus, the vaccines do not protect from infection, but vaccines do provide excellent immunity that prevents hospitalization and deaths, especially in the elderly.”

Shiv Pillai MD, PhD

How many older adults intend to take the updated booster

When we asked older adults about their likelihood of getting the updated bivalent booster, most said they were “likely” (18.93%) or “very likely” (38.26%).

Others indicated that they were “neutral” (18.04%), “unlikely” (7.33%), or “very unlikely” (17.44%).

The weighted average response to this question was 3.53, with four being “very likely” and zero being “very unlikely.”

This suggests that most vaccinated older adults intend to get the updated bivalent booster shot, but this does not necessarily mean they will follow through.

Older adults’ top five reasons to get the booster

For those who indicated they were “likely” or “very likely” to get the updated booster, the survey found a few primary factors were motivating their decision.

Protection from the new omicron variants was the most common factor (88.89%), followed by protection against severe illness due to COVID-19 (69.97%).

Dr. Pillai clarified that the vaccine does not protect against infection but instead provides improved immunity that can help to prevent severe illness and hospitalization.

“The virus continues to evolve. Essentially the vaccines, even the bivalent booster, attenuate infection and protect recipients from severe disease by making non-neutralizing antibodies and activating T cells. Repeated vaccination is critical for protection from hospitalization in older people. However, vaccines do not make a sufficient range of neutralizing antibodies, so they cannot protect the vaccinated person from infection. Vaccination ensures the disease is mild.”

Shiv Pillai MD, PhD

Older adults’ next most common reasons to get the booster were:
  • The desire to protect others (63.02%)
  • Preventing long-term symptoms of COVID-19 (60.86%)
  • Following the recommendation of the CDC to get the booster dose (53.82%)

The CDC recommended the first bivalent boosters round in September 2022.

With following CDC recommendations being among the top five motivators for getting the booster, awareness of this recommendation is presumably increasing.

Rating the importance of positive motivators

Upon rating the importance of their motivators on a 3-point scale, protection from severe illness (2.66) and long-term symptoms (2.62) due to COVID-19 were the only two motivators to score “very important.”

The one motivator to score “not at all important” was a requirement by their employer or school to get the updated bivalent booster shot (1.04), which matches expectations for this population.

Older adults’ top five reasons not to get the booster

The survey results also revealed that some older adults are hesitant to get additional doses of the updated vaccine.

Of those who indicated they were “unlikely” or “very unlikely” to get the updated bivalent booster, the survey found that their primary reason was hesitation due to not knowing if the newly formulated vaccine was safe (40.73%).

The second most cited reason was concern over potential side effects (31.05%).

Vaccines for COVID-19 typically have mild side effects, such as pain and swelling at the injection site, fever, headache, muscle aches, and chills.

There have been reports of rare adverse reactions being linked to both the adenoviral vector and mRNA vaccines, including blood clots (especially with the adenoviral vector vaccines), myocarditis, glomerular diseases, and skin reactions (especially with the mRNA vaccines).

According to the CDC, early reports of adverse reactions to the bivalent boosters are similar to those described for the original monovalent vaccines.

However, the potential for unexpected side effects may be lower in the older adult population, as “all immune responses are less prominent with age”, Dr. Pillai explained.

He added, “Overall, the side effects of the mRNA vaccines are very rare, and these rare side effects have sometimes occurred in teenage boys more than in anyone else.”

“If anything, side effects are rarer in older people”, he concluded.

Older adults’ next most common reasons not to get the booster were:
  • Skepticism about the new formula’s effectiveness (27.82%)
  • A belief that they still have strong protection against COVID-19 (29.44%)
  • A belief that they still have strong protection against severe illnesses that could result from COVID-19 (20.56%)

Dr. Pillai explained how these beliefs may be misguided, telling Health Canal, “[The omicron variant] is still very serious for unvaccinated individuals and in populations where the previous natural infection is rare. In unvaccinated populations, as was seen in China, there is enough evidence to suggest a very high fraction of deaths in the elderly in late 2022 and early 2023.”

Supporting the theory that awareness of the new bivalent booster is increasing, only 4.84 percent of respondents said they did not plan to get the updated vaccine because they didn’t know it was available, and only 4.44 percent didn’t know if they were eligible.

Rating the importance of positive motivators

Upon rating the importance of their motivators on a 3-point scale, no single negative motivator scored higher than “somewhat important,” with concern over safety being the highest (2.34).

The least important motivators for older adults were having to take time off from work (1.41) and feeling that getting the booster was too much effort (1.43), both “not important at all” in their decisions.

Convenience and knowledge of availability and eligibility do not appear to be major factors or motivators in older adults’ decisions regarding the updated bivalent booster.

Main findings and implications

The survey results revealed that concern for personal safety is the predominant factor motivating older adults to get or not to get the updated bivalent booster shot.

Safety being the primary driver indicates that more information about the omicron variant and potential vaccine side effects and adverse reactions must be available for this population.

This will aid them in making informed decisions based on their health, medical conditions, and other factors.

CDC recommendations for the booster shot seem well known among older adults, as evidenced by the survey results; however, greater public awareness of the vaccine’s level of protection against the omicron variant, as well as the potential side effects and adverse reaction rarity, appear to be necessary.

The survey findings imply that health care providers should provide more detailed information to ensure patients understand the current primary variant of COVID-19 and the updated bivalent vaccine.

Healthcare policymakers should also consider making more detailed information available to the general public in a way that is accessible and understandable.


The survey is limited by the sample size (1,113 respondents) and the period covered (24 hours).

Most participants self-identified as white, meaning other racial identities may not have been adequately represented.

California, Florida, and Texas had the highest representation in the survey responses, which may not accurately reflect the opinions of other states.

Additionally, because the survey was conducted online, technology access and internet access may have impacted participation and the accuracy of results.

These potential biases should be considered when interpreting the survey results.


The survey results provide a valuable snapshot into the thoughts and motivations of older adults concerning vaccination with the updated bivalent booster shot.

Safety concerns are indicated as a primary factor motivating their intentions and attitudes, highlighting the need for greater public awareness.

More information must be available regarding vaccine side effects and potential adverse reactions, provided in an unbiased comparison of the risks of not getting vaccinated.

Informing older adults of the risks and benefits associated with either choice is critical in empowering them to make decisions based on their needs and ensuring patient safety is always prioritized.

Further research is needed to understand better the older adult population’s attitudes, behaviors, and motivations regarding vaccination with the updated bivalent booster shot. Also, any additional research should attempt to avoid disproportion among ethnic and geographical responses.

If you have any questions or comments about the survey results, please don’t hesitate to contact Health Canal staff. We welcome your feedback.

Competing interests
The author declares they have no competing interests.

Data availability
The data supporting this survey’s findings are available from Health Canal upon reasonable request.

Health Canal funded this study, and no external funding sources were used.

Dr. Britney Blair – Licensed clinical psychologist, Board-certified behavioral sleep medicine specialists, theclinicca.org

“I am not at all surprised at the results! The prevalence of insomnia, as you may know, is typically 30% in the general population but with this collective trauma we are seeing rates that are much higher! In addition, the lack of physical and mental stimulation as well as the never ending onslaught of negative/panicked news is impacting the quality of folk’s sleep as well as their dream content.”

Author information
Kelsey Costa, MS, RDN
Health Research Consultant

Media contact
Erik Pham
Founder of Health Canal
[email protected]


Costa, K. (2023, April 26). Older Adults' Intentions and Attitudes Toward the Updated Bivalent COVID-19 Booster – Survey, United States, April 2023. Health Canal. Retrieved from https://www.healthcanal.com/health/the-bivalent-covid-19-booster-survey
Costa, K. (2023) Older Adults' Intentions and Attitudes Toward the Updated Bivalent COVID-19 Booster – Survey, United States, April 2023, Health Canal. Available at: https://www.healthcanal.com/health/the-bivalent-covid-19-booster-survey.