https://orcid.org/0000-0003-1336-1510
ABSTRACT
Although COVID-19 vaccine uptake was high in Quebec for the primary series, vaccine acceptance decreased for the subsequent booster doses. This article presents the evolution of vaccine intention, self-reported vaccination behaviors, and vaccine hesitancy over 2 years. A series of cross-sectional surveys were conducted in Quebec between March 2020 and March 2023, with a representative sample of 3,330 adults recruited biweekly via a Web panel. Panelists could have answered multiple times over the course of the project. A cohort of respondents was created to assess how attitudes and behaviors about COVID-19 vaccines evolved. Descriptive statistics and multivariate logistic regressions were performed. Among the 1,914 individuals with no or low intention of getting vaccinated in Fall 2021 (Period 1), 1,476 (77%) reported having received at least two doses in the Winter 2023 (Period 2). Not believing in conspiracy theory (OR = 2.08, 95% CI: 1.65–2.64), being worried about catching COVID-19 (OR = 2.12, 95% CI: 1.65–2.73) and not living in a rural area (ORs of other areas are 2.27, 95% CI: 1.58–3.28; 1.66, 95% CI: 1.23–2.26; 1.82 95% CI: 1.23–2.73) were the three main factors associated with being vaccinated at Period 2. Among the 11,117 individuals not hesitant at Period 1, 1,335 (12%) became hesitant at Period 2. The three main factors significantly associated with becoming vaccine hesitant were the adherence to conspiracy theories (OR = 2.28, 95% CI: 1.95–2.66), being a female (OR = 1.67, 95% CI: 1.48–1.90) and being younger than 65 years old (the ORs for 18–34, 35–49, and 50–64 compared with 65 and over are 2.82, 95% CI: 2.32–3.44; 2.39, 95% CI: 2.00–2.86 and 1.82, 95% CI: 1.55–2.15 respectively). As the pandemic is over, monitoring the evolution of vaccine attitudes and uptake will be important.
Introduction
Vaccine hesitancy (i.e., delay in vaccine acceptance or vaccine refusal despite the availability of vaccination servicesCitation1 has been identified as a significant threat to global health a year before the pandemic.Citation2 The availability of safe and effective vaccines was a game-changer in controlling the COVID-19 pandemic. COVID-19 vaccination reduces the risk of severe disease that could potentially result in hospitalization and death and has been associated with improved quality of life.Citation3,Citation4 In Canada, COVID-19 vaccine uptake was above 90% among Canadian adults for the first two doses.Citation5 However, vaccine acceptance and uptake decreased for the subsequent booster doses.Citation6
In addition to easy access to COVID-19 vaccination services, attitudes, risk perception, knowledge, values, and motivation are key determinants of COVID-19 vaccine acceptance and hesitancy.Citation7–9 Several studies assessed the determinants of COVID-19 vaccine hesitancy in the past 3 years. A study conducted in the United States (US) identified that individual-level degree of trust in (and consumption of) sources of COVID-19 information changed over time and were associated with COVID-19 initial series and booster uptakes.Citation10 Another US study found that political conservatism, male gender, lower level of education and low income were associated with low uptake of COVID-19 vaccines.Citation11 A study among caregivers of patients showed that increased care burden may lead to lower COVID-19 vaccine acceptance.Citation12 In Canada, findings from repeated cross-sectional surveys conducted in 2020–21 showed that younger age, being a parent of children under the age of 18 years, identifying as nonwhite, having a low level of education, having low annual household incomes, working as essential and healthcare workers, not getting regular influenza vaccines were associated with a higher level of COVID-19 vaccine hesitancy.Citation13 A scoping review of the global literature concluded that COVID-19 vaccine hesitancy was associated with risk perceptions, trust in healthcare systems, solidarity, previous vaccine experiences, misinformation, concerns about vaccine side effects and political ideology.Citation14
It is recognized that vaccination intentions and behaviors can change over time due to a multitude of factors.Citation15 Studies conducted at different times during the pandemic clearly showed fluctuations in intentions toward the COVID-19 vaccines, but most of the published studies are based on cross-sectional design.Citation16 This article presents data on the evolution of COVID-19 vaccination intention, vaccine hesitancy, and self-reported vaccine behaviors collected in multiple surveys conducted between September 2020 and February 2023. Due to the longitudinal analyses, our article makes an original contribution to the published literature by illustrating the socio-demographic and attitudinal characteristics associated with changes in intentions and hesitancy in relation to vaccination against COVID-19.
Methods
Design and recruitment
A series of cross-sectional surveys were conducted in Quebec from March 21, 2020, to March 31, 2023. The questionnaire assessed Quebecers’ attitudes and behaviors during the pandemic.Citation17 A representative sample of 3,330 Quebec adults was recruited biweekly via a Web panel. Invitations to participate were sent by e-mail. Adults aged 18 years and older were targeted to answer the survey in two of Quebec’s most widely used languages (French and English).
The survey was conducted by a specialized research firm.Citation18 The firm was responsible for recruitment, survey administration, and ensuring quality (e.g., preventing multiple entries from the same individual and removing careless responses). After having completed the questionnaire, respondents did not receive further invitations within the next 21 days. All responses were anonymous, and a unique code identified each respondent. The response rate was estimated at 10%. Details about the survey methodology are available elsewhere.Citation17
Data collection tool
In addition to sociodemographic questions (i.e., age, gender, level of education, household composition, and employment), this article reports findings from questions that measured respondents’ perceptions of COVID-19 risks, adherence to conspiracy theories (using the Generic Conspiracist Beliefs scale developed by Bruder and collaborators),Citation19 attitudes, and intentions regarding COVID-19 vaccination and vaccine hesitancy. The research firm was responsible for programming and testing the survey. To prevent biases, the questionnaire’s items were randomized. To lower the number of questions and the complexity of the survey, adaptive questioning was used (i.e. certain items were displayed based on answers from other items). Participants could check on the completeness and review their responses before submission.
Ten items directly assessed respondents’ attitudes and intentions regarding COVID-19 vaccines. The survey questions on vaccination were informed by our previous work.Citation20 All questions tested in our analysis were close-ended, and responses were recorded on a 5-point Likert scale. From September 2020 to January 2021, an item measured intention to receive COVID-19 vaccines: “I intend to get the vaccine against COVID-19 once available”. After January 8, 2021, all adults were eligible for vaccination in Quebec; the item was modified for “I intend to get the vaccine against COVID-19” and a new item to measure self-report COVID-19 vaccination was added (“Since December 2020, have you been vaccinated against COVID-19?” with answers options yes, no, refuse to answer). Respondents who reported having been vaccinated were asked about the number of vaccine doses they had received. A general item was used to measure vaccine hesitancy, “In general, do you consider yourself hesitant (fearful) about vaccination?” with four answer options from “not at all hesitant” to “very hesitant.” Items included in the analysis are detailed in Appendix 1.
Postal codes were collected to identify respondents’ areas of residence. Areas of residence were grouped into four categories: census metropolitan areas (CMA) of Montreal, others CMA, cities >10,000 inhabitants, and small towns/rural areas. This information allows us to include the Material Deprivation Index (MDI) of respondents’ areas of residence in the analysis.Citation21 MDI declined in quintiles of population based on factor scores from indicators of Canadian Census data that reflect the deprivation of goods and conveniences based on average personal income, unemployment rate, and high-school education rate in a specific geographic area.Citation22 The first quintile (Q1) indicates the best status (20% more privileged population), while the last quintile (Q5) refers to the worst status (20% more deprived population).
Data analysis
As participants could participate more than once, it was possible to create cohorts of respondents who filled out the survey multiple times over the study period using their ID code. In this article, we report an analysis of two groups of the cohort of respondents created to explore COVID-19 vaccination attitudes, self-reported behaviors, and vaccine hesitancy.
The first group (hereafter named: vaccine intention group) is composed of respondents who answered that they had no or low intention of getting vaccinated against COVID-19 (answers “totally disagree” and “somewhat disagree” to the item “I intend to get the vaccine against COVID-19 once available”) in surveys collected in one of 3 data points before the start of the vaccination campaign (i.e., Sept. 4–23, 2020, Nov. 13–18, 2020, Nov. 27 2020–Jan. 6, 2021). To be included in this group, respondents also needed to have answered at least once the item collecting self-reported vaccination at Period 2 (i.e., Sept. 3, 2021–Feb. 15, 2023). Respondents who answered the intention item more than once in Period 1 and had conflicting responses (e.g., disagreeing vs. agreeing) were excluded.
A second group was created to assess vaccine hesitancy (hereafter named vaccine hesitancy group). This second group included respondents who answered “not at all hesitant” or “not very hesitant” to the vaccine hesitancy item at Period 1 (i.e., Apr. 30–Sept. 29, 2021) and had answered at least once the vaccine hesitancy item at Period 2 (i.e., Apr. 1–Aug. 17, 2022). Respondents who answered the vaccine hesitancy item more than once in Period 1 and had conflicting responses (e.g., disagreeing vs. agreeing) were excluded. Respondents were qualified as vaccine-hesitant when they answered “somewhat hesitant” or “very hesitant” at least once.
Descriptive statistics were generated for all items of completed questionnaires. Multivariate logistic regressions were performed to explore factors associated with changes between Period 1 and Period 2. The odds ratios of vaccinated individuals were estimated using a logistic regression model. The two dependent variables were as follows: the probability of being vaccinated at Period 2 among people who did not intend to be vaccinated at Period 1 [vaccine intention group] and the probability of being hesitant at Period 2 among people who were not hesitant at Period 1 [vaccine hesitancy group].
For both groups, multivariate analyses were performed in two steps. First, all independent variables listed in Appendix 1 were included in the model. Second, only statistically significant variables were retained, and the model was adjusted for confounding factors (i.e., age, gender, education, and area of residence). All analyses were performed using SAS version 9.4; the threshold of statistical tests was α = 5%, and the confidence interval (CI) was 95%.
Ethics approval
The surveys were conducted as part of a multicomponent plan to evaluate public health interventions during the health emergency of COVID-19. The Ethics Review Board of the Centre de recherche du CHU de Québec – Université Laval provided a waiver for the requirement for research ethics approval for this study (waiver 2021-5714). The specialized research firm is responsible for the informed consent process and data protection of voluntary participants. All participants in the Web panel have provided written consent to receive e-mail invitation to participate in surveys by the research firm’s privacy policy.Citation23 The research team received anonymous data for analysis.
Results
For the vaccine intention group 14,013 individuals answered at least once in Period 1 and 2. However, 87 refused to answer the questions on vaccine intention, leaving 13,926 eligible respondents for this group. Among them 11,863 always intended to be vaccinated during Period 1, 149 had mixed answers on vaccine intention, and 1,914 never intended to be vaccinated during Period 1. This latter group of respondents were included in the vaccine intention group.
For the vaccine hesitancy group 14,615 individuals answered at least once in both Period 1 and Period 2, but 170 refused to answer questions on vaccine hesitancy, leaving 14,445 eligible respondents. Among them, 3,328 eligible respondents were vaccine-hesitant in Period 1. The remaining 11,117 respondents who were not vaccine-hesitant during Period 1 were included in the vaccine hesitancy group.
Vaccine intention group
Among the 1,914 individuals with no or low intention to receive the COVID-19 vaccine, 1,476 (77%) reported receiving at least two doses in Period 2. Their sociodemographic characteristics are presented in . One-third of respondents (30.3%) who received at least two doses at Period 2 had no intention to be at Period 1 adhered to conspiracy theories, and 43% were worried about catching the virus.
Table 1. Sociodemographic characteristics of respondents who had not or a low vaccination intention at period 1 according to their vaccinal status at period 2.
presents the multivariate analysis findings to identify factors associated with self-reported COVID-19 vaccination at Period 2 among respondents with no or low intention at Period 1. Not believing in conspiracy theories, worrying about catching the virus, being a student, and not living in a rural area were statistically significant predictors of self-report vaccination.
Table 2. Results of the logistic regression modeling the probability of being vaccinated against COVID-19 with two doses at period 2 among respondents with no or low intention at period 1 (N = 1,914).
Vaccine hesitancy group
Among the 11,117 individuals who were not hesitant at Period 1, 1,335 (12%) became hesitant at Period 2. Characteristics of respondents included in this hesitancy group are presented in . Among the respondents who became vaccine-hesitant during Period 2, 20.5% adhered to conspiracy theories, and almost half (47.6%) were worried about catching the SARS-CoV-2 virus.
Table 3. Sociodemographic characteristics of respondents who were not hesitant at Pperiod 1 according to their hesitation level at Period 2 (N, %).
presents findings from the multivariate analysis. Adherence to conspiracy theories, being a female, being a student, living in the CMA of Montréal, having a university degree, and being younger than 65 y/o were statistically significant predictors of becoming vaccine hesitant at Period 2.
Table 4. Results of the logistic regression modeling the probability of becoming vaccine hesitant at Period 2 among respondents who were not vaccine-hesitant at Period 1 (N = 11,117).
Discussion
Vaccination decisions and attitudes are multidimensional, and it is recognized that vaccine hesitancy can vary across time, for different vaccines and between context and groups.Citation1,Citation24 The reasons to accept or refuse are complex and involve emotional, cultural, social, spiritual, political, and cognitive factors.Citation25 Furthermore, vaccine hesitancy and vaccination behaviors do not always correlate, as people can be hesitant and still agree to receive a vaccine.Citation26
This study explored vaccine intentions, self-reported vaccination behaviors, and vaccine hesitancy based on cross-sectional surveys over 2 years of the pandemic. Our findings illustrate that most respondents who did not intend to vaccinate against COVID-19 finally reported receiving two doses. New vaccines are known to generate more vaccine hesitancy, and this was to be expected given the rapid development of the vaccines and the use of new vaccine technologies.Citation27,Citation28 This change in intention may be explained by the availability of more information about the vaccines after the launch of the vaccination campaign. In addition, extraordinary incentives and disincentives measures were implemented in Quebec to enhance vaccine uptake and may have impacted vaccination behaviors (i.e., vaccine lottery, vaccine passports, mandatory vaccination policies by some employers).Citation29,Citation30 Another interesting finding of this study is that a significant proportion of non-vaccine-hesitant respondents became less confident over time. While the quantitative design of our study does not allow us to have an in-depth understanding of the factors that led to this increase, it is possible that the decline in that the circulation of the Omicron variant escaping the vaccine protection and the need for additional booster doses due to decline in the protection conferred by the initial series negatively impacted attitudes toward vaccination.Citation31
Different sociodemographic characteristics were associated with vaccine hesitancy and vaccine intention. Being a female increased the likelihood of being vaccine-hesitant and decreased the probability of being vaccinated against COVID-19, similar to what was observed in other studies.Citation32–37 As shown in other studies, older age was an important determinant of vaccine confidence and COVID-19 vaccine acceptance.Citation32,Citation34–41 This association was expected as the elderly are at greater risk of infection and mortality from COVID-19 and were targeted as a priority group for vaccination.Citation42 Living in an urban area was associated with higher COVID-19 vaccine acceptance, which is also supported by findings of a systematic review.Citation37 In the literature, higher income was associated with higher odds of intention to be vaccinated and vaccine uptake.Citation34,Citation36,Citation38,Citation40 In this study, we did not observe any difference related to the material deprivation index, however.
Our study also identified that low-risk perception of COVID-19 and adherence to conspiracy theories were associated with lower vaccine uptake and hesitancy. The perception of the severity of COVID-19 and perceived susceptibility were positive predictors of vaccine uptake.Citation37 This was also true for fear, anxiety, panic, and worries regarding COVID-19.Citation32,Citation35,Citation37,Citation43 Indeed, being fearful of catching the virus [19] and greater perceived severity and susceptibility of the COVID-19 disease were found in other studies.Citation14,Citation32,Citation44 Adherence to conspiracy theories significantly impaired people’s intentions to vaccinate against COVID-19.Citation14,Citation32,Citation36 A systematic review published in 2023 also stated that belief in false information that was widely shared during the pandemic (e.g., the belief that the virus was a biological weapon, the belief that 5G mobile networks spread the disease, the belief that Big Pharma created the disease to sell vaccines) was negatively correlated with vaccine uptake.Citation37 Lack of trust in the health authorities, the government and the healthcare system are key factors leading to adherence to conspiracy theories and key determinants of vaccine acceptance.Citation45–47 In the context where primo-vaccination and booster doses of COVID-19 vaccination for at-risk groups are still recommended, our findings indicate that vaccine promotion efforts should focus on increasing risk perceptions and addressing adherence to conspiracy theories. Similarly, trust-building interventions to address vaccine hesitancy should target young adults.
Strengths and limitation
The large number of respondents and the longitudinal data analysis are strengths of this study. Data were collected from non-probability samples; thus, the findings may not represent the Quebec population. Although the research firm’s web panel is the largest in Quebec, some population groups are excluded (e.g., people without Internet access and people who do not understand French or English). There is also an overall risk of low representativeness for other groups (e.g., newcomers, low-income people, First Nations and Inuit). The response rate for each data collection point is also low and we were not able to conduct non-response analysis. The weighting process can partially correct some of these biases, but the findings should be interpreted in light of these limitations. It is thus possible that our findings under- or overestimate changes in intention and vaccine hesitancy. However, it is reassuring to note that self-reported COVID-19 vaccination in our study closely aligned with official vaccination data from Quebec ministry of Health. Desirability bias could not be excluded, as with any survey. However, this bias should be minimized since the questionnaire is anonymous and filled out by the respondents themselves without the help of an interviewer. Finally, our surveys were conducted in Quebec and, as vaccine hesitancy varies between context and places, our findings may not be generalizable to other contexts.
Conclusion
Attitudes regarding vaccines may change over time, especially in a new and fast-moving context such as the COVID-19 pandemic. Personal, social and political factors could influence vaccine hesitancy and behavior related to the uptake. Also, coercive measures could influence the decision to get immunized (e.g., mandatory vaccine policies) and encourage people to go against their beliefs and get vaccinated.
Our study also showed that a significant proportion of individuals who accepted vaccines without hesitation became vaccine-hesitant. As the pandemic is over, monitoring the evolution of vaccine attitudes and uptake will be important. As COVID-19 vaccine uptake is decreasing for each additional dose recommended, especially among young adults,Citation30 it will be important to develop tailored strategies to maintain vaccine confidence and avoid spillover effect on other routinely recommended vaccinations.
Author contributions
All the authors contributed to all aspects of the work.
Appendix_revised_Dec19.docx
Download MS Word (17.4 KB)Acknowledgments
Thanks to the Ministère de la santé et des services sociaux du Québec for funding this study and to the survey participants. We would also like to thank Mélanie Tessier for her contribution with the surveys and Mamady Magassouba for his contribution in the conception, design, an analysis of the cohort.
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/10.1080/21645515.2024.2309006
Additional information
Funding
References
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