“When did you decide to receive the Covid-19 vaccine?” Survey in a high-volume vaccination center

ABSTRACT

Highly efficient and safe Covid-19 vaccines are available in Europe in amounts that theoretically allow for a high immune coverage. However, a notable proportion of the population is reluctant toward immunization. We aimed to determine, among people who chose to be vaccinated, when they made the decision and whether they would have preferred an earlier vaccination. A survey was conducted in a high-volume Covid-19 vaccination center in France from 28 May to 9 July 2021 through an anonymous questionnaire. The 2519 participants (54.1% males; median age 39 years) attributed lower efficacy and safety to Covid-19 vaccines than to vaccines in general. When asked when they decided to receive the vaccine, 15.5% and 16.0% answered “less than one month ago” and “less than one week ago,” respectively; age <40 and female sex were independently associated with these responses. When asked whether they would have preferred to have been vaccinated earlier, 57.6% answered “definitely no,” “rather no,” or “neither yes nor no”; female sex (independently from age) was associated with these answers. When asked whether they would have preferred to receive the vaccine as early as January 2021, 65.2% answered “definitely no,” “rather no,” or “neither yes nor no”; age <40 and female sex were independently associated with these responses. In conclusion, one-third people had made the decision to be vaccinated only recently, while more than half would not have preferred an earlier vaccination, in particular women and those aged <40 years. Vaccine campaigns should take such short-term decision-making processes into account.

KEYWORDS:

• Covid-19
• vaccines
• vaccine hesitancy
• decision-making process
• vaccine perception

Introduction

Efficient and safe Covid-19 vaccines were developed during the year 2020 and made available in December 2020. Immunization campaigns relying on RNA vaccines and adenovirus-based vaccines were subsequently launched in North America and Europe, among others, with a progressive rollout due to the number of available doses. “Real-life” data from countries with high vaccine coverage showed the dramatic impact of the vaccine on severe forms and deaths attributed to Covid-19,¹ as well as the positive effect on infection² and transmission rates.³ However, in several countries, the uptake of vaccines is not optimal,⁴ thus leading to the circulation of SARS-CoV-2 in unvaccinated populations. This discrepancy may be due to practical issues (e.g., reaching isolated or elderly populations) but also to vaccine hesitancy. In parallel to their unprecedented scale, the Covid-19 vaccine campaigns have been associated with a massive wave of disinformation regarding both vaccine efficacy and safety.^5,6 The wide dissemination of conspiracy theories may have worsened the already high level of vaccine mistrust that exists, particularly in France.⁷ More generally, the perceived lack of scientific consensus and the politicization of virtually all aspects of the Covid-19 crisis⁸ may have contributed to delaying people’s decision to receive the vaccine.

We conducted a study to investigate, among people attending a Covid-19 vaccination center, when they made the decision to receive the vaccine and whether they would have preferred to have been vaccinated earlier.

Material and methods

Vaccine facility

In the Isère department (population 1.288 million) in south-east France, 14 Covid-19 vaccination centers were opened in 2021 (in addition to general practitioners and retail pharmacies administering Covid-19 vaccines). We conducted a questionnaire-based survey in the main vaccination center of this area located in the periphery of the main city of Grenoble. The center performs 2,500 to 5,000 injections of mRNA-based vaccines daily (7 days/week).

Questionnaire

Covid-19 vaccination guidelines in France recommend that people receiving a dose of mRNA vaccine remain under medical supervision for 15 minutes to detect and treat any anaphylactic reaction. Voluntary anonymous participation in the study was actively proposed to people during this post-vaccination time. The questionnaire was accessible on a digital platform (Limesurvey®) on a tablet PC; most participants completed the questionnaire by themselves, although some required help from the investigators.

The questionnaire included questions on gender, age, distance between the participant’s residence and the vaccination center, perceptions about the efficacy and safety of vaccines in general and Covid-19 vaccines in particular, and any recent changes in their perceptions about Covid-19 vaccines. The questionnaire also explored when participants made the decision to be vaccinated, and whether they would have preferred to have been vaccinated earlier or receive the vaccine as early as January 2021 (the Covid-19 vaccination campaign began in France in the final days of December 2020) (cf. Supplementary Table 1).

Time period

The vaccination center where the survey was performed opened on 9 April, and the questionnaire was proposed over a period of 19 different days from 28 May to 9 July. In parallel, in France, vaccination was recommended for all people ≥55 years or those with comorbidities ≥16 years until May 31, then all people aged ≥16 years until June 15, and finally, all people ≥12 years.

Statistical analysis

The chi2 test was used to explore the association between two nominal variables, the Mann-Whitney test to explore the difference between two groups regarding one continuous variable, and the Spearman test to explore the correlation between two continuous variables. Logistic regression was used to assess whether two variables were independently associated with a nominal variable.

Results

Participants

A total of 2,519 participants completed the questionnaire. Median age was 39 years [IQR 27–51] (extremes: 18–87); 54.1% were males, who were younger than female participants (33 [IQR 24–47] vs 44 [IQR 32–55], p < .001). By comparison, in June 2021, 88,054 adults were vaccinated at the center (median age 44 [IQR 31–54]; 51.0% were males (median age 43 [IQR 30–53] and 49.0% were females (median age 44 [IQR 31–54]). Participants lived at a median of 5 km [IQR 4–15] from the vaccination center. When asked whether they considered themselves at risk of severe Covid-19, 24.5% answered “not at all,” 28.5% “not really,” 18.5% “neither yes nor no,” 17.0% “rather yes,” and 11.5% “definitely yes,” with an increase observed in the median age according to the answer (29, 38, 43, 43, and 52 years, respectively). Men considered themselves to be less at risk than women (not at all/not really: 43.4% vs 52.2%), but this association disappeared in the regression logistic analysis with the inclusion of age and gender. When asked whether they considered themselves well informed about Covid-19 vaccination, 43.9% answered “definitely yes,” 38.6% “rather yes,” 6.6% “neither yes nor no,” 9.3% “not really,” and 1.6% “not at all.”

Perceptions of vaccines

On a 0–100 scale, participants were asked to evaluate their perceptions of vaccines in general and Covid-19 vaccines in particular. Median perception of the efficacy of vaccines in general was 10 points higher than that of Covid-19 vaccines, and more participants had a lower perception of the safety of Covid-19 vaccines than vaccines in general (Table 1). Nevertheless, perceptions regarding the efficacy of vaccines in general and Covid-19 vaccines were correlated (R = 0.573, p < .001); the same observation was made for perceptions of safety (R = 0.706, p < .001). Among both men and women, those aged ≥40 years had significantly lower perceptions of efficacy and safety of vaccines in general but not of Covid-19 vaccines (Table 1).

Table 1. Perceptions of the efficacy and safety of vaccines in general and Covid-19 vaccines in particular on a 0–100 scale

				Vaccines in general				Covid-19 vaccines
				Efficacy Median [IQR]	p	Safety Median [IQR]	p	Efficacy Median [IQR]	p	Safety Median [IQR]	p
General				90 [80–95]		80 [70–90]		80 [70–90] (p < .001 vs vaccines in general)		80 [50–90] (p < .001 vs vaccines in general)
Gender	M	Age	<40	90 [80–98]	<.001	90 [75–95]	.008	80 [70–90]	.730	80 [65–90]	.216
			≥40	90 [80–95]		80 [70–90]		80 [70–90]		80 [60–90]
	F		<40	90 [80–95]	.004	80 [60–90]	.022	80 [60–90]	.556	70 [50–85]	.078
			≥40	80 [75–90]		80 [60–90]		80 [60–85]		70 [50–80]
At risk of severe Covid-19		Not at all/not really		90 [80–95]	.483	80 [70–90]	.149	80 [70–90]	.308	80 [55–90]	.125
		Other		90 [80–95]		80 [70–90]		80 [70–90]		75 [50–90]

Decision to receive the vaccine

Regarding the question “When did you decide to receive the vaccine?” the answers ranged from “as soon as the pandemic began in early 2020” (9.3%) to “less than one month ago” (15.5%) and “less than 1 week ago” (16%) (Table 2). Being aged <40 and being a woman were independently associated with the last two answers. Moreover, participants who did not perceive themselves to be at risk of severe Covid-19 (“not at all” or “not really”) made their decision more recently than others.

Table 2. Answers to the questions regarding the timing of the decision to receive the vaccine, and the preference to have received the vaccine earlier

		General	Age				Gender				Being at risk of Covid-19
			<40	≥40	p	p (MV*) OR (95% CI)	M	F	p	p (MV*) OR	Not at all/not really	Other	p
When did you decide to receive the vaccine?	As soon as the pandemic began in early 2020	9.3%	62.4%	74.9%	<.001	<0.001 0.53 [0.44–0.63] (OR for those ≥40 for the answer “less than 1 month/week”)	69.2%	67.7%	.445	0.014 1.25 [1.05–1.47] (OR for women for the answer “less than 1 month/week”)	59.1%	79.0%	<.001
	As soon as the vaccines were announced in late 2020	21.1%
	Between 6 and 3 months ago	10.7%
	Between 3 and 1 months ago	27.4%
	Less than 1 month ago	15.5%	37.6%	25.1%			30.8%	32.3%			40.9%	21.0%
	Less than 1 week ago	16.0%
Would you have preferred to receive the vaccine earlier?	Not at all	23.2%	57.5%	57.3%	.984	0.052 1.17 [1.00–1.39] (OR for those ≥40 for the answer “rather/definitely yes”)	50.4%	65.8%	<.001	<0.001 0.51 [0.43–0.60] (OR for women for the answer “rather/definitely yes”)	62.4%	51.9%	<.001
	Not really	22.4%
	Neither yes nor no	11.9%
	Rather yes	14.8%	42.5%	42.6%			49.6%	34.2%			37.6%	48.1%
	Definitely yes	27.7%
Would you have preferred to receive the vaccine as early as January 2021?	Not at all	30.8%	66.7%	63.6%	.118	0.002 1.31 [1.10–1.55] (OR for those ≥40 for the answer “rather/definitely yes”)	59.9%	71.4%	<.001	<0.001 0.56 [0.47–0.67] (OR for women for the answer “rather/definitely yes”)	71.2%	58.4%	<.001
	Not really	24.1%
	Neither yes nor no	10.3%
	Rather yes	13.1%	33.3%	36.4%			40.1%	28.6%			28.8%	41.6%
	Definitely yes	21.7%

F: females, M: males. *multivariate analysis including gender and age </≥40.

As participants’ answer to this question may have been influenced by the fact that certain age groups could not receive the vaccine during the first months of 2021, participants were also asked whether they would have preferred to receive the vaccine earlier: 23.2% answered “definitely no” and 22.4% “rather no,” while 26.7% answered “definitely yes” (Table 2). There was no statistically significant difference regarding age for this question (p = .052); being a man was independently associated with the answers “rather yes” and “definitely yes.” Conversely, those who did not perceive themselves at risk of severe Covid-19 (“not at all” or “not really”) were less prone to give these responses.

Finally, participants were asked whether they would have preferred to receive the vaccine as early as January 2021 when the vaccination campaign began; answers were distributed from “not at all” (30.8%) to “rather yes” (13.1%) and “definitely yes” (21.7%) (Table 2). Being aged ≥40 and being a man were independently associated with the last two answers. Again, those who did not perceive themselves at risk of severe Covid-19 (“not at all” or “not really”) were less prone to give these responses.

As expected, the answers to these three questions regarding the timing of vaccination were related to the perceptions of Covid-19 vaccines: those whose answers reflected a desire to be vaccinated earlier attributed better scores to the efficacy and safety of Covid-19 vaccines (Figure 1).

Figure 1. Score attributed to Covid-19 vaccine efficacy and safety according to the answers to the questions “When did you decide to receive the vaccine?” “Would you have preferred to receive the vaccine earlier?” and “Would you have preferred to receive the vaccine as early as January 2020?”

Participants were asked what motivated their decision to receive the vaccine; among the proposed list, the most cited reasons were “to see my relatives” (chosen by 50.0%), “to contribute to ending the pandemic” (45.9%), “to limit the circulation of the virus” (45.3%), “to protect myself against a severe form of Covid-19” (40.2%), “to be able to travel again” (38.2%), and “to be able to go out to a restaurant, cinema, etc.” (34.1%).

Evolution of perceptions regarding Covid-19 vaccines

Participants were asked whether their perceptions of Covid-19 vaccines had changed: 69.1% answered that they had not changed and declared that they already had negative (8.3%) or positive (61.8%) perception. Among the 29.9% of participants who declared a change in their perceptions, 0.6% declared that they had become much more negative, 1.6% slightly more negative, 19.5% slightly more positive, and 8.3% much more positive.

Discussion

In the unprecedented vaccine campaign rolled out to contain the Covid-19 pandemic, it has been decided in France not to make this vaccination mandatory in the general population (significantly, a law promulgated in July 2021 mandated the vaccine for healthcare workers). Therefore, reaching high vaccine coverage depends on the will of the population to be vaccinated. We therefore aimed to determine, among those who visited a vaccination center, when they made this decision.

We observed that the perceptions of vaccine efficacy and safety were lower for Covid-19 vaccines than for vaccines in general. This difference was already observed in a recently published study in Belgium⁹ and probably reflects both the very recent use of these vaccines and the impact of the anti-vaccination narrative echoed by the “traditional” media as well as social media.¹⁰ This may suggest that the acceptance of Covid-19 vaccines could progress in the coming years, as they will be considered “routine” immunizations.

We observed that the decision to receive the vaccine was recent (<1 month or <1 week) in nearly one-third of participants (15.5% and 16.0%, respectively). This illustrates the volatility of the decision-making process regarding Covid-19 immunization, which can potentially be related to the fact that a myriad of elements may influence this decision: the number of reported Covid-19 cases, the perception of disease severity, the communication of information about the efficiency of vaccines in “real-life” conditions, information about adverse effects (myocarditis, thrombosis with thrombocytopenia syndrome), family debates, the “anti-vaxx” messages regarding vaccine safety,¹¹ and so on. This may also explain changes in the intentions to receive the vaccine: in April 2020, one-quarter of participants in a French survey declared that they would refuse the vaccine;⁸ in October 2020, in response to the statement “if a vaccine for Covid-19 were available, I would get it,” 25% and 21% of French participants respectively declared that they “somewhat disagree” and “strongly disagree”;¹² the results were comparable in a survey from January 2021 (22% and 21%, respectively);¹³ however, in April 2021, a similar survey¹⁴ observed that among the unvaccinated (79% of the French adult population at the time), 42% “somewhat disagree” or “strongly disagree” with the aforementioned statement, meaning that the proportion of those refusing to be vaccinated had dropped to 33% of the total adult population. Our study confirms that vaccine hesitancy is a labile attitude, and that during a vaccination campaign, people may rapidly change their minds in favor of vaccination. Interestingly, this unstable attitude was also described in relation to other aspects of the Covid-19 pandemic such as wearing masks or accepting lockdowns.¹⁵

The fact that some participants had only recently decided to receive the vaccine may be because younger age groups were initially not targeted by the vaccine campaign. However, we also observed that more than 45% of participants would “definitely no[t]” or “rather no[t]” have preferred to receive the vaccine earlier, and more than 44% would “definitely no[t]” or “rather no[t]” have preferred to receive the vaccine in January 2021. This suggests that those who recently made the decision to be vaccinated were not impacted by the broadening of the vaccine targets. These declarations may potentially be related to the diverse perceptions of participants regarding Covid-19 in general and Covid-19 vaccines: the perception that they were not at high risk of contracting a severe form (as expressed by more than half of participants); the desire not to be one of the first people vaccinated so as to observe any adverse effects in the first recipients (the perception of Covid-19 vaccine safety increased with more positive responses in favor of earlier vaccination; Figure 1); or, as mentioned in another survey,¹⁶ the desire expressed by 59% of respondents to wait for a “French vaccine.” Interestingly, young age was also associated with higher level of vaccine hesitancy in previous studies; for example, among people aged 16 years and over, those aged 16–29 expressed the highest level of vaccine hesitancy in a British study performed during the first weeks of 2021.¹⁷ In a study performed in France in June and July 2020 among people aged 18–64 years,¹⁸ The effect of age was more complex, with a U-shaped relationship: those aged 25–64 years were more prone to negative attitude regarding Covid-19 vaccination than those younger and older.

We observed that women were less prone to receive the vaccine earlier. This may be related, once again, to their perception of being less at risk of severe forms. However, in multivariate analysis, the female participants of our study did not consider themselves less at risk than males when taking age in account. Moreover, the false allegation that Covid-19 vaccination leads to infertility was propagated during the first months of 2021;¹⁹ women may therefore have been more reluctant to receive the vaccine due to such alleged adverse events. This association between female sex and vaccine hesitancy may also be related to the fact that mothers are generally more committed (either positively or negatively) in vaccine-related questions regarding their children that fathers are,²⁰ which may result in women being more prone to consider vaccine-associated risks, even those suggested by unfounded rumors. This association of gender with Covid-19 vaccination intentions was already observed in previous French,²¹ Italian,²² British,²³ Japanese,²⁴ and multinational^25,26 studies.

We observed that among this population visiting a vaccination center for an immunization, 61.8% declared that they previously had a positive perception of Covid-19 vaccines with no recent evolution regarding this perception; among the 29.9% who declared a change in their perceptions, the vast majority (27.8% of participants) had a slightly or much better perception. Of course, as we only included subjects who had received the vaccine, very few answers reflected a negative change of perception. However, this is in accordance with the fact that a high proportion of participants decided only recently to be vaccinated, which also illustrates that positive changes in vaccine perceptions can occur, leading to a better vaccine coverage than could be expected from early intention polls.

Our study has several limitations, the first being the inclusion of participants whose vaccine perceptions were positive enough to lead to their immunization. People refusing the vaccination (at least at the time of the survey) may have also changed their mind recently, in a reverse manner as reported in this study. Moreover, the population who participated in this study was not identical to the general population attending the center, as our study participants were younger, with a higher proportion of men, and a greater difference in median age according to gender. The logistic regression performed in the study may mitigate this imbalance, although our results may not necessarily be extrapolated to the entire population. Finally, the survey duration was short, and we might have observed other trends before the end of May and after the beginning of July.

Conclusion

Our study illustrates that the decision to be vaccinated against Covid-19 is recent in a large part of the population. Communication efforts that target subjects who refuse or delay their immunization at a given time should be maintained, as positive changes may occur rapidly.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2021.2013081.

Disclosure statement

No potential conflictof interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.