ABSTRACT
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.
Introduction
The World Health Organization has declared that “COVID-19 no longer constitutes a Public Health Emergency of International Concern,” but this does not mean that the COVID-19 pandemic is over.Citation1 Low quantities of COVID-19 continue to circulate globally, endangering the health of certain populations. Vaccination is the most cost-effective way to prevent and control the coronavirus pandemic and is one of the most effective public health interventionsCitation2,Citation3 COVID-19 booster vaccines have been shown to reduce infection rates, hospitalizations, and deaths.Citation4,Citation5 Therefore, in order to maintain the protective effect of vaccines, booster vaccination should be continued.
Numerous studies have demonstrated the safety and efficacy of COVID-19 booster vaccines.Citation6,Citation7 However, there are still some residents who do not intend to receive COVID-19 booster vaccines. Vaccine Hesitancy is defined as residents’ delayed acceptance or refusal of vaccination despite availability of vaccination services.Citation8 The World Health Organization (WHO) has identified vaccine hesitancy as one of the greatest threats to global public health.Citation9 COVID-19 vaccine hesitancy is prevalent among different countries, regions, and populations. In developed countries such as the United States, France and Italy, vaccine acceptance rates are below 60% (from 53.7% to 58.9%).Citation10 Among them, the COVID-19 booster vaccine has a higher hesitancy rate. A survey in Japan showed that 58.8% of residents were hesitant to give a COVID-19 booster dose.Citation11 In Italy, the rate of booster dose hesitancy reached 64.57%.Citation12,Citation13
The reasons for vaccine hesitancy are complex and diverse. Early studies used the epidemiological triad (EAH framework) to explore the complexity of vaccine hesitancy, which covers three factors: environment (policy setting, values, etc.), agent (disease susceptibility, vaccine safety, etc.), and host (race, education, income, etc.).Citation14,Citation15 The WHO developed a framework of complacency, confidence and convenience (3Cs framework) to analyze the determinants of vaccine hesitancy. When people have low awareness of the need for vaccination (known as complacency), concern about the efficacy and safety of vaccines (known as low confidence), and lack of vaccine availability (known as convenience), there is a significant difference between the three groups (p < .05). Based on the EAH and 3Cs frameworks, age, gender, income, education, risk perception of COVID-19, and trust in the health care system are among the factors that may affect COVID-19 vaccine hesitancy. During the early of COVID-19 pandemic, relevant studies had shown that these factors were also affecting the booster vaccine hesitancy of urban and rural residents in China. The lack of trust in doctors and vaccine developers emerged as a significant influencing factor contributing to the high vaccine hesitancy rate among urban residents. On the other hand, for rural residents, the limited accessibility of vaccination services was identified as influencing factor leading to a higher vaccine hesitancy rate.
China still faces a few obstacles in promoting COVID-19 booster vaccination, but the most notable of these is the country’s unique dual urban-rural social structure. In this system, urban and rural areas are artificially separated by the household registration system,Citation16 and in the context of urban-rural dual social structure, urban and rural residents differ greatly in terms of economic, educational and healthcare systems.Citation17 In 2021, about 914 million people (64.72%) will resided in urban areas and 498 million (35.28%) in rural areas in China.Citation18 Given the spread of COVID-19 and rural-urban population mobility, it is difficult to control the epidemic of COVID-19 at a stable state by increasing the COVID-19 booster vaccination rate in either urban or rural areas alone. Therefore, accurate policies should be formulated based on accurate assessment of the COVID-19 booster vaccine hesitancy rate and differences among participants in urban and rural Settings. To facilitate COVID-19 booster vaccination.
On January 8, 2023, the Chinese government announced the implementation of the “Class B epidemic and B management” policy for the COVID-19 epidemic in China.Citation19 Previous studies have confirmed that there are urban-rural differences in the hesitancy of a booster dose of COVID-19.Citation20 However, after the policy changed, there remains a research gap regarding the existing disparities in COVID-19 booster vaccine hesitancy between urban and rural residents. The current study aims to evaluate the hesitancy rate of COVID-19 booster vaccine and its influencing factors in urban and rural areas of China following. In addition, the study explored the differences in the COVID-19 vaccine hesitancy between rural and urban residents and provided evidence to support the vaccination of other unknown emerging infectious diseases.
Materials and methods
Participants and procedures
From February 1 to 8, 2023, a cross-sectional study was conducted in the eastern (Changzhou), central (Zhengzhou), western (Xining) and northeastern (Mudanjiang) areas of mainland China using a stratified random sampling method (Supplementary material: Figure S1). More than two rural areas and two urban areas were randomly selected from each area. An online survey was conducted among adults aged 18 years and above in each household, resulting in a valid sample size of 5780. Exclusion criteria were as follows: (1) minors less than 18 years old; (2) Participants with incomplete information in the questionnaire; (3) those who are not concerned or interested in vaccination; (4) It is not the participating object of mainland China. Finally, 5462 valid samples (56.6% in urban areas) were obtained. 1:1 nearest neighbor matching was performed between urban and rural residents in the sample, and 1792 urban and rural residents were included in the matching. The flow chart of study subject selection is shown in . This study was approved by the Ethical Review Committee of Zhengzhou University, and all participants signed the informed consent form for the questionnaire.
Figure 1. The flowchart of participants selection of this study.
Assessments
In this study, the Oxford COVID-19 Vaccine Hesitancy Scale was employed to ascertain individuals’ self-reported status regarding COVID-19 vaccination at the current stage. The specific item that was used to estimate the hesitancy level was the one that gave the participant the room to describe their themselves in terms of COVID-19 booster vaccine. During the data analysis, the responses to the item were coded on a scale of 1 to 4. These options included: (1) willingness to receive a COVID-19 booster vaccine, (2) hesitancy or delay in receiving a COVID-19 booster vaccine, (3) refusal to receive a COVID-19 booster vaccine, and (4) disinterest in receiving a COVID-19 booster vaccine. To align with the definition of vaccine hesitancy, option (1) was categorized as “acceptance,” options (2) and (3) were combined and considered as “hesitation,” and option (4) was classified as vaccine apathy for the purpose of data analysis.
Our study included four types of independent variables: (1) personal characteristics (i.e., sociodemographic information, personal health behaviors), (2) awareness of COVID-19 pandemic (i.e., severity of COVID-19, risk of COVID-19 infection,), (3) awareness of COVID-19 vaccine (i.e., knowledge of COVID-19 vaccination, benefits of vaccination, and barriers to vaccination), and (4) health care system dimensions (i.e., level of trust in physicians and vaccine manufacturers, and ease of access to vaccines). We used China’s “hukou registration” system to identify respondents as urban or rural residents.
Statistical analysis
The Chi-square test was used to test for between-group differences in vaccine hesitancy between urban and rural areas. Binary logistic regression was used to analyze the influencing factors of COVID-19 booster dose hesitancy. To reduce potential confounding bias, propensity score matching was performed. Probit regression model was used for covariate selection as well as to estimate the propensity scores for urban and rural participants. A total of 5,462 participants were matched in a 1:1 ratio between urban and rural groups using propensity score matching. The matching was performed with a caliper value set at 0.03 to ensure the comparability of individuals from both urban and rural areas. The statistical analysis was conducted using STATA 17.0 software. A significance level of less than 0.05 (p < .05) was considered a statistically significant.
The study was deemed exempt from assessment by the ethics review Committee of the Life Sciences Ethics Review Committee of Zhengzhou University (Approval number: 2021-01-12-05).
Results
Prevalence of COVID-19 booster vaccine hesitancy and the associated characteristics among urban and rural participants
A total of 5462 subjects were included in our analysis, of which 56.6% were urban residents and 43.3% were rural residents. shows that the overall COVID-19 booster vaccine hesitancy rate was 28.43%, (95%CI: 27.23 to 29.65). The hesitancy rate of COVID-19 booster vaccine among urban residents (34.70%, 95%CI: 33.02 to 36.41) was higher than that among rural residents (20.25%, 95%CI: 18.65 to 21.93). In addition, whether in urban or rural areas, respondents without chronic diseases, with higher income, and with a history of COVID-19 infection had higher vaccine hesitancy (p < .05). Among urban residents, those with poor hygiene habits had higher vaccine hesitancy. Among rural residents, Han nationality and atheists had higher vaccine hesitancy. Among all subjects, women had a higher rate of vaccine hesitancy than men, while among rural residents, women had a lower rate of vaccine hesitancy than men, although the difference is not significant. (Supplementary material: Table S1).
Table 1. Characteristics of the study participants in association to the COVID-19 booster vaccine hesitancy.
Factors influencing COVID-19 booster vaccine hesitancy among urban and rural participants
After adjusting for confounding factors, among urban residents, having chronic diseases (aOR = 0.59, 95%CI 0.46–0.75), being infected (aOR = 0.76, 95%CI 0.63–0.91), the benefit of vaccination (high: aOR = 0.24,95%CI 0.15–0.38; moderate: aOR = 0.32,95%CI 0.22–0.47; low: aOR = 0.58, 95%CI 0.41–0.83), trust in vaccine developers (high: aOR = 0.36, 95%CI 0.22–0.59, moderate: aOR = 0.51, 95%CI 0.35–0.74. Low: aOR = 0.68,95%CI 0.47–0.98). In rural participants, SARS-CoV-2 vaccine hesitancy was associated with barriers to vaccination (high: aOR = 5.02, 95%CI 2.49–10.11. Medium: aOR = 5.58, 95%CI 2.62–11.89; Low: aOR = 2.43, 95%CI 1.20–4.92), and residents with higher barriers to vaccination had higher vaccine hesitancy ().
Table 2. The prevalence of COVID-19 booster vaccine hesitancy and vaccine acceptance between urban and rural Chinese populations pre.
Propensity scores matching analysis
A total of 1,792 pairs, comprising 3,580 urban and rural residents, were successfully matched out of the initial 5,462 urban and rural participants by using PSM. The covariates included in the PSM analysis income, education, ethnicity, and religion, and the kernel density plots before and after matching are shown in supplementary material Figure 1. The differences in vaccine hesitancy rates between urban and rural residents in the matched sample are shown in . No statistical differences were found in the covariates controlled (all <0.05) (balance test and common support domain of PSM for urban and rural samples are shown in supplementary material: Table S2 and Figure S2, respectively). Based on the matched data, we found that the COVID-19 booster vaccine hesitancy rate among urban subjects (31.12%, 95%CI 27.4–31.5) was still higher than that among rural subjects (24.92%, 95%CI 19.8–23.5), with a net difference of 6.20% (p < .05). The relevant results are shown in and supplementary material Table S3.
Figure 2. The prevalence of COVID-19 vaccine hesitancy and vaccine acceptance between urban and rural Chinese populations pre- and post-PSM.
Discussion
Statement of principal findings
This study investigated the prevalence and influencing factors for the COVID-19 booster vaccine hesitancy in rural and urban areas of China. The results indicate that 28.43% of the participants had vaccine hesitancy. Vaccine hesitancy was higher among urban participants than among rural participants. Urban participants had higher vaccine hesitancy rate, which was associated with absence of chronic diseases, previous COVID-19 infection, lower benefit of booster vaccination and lower trust in vaccine developers. Vaccine hesitancy among rural participants was associated with higher barriers to receiving a COVID-19 booster vaccine. Following the PSM matching, the hesitancy rate of COVID-19 booster vaccine in urban residents was still higher than that in rural residents, with a net difference of 6.20%.
Interpretation of principal findings and relationship with previous studies
This study found that the overall COVID-19 booster vaccine hesitancy rate of urban and rural residents in China reached 28.43%, which was much higher than that before the policy was adjusted to “Class B epidemic and B management”. Nearly 90% of urban and rural residents are willing to accept the reported data of COVID-19 booster vaccinationCitation21,Citation22 We speculate that this may be related to the following reasons: First, the increased escape and spread of COVID-19 virus, despite a significant reduction in the lethality and morbidity of the virus,Citation23 combined with the greatly increased population mobility resulting from the change to “Class B epidemic and B management” policy, may have increased the rate of COVID-19 infection. In our study, 2981 (54.6%) urban and rural residents were infected with SARS-CoV-2, of whom 974 (32.7%) were hesitant to be vaccinated. Evidence suggests that vaccine hesitancy is associated with complacency, confidence and convenience (3Cs framework), and immunity acquired from previous infection may be one of the reasons for complacency in patients recovering from COVID-19 infection.Citation24 Thus, such complacency may have contributed to the increase in vaccine hesitancy for the COVID-19 booster vaccine in the current study. Second, infection with COVID-19 despite receiving COVID-19 booster vaccine increases residents’ doubts about the effectiveness of the vaccine.Citation25 Considering the impact of vaccination costs (side effects of vaccination, time of vaccination, distance cost, etc.) and the benefits of vaccination, some residents may choose to refuse the vaccination,Citation26 which in turn lead to a significant increase in vaccine hesitancy. More valuable information from health systems and authorities highlighting the loss of immunity from natural infection over time and the role of COVID-19 booster vaccines to prevent severe disease may improve vaccination rates among people who have recovered from COVID-19 infection and ensure their protection from reinfection.
Our findings show that the rate of COVID-19 booster vaccine hesitation remained higher among urban participants than among rural participants, with a difference of 6.2%. This is consistent with the findings of a study in Japan, where people living in rural areas were more willing to be vaccinated than those in urban areas.Citation27 One possible explanation for this discrepancy is that urban participants in our findings had lower perceived severity of the COVID-19 pandemic and lower risk of infection than rural participants (p < .05), which may have contributed to lower COVID-19 booster vaccine hesitancy among urban participants.Citation28
Our findings also suggest that urban COVID-19 booster vaccine hesitance is associated with trust in vaccine developers, which may be one of the reasons for their low willingness to receive COVID-19 booster vaccine. A notable association was observed between vaccine hesitancy for COVID-19 booster vaccines and the level of distrust toward vaccine developers.Citation29 Vaccine-related adverse events and instances of counterfeit vaccines have led to a significant decline in public trust in healthcare professionals and vaccine developers.Citation30 Therefore, China should accelerate the development of the integrity system for the vaccine industry, and encourage enterprises to play a leading role in vaccine production and circulation while ensuring the quality and safety of vaccine products from the development to the circulation. Previous research has also shown that communication strategies by health workers may be particularly effective in overcoming COVID-19 booster vaccine hesitancy.Citation31 To build trust and confidence in COVID-19 booster vaccines in cities, vaccination service institutions should cultivate and develop doctor-patient communication skills to improve the quality of vaccination services. On the other hand, relevant Chinese authorities should promote in-depth communication between health authorities, vaccine manufacturing companies, and urban and rural residents.Citation32
Among rural residents, the hesitancy of COVID-19 booster vaccination was associated with self-perceived barriers to action on vaccination (eg, distrust of vaccine booster vaccinators and vaccine developers, distrust of the safety and effectiveness of vaccine booster). According to the protective motivation theory, people’s behavior is the result of psychological activities. Without appropriate coping information, threatening information and fear may directly cause individuals to carry out maladaptive reactions and further enhance unnecessary behaviors.Citation33 This may be one of the reasons why rural residents have adverse psychological activities against vaccination and thus trigger vaccine hesitancy for booster vaccination. We believe that education always plays an important role in addressing vaccine hesitancy, particularly among individuals with limited access to accurate information and lower health literacy. It is hence possible to empower individuals to acquire a correct understanding of vaccines, ultimately leading to a reduction in vaccine hesitancy.Citation34 Secondly, relevant departments and authorities should effectively screen the vaccine information spread on the Internet and the media, disseminate correct vaccine knowledge, and eliminate residents’ misunderstanding of the vaccine.
In addition, when the role of gender in COVID-19 vaccine hesitancy, we found that women were more hesitant to get the COVID-19 vaccine than men, a finding that differed from previous studies,Citation35 however, there was no significant difference in vaccine hesitation rates between men and women in this study. We believe that gender factors may interact with other factors to influence vaccination attitudes and behaviors, which needs further research to explore. Some studies have shown that regular vaccination with booster shots can also lead to an increase in vaccine hesitation.Citation36 This study mainly discussed the effect of vaccine booster on vaccine hesitation，our future research may further explore the effect of the number of vaccine booster doses about vaccine hesitation and other possible influencing factors.
Strengths and weaknesses of the study
The strengths of this study are as follows: Firstly, this is the first large-scale study to assess the COVID-19 booster vaccine hesitancy rate and the factors associated with it in mainland China since this policy was changed to “Class B epidemic and B management” in January 2023. Secondly, the propensity score matching method was used to control the confounding factors and ensure the reliability and robustness of the absolute difference of vaccine hesitancy rate between urban and rural residents in this study, which was better than previous similar studies.
This study is subject to certain limitations and hence warrant acknowledgment. Firstly, the assessment of COVID-19 booster vaccine hesitancy relied on self-report measures, which may have introduced recall as well as subjective bias. Secondly, there exist various factors that can influence vaccine hesitancy, and although the study incorporated the protective motivation theory and employed propensity score matching (PSM) to address confounding factors, the analysis may not capture the full breadth of influencing variables, indicating a potential lack of comprehensiveness. Thirdly, the cross-sectional nature of the study design may be another limitation, given the dynamic nature of public perceptions and attitudes toward vaccination, unable to capture changes and evolution of hesitation rates over time. Preclude the establishment of a causal relationship.
Conclusion
In the overall Chinese population, there has been a significant increase in the rate of COVID-19 booster vaccine hesitancy. Furthermore, the rate of hesitancy in urban regions was found to be higher compared to rural areas. It is crucial for urban areas to prioritize the vaccination status of their residents through intensifying efforts in promoting the benefits of vaccination and enhancing trust in the healthcare system. In addition, it is necessary to spread the knowledge about the COVID-19 booster vaccine among rural residents to reduce their concerns about the safety and efficacy of the vaccine, and achieve the effective promotion of the COVID-19 booster vaccination in both urban and rural residents.
Data Availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Informed consent statement
We have obtained consent to publish from all participants (or legal parent or guardian for children).
Institutional review board statement
The studies involving human participants were reviewed and approved by the Life Science Ethics Review Committee of Zhengzhou University (Record No: 2021-12-21-05).
Authors’ contributions
Y.M. and W.W. conceived, designed and supervised the study; J.B., W.Z., Y.L., Z.S., D.Z., R.R. and J.Z., D.G. participated in data collection; Y.M. and J.B. analyzed the data, and prepared the tables and figures; Y.M. and J.B. prepared the original draft of manuscript; Y.M. and W.W. acquired the funding; W.D.; Y.M. and W.D. administrated the project; Y.M., J.H., R.L., Q.Z., M.L. and C.T. reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. The authors read and approved the final manuscript.
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All authors thank all participants involved in the study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplementary material
Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2023.2297490
Additional information
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References
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