ABSTRACT
Background
COVID-19 vaccination has been accepted widely. However, there are only a few reports on patients’ willingness to be vaccinated. This study investigated the willingness of Chinese outpatients to accept COVID-19 vaccination as well as influencing factors.
Methods
A cross-sectional survey was conducted in Jiangsu province, China in December 2020. Self-administered questionnaires, which were distributed to 625 outpatients among secondary hospitals, addressed demographic characteristics, sociological characteristics, and subjective reasons. There were 522 (83.5%) participants who gave completely valid responses. Logistic regression analysis was performed to explore the risk factors for willingness of COVID-19 vaccination.
Results
71.5% of participants were willing to receive the COVID-19 vaccine. “worried about contracting COVID-19” (49.6%) and “vaccines have just been introduced and need time to consider” (38.9%) were the main reasons for being willing and unwilling to receive COVID-19 vaccine, respectively. The logistic regression analysis showed that “vaccines are an effective way to prevent diseases” (OR = 5.07, 95%CI: 3.32–7.75), “the price you are willing to pay for non-free vaccines (yuan) (101–500 vs ≤100)″ (OR = 1.87, 95%CI: 1.16–3.02), “per capital monthly income(yuan) (>6000 vs ≤3000)”(OR = 2.13, 95%CI: 1.03–4.41), and “self- assessed health status (Good vs Bad)″ (OR = 1.71, 95%CI: 1.01–2.90) were the main risk factors for outpatients to be willing to receive the COVID-19 vaccine.
Conclusions
The willingness of Chinese outpatients to receive COVID-19 vaccine was not high. The government should do more to increase publicity of knowledge about COVID-19 vaccine thus increasing willingness to vaccinate, and provide free vaccine to eliminate the cost impact.
Introduction
In December 2019, the novel severe acute respiratory syndrome coronavirus 2 caused the coronavirus disease (COVID-19) outbreak in Wuhan, China. On January 30, 2020, the World Health Organization (WHO) listed the COVID-19 epidemic as a “public health emergency of international concern,” and it was declared a global pandemic on March 11, 2020.Citation1 This epidemic has tremendously damaged not only the health of humans, but also the global economy. The population is generally susceptible to COVID-19, which is highly contagious. Due to the lack of specific drugs, vaccines have been regarded as an effective option to prevent the pandemic and have become the most effective and economical means to limit its spread.Citation2,Citation3 The pandemic has not yet ended, the epidemic has recurred frequently, and global vaccination is in a critical period. However, more than 75.0% of the vaccine doses have been used in only 10 countries, and the lowest income countries have used less than half of the global doses.Citation4
As of June 2, 2021, China has reported 91,170 confirmed cases, and 1,027,007 close contacts have been traced.Citation5 Maslow’s hierarchy of needs points that physiological needs are the most basic needs that humans must meet to maintain life.Citation6 In the face of the COVID-19 pandemic, people’s physiological needs to maintain health and the physical and mental impact of the epidemic are important issues that need urgent resolution. China has adopted effective epidemic prevention and control measures to ensure the safety of the people to the greatest extent.Citation7 However, the impact of COVID-19 on the health of residents persists, and the prevention and control of the epidemic presents a complicated situation. Studies have confirmed that COVID-19 vaccination could effectively improve the immunity of individuals and control the spread and prevalence of COVID-19.Citation8,Citation9 The mass COVID-19 vaccination drive is expected to have a significant and positive impact on the control of the COVID-19 spread in China and the world. However, its success depends on the people’s willingness for COVID-19 vaccination, and it is very important to evaluate this.
The acceptance of vaccines reflects the general population’s overall view regarding the disease risks, attitude toward vaccines, and health needs, which is critical for the successful realization of high vaccination rates, especially for new infectious diseases.Citation10,Citation11 The WHO report pointed that most countries recommend influenza vaccination for individuals with underlying diseases.Citation12 However, there are only few research reports on the willingness of people to be vaccinated against COVID-19. The existing studies mostly focused on surveying the common people’s willingness for COVID-19 vaccination in China,Citation13 Italy,Citation14 Japan,Citation15 United States,Citation16 etc. Very few studies have focused on the willingness of the medical staff to be vaccinated against COVID-19.Citation17 Currently, there are only few studies on patients’ willingness for COVID-19 vaccination, especially studies on outpatients.
According to the theory of fear induction, when people try to deal with threats, fear usually evolves into anxiety disorders.Citation18 COVID-19 is contagious and fatal, especially in outpatients who may have the disease. This is a very big health threat, which is likely to cause psychological distress in outpatients and affect their willingness to be vaccinated against COVID-19. Studies have shown that whether it is daily medical treatment or treatment during the COVID-19 pandemic, the psychological distress of outpatients is equally serious, including health anxiety, post-traumatic stress disorder, etc.Citation19,Citation20 Especially during the pandemic, outpatients are greatly restricted from visiting the outpatient clinics and are required to follow several protocols for the same, such as measure their body temperature, provide nucleic acid test reports, etc. These measures are likely to aggravate the psychological distress of the outpatients seeking medical treatment and affect their willingness to be vaccinated during the pandemic. Outpatients are highly mobile, and their vaccination willingness is likely to affect the overall decision making of their families. Moreover, compared to inpatients and the general population, outpatients are a group that is easily ignored. Therefore, this study aimed to assess the willingness of Chinese outpatients to be vaccinated against COVID-19 and to analyze the reasons for their willingness/unwillingness to facilitate the government and hospitals in formulating strategies for efficient COVID-19 vaccination.
Patients and methods
Study design and participants
This was a cross-sectional survey study. A multi-stage random sampling method was used, and one city was randomly selected from the east, south, west, north, and center regions of Jiangsu Province, China. Following this, one second-level hospital (with more than 300 beds) was randomly selected from the selected cities, and 125 outpatients (those who could visit the hospital on their own and stay there for more than 1 hour) were randomly selected from each hospital. Before the questionnaire was issued, a questionnaire “QR code” was formed using the questionnaire star platform. The project research team recruited 20 outpatient nurses as investigators, and they were trained to conduct the questionnaire surveys. From December 15, 2020 to January 15, 2021, after all investigators had obtained written informed consent from the participants, the QR code of the questionnaire was directly distributed to 625 participants from different hospitals to conduct a one-to-one survey. Each participant participated voluntarily and completed the questionnaire in a private place. The questionnaire collection process followed a strict quality control protocol. Ultimately, 522 effective questionnaire responses were obtained, with a response rate of 83.5%.
Questionnaire
The questionnaire was divided into three parts. The first part comprised 10 variables describing the demographic characteristics of the participants: age, sex, per capita monthly income, whether insurance is provided for treatment expenses, self-assessed health status, region, marital condition, education level, occupation, and presence or absence of chronic diseases.
The second part comprised 5 variables assessing the sociological characteristics of the participants: “vaccines are an effective way to prevent diseases,” “the price you are willing to pay for non-free vaccines (yuan),” do you know about the COVID-19 vaccine,” “do you know about the COVID-19 mutant strain,” and “the way to get COVID-19 messages.”
The third part collected the subjective reasons for the participants’ willingness or unwillingness to be vaccinated against COVID-19. The subjective reasons for willingness included “worried about contracting COVID-19,” “avoid getting pneumonia,” “frequent travel for business,” “people around are willing to be vaccinated,” “risk of contracting COVID-19 due to occupation,” “vaccines are an effective way to prevent diseases,” and “others.” The subjective reasons for unwillingness included “worried about the effectiveness of the vaccine,” “worried about the safety of the vaccine,” “vaccines have just been introduced and need time to consider,” and “others.”
Statistical analyses
The Statistical Product and Service Solutions version SPSS22.0 (IBM, Asia Analytics Shanghai) software was used for statistical analysis of the data, and the two-tailed P-values p < .05 in two-tailed tests was were considered statistically significant. First, a one-way chi-square test was performed to compare the difference in the willingness among the outpatients with different demographic and sociological characteristics to be vaccinated. Second, the rate was calculated to describe the subjective reasons for the willingness of outpatients to be vaccinated against COVID-19. Finally, a binary logistic regression analysis was performed to explore the factors influencing the outpatients’ willingness.
Results
Willingness for COVID-19 vaccination according to different demographic variables
The demographic characteristics of the participants are presented in . The average age of the participants was 38.32 ± 12.97 years. Of the 522 participants, 373 (71.5%) were willing to receive the COVID-19 vaccine, while 149 (28.5%) were not. There were statistical differences in the per capita monthly income, whether insurance is provided for treatment expenses, self-assessed health status, and occupation for willingness for vaccination (P< .05). However, there was no statistical difference with respect to age, sex, region, marital condition, education level, and presence or absence of chronic diseases (P> .05).
Table 1. COVID-19 vaccination willingness with different demographic variables
Willingness for COVID-19 vaccination according to different sociological variables
The distribution of the sociological characteristics of the participants is presented in . Of the 522 participants, 336 (64.4%) agreed that vaccines are an effective way to prevent diseases. Of these, 207 (39.7%) could not accept vaccination fees of more than 100 yuan. A total of 303 (58.1%) patients did not understand the COVID-19 vaccine, and 307 (58.8%) did not know about the COVID-19 mutant strain. Furthermore, 294 (56.3%) participants learned about the COVID-19 vaccine through the internet. Among them, the variables “vaccines are an effective way to prevent diseases” and “the price you are willing to pay for non-free vaccines (yuan)” were statistically different for willingness for vaccination (P< .05). However, there was no statistical difference with respect to the variables of “do you know about the COVID-19 vaccine,” “do you know about the COVID-19 mutant strain,” and “the way to get COVID-19 messages” (P> .05).
Table 2. COVID-19 vaccination willingness for different sociological variables
Subjective reasons for willingness to get COVID-19 vaccination
The subjective reasons for willingness to receive the COVID-19 vaccine are shown in . Among the 373 willing participants, 185 (49.6%) outpatients chose the reason “worried about contracting COVID-19,” 114 (30.6%) chose “vaccines are an effective way to prevent diseases,” and 39 (10.5%) chose “risk of contracting COVID-19 due to their occupation.”
Table 3. Subjective reasons for being willing to get COVID-19 vaccine
Subjective reasons for unwillingness to get COVID-19 vaccination
The subjective reasons for reluctance to receive the COVID-19 vaccine are shown in . Among the 149 unwilling participants, 58 (38.9%) chose “vaccines have just been introduced and need time to consider,” 46 (30.9%) chose “worried about the safety of the vaccine,” and 29 (19.5%) chose “others.”
Table 4. Subjective reasons for reluctance to get COVID-19 vaccine
Factors associated with willingness for COVID-19 vaccination
Binary logistic regression analysis was conducted to identify the factors influencing the willingness of outpatients to be vaccinated against COVID-19. With willingness for COVID-19 vaccination as the dependent variable, “willingness for inoculation” was assigned a value of 1 and “unwillingness for inoculation” a value of 0. Based on the chi-square test results, whether insurance is provided for treatment expenses, per capita monthly income, self-assessed health status, “vaccines are an effective way to prevent diseases,” “the price you are willing to pay for non-free vaccines (yuan),” and occupation were considered as the independent variables for binary logistic regression analysis. The results showed that “vaccines are an effective way to prevent diseases” (odds ratio [OR] = 5.07, 95% confidence interval [CI]: 3.32–7.75), “the price you are willing to pay for non-free vaccines (yuan)” (101–500 vs. ≤100) (OR = 1.87, 95% CI: 1.16–3.02), per capita monthly income (yuan) (>6000 vs. ≤3000) (OR = 2.13, 95% CI: 1.03–4.41), and self-assessed health status (good vs. bad) (OR = 1.71, 95% CI: 1.01–2.90) were the factors associated with willingness for COVID-19 vaccination. The data are shown in .
Table 5. Analysis of influencing factors of COVID-19 vaccination willingness
Discussion
The results of this study showed that 71.5% of the outpatients were willing to receive the COVID-19 vaccine. This result was close to the reported percentage of population willing to be vaccinated in Professor Jeffrey’s study (71.5%)Citation21 and a French study (77.1%).Citation22 It was higher than the research results reported by the scholars in the United States (66.1%), Japan (65.7%), and Turkey (54.0%),Citation15,Citation23,Citation24 but lower than the survey results reported in China (83.8%), Ecuador (97.4%), and Indonesia (93.3%).Citation25–27 This could be due to the fact that outpatients usually suffer from some kind of underlying illness; therefore, they are cautious about vaccination due to health concerns. Moreover, public ignorance of COVID-19 vaccines could be another cause. Therefore, it is recommended that the government agencies immediately take effective measures to disseminate knowledge about COVID-19 vaccines to increase the people’s willingness for vaccination.
Among the subjective and objective reasons for willingness for COVID-19 vaccination, “vaccines are an effective way to prevent diseases” was a significant factor in both. Additionally, nearly half of the patients chose “worried about contracting COVID-19” as the subjective reason for willingness for vaccination, whereas more than half of the participants did not understand the COVID-19 vaccine. People have some understanding of COVID-19 after its outbreak, but the lack of knowledge about the vaccine has led to reluctance toward vaccination. Therefore, popularizing the scientific rationale of the COVID-19 vaccine may be an effective way to encourage the outpatients to be vaccinated and to prevent infection.
Currently, public trust in vaccine safety is a global public health issue.Citation28 In this study, the unwillingness to receive the COVID-19 vaccine was mainly because the vaccine has just been introduced in the market and the participants had a wait-and-watch attitude toward the safety of the vaccine. Recently, certain vaccine problems have emerged one after another, and people’s trust in vaccines has dwindled.Citation29 Therefore, measures such as establishing and improving vaccine supervision and standardizing the vaccination services are key factors in the effective promotion of COVID-19 vaccines.
In this study, more than half of the participants stated that they learned about the vaccine through the internet, but the online information was intricate and required scientific knowledge. The lessons from previous public health emergencies, such as the Fukushima nuclear leak, Ebola outbreak, and bird flu, remind us that reliable sources of information are essential for disease control and maintaining social stability. Therefore, it is recommended that the government strengthen the regulation of the information in the online media. Furthermore, its emergency response ability in managing public health emergencies should include increase in the offline training and publicity of COVID-19 vaccines among the population. For example, publicizing information about COVID-19 in hospitals and distribution of information brochures can effectively cultivate the patients’ abilities to identify the authenticity and effectiveness of the information disseminated on the internet and to avoid the spread of false information.Citation30
This study found that the price of the vaccine was an influential factor for the willingness to be vaccinated, which was consistent with the findings of Wong et al.Citation31 The logistic regression analysis showed that people were more willing to get vaccinated if the vaccine price was 101–500 yuan than when the price was under 100 yuan (OR = 1.87, 95% CI: 1.16–3.02). As a health-related product, a low-priced vaccine will make the people doubt its effectiveness, while a very high price will make it difficult for the people to afford. However, considering the severity of COVID-19, it is recommended that the government make it available to the population as a free public health product. Compared to outpatients with a monthly income of less than 3,000 yuan, those with a monthly income of more than 6,000 yuan were more willing to receive the COVID-19 vaccine (OR = 2.13, 95% CI: 1.03–4.41). This is consistent with the findings of Yang et al.Citation32 Compared to the general population, outpatients are more concerned about their health problems and may suffer psychologically due to their illness.Citation33 Vaccination against COVID-19 can reduce the chances of being infected and help reduce their mental burden. Therefore, high-income outpatients paid serious attention to the media news about COVID-19 vaccines and looked forward to being vaccinated. Those with good self-rated health condition were more willing to receive COVID-19 vaccination (OR = 1.71, 95% CI: 1.01–2.90). Individuals with good self-rated health condition usually tend to purse good health conditions, and the COVID-19 vaccine provides them with a chance to avoid infection. On the other hand, those with bad self-rated health may worry about the side effects of the COVID-19 vaccine on their body and may be unwilling to be vaccinated. It is recommended that the government strengthen the popularization of the scientific rationale of vaccines among the population.
During this study, the COVID-19 epidemic occurred repeatedly in China, and the number of outpatients in hospitals was greatly reduced, resulting in a small sample size for this investigation. This is a limitation of this study, and we will conduct further in-depth research after the epidemic has stabilized.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
Ethical considerations
The study was accessed by ethics commission of the university and approved by the person responsible for the university. The participates were obtained after reading the informed consent and ensuring that they were voluntary in the study.
Acknowledgments
We would like to thank the leaders, managers, and all participants in the project for the hospitals. This study was supported by Humanity and Social Science Youth Foundation of Ministry of Education of China (16YJC880098), Medical education project of Chinese Medical Association and Chinese Higher Education Association (2018B-N18055), Project of the 13th Five-Year Plan for Education Science of Jiangsu Province of China (C-c/2018/01/10), Project of Research on Education Informatization of Jiangsu Province of China (20172223), Top-quality project of social science application research in Jiangsu Province(20SYC-164).
Correction Statement
This article has been republished with minor changes. These changes do not impact the academic content of the article.
Additional information
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