Abstract
Objectives. To identify factors associated with persistent COVID-19 vaccine refusal among Nebraska residents 6 months after an initial COVID-19 diagnosis. Methods. Using case investigation surveillance data and vaccination records from the Nebraska Department of Health and Human Services, a cohort of 16 344 unvaccinated, COVID-19‒confirmed individuals (May 2021‒February 2023) were asked for their reason for nonvaccination (RNV), then followed for 6 months to assess subsequent vaccination status. We used a modified Poisson regression to estimate risk of unvaccinated status at follow-up against predictors, including RNV, demographic characteristics, adherence to mitigation measures, hospitalization, and rurality. Results. Compared with those whose RNV was missed opportunity/lack of convenience, individuals who cited religious exemption (adjusted incidence risk ratio [AIRR = 1.36; 95% confidence interval [CI] = 1.31, 1.41), philosophical objection (AIRR = 1.28; 95% CI = 1.24, 1.34), or institutional confidence/complacency concerns (AIRR = 1.26; 95% CI = 1.19, 1.33) showed greatest risk of nonvaccination. Older age, nonadherence to mitigation measures, and higher rurality are positively associated with nonvaccination. Minority status and hospitalization were correlated with vaccination. Conclusions. Ideology-centered objections held significant weight among previously infected individuals who displayed sustained reluctance toward COVID-19 vaccination. Distinguishing sources of misinformation among ideologically similar communities could instigate reconsideration for vaccination. (Am J Public Health. 2025;115(3):414-424. https://doi.org/10.2105/AJPH.2024.307921).