Facing a Health Threat in a Complex Information Environment: A National Representative Survey Examining American Adults' Behavioral Responses to the 2009/2010 A(H1N1) Pandemic

The impact of collective action dilemma on vaccine hesitancy: Evidence from China

Vaccine hesitancy has dramatically decreased the speed of vaccination and stalled global health development. While the factors influencing vaccine hesitancy and mitigation measures have been explored in depth by existing studies, research from the perspective of human interaction is lacking. Based on the theory of collective action, this paper analyzes how free riding behavior affects vaccine hesitancy and how the vaccine hesitancy caused by free riding behavior can be solved. Using 2,203 survey data sets from China, this paper examines the influence of the collective action dilemma - represented by free riding behavior - on COVID-19 vaccine hesitancy. The empirical results show that the existence of free riding behavior is an essential cause of vaccine hesitancy. Based on this conclusion, this paper discusses how to further alleviate the problem of vaccine hesitancy caused by collective action dilemmas by promoting cooperation. The findings of this paper may be helpful to promote various types of vaccines and further suggest that countries should assume the perspective of solving the collective action dilemma to achieve increased vaccination rates.

Effects of the COVID-19 Pandemic on the Decision and Doubts About Vaccination in Catalonia: Online Cross-sectional Questionnaire

BACKGROUND

Hesitancy to get vaccinated during the COVID-19 pandemic may decrease vaccination coverage and facilitate the occurrence of local or global outbreaks.

OBJECTIVE

The objective of this study was to analyze the impact of the COVID-19 pandemic in Catalonia on 3 aspects: the decision to get vaccinated against COVID-19, changes in opinion about vaccination in general, and the decision to get vaccinated against other diseases.

METHODS

We performed an observational study with the population of Catalonia aged 18 years or over, obtaining information through a self-completed questionnaire in electronic format. Differences between groups were determined using the chi-square test, Mann-Whitney U test, or the Student t test.

RESULTS

We analyzed the answers from 1188 respondents, of which 870 were women, 47.0% (558/1187) had sons or daughters under the age of 14 years, and 71.7% (852/1188) had studied at university. Regarding vaccination, 16.3% (193/1187) stated that they had refused a vaccine on some occasion, 76.3% (907/1188) totally agreed with vaccines, 1.9% (23/1188) were indifferent, and 3.5% (41/1188) and 1.2% (14/1188) slightly or totally disagreed with vaccination, respectively. As a result of the pandemic, 90.8% (1069/1177) stated that they would get vaccinated against COVID-19 when they are asked, while 9.2% (108/1177) stated the opposite. A greater intention to get vaccinated was observed among women; people older than 50 years; people without children under 15 years of age; people with beliefs, culture, or family in favor of vaccination; respondents who had not previously rejected other vaccines, were totally in favor of vaccines, or had not increased their doubts about vaccination; and respondents who had not changed their decision about vaccines as a result of the pandemic. Finally, 30.3% (359/1183) reported an increase in their doubts regarding vaccination, and 13.0% (154/1182) stated that they had changed their decision about routinely recommended vaccines as a result of the pandemic.

CONCLUSIONS

The population studied was predominantly in favor of vaccination; however, the percentage of people specifically rejecting vaccination against COVID-19 was high. As a result of the pandemic, we detected an increase in doubts about vaccines. Although the final decision about vaccination did not primarily change, some of the respondents did change their opinion about routine vaccinations. This seed of doubt about vaccines may be worrisome as we aim to maintain high vaccination coverage.

Understanding COVID-19 Risk Perceptions and Precautionary Behaviors in Black Chicagoans: A Grounded Theory Approach

OBJECTIVES

To determine whether actual community-level risk for COVID-19 in the Black community influenced individual perceptions of community-level and personal risk and how self-assessment of personal risk was reflected in the adoption of COVID-19 precautionary behaviors.

METHODS

Semistructured interviews were conducted with 20 Black Chicago adults from February to July 2021. A grounded theory approach was used for the qualitative analysis and initial, focused, and theoretical coding were performed.

RESULTS

We developed a grounded model consisting of four major themes: (a) Pre-Existing Health Conditions; (b) Presence of COVID-19 Infection in Participant Social Network; (c) COVID-19-Related Information, Participant Trust, and Perceived Personal Risk; and (d) Perceived Higher Burden of COVID-19 in the Black Community.

CONCLUSIONS

Higher perceptions of personal risk were shaped by pre-existing health conditions and experiences with COVID-19 in one's social network but were not influenced by perceived higher burden of COVID-19 in the Black community.

POLICY IMPLICATIONS

Black adults' perceptions of their individual risk and precautionary behaviors were not congruent with public health data and recommendations. Therefore, COVID-19 messaging and mitigation should be informed by local community engagement and transparent communication.

Factors Associated with Health Inequalities in Infectious Disease Pandemics Predating COVID-19 in the United States: A Systematic Review

Objective

Previous pandemics may offer evidence on mediating factors that contributed to disparities in infection and poor outcomes, which could inform the effort to mitigate potential unequal outcomes during the current COVID-19 pandemic. This systematic review sought to examine those factors.

Methods

We searched MEDLINE, PsycINFO, and Cochrane to May 2020. We included studies examining health disparities in adult U.S. populations during infectious disease epidemics or pandemics. Two investigators screened abstracts and full text. We assessed study quality using the Newcastle/Ottawa Scale or the Critical Appraisal Skills Programme Checklist for Qualitative Studies.

Results

Sixteen articles were included, of which 14 focused on health disparities during the 2009 H1N1 influenza pandemic. Studies showed that disparities during the H1N1 pandemic were more related to differential exposure to the virus than to susceptibility or access to care. Overall, pandemic-related disparities emanate primarily from inequalities in social conditions that place racial and ethnic minorities and low socioeconomic status populations at greater risk of exposure and infection, rather than individual-level factors such as health behaviors and comorbidities.

Conclusions

Policy- and systems-level interventions should acknowledge and address these social determinants of heightened risk, and future research should evaluate the effects of such interventions to avoid further exacerbation of health inequities during the current and future pandemics.

Determinants of health behaviours intended to prevent spread of respiratory pathogens that have pandemic potential: A rapid review

Effective public health messages to encourage behaviours to reduce the spread of COVID-19 should be informed by existing research that identifies the factors that are associated with these preventive behaviours. This rapid review summarises the existing research on the determinants of behaviours that aim to prevent the spread of COVID-19. The review focuses on the body of research (excluding research conducted with health care workers) that was produced in the context of viruses other than SARS CoV-2 that cause severe respiratory illness and are transmitted in a similar way. A total of 58 published peer-reviewed studies included in the review were identified through searches of Medline, Embase, PsychInfo and CINAHL. Most were conducted in the context of the influenza A (H1N1) pandemic in 2009. Most studies examined the determinants of wearing a face covering, handwashing and social or physical distancing. The findings suggest that public health messages to encourage preventive behaviours should emphasise the potential seriousness of COVID-19 to elicit appropriate concern, strengthen perceptions of risk or threat from COVID-19, enhance self-efficacy about preventive behaviours, and improve knowledge about SARS-CoV-2, how it is transmitted, and how preventive behaviours can reduce the risk of transmission.

What factors promote vaccine hesitancy or acceptance during pandemics? A systematic review and thematic analysis

Examine the factors that promote vaccine hesitancy or acceptance during pandemics, major epidemics and global outbreaks. A systematic review and thematic analysis of 28 studies on the Influenza A/H1N1 pandemic and the global spread of Ebola Virus Disease. We found seven major factors that promote vaccine hesitancy or acceptance: demographic factors influencing vaccination (ethnicity, age, sex, pregnancy, education, and employment), accessibility and cost, personal responsibility and risk perceptions, precautionary measures taken based on the decision to vaccinate, trust in health authorities and vaccines, the safety and efficacy of a new vaccine, and lack of information or vaccine misinformation. An understanding of participant experiences and perspectives toward vaccines from previous pandemics will greatly inform the development of strategies to address the present situation with the COVID-19 pandemic. We discuss the impact vaccine hesitancy might have for the introduction and effectiveness of a potential COVID-19 vaccine. In particular, we believe that skepticism toward vaccines can still exist when there are no vaccines available, which is contrary to contemporary conceptualizations of vaccine hesitancy. We recommend conducting further research assessing the relationship between the accessibility and cost of vaccines, and vaccine hesitancy.

Macro level factors influencing strategic responses to emergent pandemics: A scoping review

BACKGROUND

Strategic planning is critical for successful pandemic management. This study aimed to identify and review the scope and analytic depth of situation analyses conducted to understand their utility, and capture the documented macro-level factors impacting pandemic management.

METHODS

To synthesise this disparate body of literature, we adopted a two-step search and review process. A systematic search of the literature was conducted to identify all studies since 2000, that have 1) employed a situation analysis; and 2) examined contextual factors influencing pandemic management. The included studies are analysed using a seven-domain systems approach from the discipline of strategic management.

RESULTS

Nineteen studies were included in the final review ranging from single country (6) to regional, multi-country studies (13). Fourteen studies had a single disease focus, with 5 studies evaluating responses to one or more of COVID-19, Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), Influenza A (H1N1), Ebola virus disease, and Zika virus disease pandemics. Six studies examined a single domain from political, economic, sociological, technological, ecological or wider industry (PESTELI), 5 studies examined two to four domains, and 8 studies examined five or more domains. Methods employed were predominantly literature reviews. The recommendations focus predominantly on addressing inhibitors in the sociological and technological domains with few recommendations articulated in the political domain. Overall, the legislative domain is least represented.

CONCLUSIONS

Ex-post analysis using the seven-domain strategic management framework provides further opportunities for a planned systematic response to pandemics which remains critical as the current COVID-19 pandemic evolves.

Disparities in H1N1 Vaccination Rates: a Systematic Review and Evidence Synthesis to Inform COVID-19 Vaccination Efforts

BACKGROUND

Data suggest that there were disparities in H1N1 vaccine uptake, and these may inform COVID-19 vaccination efforts. We conducted a systematic review to evaluate disparities in H1N1 vaccine uptake, factors contributing to disparities, and interventions to reduce them.

METHODS

We searched English-language articles in MEDLINE ALL, PsycINFO, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from database inception through May 8, 2020. Observational studies examining H1N1 vaccine uptake by race/ethnicity, socioeconomic status, rurality, and disability status in US settings were included. Two reviewers independently assessed study eligibility. Single-reviewer data abstraction was confirmed by a second reviewer. We conducted independent dual quality assessment, and collective strength of evidence assessment.

RESULTS

We included 21 studies. African American/Black, Latino, and low-socioeconomic status participants had disproportionately lower H1N1 vaccination rates (low- to moderate-strength evidence). However, Latinos were more likely than Whites to intend to be vaccinated, and African American/Blacks and participants with lower-socioeconomic status were just as likely to intend to be vaccinated as their White and higher-socioeconomic status counterparts (low-strength evidence). Vaccine uptake for other groups has been insufficiently studied. Factors potentially contributing to disparities in vaccine uptake included barriers to vaccine access, inadequate information, and concerns about vaccine safety and efficacy. Studies were largely cross-sectional. Many of the studies are a decade old and were conducted in the context of a different pandemic. The categorization of racial and ethnic groups was not consistent across studies and not all groups were well-studied.

DISCUSSION

Efforts to avoid disparities in COVID-19 vaccination uptake should prioritize vaccine accessibility and convenience in African American/Black, Latino, and low-SES communities; engage trusted stakeholders to share vaccine information; and address concerns about vaccine safety and efficacy.

PRIMARY FUNDING SOURCE

Department of Veterans Affairs, Veterans Health Administration, Health Services Research & Development.

PROTOCOL REGISTRATION

PROSPERO CRD42020187078.

Determinants of protective behaviours during a nationwide lockdown in the wake of the COVID-19 pandemic

OBJECTIVES

Without pharmaceutical measures available, endorsement of protective behaviours, such as hygiene behaviours, social distancing, and adherence to recommended behaviours in case of symptoms is of key importance to curb the ongoing COVID-19 pandemic. Based on an extended version of the protection motivation theory, this study examined the role of perceived risks to oneself and to others, self-efficacy, response efficacy, and perceived social norms for intentions to and the endorsement of several protective behaviours and alternative behaviours known to be ineffective. Further, it was hypothesised that effects of risk perceptions depended on high levels of self-efficacy.

DESIGN

Data were collected by telephone at the beginning of the lockdown in Switzerland with a large sample (N = 1,009) representative of the adult Swiss population.

METHODS

All predictors (self-efficacy, response efficacy, perceived social norms, intentions) but risk perceptions were assessed for hygiene behaviours, social distancing, adherence to recommended behaviours in case of symptoms, and alternative measures known to be ineffective.

RESULTS

Across all analyses of intentions for and endorsement of protective and alternative behaviours, response efficacy and self-efficacy emerged as the most important predictors. Social norms were mainly related to intentions, but not to behaviours. The different risk perceptions were rarely and inconsistently related to intentions and behaviours. No consistent pattern of interactions between self-efficacy and risk perceptions emerged.

CONCLUSION

This study demonstrates that even in the face of a pandemic of an unknown virus, the resources (self-efficacy, response efficacy) rather than the risk perceptions have the potential to promote protective behaviours.

The Importance of Understanding COVID-19: The Role of Knowledge in Promoting Adherence to Protective Behaviors

Background: Past research suggests that knowledge supports- but strong illness expectations thwart- adoption of protective behaviors (e.g., handwashing). Strong illness expectations may place COVID-19 essential workers at risk. It is unclear, however, whether knowledge can moderate the negative effects of pessimistic illness expectations on protective behaviors. We test COVID-19 knowledge as a moderator of the effects of (1) pessimistic illness expectations and (2) essential worker status on adherence to protective behaviors. Methods: Participants (n = 350) completed measures of knowledge, illness expectations, and protective behaviors. We used chi-square tests to examine associations between variables and logistic regressions to test the moderation models predicting adherence (low, high) while controlling for demographics. Results: Knowledge, illness expectations, and adherence were significantly associated with each other (p < 0.05). Essential workers had stronger illness expectations and lower knowledge than did non-essential workers (p < 0.001). Logistic regressions showed a non-significant Worker Status × Knowledge interaction (p = 0.59) but a significant Knowledge × Illness Expectations interaction (p < 0.05) indicating that those with strong illness expectations and low knowledge were disproportionately at risk of failing to adhere to recommended behaviors. Conclusions: Knowledge promotes protective behaviors by buffering the negative effects of pessimistic illness expectations. Essential workers are more likely to have low levels of knowledge with strong illness expectations, suggesting that educational policies may be warranted.

Knowledge, socio-cognitive perceptions and the practice of hand hygiene and social distancing during the COVID-19 pandemic: a cross-sectional study of UK university students

BACKGROUND

During the first wave of the COVID-19 pandemic, social distancing and hand hygiene have been the primary means of reducing transmission in the absence of effective treatments or vaccines, but understanding of their determinants is limited. This study aimed to investigate knowledge and socio-cognitive perceptions, and their associations with such protective behaviours, in UK university students.

METHODS

A cross-sectional online survey of 293 students was undertaken on 13 May 2020. Survey questions addressed demographics, knowledge of the disease and effectiveness of the protective measures, risk perception, socio-cognitive perceptions (e.g. attitude, social support, and self-efficacy), habit, time factors and trust, as well as the hand hygiene and social distancing behaviours. Multiple linear regression was used to identify the strongest associations of potential determinants with behaviour.

RESULTS

Participants reported high levels of social distancing with 88.9% answering "Mostly" or "Always" for every activity, but only 42.0% reporting the same for all hand hygiene activities. Knowledge of the effectiveness of each activity in preventing transmission was high, with 90.7% and 93.5% respectively identifying at least 7 of 8 hand hygiene or 9 of 10 social distancing activities correctly. Habit (β = 0.39, p = 0.001) and time factors (β = 0.28, p = 0.001) were the greatest contributors to unique variance in hand hygiene behaviour, followed by ethnicity (β = - 0.13, p = 0.014) and risk perception (β = 0.13, p = 0.016). For social distancing behaviour, the determinants were self-efficacy (β = 0.25, p < 0.001), perceived advantages (β = 0.15, p = 0.022), trust in policy (β = 0.14, p = 0.026) and gender (β = - 0.14, p = 0.016). Regression models explained 40% hand hygiene and 25% social distancing variance.

CONCLUSIONS

This study indicated that communications about effectiveness of hand hygiene and social distancing behaviours had been effective in terms of knowledge acquisition. However, in the light of likely second waves of COVID-19, attention to maintaining social distancing behaviour and improving hand hygiene behaviour may need to address more difficult areas of changing habits, overcoming time factors and building trust, as well as interventions to increase self-efficacy and address risk perception concerns.

Prevention for oneself or others? Psychological and social factors that explain social distancing during the COVID-19 pandemic

Identifying the underlying psychological and social factors of social distancing is crucial to foster preventive behavior during a pandemic effectively. We investigated the relative contribution of self-focused factors (fear of infection, fear of punishment) and other-focused factors (moral judgment, moral identity, empathy for unspecific others, empathy for loved ones) in an online study in Germany (N = 246) while COVID-19 was climaxing. Importantly, other-oriented factors were related to social distancing behavior beyond self-oriented factors. Moral judgment and empathy for loved ones remained the dominant factors while controlling for all aspects. These findings underline the relevance of interpersonal considerations when engaging in preventive behavior.

Emotional Responses and Self-Protective Behavior Within Days of the COVID-19 Outbreak: The Promoting Role of Information Credibility

Due to changes in the information environment since the last global epidemic, high WHO officials have spoken about the need to fight not only the current COVID-19 pandemic but also the related infodemic. We thus explored how people search for information, how they perceive its credibility, and how all this relates to their engagement in self-protective behaviors in the crucial period right after the onset of COVID-19 epidemic. The online questionnaire was circulated within 48 h after the first case of COVID-19 was confirmed in Slovenia. We gathered information on participants' demographics, perception of the situation, their emotional and behavioral responses to the situation (i.e., self-protective behavior), perceived subjective knowledge, perceived credibility of different sources of information, and their level of trust. We looked into the relationships between perceived credibility and trust, and self-protective behavior of 1,718 participants and found that mass media, social media, and officials received relatively low levels of trust. Conversely, medical professionals and scientists were deemed the most credible. The perceived credibility of received information was linked not only with lower levels of negative emotional responses but also with higher adherence to much needed self-protective measures, which aim to contain the spread of the disease. While results might vary between societies with different levels of trust in relevant governmental and professional institutions, and while variances in self-protective behavior scores explained by our model are modest, even a small increase in self-protective behavior could go a long way in viral epidemics like the one we are facing today.

Much ado about flu: A mixed methods study of parental perceptions, trust and information seeking in a pandemic

BACKGROUND

Effective public health messaging is essential in both the planning phase and duration of a pandemic.

OBJECTIVES

This study aimed to gain an understanding of parental information seeking, trusted sources and needs in relation to pandemic influenza A 2009 (pH1N1) to inform future policy planning and resource development.

PATIENTS/METHODS

We conducted a mixed methods study; parents from 16 childcare centres in Sydney, Australia, were surveyed between 16 November and 9 December 2009, and interviews were conducted with participants from six childcare centres between June 2009 and May 2011.

RESULTS

From 972 surveys distributed, 431 were completed; a response rate of 44%. Most parents (90%) reported that doctors were "trusted a lot" as a source of influenza information, followed by nurses (59%), government (56%) and childcare centres (52%). Less trusted sources included media (7% selected "trusted a lot"), antivaccination groups (6%) and celebrities (1%). Parents identified a range of key search terms for influenza infection and vaccine. From 42 in-depth interviews, key themes were as follows: "Action trigger," "In an emergency, think Emergency," "Fright to hype" and "Dr Google and beyond." Parents relied heavily on media messages, but cynicism emerged when the pandemic was milder than expected. Parents viewed a range of information sources as trustworthy, including doctors, authoritative hospital or government websites, and childcare centres and schools.

CONCLUSIONS

A user-centred orientation is vital for pandemic communications including tailored information provision, via trusted sources based on what parents want to know and how they can find it.