key: cord-0907942-ox0zn0yx
authors: Malesza, M.; Wittmann, E.
title: Acceptance and intake of COVID-19 vaccines among older Germans
date: 2021-03-12
journal: nan
DOI: 10.1101/2021.03.10.21253346
sha: 5a8841619b3dae66612d7689190a5c7e26850f84
doc_id: 907942
cord_uid: ox0zn0yx

The main aim of this study was to investigate the various factors influencing COVID-19 vaccination acceptance and actual intake among older Germans aged over 75 years old (N = 1037). We found that the intention to get vaccinated or intake of the COVID-19 vaccine were positively related to the perceptions of becoming infected, perceptions of the severity of the potential long-term effects, the vaccine's efficacy, and the benefits of vaccination. Meanwhile, the intention to get the vaccine or vaccine intake were decreased by perceptions of the negative side-effects and the general impediments to vaccination.

In December 2019, a new coronavirus disease (COVID-19) emerged in Wuhan (China) and then rapidly spread worldwide. The incident was classified as a Public Health workers that are on call for emergencies or are ready to carry out extra consultations to deal with the pandemic, as well as those who show positive attitudes towards protection methods, are more likely to accept a COVID-19 vaccination [11] .

Besides, more remarkable, there is a significant gap between intention and actual behavior to get vaccinated. A recent investigation showed that the willingness for influenza vaccination was 45% in general population [12] , while the actual vaccination coverage was 9.4%, which was reported by a meta-analysis [13] . These indicate that there are barriers existed from intention to behavior besides the cognitive factors, which affected the vaccination willingness, such as not receiving recommendation from doctor and not having cost-free vaccination [13] . Previous studies have examined factors associated with intention of 9, 10] . However, less is known about COVID-19 vaccination intention, actual uptake and the related factors among older adults.

Vaccine acceptance among general population was also associated with factors such as the perceived risk of COVID-19 infection and concern regarding side effects [14] [15] [16] . Studies on the uptake of seasonal influenza vaccination have shown that the perceived risk of catching influenza and belief in the efficacy of the vaccine are the main drivers towards vaccine acceptance whilst fear of adverse effects is the main deterrent [15] [16] [17] . Moreover, literature related to SARS and A/H1N1 indicated that people are more likely to comply with the recommendations if they believe that the consequences of the illness are serious, that the information provided by the government on the outbreak is accurate; that the government can be trusted to manage the outbreak; and that the outbreak is likely to last for a long time [18] [19] [20] . People with a family and/or children and those suffering from a severe chronic illness are also likely to accept the COVID-19 vaccination [7-9]. The effectiveness of a vaccination program is dependent on wide vaccine uptake, even for vaccines with high efficacy. Thus, it . CC-BY-NC 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253346 doi: medRxiv preprint is important to understand the various factors that affect a person's willingness to get vaccinated in order to establish effective public health strategies during a pandemic [14, 16] .

This study investigated the associations between various beliefs and perceptions and the intention to accept and to intake a vaccination against COVID-19. It will be useful to understand older Germans' views on COVID-19 vaccination for an outbreak response and management, as well as for the period after the pandemic. Therefore, this study investigated the various factors influencing COVID-19 vaccination acceptance and actual intake among older Germans aged over 75 years old.

Data collection was conducted in Germany from 4 th to 17 th January 2021. At the time, the country was experiencing high death and infection rates due to the COVID-19 pandemic, although a vaccine had recently been made available. The questionnaire was first submitted to two professional psychologists to assess the face validity, and then a pilot survey was performed on 15 psychology students. These same students were also instructed in the data collection method, and they subsequently gathered the study's final data in their respective hometowns. The sample population comprised conveniently approached individuals with a minimum age of 75 residing in different households. Students, who conducted the present study, followed appropriate health guidelines such as social distancing during data collection to protect the health and safety of respondents. Study was approved by the appropriate ethics review committee of the University of xxx, prior to initiation. Prospective participants were assured of confidentiality and asked to complete the form anonymously. Additionally, the questionnaire form did not include any questions about such issues that may be perceived as personal or sensitive ones. The ratio of the number of individuals asked to participate to the number of completed responses received was considered the response rate. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint that most were middle-class, had completed secondary or higher education, were either single/divorced/or widowed. This underlines that the sample population is not representative of the German population but rather represents the educated urban middle class.

The research form included questions regarding the following demographic factors: gender, age, education, socioeconomic status, marital status, and having children. In addition, the respondents' were questioned about their health conditions with the following two questions: ''How good is your health generally?'' with the choices of ''Very good'', ''Good'', ''Bad'' and ''Very bad'', and ''Do you have any of the following chronic illnesses?'' with the choices of ''cancer'', ''heart disease'', ''lung disease'', ''liver or kidney disease'' and ''any other illness'' (Table 1) .

[ Table 1 about here]

Participants' perceptions of COVID-19 were evaluated through items on susceptibility, long-term effects, the pandemic's impact on daily life, and their predictions on the pandemic situation in the country in three months' time. We also used two items to assess to what extent they had faith in the health authorities (Table 2 ). Next, the questionnaire is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint [ Table 2 about here]

Intake of the vaccine was measured with a question ''Have you already been vaccinated against COVID-19?''. If the answer was ''no'', data collectors asked a question "If it were offered now, would you take the COVID-19 vaccine?" was used to assess the participants' attitudes towards COVID-19 vaccination.

Moreover, the study used a survey questionnaire to assess the sample population's perception of COVID-19 vaccination in terms of the barriers (4 items) and benefits (4 items) on a 5-point Likert scale (from ''1 -strongly disagree'' to ''5 -strongly agree'') (adapted from previous research [12 -16] ). The questionnaire items on participants' perceptions of vaccines were partially derived from the Health Belief Model (HBM). This model is used to describe individuals' health-related behavior according to their perception of predisposition, efficacy, and outcomes. Questions investigated the participants' perceptions of the vaccine's efficacy and the likelihood of developing negative side-effects after vaccination as well as the severity of these effects (all items are presented in Table 2 ). The scores of the eight items were subjected to principal factor analysis, presenting a two-factor orthogonal rotation (r = -0.30, p < 0.01). All items showed factor loadings above 0.57 and no cross-loadings were found. The benefits and barriers had Cronbach's alphas of 0.78 and 0.80, respectively.

The categorical variables were subjected to chi-square analysis (Table 1) , while oneway ANOVA was performed for the continuous variables (Table 2 ). Based on the results of the chi-square and ANOVA analyses, variables were selected for multinomial logistic regression, which was chosen as three response categories were included in the dependent . CC-BY-NC 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253346 doi: medRxiv preprint variable, i.e. "intention to get vaccinated" (''yes'', ''no'', ''already vaccinated''). Those participants who reported having already received the COVID-19 vaccine were no longer susceptible to the disease, thereby distinguishing them from the other two groups; they were nonetheless not excluded from the analysis. The aim hereby was to achieve a full response set that ranged from "no intention" to "full intention".

The model fitting statistics presented that the final model outperformed the null model (ꭓ2= 507.65, p < 0.01) and clarified a critical sum of variety in deliberate of taking the immunization (Nagelkerke pseudo-R 2 value was 0.61). The full model with all three variable types was used to produce the following results, as presented in Table 3 . We found that the intention to get vaccinated or intake of the COVID-10 vaccine were positively related to the perceptions of becoming infected, perceptions of the severity of the potential long-term effects, the vaccine's efficacy, and the benefits of vaccination. Meanwhile, the intention to get the vaccine or vaccine intake were decreased by perceptions of the negative side-effects and the general impediments to vaccination. The most crucial factor was the perception of the vaccine's efficacy, and respondents with this belief had over 4 times greater likelihood of intending to receive the vaccine. There was also a significant relationship between being vaccinated and the perception of the pandemic situation in the country in three months' time.

Next, it is interesting to note that while the media's overreporting of the side-effects was associated with the intention to get vaccinated, no such relationship was found for having been vaccinated. Additionally, having a chronic illness and general health conditions were both associated with having been vaccinated and the intention to get vaccinated. Meanwhile, marital status (being single, widowed or divorced) was not associated with having already been vaccinated; however it was significantly associated with the intention to get vaccine in the future. Belief in the vaccine's efficacy and benefits increased the likelihood of having is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253346 doi: medRxiv preprint already been vaccinated, while the perception of the side effects was negatively associated with having already been vaccinated.

[ Table 3 about here]

The main aim of this study was to investigate the various factors influencing COVID-19 vaccination acceptance and actual intake among older Germans aged over 75 years old.

Single people showed increased intention to get vaccinated, and having a chronic illness was associated with an increased likelihood of being vaccinated against COVID-19.

This stronger tendency to accept the vaccination amongst single people could be related to concerns about not having someone to care for them if they fall ill. Another explanation could be that single people are less worried about the potential risks from vaccination because they have no dependents to be affected by these risks. The fact that chronically ill people already received the COVID-19 vaccine might be concordant with the fact that those with a chronic illness were more likely to follow rules, guidelines, and recommendations during the COVID-19 pandemic, or to take a seasonal influenza vaccination [9, 21] . The presence of a chronic illness seemed to be well correlated with vaccination status, although it did not directly affect the intention to get vaccinated. Health authority recommendations were better adhered to by people with a chronic illness than those without [3]. Females and parents of children have been previously reported to show good adherence to the recommended behaviors, whereas people of low socioeconomic or educational status were less likely to follow the recommendations [21] [22] [23] [24] [25] . However, in the present study, these factors were not found to be associated with vaccination intention. Vaccination uptake intention was found to be rather medium, irrespective of socioeconomic or demographic factors. Despite this low uptake, an is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253346 doi: medRxiv preprint encouraging aspect of this result is that the campaigns intended to increase vaccine uptake rates are likely to be equally effective among a wide range of people.

In previous research, susceptibility to infection has been reported to be one of the main predictors for vaccine uptake [15] [16] . Other reported predictors of vaccine uptake include the possible severe consequences of the disease, believing that the pandemic is likely to continue for a long time, and trust in the information supplied by the authorities [22] [23] [24] [25] . In the present study, there was also an association between susceptibility to illness and either COVID-19 vaccination intention or intake. An association was found between the possible severe consequences of the illness and the intention to get vaccinated, as well as with the status of having already been vaccinated. These results are consistent with the outcome of a previous study indicating that the correlations between perceived susceptibility, severity, and COVID-19 vaccine acceptance were statistically significant. People who felt that the epidemic seemed to worsen in Germany were generally have already been vaccinated, whilst intention to be vaccinated was not linked to the perceptions regarding the duration of the epidemic.

Furthermore, the perceived impact of the epidemic on everyday life, trust in the information on COVID-19 provided by the government, or trust in the government's management of the epidemic were not associated with the intention to be vaccinated or the vaccination intake. No strong link was found between the intention to be vaccinated or the vaccination intake and the perceptions of COVID-19. This could be because the data were collected some time after the epidemic started, so people might be taking COVID-19 less seriously and treating it like ordinary seasonal respiratory illness.

From the start of 2021, the media moved its focus from COVID-19 to the vaccine. Accordingly, the intention to be vaccinated was more closely related to the vaccine-related is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253346 doi: medRxiv preprint factors than to the illness. In line with previous studies on vaccination for seasonal influenza, this study also found that trust in the vaccine's effectiveness was associated with both the intention to be vaccinated and the vaccination intake [26] [27] . Effectiveness of the vaccine in the face of mutated versions was a significant worry regarding the vaccine. The likelihood, but not the expected severity, of side effects was significantly associated with both the vaccination intake and the intention to be vaccinated. The respondents mainly based their risk estimations on the likelihood rather than the severity of the side effects. Concerns over side effects has been shown in previous studies to be closely related to vaccination acceptance [15] [16] . People's perception of the information on the COVID-19 vaccine provided by the media might be related to vaccination intention; thus, people who believe that the adverse effects are exaggerated by the media might be more likely to be willing to receive the vaccine. Perhaps counterintuitively, this may be due to people's attitude to the vaccine rather than their actual perceptions of the media reportspeople who already view vaccination positively believe that negative side effects are exaggerated in media reports.

Barriers to vaccination identified in this study include the worries and negative attitudes towards the vaccine, while the benefits factor comprised the positive attitudes [15] [16] [28] [29] [30] . The barriers to vaccination were linked with the vaccination intention but not with the actual vaccination intake. It is likely that the respondents who had already been vaccinated had overcome the barriers in their minds, whilst those who expressed their intention to get vaccinated still had some doubts. This could also be explained by dissonance reduction, whereby people who have already received the vaccination feel the need to justify to themselves why they received it. Both the vaccination intention and the vaccination intake were significantly associated with the perception of the benefits of the vaccine. Studies related to vaccination against seasonal influenza have shown that both benefits and barriers are related to vaccination intention and likelihood [15] [16] . The present study suggests that for . CC-BY-NC 4.0 International license It is made available under a perpetuity.

is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253346 doi: medRxiv preprint vaccine uptake, it is more important to increase the public's sense of benefiting from the vaccine than to focus on removing barriers.

Our work suffers from limitations. First, our sample is not completely representative of the German elderly. Since the sample was not chosen at random, the inherent bias in convenience sampling means that the sample was unlikely to be representative of the population being studied. This undermines our ability to make generalisations from our sample to the population we were studying. Moreover, participants from our study might stay home most of time during the pandemic with limited social interactions. This means that these results cannot necessarily be extrapolated to the general elderly population. Next, in the same vein, we did not collect demographical characteristics as region of residence. Vaccine is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253346 doi: medRxiv preprint wave of COVID-19 pandemic in Germany was growing over the study period [2] . Future longitudinal research is needed to determine the direction of causality for these associations. It would also be desirable to compare the public's responses in other countries that were similarly affected.

The final regression model revealed that there was no link between the demographic (apart from marital status and having a chronic illness) or situational factors and the respondent's intention to be vaccinated against COVID-19. It is clear from the results reported in this study that vaccine-related factors are more important than epidemic-related factors in determining vaccination intention and intake. Thus, to improve the vaccination uptake rates during the COVID-19 pandemic, health authorities should focus on the vaccinerelated factors rather than the aspects related to the illness. This could be particularly important in encouraging vaccine uptake in the later stages of the outbreak since people are likely to be well-informed about the illness but have misconceptions and concerns about the vaccine. Eliminating these misunderstandings and concerns is likely to increase the vaccine uptake rates during the current COVID-19 pandemic. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint

The copyright holder for this this version posted March 12, 2021. ; https://doi.org/10.1101/2021.03.10.21253346 doi: medRxiv preprint

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