Promoting COVID-19 vaccine acceptance: recommendations from the Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA

How urban versus rural population relates to COVID-19 booster vaccine hesitancy: A propensity score matching design study

During the COVID-19 pandemic, the vaccine hesitancy has significantly affected the vaccination. To evaluate the booster vaccine hesitancy and its influencing factors among urban and rural residents, as well as to estimate the net difference of booster vaccine hesitancy between urban and rural residents. We conducted a nationwide, cross-sectional Internet survey on 1-8 February 2023, and employed stratified random sampling technique to select participants (≥18 years old) from urban and rural areas. Multivariate logistic regression was used to determine the factors impacting booster vaccine hesitancy. Propensity Score Matching was used to estimate the net difference of COVID-19 booster vaccine hesitancy between urban and rural residents. The overall COVID-19 booster vaccine hesitancy rate of residents was 28.43%. The COVID-19 booster vaccine hesitancy rate among urban residents was found to be 34.70%, among rural residents was 20.25%. Chronic diseases, infection status, vaccination benefits, and trust in vaccine developers were associated with booster vaccine hesitancy among urban residents. Barriers of vaccination were associated with booster vaccine hesitancy among rural residents. PSM analysis showed that the urban residents have a higher booster vaccine hesitancy rate than rural residents, with a net difference of 6.20%. The vaccine hesitancy rate increased significantly, and the urban residents have a higher COVID-19 booster vaccine hesitancy than rural residents. It becomes crucial to enhance the dissemination of information regarding the advantages of vaccination and foster greater trust among urban residents toward the healthcare system.

Spatiotemporal dynamic and regional differences of public attention to vaccination: An empirical study in China

BACKGROUND

Internet searches offer an indicator of public attention and possible demand for certain things. Studying the spatiotemporal characteristics of the public's concern for vaccination can determine the spatiotemporal distribution of demand for vaccines in China, and capture the changes in the health awareness of the Chinese population, thus informing future vaccination strategies.

METHODS

Based on the collection of Baidu search indices for vaccination-related keywords in 363 cities in China, This paper seeks to explore the spatiotemporal changes and regional differences in public attention toward vaccination in China by using the seasonal index, seasonal concentration index, Herfindahl index, Moran index, and Dagum Gini coefficient.

RESULTS

The following findings are presented. First, there are significant seasonal fluctuations and unbalanced monthly distributions of vaccination-related public attention in China. Second, the public attention in Chinese cities shows the spatial characteristics of "leading in the east, followed by the central, western and northeastern regions". The spatial correlation of attention has been strengthened, and the high-high clusters are mainly distributed in the Beijing-Tianjin-Hebei (BTH), Yangtze River Delta (YRD), and Greater Bay Area (GBA) urban agglomerations. Third, regional differences in overall public attention narrowed in China, with intra-regional differences narrowing in seven regions (Northwest China, Central China, and so on), and intra-regional differences increasing in East China. The dominant role in the Gini coefficient changes from transvariation intensity to inter-regional differences.

CONCLUSION

Major public health emergencies stimulate the public's attention to health topics. Although the short-term increase in vaccination-related public attention was not observed to translate into a long-term increase in public vaccine literacy, the seasonal and regional differences in vaccination-related public attention in China have significantly narrowed before and after COVID-19, suggesting that the imbalance between public health literacy levels has improved.

Cultural Defaults in the Time of COVID: Lessons for the Future

Five years after the beginning of the COVID pandemic, one thing is clear: The East Asian countries of Japan, Taiwan, and South Korea outperformed the United States in responding to and controlling the outbreak of the deadly virus. Although multiple factors likely contributed to this disparity, we propose that the culturally linked psychological defaults ("cultural defaults") that pervade these contexts also played a role. Cultural defaults are commonsense, rational, taken-for-granted ways of thinking, feeling, and acting. In the United States, these cultural defaults include optimism and uniqueness, single cause, high arousal, influence and control, personal choice and self-regulation, and promotion. In Japan, Taiwan, and South Korea, these defaults include realism and similarity, multiple causes, low arousal, waiting and adjusting, social choice and social regulation, and prevention. In this article, we (a) synthesize decades of empirical research supporting these unmarked defaults; (b) illustrate how they were evident in the announcements and speeches of high-level government and organizational decision makers as they addressed the existential questions posed by the pandemic, including "Will it happen to me/us?" "What is happening?" "What should I/we do?" and "How should I/we live now?"; and (c) show the similarities between these cultural defaults and different national responses to the pandemic. The goal is to integrate some of the voluminous literature in psychology on cultural variation between the United States and East Asia particularly relevant to the pandemic and to emphasize the crucial and practical significance of meaning-making in behavior during this crisis. We provide guidelines for how decision makers might take cultural defaults into account as they design policies to address current and future novel and complex threats, including pandemics, emerging technologies, and climate change.

The nurse's role in a patient-centered approach for reducing COVID-19 vaccine hesitancy during pregnancy: An American Academy of Nursing consensus paper

The evidence shows that COVID-19 vaccines can reduce the risks of poor pregnancy outcomes. Yet, reluctance to vaccinate remains high in pregnant populations. In this paper, we take a precision health and patient-centered approach to vaccine hesitancy. We adopted the society-to-cells vaccine hesitancy framework to identify society, community, family, individual, and physiologic factors contributing to COVID-19 vaccine hesitancy in pregnancy. Nurses are particularly well-suited to impact the factors associated with vaccine hesitancy. Because of their proximity to the patient, nurses are positioned to provide individualized, timely health information, and clinical guidelines to assist patients with decision-making related to vaccinations. Recommendations are provided to bolster nurses' engagement in precision health and patient-centered models of care to mitigate COVID-19 vaccine hesitancy in pregnancy.

Risk of COVID-19 in Children throughout the Pandemic and the Role of Vaccination: A Narrative Review

At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, persons ≥65 years of age and healthcare personnel represented the most vulnerable groups with respect to risk of infection, severe illness, and death. However, as the pandemic progressed, there was an increasingly detrimental effect on young children and adolescents. Severe disease and hospitalization increased over time in pediatric populations, and containment measures created substantial psychosocial, educational, and economic challenges for young people. Vaccination of children against COVID-19 has been shown to reduce severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and severe outcomes in pediatric populations and may also help to prevent the spread of variants of concern and improve community immunity. This review discusses the burden of COVID-19 on children throughout the pandemic, the role of children in disease transmission, and the impact of COVID-19 vaccination.

A population-based study of COVID-19 mortality risk in US cancer patients

BACKGROUND

In this study, we provide the largest analysis to date of a US-based cancer cohort to characterize death from COVID-19.

METHODS

A total of 4 020 669 patients across 15 subtypes living with cancer in 2020 and included in the National Cancer Institute's Surveillance, Epidemiology, and End Results database were abstracted. We investigated prognostic factors for death due to COVID-19 using a Cox proportional hazards model and calculated hazard ratios (HRs). Standardized mortality ratios were calculated using observed mortality counts from Surveillance, Epidemiology, and End Results and expected mortality based on US mortality rates.

RESULTS

A total of 291 323 patients died, with 14 821 (5.1%) deaths attributed to COVID-19 infection. The COVID-19 disease-specific mortality rate was 11.81/10 000-persons years, and the standardized mortality ratio of COVID-19 was 2.30 (95% confidence interval [CI] = 2.26 to 2.34; P < .0001). COVID-19 ranked as the second leading cause of death following ischemic heart disease (5.2%) among 26 noncancer causes of death. Patients who are older (80 years and older vs 49 years and younger: HR = 21.47, 95% CI = 19.34 to 23.83), male (vs female: HR = 1.46, 95% CI = 1.40 to 1.51), unmarried (vs married: HR = 1.47, 95% CI = 1.42 to 1.53), and Hispanic or non-Hispanic African American (vs non-Hispanic White: HR = 2.04, 95% CI = 1.94 to 2.14 and HR = 2.03, 95% CI = 1.94 to 2.14, respectively) were at greatest risk of COVID-19 mortality.

CONCLUSIONS

We observed that people living with cancer are at 2 times greater risk of dying from COVID-19 compared with the general US population. This work may be used by physicians and public health officials in the creation of survivorship programs that mitigate the risk of COVID-19 mortality.

COVID-19 Vaccine Decision-Making Among Black Pregnant and Postpartum Women

INTRODUCTION

The history of biomedical research is marred by racially discriminatory and abusive practices that impacted Black/African Americans. Medical racism impacts the trust and utilization of new medical interventions, such as the COVID-19 vaccine. This study aimed to understand Black pregnant and postpartum women's perspectives and decision-making about the COVID-19 vaccine.

METHODS

We used a qualitative descriptive design and recruited 23 pregnant and postpartum Black women aged 18 years and above. Data was collected using a semi-structured interview guide. Data were analyzed using content analysis.

FINDINGS

The participants described factors influencing their decision to receive or not receive the COVID-19 vaccines. These factors included individual, cultural, ethnicity, religious, and family-related factors (individual-personal beliefs influenced decisions about the vaccine; ethnicity, culture, and religion influenced vaccine decision-making; group-family and friends played a role in decision-making), vaccine or vaccination-related issues (concerns about vaccination and pregnancy outcomes and mistrust in the vaccine information), and contextual influence (sources of vaccine information influenced decision-making and healthcare providers influenced decision-making).

CONCLUSION

Understanding the vaccine decision-making process of underserved populations likely to decline vaccination due to pregnancy, postpartum, and breastfeeding status will help design tailored interventions to improve vaccine acceptance in minority communities, especially for pregnant and postpartum women.

Validity and Reliability of the Greek Version of Adult Vaccine Hesitancy Scale in Terms of Dispositional Optimism in a Community-Dwelling Population: A Cross-Sectional Study

Vaccine hesitancy is an important public health issue referring to concerns about the safety and efficacy of vaccination. Within a framework, this study aimed to assess the cultural adaptation, validity, and reliability of the Greek version of the adult Vaccine Hesitancy Scale (aVHS) as well as to identify the determinants of vaccine hesitancy among a large regional population in central Greece. A cross-sectional study was conducted enrolling 300 adults who had received primary healthcare services in the Health Centers and Local Health Units of the Magnesia Region from October to December 2022. The aVHS and the Life Orientation Test-Revised (LOT-R) were used to identify vaccine hesitancy and the dispositional level of optimism, respectively. For survey translation, the procedure of forward and backward translation was followed. Also, the aVHS was tested in a pilot study with a sample of 18 responders. Construct validity and internal consistency reliability were investigated via exploratory and confirmatory factor analysis and Cronbach's alpha coefficients, respectively. Simple and multiple linear regression analysis were used to determine predictors for vaccine hesitancy. Factor analyses indicated that the aVHS comprises two constructs ("lack of confidence" and "risk perception") explaining 68.9% of the total variance. The Cronbach's alpha of the total scale was 0.884, indicating its high internal consistency. Participants who lived in rural areas, had a lower annual income, and reported a lower level of optimism showed a higher lack of confidence in vaccination. On the other hand, people aged above 45 years old who had graduated from high school or elementary school and were unemployed showed greater aversion to the risks of side effects. Finally, certain socio-demographic characteristics were associated with vaccine hesitancy. Our data suggest that the aVHS is a valid and reliable instrument for measuring vaccine-related attitudes and perceptions in Greek society, providing meaningful insight into designing vaccination-related preventive interventions in the community.

Dynamic evolution of COVID-19 vaccine hesitancy over 2021-2023 among Chinese population: Repeated nationwide cross-sectional study

Globally, the rollout of COVID-19 vaccine had been faced with a significant barrier in the form of vaccine hesitancy. This study adopts a multi-stage perspective to explore the prevalence and determinants of COVID-19 vaccine hesitancy, focusing on their dynamic evolutionary features. Guided by the integrated framework of the 3Cs model (complacency, confidence, and convenience) and the EAH model (environmental, agent, and host), this study conducted three repeated national cross-sectional surveys. These surveys carried out from July 2021 to February 2023 across mainland China, targeted individuals aged 18 and older. They were strategically timed to coincide with three critical vaccination phases: universal coverage (stage 1), partial coverage (stage 2), and key population coverage (stage 3). From 2021 to 2023, the surveys examined sample sizes of 29 925, 6659, and 5407, respectively. The COVID-19 vaccine hesitation rates increased from 8.39% in 2021 to 29.72% in 2023. Urban residency, chronic condition, and low trust in vaccine developer contributed to significant COVID-19 vaccine hesitancy across the pandemic. Negative correlations between the intensity of vaccination policies and vaccine hesitancy, and positive correlations between vaccine hesitancy and long COVID, were confirmed. This study provides insights for designing future effective vaccination programs for emerging vaccine-preventable infectious X diseases.

Polarization, the Pandemic, and Public Trust in Health System Actors

CONTEXT

Public opinion on the performance of health system actors is polarized today, but it remains unclear which actors enjoy the most or the least trust among Democrats and Republicans, whether the COVID-19 pandemic has influenced how people view their own physicians, and whether doctors have retained the ability to influence public beliefs about policy issues.

METHODS

The authors conducted two national surveys in 2022 and 2023 to examine these questions.

FINDINGS

Democrats rated the performance of medical research scientists and public health experts during the pandemic more highly than did Republicans and independents. About three in ten Republicans said the pandemic decreased their trust in their personal doctors. Nonetheless, most Americans reported confidence in physicians. The authors replicated the findings of Gerber and colleagues (2014) to demonstrate that respondents continued to have more positive views of doctors than other professionals and that public opinion was responsive to cues from a doctors' group.

CONCLUSIONS

What polarizes Democrats and Republicans today is not the question of whether medical scientists and public health experts are competent but whether the advice offered by these actors is in the public interest and should guide policy makers' decisions. Democrats strongly believe the answer to these questions is yes, while Republicans exhibit skepticism.

Differences in Vaccination Consultation Preferred by Primary Health Care Workers and Residents in Community Settings

OBJECTIVE

To evaluate the preference of primary HCWs and residents on vaccination consultation in community health services to provide evidence for vaccine hesitancy intervention strategies.

METHODS

A discrete choice model (DCM) was constructed to evaluate the preference difference between primary HCWs and residents on vaccination consultation in community health services in China during May-July 2022.

RESULTS

A total of 282 residents and 204 HCWs were enrolled in this study. The residents preferred consulting with an HCW-led approach (β = 2.168), with specialized content (β = 0.954), and accompanied by telephone follow-up (β = 1.552). In contrast, the HCWs preferred face-to-face consultation (β = 0.540) with an HCW-led approach (β = 0.458) and specialized content (β = 0.409), accompanied by telephone follow-up (β = 0.831). College residents and residents with underlying self-reported disease may be near-critically inclined to choose traditional consultation (an offline, face-to-face consultation with standardized content and more prolonged duration) rather than a new-media consulting group (an online consultation with specialized content within 5 min). Urban HCWs preferred long-term consultation groups (the resident-led offline consultation with follow-up lasting more than 5 min). In contrast, rural HCWs preferred efficient consultation (the HCW-led, short-duration, standardized offline consultation mode).

CONCLUSION

The selection preference for vaccine consultation reveals a gap between providers and demanders, with different groups exhibiting distinct preferences. Identifying these targeted gaps can help design more acceptable and efficient interventions, increasing their likelihood of success and leading to better resource allocation for policymakers to develop targeted vaccination policies.

Policy Approaches for Increasing Adolescent HPV Vaccination Coverage: A Systematic Review

CONTEXT

US jurisdictions have enacted a wide range of policies to address low human papillomavirus (HPV) vaccination coverage among adolescents, but it is unclear which policies are effective.

OBJECTIVE

To systematically review the impact of governmental policies on adolescent HPV vaccination coverage.

DATA SOURCES

PubMed, Embase, and Scopus databases.

STUDY SELECTION

Eligible studies, published from 2009 to 2022, evaluated the impact of governmental policies on HPV vaccination coverage among adolescents ages 9 to 18.

DATA EXTRACTION

Two investigators independently extracted data on study sample, study design and quality, policy characteristics, and HPV vaccination outcomes. We summarized findings by policy type: school-entry requirements (SERs), federally-funded policies related to the Vaccines for Children program and Medicaid, educational requirements, and others.

RESULTS

Our search yielded 36 eligible studies. A majority of studies evaluating HPV vaccine SERs found positive associations between SERs and HPV vaccination coverage (8 of 14), particularly for SERs in Rhode Island and Washington, DC. All studies evaluating SERs for other adolescent vaccines observed positive spillover effects for HPV vaccination (7 of 7). Federally-funded policies related to Vaccines for Children and Medicaid were consistently associated with higher HPV vaccination coverage (7 of 9). Relatively few studies found associations between educational requirements and HPV vaccination coverage (2 of 8).

LIMITATIONS

Studies used limited vaccination data sources and non- or quasi-experimental designs. Some studies had no or poorly matched comparison groups.

CONCLUSIONS

Our findings suggest promise for SERs and federally-funded policies, but not educational requirements, for increasing HPV vaccination coverage among adolescents.

COVID-19 Vaccine Hesitancy: Umbrella Review of Systematic Reviews and Meta-Analysis

BACKGROUND

The unprecedented emergence of the COVID-19 pandemic necessitated the development and global distribution of vaccines, making the understanding of global vaccine acceptance and hesitancy crucial to overcoming barriers to vaccination and achieving widespread immunization.

OBJECTIVE

This umbrella review synthesizes findings from systematic reviews and meta-analyses to provide insights into global perceptions on COVID-19 vaccine acceptance and hesitancy across diverse populations and regions.

METHODS

We conducted a literature search across major databases to identify systematic reviews and meta-analysis that reported COVID-19 vaccine acceptance and hesitancy. The AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews) criteria were used to assess the methodological quality of included systematic reviews. Meta-analysis was performed using STATA 17 with a random effect model. The data synthesis is presented in a table format and via a narrative.

RESULTS

Our inclusion criteria were met by 78 meta-analyses published between 2021 and 2023. Our analysis revealed a moderate vaccine acceptance rate of 63% (95% CI 0.60%-0.67%) in the general population, with significant heterogeneity (I2 = 97.59%). Higher acceptance rates were observed among health care workers and individuals with chronic diseases, at 64% (95% CI 0.57%-0.71%) and 69% (95% CI 0.61%-0.76%), respectively. However, lower acceptance was noted among pregnant women, at 48% (95% CI 0.42%-0.53%), and parents consenting for their children, at 61.29% (95% CI 0.56%-0.67%). The pooled vaccine hesitancy rate was 32% (95% CI 0.25%-0.39%) in the general population. The quality assessment revealed 19 high-quality, 38 moderate-quality, 15 low-quality, and 6 critically low-quality meta-analyses.

CONCLUSIONS

This review revealed the presence of vaccine hesitancy globally, emphasizing the necessity for population-specific, culturally sensitive interventions and clear, credible information dissemination to foster vaccine acceptance. The observed disparities accentuate the need for continuous research to understand evolving vaccine perceptions and to address the unique concerns and needs of diverse populations, thereby aiding in the formulation of effective and inclusive vaccination strategies.

TRIAL REGISTRATION

PROSPERO CRD42023468363; https://tinyurl.com/2p9kv9cr.

Understanding Clinic and Community Member Experiences with Implementation of Evidence-Based Strategies for HPV Vaccination in Safety-Net Primary Care Settings

HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in safety-net populations with persistent disparities in HPV-associated cancer burden. Perspectives on evidence-based strategies (EBS) for HPV vaccination among key implementation participants, internal and external to clinics, can provide a better understanding of why these disparities persist. We conducted virtual interviews and focus groups, guided by the Practice Change Model, with clinic members (providers, clinic leaders, and clinic staff) and community members (advocates, parents, policy-level, and payers) in Los Angeles and New Jersey to understand common and divergent perspectives on and experiences with HPV vaccination in safety-net primary care settings. Fifty-eight interviews and seven focus groups were conducted (n = 65 total). Clinic members (clinic leaders n = 7, providers n = 12, and clinic staff n = 6) revealed conflicting HPV vaccine messaging, lack of shared motivation to reduce missed opportunities and improve workflows, and non-operability between clinic electronic health records and state immunization registries created barriers for implementing effective strategies. Community members (advocates n = 8, policy n = 11, payers n = 8, and parents n = 13) described lack of HPV vaccine prioritization among payers, a reliance on advocates to lead national agenda setting and facilitate local implementation, and opportunities to support and engage schools in HPV vaccine messaging and adolescents in HPV vaccine decision-making. Participants indicated the COVID-19 pandemic complicated prioritization of HPV vaccination but also created opportunities for change. These findings highlight design and selection criteria for identifying and implementing EBS (changing the intervention itself, or practice-level resources versus external motivators) that bring internal and external clinic partners together for targeted approaches that account for local needs in improving HPV vaccine uptake within safety-net settings.

Evaluation of the concerns of Spanish university students in the face of current major challenges

The concerns of students and young people have been on the rise in recent years. Recent events such as the Covid-19 pandemic or the invasion of Ukraine have contributed to this. Mental health, the high cost of living, the need to re-evaluate the way we work or the fight against climate change are among the main concerns of young people. The aim of this work is to find out the level of concern of university students about these problems that can condition their current life and to analyze whether these concerns can affect their academic performance, also distinguishing according to gender and age. To this end, a nationwide survey was carried out among this group in Spain. This work is the first of its kind to be carried out in Spain. The results obtained may be of great use to both educational institutions and government agents, with a view to offering policies that will improve the educational level and welfare of university students.

Trends in primary, booster, and updated COVID-19 vaccine readiness in the United States, January 2021-April 2023: Implications for 2023-2024 updated COVID-19 vaccines

OBJECTIVE

COVID-19 vaccines have mitigated the severity of COVID-19 and its sequelae. The emergence of new SARS-CoV-2 variants and waning immunity conferred by COVID-19 vaccination have necessitated booster and updated COVID-19 vaccines. This study examined trends in vaccine readiness-a composite measure of intention and uptake-for the primary, booster, and 2022-2023 updated (bivalent) COVID-19 vaccines among U.S. adults.

METHODS

Data from the nationally-representative U.S. Department of Health and Human Services' COVID-19 Monthly Outcome Survey from January 2021 to April 2023 were analyzed (N = 140,180). We conducted pairwise comparisons (weighted t-tests) to assess for significant between-month differences in the proportion of participants in each vaccine-readiness category (vaccine ready, wait and see, and no vaccine intention) for the following outcomes: (1) primary; (2) booster; and (3) updated COVID-19 vaccine readiness.

RESULTS

From January 2021 to April 2023, significant increases in the primary vaccine ready group were accompanied by decreases in the wait and see and no vaccine intention groups (p < 0.001). From January to September 2022, the no booster intention group notably increased (p < 0.001), whereas the booster ready group decreased (p < 0.001), and the wait and see group remained stable (p = 0.116). From October 2022 to April 2023, the no updated vaccine intention group increased (p < 0.001), the wait and see group decreased (p < 0.01), and the updated vaccine ready group remained unchanged (p = 0.357).

CONCLUSIONS

Findings show decreased vaccine readiness for the booster and 2022-2023 updated (bivalent) COVID-19 vaccines relative to the primary COVID-19 vaccines. Implications for the 2023-2024 updated COVID-19 vaccines are discussed.

Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review

BACKGROUND

Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health.

OBJECTIVE

In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools.

METHODS

We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively.

RESULTS

Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature.

CONCLUSIONS

Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts.

Causes of death among people living with metastatic cancer

Studying survivorship and causes of death in patients with advanced or metastatic cancer remains an important task. We characterize the causes of death among patients with metastatic cancer, across 13 cancer types and 25 non-cancer causes and predict the risk of death after diagnosis from the diagnosed cancer versus other causes (e.g., stroke, heart disease, etc.). Among 1,030,937 US (1992-2019) metastatic cancer survivors, 82.6% of patients (n = 688,529) died due to the diagnosed cancer, while 17.4% (n = 145,006) died of competing causes. Patients with lung, pancreas, esophagus, and stomach tumors are the most likely to die of their metastatic cancer, while those with prostate and breast cancer have the lowest likelihood. The median survival time among patients living with metastases is 10 months; our Fine and Gray competing risk model predicts 1 year survival with area under the receiver operating characteristic curve of 0.754 (95% CI [0.754, 0.754]). Leading non-cancer deaths are heart disease (32.4%), chronic obstructive and pulmonary disease (7.9%), cerebrovascular disease (6.1%), and infection (4.1%).

US seniors' intention to vaccinate against RSV in fall and winter 2023-2024

In the fall and winter of 2023-2024, the United States may experience a "tripledemic" of COVID-19, influenza, and respiratory syncytial virus (RSV) that may lead to 100 000 deaths. Seniors will be disproportionally affected. The newly released RSV vaccines for those age 60 years and over may reduce the number of deaths for the expected 6000 to 10 000 seniors expected to die from RSV alone. Using a large national survey, we queried Americans over age 60 about their RSV vaccination status and their intention to vaccinate this fall and winter. We found that 9% of seniors had already been vaccinated. Of the remaining unvaccinated, 42% indicated their intent to vaccinate. We found that those with higher levels of concerns for the disease, higher levels of self-assessed risk, believing that vaccines were safe and important, higher levels of trust in health institutions, and men were more likely to seek out vaccinations. Vaccine-hesitant respondents listed a lack of necessity, concerns about side effects and safety, and a lack of information as primary reasons. The large number of unvaccinated seniors will likely lead to an excessive number of hospitalizations and deaths as well as augmented social costs. Evidence-based mitigation measures tailored to seniors' concerns should be implemented immediately.

Spatial Analysis of Determinants of COVID-19 Vaccine Hesitancy in Portugal

Vaccine hesitancy tends to exhibit geographical patterns and is often associated with social deprivation and migrant status. We aimed to estimate COVID-19 vaccination hesitancy in a high-vaccination-acceptance country, Portugal, and determine its association with sociodemographic risk factors. We used the Registry of National Health System Users to determine the eligible population and the Vaccination Registry to determine individuals without COVID-19 vaccine doses. Individuals older than five with no COVID-19 vaccine dose administered by 31 March 2022 were considered hesitant. We calculated hesitancy rates by municipality, gender, and age group for all municipalities in mainland Portugal. We used the spatial statistical scan method to identify spatial clusters and the Besag, Yorke, and Mollié (BYM) model to estimate the effect of age, gender, social deprivation, and migrant proportion across all mainland municipalities. The eligible population was 9,852,283, with 1,212,565 (12%) COVID-19 vaccine-hesitant individuals. We found high-hesitancy spatial clusters in the Lisbon metropolitan area and the country's southwest. Our model showed that municipalities with higher proportions of migrants are associated with an increased relative risk (RR) of vaccine hesitancy (RR = 8.0; CI 95% 4.6; 14.0). Social deprivation and gender were not associated with vaccine hesitancy rates. We found COVID-19 vaccine hesitancy has a heterogeneous distribution across Portugal and has a strong association with the proportion of migrants per municipality.

The Worrying Phenomenon of COVID-19 Vaccine Hesitancy and Its Negative Impact on Pandemic Control Efforts: Common Themes that Emerged in the Middle East and North Africa (MENA) Region

Since the declaration of coronavirus disease 2019 (COVID-19) as a pandemic, intensive measures were taken to mitigate its negative health, psychological, social, and economic impact. COVID-19 continues to pose serious threats globally, with vaccination as the central safe strategy to control the pandemic. However, COVID-19 vaccine hesitancy is a major concern, especially in the Middle East and North Africa (MENA). Concerns regarding vaccine safety, efficacy, and misinformation contribute to vaccine hesitancy. Addressing these concerns and providing accurate information is crucial for increasing COVID-19 vaccine acceptance and uptake in this region, where the coverage is low. Variable rates of COVID-19 vaccine hesitancy were found in the numerous studies conducted in the region. Complex factors contributed to vaccination hesitancy in the region including concerns about COVID-19 vaccine safety and efficacy, low trust in healthcare systems, complacency toward the risks of COVID-19, constraints hindering access to COVID-19 vaccination services, as well as the circulation of misinformation and conspiracy beliefs about COVID-19 and its vaccination. Effective approaches to address COVID-19 vaccine hesitancy in the MENA region rely on developing evidence-based communication strategies that are recommended to build trust in vaccination, highlight the disease risks, and counter COVID-19 vaccine-related misinformation. Ensuring COVID-19 vaccine affordability is also necessary besides the cautious consideration of implementing COVID-19 vaccine mandates. Based on the preceding discussion, this chapter aims to identify the common themes of COVID-19 vaccine hesitancy in the MENA region. In addition, the chapter highlights the importance of understanding the root causes of COVID-19 vaccination hesitancy and its associated determinants to develop effective strategies for promoting COVID-19 vaccine acceptance and uptake in the MENA region. To build community trust, promote community education and awareness, and counter misinformation for better COVID-19 vaccine coverage in the region, it is recommended to involve healthcare professionals and policymakers.

A systematic review and meta-analysis of the global prevalence and determinants of COVID-19 vaccine acceptance and uptake in people living with HIV

People living with HIV (PLHIV) are at higher risk of poor outcomes of SARS-CoV-2 infection. Here we report the pooled prevalence of COVID-19 vaccine acceptance/uptake and determinants among this vulnerable population of PLHIV based on a systematic review and meta-analysis of studies published by 25 August 2023. Among the 54 included studies (N = 167,485 participants), 53 (N = 166,455) provided data on vaccine acceptance rate, while 27 (N = 150,926) provided uptake data. The global prevalences of COVID-19 vaccine acceptance and uptake were 67.0% and 56.6%, respectively. Acceptance and uptake rates were 86.6% and 90.1% for the European Region, 74.9% and 71.6% for the Region of the Americas, 62.3% and 78.9% for the South-East Asian Region, 64.6% and 19.3% for the Eastern Mediterranean Region, 58.0% and 35.5% for the African Region, and 57.4% and 44.0% for the Western Pacific Region. The acceptance rate increased from 65.9% in 2020 to 71.0% in 2022, and the uptake rate increased from 55.9% in 2021 to 58.1% in 2022. Men, PLHIV aged ≥40 years and those who had recently received the influenza vaccine were more likely to accept and receive the COVID-19 vaccine. Factors associated with lower uptake included Black race, other races (Latinx/Hispanic/mixed race), low education level and being unemployed. Vaccine-related factors associated with higher acceptance included belief in vaccine effectiveness, vaccine trust, perceived high susceptibility to SARS-CoV-2 infection and fear of potential COVID-19 effect in PLHIV. Sustained efforts and targeted interventions are needed to reduce regional disparities in COVID-19 vaccine uptake among PLHIV.

Assessing parental intention to vaccinate against COVID-19, influenza, and RSV in the United States in late 2023

Vaccine hesitancy is a substantial public health threat. We used a national survey to query parents about their intention to vaccinate their children against COVID-19, influenza, and RSV in the fall and winter 2023-2024. We found that about 40% of parents intended to vaccinate their children against COVID-19, 63% against influenza, and 71% against RSV. Intention to vaccinate was consistently correlated with concerns about the disease, trust in health institutions, and previous vaccinations. Women showed lower intentions for COVID-19 and influenza. For COVID-19 and RSV, intentions were higher for those who thought vaccines were important. Concerns about autism were negatively associated for COVID-19. Liberals showed larger intentions for COVID-19. Major reasons for hesitancy include concerns about safety, necessity, and lack of information. The large number of unvaccinated children will likely lead to large numbers of excessive disease in children as well as exert large negative externalities on society at large.

Assessing past and future COVID-19 vaccine hesitancy in the United States in light of federal policy changes

Vaccinations provide an effective solution against the ongoing COVID-19 pandemic. Using a national survey (n = 3958), this study explored vaccination hesitancy for various COVID-19 vaccines and boosters, including the newly released annual vaccine for fall and winter 2023-2024. It also assessed support for federal funding for COVID-19 testing, vaccinations, and treatment. Consistent correlates of past vaccination refusal were perceptions of vaccines as safe and important, previous COVID-19 tests, concern about COVID-19, having voted for President Trump, higher religiosity, being liberal, trust in health institutions, health insurance status, and education. Other predictors showed inconsistent results across the various stages. Drivers of vaccination refusal were concerns about vaccine safety and side effects, perceived lack of information, and having previously contracted COVID-19. Intention to vaccinate was associated with concerns about COVID-19, liberalism, and trust in health institutions. Other factors were intermittently significant. We found consistent support for federal funding for those concerned about COVID-19, those concerned about the effectiveness of existing vaccines, those with trust in health institutions, those who thought vaccines are important, women, and those with lower levels of education. Opposition came from conservatives and Trump voters.

Assessing vaccine hesitancy and support for vaccination requirements for pets and potential Spillovers from humans

BACKGROUND

Growing vaccination hesitancy is well-document among humans. However, we know very little about vaccination hesitancy for pets as well as whether the two phenomena are interconnected. Moreover, support for pet vaccination requirements also remain underassessed.

METHODS

We fielded a large, national survey (N = 3,958) on August 18 and August 19, 2023, to assess U.S. public opinion about the vaccination status of dogs (rabies, canine parvovirus, canine distemper, canine influenza, and Lyme disease) and cats (rabies, feline panleukopenia (parvo), feline herpesvirus-1, feline chlamydia, and feline Bordetella) in the United States. We also queried respondents about their support for vaccination requirements for the 10 diseases.

RESULTS

We find that the vast majority of cats and dogs are vaccinated. However, a substantial minority of pets is not, particularly for cats and for non-core vaccines. We find that attitudinal measures of human and pet vaccine hesitancy are closely related to each other. Moreover, they are strong predictors of vaccine behavior. Measures of vaccine hesitancy are also strong predictors of support for vaccination mandates. Common measures used to assess human vaccine hesitancy showed inconsistent effects. However, pet vaccinations appear to be less politically polarizing.

CONCLUSION

The high correlation between pet and human measures raises the stake for public health efforts to improve attitudes about vaccines and vaccination rates across the board. Strong support for vaccination requirements should encourage policymakers to explore policy change. Moreover, veterinarians and their associations should consider expanding the number of core vaccinations.

How to increase and maintain high immunization coverage: Vaccination Demand Resilience (VDR) framework

BACKGROUND

Resilience in vaccination demand is ever more critical as the COVID-19 pandemic has increased our understanding of the importance of vaccines on health and well-being. Yet timid demand for COVID-19 vaccines where available and reduced uptake of routine immunizations globally further raise the urgent need to build vaccination resilience. We demonstrate the complexity of vaccination demand and resilience in a framework where relevant dimensions are intertwined, fluid, and contextual.

METHODS

We developed the Vaccination Demand Resilience (VDR) framework based on a literature review on vaccination demand and expert consultation. The matrix framework builds on three main axes: 1) vaccination attitudes and beliefs; 2) vaccination seeking behavior; and 3) vaccination status. The matrix generated eight quadrants, which can help explain people's levels of vaccination demand and resilience. We selected four scenarios as examples to demonstrate different interventions that could move people across quadrants and build vaccination resilience.

RESULTS

Incongruence between individuals' attitudes and beliefs, vaccination behavior, and vaccination status can arise. For example, an individual can be vaccinated due to mandates but reject vaccination benefits and otherwise avoid seeking vaccination. Such incongruence could be altered by interventions to build resilience in vaccination demand. These interventions include information, education and communication to change individuals' vaccination attitudes and beliefs, incentive programs and reminder-recalls to facilitate vaccination seeking, or by strengthening healthcare provider communications to reduce missed opportunities.

CONCLUSIONS

Vaccination decision-making is complex. Individuals can be vaccinated without necessarily accepting the benefits of vaccination or seeking vaccination, threatening resilience in vaccination demand. The VDR framework can provide a useful lens for program managers and policy makers considering interventions and policies to improve vaccination resilience. This would help build and sustain confidence and demand for vaccinations, and help to continue to prevent disease, disability, and death from vaccine-preventable diseases.

Exploring predictors of COVID-19 vaccine acceptance among students, faculty, and staff at a Southeastern University in the United States

OBJECTIVE

Explore predictors of early COVID-19 vaccine adoption on a university campus.

PARTICIPANTS

Students, faculty, staff, and administration (N = 1,234) completed an online survey exploring COVID-19 vaccine-related experiences, perspectives, and knowledge, from September to October 2021.

METHODS

Based on vaccination status participants were identified as vaccine hesitant or early vaccine adopters. Binary logistic regression was used to examine association between independent variables and vaccine adoption status.

RESULTS

Democrats (OR = 4.3, p = <.001), participants without a positive COVID-19 test (OR = 2.5, p = <.001), noted seeing/hearing COVID-19 misinformation (OR = 1.8, p = 0.27), and reported trust in public health agencies (OR = 26.2, p = <.001) were more likely to be early COVID-19 vaccine adopters, compared to Republicans, those with a positive COVID-19 test, those who had not seen/heard COVID-19 misinformation, and those reporting distrust in public health agencies, respectively.

CONCLUSION

Findings indicate that COVID-19 vaccine adoption is multifactorial. Future research should focus on vaccination status-related trust and health communication.

Meditation-induced bloodborne factors as an adjuvant treatment to COVID-19 disease

The COVID-19 pandemic has resulted in significant morbidity and mortality worldwide. Management of the pandemic has relied mainly on SARS-CoV-2 vaccines, while alternative approaches such as meditation, shown to improve immunity, have been largely unexplored. Here, we probe the relationship between meditation and COVID-19 disease and directly test the impact of meditation on the induction of a blood environment that modulates viral infection. We found a significant inverse correlation between length of meditation practice and SARS-CoV-2 infection as well as accelerated resolution of symptomology of those infected. A meditation "dosing" effect was also observed. In cultured human lung cells, blood from experienced meditators induced factors that prevented entry of pseudotyped viruses for SARS-CoV-2 spike protein of both the wild-type Wuhan-1 virus and the Delta variant. We identified and validated SERPINA5, a serine protease inhibitor, as one possible protein factor in the blood of meditators that is necessary and sufficient for limiting pseudovirus entry into cells. In summary, we conclude that meditation can enhance resiliency to viral infection and may serve as a possible adjuvant therapy in the management of the COVID-19 pandemic.

Correlates of COVID-19 vaccination intentions and opinions about mandates among four groups of adults in South Africa with distinct vaccine intentions: evidence from a large national survey

INTRODUCTION

Despite a high number of recorded COVID-19 infections and deaths in South Africa, COVID-19 vaccine coverage remained low in March 2022, ten months into the national vaccine roll-out. This study provides evidence on the correlates of vaccine intentions, attitudes towards vaccination and opinions about mandates.

METHODS

We used data from the second COVID-19 Vaccine Survey (CVACS), a telephone survey conducted February-March 2022 among 3,608 South African adults who self-reported not being vaccinated against COVID-19. The survey instrument was designed in consultation with government, policymakers, and civil society; and segmented the sample into four distinct groups with different vaccine intentions (synonymous with vaccine hesitancy levels). Kruskal-Wallis and Mann-Whitney tests were used to examine the sociodemographic characteristics, attitudes and behaviours associated with the different vaccination intentions groups. Thematic coding of responses to open-ended questions elicited insights on reasons for not being vaccinated and attitudes towards mandates.

RESULTS

Intentions to get vaccinated were greater among individuals with lower socio-economic status (Mann-Whitney Z = -11.3, p < 0.001); those believing the vaccine protects against death (Kruskal-Wallis Χ2 = 494, p < 0.001); and those who perceived themselves at risk of COVID-19-related illness (Χ2 = 126, p < 0.01). Vaccine intentions were lower among individuals who believed that the vaccine causes death (Χ2 = 163, p < 0.001); believed that the vaccine is unsafe for the babies of pregnant/breastfeeding mothers, or the chronically ill (Χ2 = 123, p < 0.01); those not trusting government health information about COVID-19 and the COVID-19 vaccine (Kendall's τ = -0.41, p < 0.01); and those in opposition to mandates (τ = 0.35, p < 0.001). Only 25% supported mandates, despite 48% thinking mandates would work well, with 54% citing individual rights as their main reason for mandate opposition.

CONCLUSION

The profile of individuals not vaccinated against COVID-19 as of March 2022 varied markedly by self-reported vaccination intentions, underscoring the importance of tailored demand-creation efforts. This paper highlights several factors which differ significantly across these groups. These findings could inform the design of future vaccination campaigns, potentially increasing their likelihood of success. This is an important policy objective given widespread vaccine hesitancy, and further work is required on this topic. Mandates remain an option to increase coverage but need to be carefully considered given extensive opposition.

COVID-19 Perceptions Among North Carolina Native Americans: Using a Qualitative Approach

Background

COVID-19 has amplified the health and economic disparities in Native American communities. However, there are limited data from Native American populations. This study is the first phase of the Building Resilience And Vital Equity (BRAVE) project, the scope of which is to understand Indigenous perceptions, attitudes, and behaviors about COVID-19 and design and implement culturally sensitive interventions to increase testing and vaccinations among Native American communities.

Method

We recruited 26 Native Americans and conducted open-ended, semi-structured interviews to explore participants' perceptions of COVID-19 and related themes, such as needed support, informational sources, trust, communication, and protection of elders.

Results

The results show that wearing a mask, hand sanitizing, and social distancing had very high support while perceptions of testing and vaccination decisions were mixed. Additionally, two themes stand out: the lack of reliable information resources to learn about COVID-19 and the lack of trust in the government.

Limitation

This study included a small sample size, which makes it difficult to include participants from diverse demographic backgrounds. Lack of familiarity with the online meeting format and the limited internet access in some indigenous communities may have prevented some people from participating.

Conclusion

The findings confirmed the need to improve existing public health information infrastructure and helped explain the intensified impact of COVID-19 on the Indigenous marginalized community. The findings help identify the key factors that affect Native Americans' testing and vaccination decisions and provide guidance on the designs of community intervention programs.

Primary care physicians' strategies for addressing COVID-19 vaccine hesitancy

OBJECTIVE

To explore the strategies that primary care physicians use to address patient COVID-19 vaccine hesitancy.

METHOD

We administered an online survey to 625 primary care physicians from May 14 to May 25, 2021, to assess the messages that primary care physicians use to encourage hesitant patients to get vaccinated against COVID-19.589 physicians from the total pool of 625 provided open-ended responses. We conducted thematic content analysis on the responses based on previous research and themes identified within the data.

SETTING

The survey was administered online using the survey research firm Dynata.

RESULTS

Eleven primary themes emerged from our analysis, which included, physicians addressing specific concerns about vaccine safety (including costs versus benefits), physicians helping patients understand what it means to remain unvaccinated, or whether physicians try to connect emotionally through the use of guilt, or personal experience, whether physicians use derisive language to communicate with unvaccinated patients. In addition, a small number of physicians indicated they would not attempt to persuade someone who is vaccine hesitant.

CONCLUSIONS

Our study shows that while some of the physicians used different strategies to address vaccine hesitancy, some of the physicians used harsh language or did not make any effort to reduce COVID-19 related vaccine hesitancy among their patients. Focused advocacy and training are needed to increase physician engagement in vaccine-related dialogues with their patients. Such efforts will ensure that critical opportunities for patient education and awareness-building are not missed and ensure high levels of vaccination uptake.

Excess Death Rates for Republican and Democratic Registered Voters in Florida and Ohio During the COVID-19 Pandemic

Importance

There is evidence that Republican-leaning counties have had higher COVID-19 death rates than Democratic-leaning counties and similar evidence of an association between political party affiliation and attitudes regarding COVID-19 vaccination; further data on these rates may be useful.

Objective

To assess political party affiliation and mortality rates for individuals during the initial 22 months of the COVID-19 pandemic.

Design, Setting, and Participants

A cross-sectional comparison of excess mortality between registered Republican and Democratic voters between March 2020 and December 2021 adjusted for age and state of voter registration was conducted. Voter and mortality data from Florida and Ohio in 2017 linked to mortality records for January 1, 2018, to December 31, 2021, were used in data analysis.

Exposures

Political party affiliation.

Main Outcomes and Measures

Excess weekly deaths during the COVID-19 pandemic adjusted for age, county, party affiliation, and seasonality.

Results

Between January 1, 2018, and December 31, 2021, there were 538 159 individuals in Ohio and Florida who died at age 25 years or older in the study sample. The median age at death was 78 years (IQR, 71-89 years). Overall, the excess death rate for Republican voters was 2.8 percentage points, or 15%, higher than the excess death rate for Democratic voters (95% prediction interval [PI], 1.6-3.7 percentage points). After May 1, 2021, when vaccines were available to all adults, the excess death rate gap between Republican and Democratic voters widened from -0.9 percentage point (95% PI, -2.5 to 0.3 percentage points) to 7.7 percentage points (95% PI, 6.0-9.3 percentage points) in the adjusted analysis; the excess death rate among Republican voters was 43% higher than the excess death rate among Democratic voters. The gap in excess death rates between Republican and Democratic voters was larger in counties with lower vaccination rates and was primarily noted in voters residing in Ohio.

Conclusions and Relevance

In this cross-sectional study, an association was observed between political party affiliation and excess deaths in Ohio and Florida after COVID-19 vaccines were available to all adults. These findings suggest that differences in vaccination attitudes and reported uptake between Republican and Democratic voters may have been factors in the severity and trajectory of the pandemic in the US.

Exploring COVID-19 education to support vaccine confidence amongst the general adult population with special considerations for healthcare and long-term care staff: A scoping review

Background

Despite the demonstrated efficacy of approved COVID-19 vaccines, high levels of hesitancy were observed in the first few months of the COVID-19 vaccines' rollout. Factors contributing to vaccine hesitancy are well-described in the literature. Among the various strategies for promoting vaccine confidence, educational interventions provide a foundationally and widely implemented set of approaches for supporting individuals in their vaccine decisions. However, the evidence around the measurable impact of various educational strategies to improve vaccine confidence is limited. We conducted a scoping review with the aim of exploring and characterizing educational interventions delivered during the pandemic to support COVID-19 vaccine confidence in adults.

Methods

We developed a search strategy with a medical information scientist and searched five databases, including Ovid MEDLINE and Web of Science, as well as grey literature. We considered all study designs and reports. Interventions delivered to children or adolescents, interventions on non-COVID-19 vaccines, as well as national or mass vaccination campaigns without documented interaction(s) between facilitator(s) and a specific audience were excluded. Articles were independently screened by three reviewers. After screening 4602 titles and abstracts and 174 full-text articles across two rounds of searches, 22 articles met our inclusion criteria. Ten additional studies were identified through hand searching. Data from included studies were charted and results were described narratively.

Results

We included 32 studies and synthesized their educational delivery structure, participants (i.e., facilitators and priority audience), and content. Formal, group-based presentations were the most common type of educational intervention in the included studies (75%). A third of studies (34%) used multiple strategies, with many formal group-based presentations being coupled with additional individual-based interventions (29%). Given the novelty of the COVID-19 vaccines and the unique current context, studies reported personalized conversations, question periods, and addressing misinformation as important components of the educational approaches reviewed.

Conclusions

Various educational interventions were delivered during the COVID-19 pandemic, with many initiatives involving multifaceted interventions utilizing both formal and informal approaches that leveraged community (cultural, religious) partnerships when developing and facilitating COVID-19 vaccine education. Train-the-trainer approaches with recognized community members could be of value as trust and personal connections were identified as strong enablers throughout the review.

Impact of a COVID-19 certificate requirement on vaccine uptake pattern and intention for future vaccination. A cross-sectional study among French adults

BACKGROUND

In August 2021, France enacted a COVID-19 certificate requirement (vaccination/recovery/test) to access specific services, with mandates for professional groups. We evaluated the impact of this incentive-coercive policy in terms of vaccine uptake equality, future vaccine intention and confidence in authorities' crisis management.

METHODS

In late August 2021, a representative sample of adults (18-75 years) completed an internet-based questionnaire. We classified vaccinated participants by stated reasons for vaccination and estimated adjusted prevalence ratios (aPR) using multivariable Poisson regression. Counterfactual vaccine status assumed non-vaccination of those vaccinated for the certificate. We analysed the association of free-text testimonial themes with level of confidence in authorities.

RESULTS

Among 972 participants, 85.7% were vaccinated or intended vaccination: 3.6% only for certificate/mandate, 17.7% mainly for certificate/mandate plus other reasons, and 64.4% mainly for other reasons. In the counterfactual situation, vaccine uptake would have been significantly more likely among older vs. younger participants (aPR = 1.35) and among those with moderate-high vs. low levels of confidence in authorities for COVID-19 crisis management (aPR = 2.04). In the observed situation, confidence was the only significant determinant of vaccine status (moderate-high vs. low, aPR = 1.39). Among those without genuine motivation for vaccination, professionally active persons were more likely to have ceded to the certificate requirement (aPR = 3.76). Those vaccinated only for the certificate were more likely to express future COVID-19 vaccine intention than unvaccinated persons (aPR = 6.41). Themes significantly associated with lower confidence were criticism of morality (aPR = 1.76) and poor communication by the authorities (aPR = 1.66).

CONCLUSION

The incentive-coercive policy has reduced the negative association of vaccine status with younger age and low confidence in authorities, but may have reinforced isolation of professionally inactive persons. The requirement did not negatively impact future COVID-19 vaccine intention. Future vaccine-incentive policies should pay special attention to populations with low levels of confidence in authorities.

Prioritizing non-communicable diseases in the post-pandemic era based on a comprehensive analysis of the GBD 2019 from 1990 to 2019

This study aimed to assess the burden of communicable diseases (CDs) and non-communicable diseases (NCDs) globally, regionally, and nationally from 1990 to 2019, and propose global strategies to transform the public health policy. Using data from the Global Burden of Disease Study (GBD) 2019, we analyzed CDs and NCDs across various factors such as sex, age, year, and location, and evaluate the temporal trends of these diseases with joinpoint analysis. We also examined the differences between regions based on their socio-demographic index (SDI). In 2019, there were 7,862,907 (95% uncertainty interval [UI], 7,183,475 to 8,654,104) deaths from CDs and 42,034,124 (40,081,323 to 43,942,475) deaths from NCDs recorded worldwide. The low SDI region had markedly high age-standardized death and DALY rates of CDs. Although the age-standardized incidence rate of CDs has decreased in about half of the regions since 1990, NCDs have been on the rise in most regions. Over the past 30 years, the global burden of CDs has decreased significantly, while the burden of NCDs has aggrandized to an extent. In the post-pandemic era, effective interventions and cooperation among countries should be promoted to allocate medical resources more reasonably and improve healthcare for NCD patients.

Social inequalities and the early provision and dispersal of COVID-19 vaccinations in the United States: A population trends study

BACKGROUND

In December 2020 the U.S. began a massive COVID-19 vaccination campaign, an action that researchers felt could catalyze inequalities in COVID-19 vaccination utilization. While vaccines have the potential to be accessible regardless of social status, the objective of this study was to examine how and when socioeconomic status (SES) and racial/ethnic inequalities would emerge in vaccination distribution.

METHODS

Population vaccination rates reported at the county level by the Centers for Disease Control and Prevention across 46 states on 3/30/2021. Correlates included SES, the share of the population who were Black, Hispanic, Female, or aged ≥65 years, and urbanicity (thousands of residents per square mile). Multivariable-adjusted analyses relied on zero-inflated negative binomial regression to estimate the odds of providing any vaccine, and vaccination rate ratios (aVRR) comparing the distribution rate for vaccinations across the U.S.

RESULTS

Across the U.S., 16.3 % of adults and 37.9 % of adults aged 65 and older were vaccinated in lower SES counties, while 20.45 % of all adults and 48.15 % of adults aged 65 and older were vaccinated in higher SES counties. Inequalities emerged after 41 days, when < 2 % of Americans were vaccinated. Multivariable-adjusted analyses revealed that higher SES was associated with improved vaccination distribution (aVRR = 1.127, [1.100-1.155], p < 1E-06), while increases in the percent reporting Black or Hispanic race/ethnicity was associated with lower vaccination distribution (aVRR = 0.998, [0.996-0.999], p = 1.03E-04).

CONCLUSIONS

Social inequalities in COVID-19 vaccines reflect an inefficient and inequitable distribution of these technologies. Future efforts to improve health should recognize the central role of social factors in impacting vaccine delivery.

Integrated analysis of online signals and insight generation about digital conversations on COVID-19 vaccines in Eastern and Southern Africa: a longitudinal analysis of social listening data

BACKGROUND

During the COVID-19 pandemic, social listening programs across digital channels have become an integral part of health preparedness and response planning, allowing to capture and address questions, information needs, and misinformation shared by users. This study identifies key social listening trends around COVID-19 vaccines in Eastern and Southern Africa and analyses how online conversations about this issue evolved over time.

METHODS

A taxonomy developed and refined in collaboration with social and behaviour change teams was used to filter online conversations into nine subtopic categories. The taxonomy was applied to online content tracked in 21 countries in Eastern and Southern Africa over the period December 1, 2020-December 31, 2021. Metrics captured included volume of posts or articles and related user engagement. Qualitative analysis of content was conducted to identify key concerns, information voids and misinformation.

RESULTS

Over 300,000 articles and posts about COVID-19 vaccines shared by users or outlets geolocated in the region were analysed. These results generated over 14 million engagements on social media and digital platforms. The analysis shows how conversations about access and availability of vaccines represented the largest share of engagement over the course of the period. Conversations about vaccine effectiveness and safety represented the second and third largest share of engagement, with peaks observed in August and November 2021. Online interest in childhood vaccination increased over time as vaccine eligibility criteria expanded in some countries in the region. Conversations mentioning mandates and certificates peaked in the last quarter of 2021, as governments as private sector entities expanded vaccine requirements.

CONCLUSIONS

Findings from this study show the importance of monitoring conversation trends over time and adjust social listening data collection systems to include emerging topics. The study also points to the need to consider concerns, information voids and misinformation around effectiveness and safety of vaccines in the context of overall concern for vaccine availability and access in Eastern and Southern Africa. This is fundamental to inform social and behaviour change strategies that promote vaccine demand effectively, without increasing public frustration over vaccine availability challenges and downplaying concerns around vaccine equity.

COVID-19 Vaccine Hesitancy: A Content Analysis of Nigerian YouTube Videos

Vaccination is key to developing herd immunity against COVID-19; however, the attitude of Nigerians towards being vaccinated stalled at the 70% vaccination target. This study engages Theory of Planned Behaviour to analyse the tone of Nigerian YouTube headlines/titles, and the tone of YouTube users' comments to examine the causes of COVID-19 vaccine hesitancy. YouTube videos uploaded between March 2021 and December 2022 were analysed using a content analytic approach. Results show 53.5% of the videos had a positive tone, while 40.5% were negative, and 6% neutral. Second, findings indicate most of the Nigerian YouTube users' comments were neutral (62.6%), while 32.4%, were negative, and 5% were positive. From the antivaccine themes, analysis shows the people's lack of trust in the government on vaccines (15.7%) and the presence of vaccine conspiracy theories mostly related to expressions of religion and biotechnology (46.08%) were the main causes of COVID-19 vaccine hesitancy in Nigeria. The study presents implications for theory and recommends ways for governments to develop better vaccination communication strategies.

Spatiotemporal characteristics of the SARS-CoV-2 Delta wave in North Carolina

We constructed county-level models to examine properties of the SARS-CoV-2 B.1.617.2 (Delta) variant wave of infections in North Carolina and assessed immunity levels (via prior infection, via vaccination, and overall) prior to the Delta wave. To understand how prior immunity shaped Delta wave outcomes, we assessed relationships among these characteristics. Peak weekly infection rate and total percent of the population infected during the Delta wave were negatively correlated with the proportion of people with vaccine-derived immunity prior to the Delta Wave, signaling that places with higher vaccine uptake had better outcomes. We observed a positive correlation between immunity via infection prior to Delta and percent of the population infected during the Delta wave, meaning that counties with poor pre-Delta outcomes also had poor Delta wave outcomes. Our findings illustrate geographic variation in outcomes during the Delta wave in North Carolina, highlighting regional differences in population characteristics and infection dynamics.

Qualitative and semi-quantitative ultrasound assessment in delta and Omicron Covid-19 patients: data from high volume reference center

OBJECTIVE

to evaluate the efficacy of US, both qualitatively and semi-quantitatively, in the selection of treatment for the Covid-19 patient, using patient triage as the gold standard.

METHODS

Patients admitted to the Covid-19 clinic to be treated with monoclonal antibodies (mAb) or retroviral treatment and undergoing lung ultrasound (US) were selected from the radiological data set between December 2021 and May 2022 according to the following inclusion criteria: patients with proven Omicron variant and Delta Covid-19 infection; patients with known Covid-19 vaccination with at least two doses. Lung US (LUS) was performed by experienced radiologists. The presence, location, and distribution of abnormalities, such as B-lines, thickening or ruptures of the pleural line, consolidations, and air bronchograms, were evaluated. The anomalous findings in each scan were classified according to the LUS scoring system. Nonparametric statistical tests were performed.

RESULTS

The LUS score median value in the patients with Omicron variant was 1.5 (1-20) while the LUS score median value in the patients with Delta variant was 7 (3-24). A difference statistically significant was observed for LUS score values among the patients with Delta variant between the two US examinations (p value = 0.045 at Kruskal Wallis test). There was a difference in median LUS score values between hospitalized and non-hospitalized patients for both the Omicron and Delta groups (p value = 0.02 on the Kruskal Wallis test). For Delta patients groups the sensitivity, specificity, positive and negative predictive values, considering a value of 14 for LUS score for the hospitalization, were of 85.29%, 44.44%, 85.29% and 76.74% respectively.

CONCLUSIONS

LUS is an interesting diagnostic tool in the context of Covid-19, it could allow to identify the typical pattern of diffuse interstitial pulmonary syndrome and could guide the correct management of patients.

From COVID-19 Vaccine Hesitancy to Vaccine Acceptance: Results of a Longitudinal Survey

OBJECTIVES

COVID-19 vaccines are widely available, but uptake is suboptimal. To develop strategies to increase vaccination rates, we sought to (1) characterize adults initially hesitant to be vaccinated for COVID-19 who later received the vaccine and (2) identify factors associated with their vaccination decision.

METHODS

In January 2021, we conducted an online survey of US adults via Prolific that assessed vaccination intent, COVID-19-related knowledge and attitudes, and demographic characteristics. In May 2021, we recontacted respondents to assess vaccination status and factors influencing their vaccination decision. We used χ² statistics and t tests to examine associations between respondents' vaccination status and their characteristics, knowledge, and attitudes. We analyzed reasons for vaccination using thematic analysis.

RESULTS

Of 756 initially vaccine-hesitant respondents, 529 (70.0%) completed the follow-up survey. Nearly half of those initially not sure about vaccination (47.3%, 112 of 237) were vaccinated at follow-up, while 21.2% (62 of 292) of those initially planning not to be vaccinated were vaccinated at follow-up. Of those initially not sure, higher educational attainment, greater knowledge of COVID-19, and a doctor's recommendation were associated with vaccination. Of those initially intending not to be vaccinated, male sex, Democratic political affiliation, receipt of an influenza shot within 5 years, being more worried about COVID-19, and having greater COVID-19 knowledge were associated with increased likelihood of being vaccinated. Of 167 respondents who gave reasons for vaccination, protecting oneself and others (59.9%), practical issues (29.9%), social influences (17.4%), and vaccine safety (13.8%) were the main reasons.

CONCLUSION

Providing information on the protective value of vaccination, implementing rules that make remaining unvaccinated burdensome, making vaccination easy, and providing social support may influence vaccine-hesitant adults to accept vaccination.

Future COVID-19 Booster Vaccine Refusal in Healthcare Workers after a Massive Breakthrough Infection Wave, a Nationwide Survey-Based Study

Background: An unprecedented coronavirus disease 2019 (COVID-19) wave occurred in China between December 2022 and January 2023, challenging the efficacy of the primary series of COVID-19 vaccines. The attitudes toward future COVID-19 booster vaccines (CBV) after the massive breakthrough infection among healthcare workers remain unknown. This study aimed to explore the prevalence and determinants of future CBV refusal after the unprecedented COVID-19 wave among healthcare workers. Methods: Between 9 and 19 February 2023, a cross-sectional nationwide online survey was conducted using a self-administered questionnaire vaccine among healthcare workers in China. Sociodemographics, profession, presence of chronic medical conditions, previous COVID-19 infection, attitudes towards future CBV, and reasons for future CBV refusal were collected. We estimated odds ratio [OR] with 95% confidence interval [CI] using a multivariable logistic regression model to explore the factors associated with future CBV refusal. Results: Among the 1618 participants who completed the survey, 1511 respondents with two or more doses of COVID-19 vaccines were analyzed. A total of 648 (41.8%) of respondents were unwilling to receive a future CBV. Multivariable logistic regression analysis revealed the association of CBV refusal with profession (vs. other staff, physician-adjusted OR 1.17, 95%CI 0.79-1.72, nurse-adjusted OR 1.88, 95%CI 1.24-2.85, p = 0.008), history of allergy (adjusted OR 1.72, 95%CI 1.05-2.83, p = 0.032), a lower self-perceived risk of future COVID-19 infection (p < 0.001), and a lower belief in CBV effectiveness (p = 0.014), safety (p < 0.001), and necessities for healthcare workers and the public (p < 0.001, respectively). Conclusions: Our findings highlight that a considerable proportion of healthcare workers were against a future booster dose after an unprecedented COVID-19 wave. Self-perception of future COVID-19 risk, and potential harm or doubtful efficacy of vaccines are the main determinants. Our findings may help public health authorities to establish future COVID-19 vaccination programs.

Current ethical and social issues in epidemiology

PURPOSE

The American College of Epidemiology held its 2021 Annual Meeting virtually, September 8-10, with a conference theme of 'From Womb to Tomb: Insights from Health Emergencies'. The American College of Epidemiology Ethics Committee hosted a symposium session in recognition of the ethical and social challenges brought to light by the coronavirus disease 2019 pandemic and on the occasion of the publication of the third edition of the classic text, Ethics and Epidemiology. The American College of Epidemiology Ethics Committee invited the book editor and contributing authors to present at the symposium session titled 'Current Ethical and Social Issues in Epidemiology.' The purpose of this paper is to further highlight the ethical challenges and presentations.

METHODS

Three speakers with expertise in ethics, health law, health policy, global health, health information technology, and translational research in epidemiology and public health were selected to present on the social and ethical issues in the current landscape. Dr. S Coughlin presented on the 'Ethical and Social Issues in Epidemiology', Dr. L Beskow presented on 'Ethical Challenges in Genetic Epidemiology', and Dr. K Goodman presented on the 'Ethics of Health Informatics'.

RESULTS

New digital sources of data and technologies are driving the ethical challenges and opportunities in epidemiology and public health as it relates to the three emerging topic areas identified: (1) digital epidemiology, (2) genetic epidemiology, and (3) health informatics. New complexities such as the reliance on social media to control infectious disease outbreaks and the introduction of computing advancements are requiring re-evaluation of traditional bioethical frameworks for epidemiology research and public health practice. We identified several cross-cutting ethical and social issues related to informed consent, benefits, risks and harms, and privacy and confidentiality and summarized these alongside more nuanced ethical considerations such as algorithmic bias, group harms related to data (mis)representation, risks of misinformation, return of genomic research results, maintaining data security, and data sharing. We offered an integrated synthesis of the stages of epidemiology research planning and conduct with the ethical issues that are most relevant in these emerging topic areas.

CONCLUSIONS

New realities exist for epidemiology and public health as professional groups who are faced with addressing population health, and especially given the recent pandemic and the widespread use of digital tools and technologies. Many ethical issues can be understood in the context of existing ethical frameworks; however, they have yet to be clearly identified or connected with the new technical and methodological applications of digital tools and technologies currently in use for epidemiology research and public health practice. To address current ethical challenges, we offered a synthesis of traditional ethical principles in public health science alongside more nuanced ethical considerations for emerging technologies and aligned these with lifecycle stages of epidemiology research. By critically reflecting on the impact of new digital sources of data and technologies on epidemiology research and public health practice, specifically in the control of infectious outbreaks, we offered insights on cultivating these new areas of professional growth while striving to improve population health.

Narratives from African American/Black, American Indian/Alaska Native, and Hispanic/Latinx community members in Arizona to enhance COVID-19 vaccine and vaccination uptake

The state of Arizona has experienced one of the highest novel coronavirus disease 2019 (COVID-19) positivity test rates in the United States with disproportionally higher case rates and deaths among African-American/Black (AA/B), American Indian/Alaska Native (Native), and Hispanic/Latinx (HLX) individuals. To reduce disparities and promote health equity, researchers from Arizona State University, Mayo Clinic in Arizona, Northern Arizona University, and the University of Arizona formed a partnership with community organizations to conduct state-wide community-engaged research and outreach. This report describes results from 34 virtually-held focus groups and supplemental survey responses conducted with 153 AA/B, HLX, and Native community members across Arizona to understand factors associated with COVID-19 vaccine hesitancy and confidence. Focus groups revealed common themes of vaccine hesitancy stemming from past experiences of research abuses (e.g., Tuskegee syphilis experiment) as well as group-specific factors. Across all focus groups, participants strongly recommended the use of brief, narrative vaccination testimonials from local officials, community members, and faith leaders to increase trust in science, vaccine confidence and to promote uptake.

Cultivating COVID-19 Vaccine Confidence in Pharmacy Professionals

Pharmacists promote vaccinations and challenge misconceptions about vaccine hesitancy, yet pharmacists' knowledge of vaccine confidence has not been assessed. The objective of this study was to compare pharmacists' knowledge of coronavirus disease 2019 (COVID-19) vaccine confidence before and after a live continuing education (CE) session. This pretest-posttest study evaluated the differences before and after a live CE session on COVID-19 vaccine confidence provided to pharmacists at a nationwide health technology company. Participants' total pretest and posttest scores were compared using paired t-tests, while pretest and posttest scores for each item were compared using chi-squared tests. A Bonferroni correction was applied, resulting in an alpha level of 0.005. A total of 279 pharmacists participated in this study. After the CE session, mean knowledge scores increased (5.2 ± 1.5 to 7.4 ± 1.35, p < 0.0001). After the CE session, there was no significant increase in pharmacists' knowledge about the approach that is not recommended when discussing vaccination beliefs with a patient (71.3% to 77.4%, p = 0.099), determinants of vaccine uptake (83.9% to 87.8%, p = 0.182), and social determinants of health that can influence vaccination rates (93.6% to 96.4%, p = 0.121). There was a significant change in pre- and posttest knowledge for the remaining seven items.

Real-world uptake of COVID-19 vaccination among individuals expressing vaccine hesitancy: A registry-linkage study

INTRODUCTION

Uptake of COVID-19 vaccination remains suboptimal in the United States and other settings. Though early reports indicated that a strong majority of people were interested in receiving the COVID-19 vaccine, the association between vaccine intention and uptake is not yet fully understood. Ourobjective was todescribe predictors of vaccine uptake, and estimate the sensitivity, specificity, and predictive values of self-reported COVID-19 vaccine status compared to a comprehensive statewide COVID-19 vaccine registry.

METHODS

A cohort of California residents that received a molecular test for SARS-CoV-2 infection during 24 February-5 December 2021 were enrolled in a telephone-administered survey. Survey participants were matched with records in a statewide immunization registry. Cox proportional hazards model were used to compare time to vaccination among those unvaccinated at survey enrollment by self-reported COVID-19 vaccination intention.

RESULTS

Among 864 participants who were unvaccinated at the time of interview, 272 (31%) had documentation of receipt of COVID-19 vaccination at a later date; including 194/423 (45.9%) who had initially reported being willing to receive vaccination, 41/185 (22.2%) who reported being unsure about vaccination, and 37/278 (13.3%) who reported unwillingness to receive vaccination.Adjusted hazard ratios (aHRs) for registry-confirmed COVID-19 vaccination were 0.49 (95% confidence interval: 0.32-0.76) and 0.21 (0.12-0.36) for participants expressing uncertainty and unwillingness to receive vaccination, respectively, as compared with participants who reported being willing to receive vaccination. Time to vaccination was shorter among participants from higher-income households (aHR = 3.30 [2.02-5.39]) and who reported co-morbidities or immunocompromising conditions (aHR = 1.54 [1.01-2.36]).Sensitivity of self-reported COVID-19 vaccination status was 82% (80-85%) overall, and 98% (97-99%) among those referencing vaccination records; specificity was 87% (86-89%).

CONCLUSION

Willingness to receive COVID-19 vaccination was an imperfect predictor of real-world vaccine uptake. Improved messaging about COVID-19 vaccination regardless of previous SARS-CoV-2 infection status may help improve uptake.

The impact of the Coronavirus disease 2019 on hospitalizations for coronary artery revascularization: results from California State Inpatient Database

BACKGROUND

Coronavirus disease 2019 (COVID-19) outbreak has negatively impacted routine cardiovascular care. In this study, we assessed the impact of COVID-19 pandemic on percutaneous coronary artery intervention (PCI) and coronary artery bypass grafting (CABG) hospitalizations and outcomes using a large database.

METHODS

The current study was a retrospective analysis of California State Inpatient Database (SID) during March-December of 2019 and 2020. All adult hospitalizations for coronary artery revascularization were included for the analysis. ICD-10-CM diagnosis and procedure codes were used for identifying hospitalizations and procedures. The primary outcome was inhospital mortality, and secondary outcomes were hospital length of stay, stroke, acute kidney injury, and mechanical ventilation. Propensity score match analysis was done to compare adverse clinical outcomes.

RESULTS

PCI hospitalizations (relative decrease, 15.0%, P for trend <0.001) and CABG hospitalizations (relative decrease, 16.4%, P for trend <0.001) decreased from 2019 to 2020, while viral pneumonia hospitalizations increased (relative increase, 1751.6%, P for trend <0.001). Monthly PCI and CABG hospitalization showed decreasing trends from January 2019 to December 2020. Propensity score match analysis showed that the odds of inhospital mortality (OR, 1.12; 95% CI, 1.01-1.24), acute kidney injury (OR, 1.12; 95% CI, 1.06-1.17), and ARDS (OR, 1.89; 95% CI, 1.18-3.01) were higher among patients who received PCI in 2020.

CONCLUSION

Results of our study indicate that initiatives such as encouraging patients to receive treatments and controlling the spread of COVID-19 should be instituted to improve PCI and CABG hospitalizations.

How urban versus rural residency relates to COVID-19 vaccine hesitancy: A large-scale national Chinese study

RATIONALE

Although urban-rural residency has been shown to influence individual COVID-19 vaccine hesitancy, the differences between urban and rural China have yet to be uncovered.

OBJECTIVE

This study aims to assess the current prevalence and factors associated with COVID-19 vaccine hesitancy in urban and rural areas and explore whether the rural versus urban residency is associated with COVID-19 vaccine hesitancy.

METHODS

A national, cross-sectional, online survey among Chinese urban and rural adults (≥18 years old) was conducted from 6th to August 9, 2021. A questionnaire was used to collect data on sociodemographic factors, perceptions of the COVID-19 pandemic and vaccination status. A multivariable logistic regression model was used to identify the factors that influence COVID-19 vaccine hesitancy. Propensity score matching (PSM) analysis was performed to explore the association between urban versus rural residency and COVID-19 vaccine hesitancy.

RESULTS

In total, 29,925 participants (80.56% urban participants) were recruited. Urban participants had a higher COVID-19 vaccine hesitancy than their rural counterparts (9.39% vs. 4.26%). After adjusting for potential confounders, we found that COVID-19 vaccine hesitancy among females was lower than that in males in both urban (aOR = 0.78, 95% CI [0.69-0.88]) and rural areas (aOR = 0.54, 95% CI [0.39-0.75]). The lack of trust towards vaccine producers was found to be associated with vaccine hesitancy among the urban participants (aOR = 2.76, 95% CI [2.22-3.43]). The rural floating population had a lower COVID-19 vaccine hesitancy than the rural permanent residents (aOR = 0.58, 95% CI [0.42-0.80]). PSM analysis revealed a 2.38% difference in COVID-19 vaccine hesitancy between urban and rural participants.

CONCLUSIONS

Urban participants were more hesitant to receive the COVID-19 vaccine than rural participants. Priority should be placed on boosting confidence in the healthcare system to reduce COVID-19 vaccine hesitancy among urban residents. Furthermore, we advocate for extra incentives and vaccination education for rural permanent residents.