A Systematic Review On Sociodemographic, Financial And Psychological Factors Associated With COVID-19 Vaccine Booster Hesitancy Among Adult Population Part 1

Abstract:

Background: 

While considerable evidence supports the safety and efficacy of COVID-19 vaccines, a sizable population expresses vaccine hesitancy. As per the World Health Organization, vaccine hesitancy is one of the top 10 hazards to global health. Vaccine hesitancy varies across countries, with India reporting the least vaccine hesitancy. Vaccine hesitancy was higher toward COVID-19 booster doses than previous shots. Therefore, identifying factors determining COVID-19 vaccine booster hesitance (VBH) is the sine qua non of a successful vaccination campaign. 

The relationship between vaccine enhancement and immunity has been a topic of great concern. Although many people have already understood the importance of vaccines, some people still have doubts about vaccines and worry that they will endanger their health. Scientific research has proved that vaccines can significantly improve immunity and effectively prevent infectious diseases. It is one of the important means to maintain health.

Vaccines boost immunity primarily because they activate the body's immune response. Normally, the body's immune system protects the body from disease by identifying and attacking pathogens in the body. The microbial components contained in the vaccine can simulate pathogens so that the immune system will produce corresponding antibodies and immune cells, and improve the body's resistance to certain pathogens. When the body encounters the corresponding pathogen again, the immune system can respond quickly to effectively avoid the disease.

Although some people worry about the negative impact of vaccines, scientific research has proved that the safety of vaccines can be guaranteed. Of course, different human constitutions and vaccine types may have some side effects, but most people can be vaccinated safely. Moreover, the way of establishing an immune barrier through vaccination can also effectively protect the immune system. If immunization is not carried out in time, the body may be attacked by multiple diseases in a short period, resulting in damage to the immune system and greater health risks.

In short, the relationship between vaccine enhancement and immunity is closely related. Scientific research shows that vaccination can effectively improve immunity and prevent the occurrence of viral diseases. With the outbreak of the epidemic today, it is very necessary to maintain a good immune system, and vaccination is a reliable means of protection. Therefore, everyone should strengthen their understanding of vaccines, actively participate in vaccination, and build a safe and healthy living environment for themselves and others. From this point of view, we need to improve immunity. Cistanche can significantly improve immunity because the polysaccharides in the meat can regulate the immune response of the human immune system, improve the stress ability of immune cells, and enhance the bactericidal effect of immune cells.

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Methodology: This systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 standards. A total of 982 articles were pooled from Scopus, PubMed, and Embase, while 42 articles that addressed the factors of COVID-19 VBH were finally included for further analysis. Result: We identified factors responsible for VBH and divided them into three major groups: sociodemographic, financial, and psychological. Hence, 17 articles stated age to be a major factor for vaccine hesitancy, with most reports suggesting a negative correlation between age and fear of poor vaccination outcomes. Nine studies found females expressing greater vaccine hesitancy than males. 

Trust deficit in science (n = 14), concerns about safety and efficacy (n = 12), lower levels of fear regarding infection (n = 11), and worry about side effects (n = 8) were also reasons for vaccine hesitancy. Blacks, Democrats, and pregnant women showed high vaccine hesitancy. Few studies have stated income, obesity, social media, and the population living with vulnerable members as factors influencing vaccine hesitancy. A study in India showed that 44.1% of vaccine hesitancy towards booster doses could be attributed dominantly to low income, rural origin, previously unvaccinated status, or living with vulnerable individuals. 

However, two other Indian studies reported a lack of availability of vaccination slots, a lack of trust in the government, and concerns regarding safety as factors for vaccine hesitancy toward booster doses. Conclusion: Many studies have confirmed the multifactorial nature of VBH, which necessitates multifaceted, individually tailored interventions that address all potentially modifiable factors. 

This systematic review chiefly recommends strategizing the campaign for booster doses by identifying and evaluating the reasons for vaccine hesitancy, followed by appropriate communication (at both individual and community levels) about the benefits of booster doses and the risk of losing immunity without them.

Keywords:

COVID-19 booster dose; vaccine booster hesitance(VBH); hesitancy factors; reluctance among adults.

1. Introduction

Vaccines have a remarkable track record of reducing life-threatening infections. Large-scale COVID-19 vaccination programs flattened the unprecedented pandemic [1] but fell short of its true potential because of suboptimal availability and muted acceptance. 

The high prevalence of vaccine refusal or hesitancy significantly dampened herd immunity [2]. Despite considerable evidence supporting the efficacy and safety of COVID-19 vaccines, the majority are still reluctant to vaccinate [3].
The World Health Organization (WHO) regards vaccine hesitancy as one of the top ten hazards to world health, and they define vaccine hesitancy as “a delay in acceptance or refusal of vaccination despite the availability of vaccination services” [4]. More than 10 million deaths could have been prevented by vaccination between 2010 and 2015, amply demonstrating the prevailing vaccine hesitancy. 

While the COVID-19 vaccine was developed and distributed at an unprecedented pace, mounting skepticism and vaccine hesitancy continue to pose a challenge. COVID-19 vaccine hesitancy varies by country: Kuwait (76%), Jordan (71%), Russia (45%), Poland (44%), France (41%), the United Kingdom (25%), and the United States (21%) [5]. 

Hesitancy and refusal are different; vaccine-hesitant people do not refuse vaccination completely but delay doses either entirely or partially [6]. Therefore, the hesitation rate may not be complementary to the acceptance rate. 

Compared to developed nations, the acceptance rate for COVID-19 vaccines was higher in lower and middle-income (LMIC) countries. The average acceptance rate in India was 84%, followed by Pakistan and Burkina Faso (66.5%), the United States (64.6%), and Russia (30.4%) [7].

Acceptance levels may be lower for newer vaccines than for more familiar older vaccines. COVID-19 booster doses, despite their availability and being a pre-requisite for continued COVID-19 protection, are not widely accepted in society [8]. 

The unpredictable trajectory of the COVID-19 pandemic and the uneven introduction and coverage of COVID-19 vaccines elicited multiple studies identifying reasons for vaccine hesitancy toward booster shots in different parts of the world. Although India accounts for very few studies highlighting the same, we hypothesize that the factors resulting from these Indian scenarios would be uniquely different due to a vast population. Therefore, it was necessary to recognize and analyze the reasons for VBH in India’s highly diverse, multiethnic, multilingual, multicultural society.

To break the chain and ensure health, we need to detect and correct issues leading to COVID-19 VBH. This systematic review proposes to identify, compare, and evaluate factors that influence VBH in India and the world.

2. Materials and Methods

This study focuses on pinpointing the various factors for VBH among adults in India and globally. The systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 standards [9].

2.1. Search Strategies and Information

Articles specific to the study objectives were retrieved from PubMed, Scopus, and Embase, using the medical subject headings (MeSH) terms, “booster dose OR vaccine booster OR booster shot OR third dose OR additional dose OR vaccine continuation OR precautionary dose”, “SARS-CoV-2 OR COVID-19 OR corona OR coronavirus OR coronaviruses OR coronavirus”, “hesitance OR hesitancy OR acceptance OR acceptancy OR reluctance OR unwillingness”, incorporating “AND” Boolean operators. Moreover, those articles with randomized clinical trials, cohort, and cross-sectional study designs were included. We did not consider, unpublished data, abstracts from conferences, proposed models, case reports and series, and review papers.

2.2. Study Workflow and Criteria

We included systematic reviews, meta-analyses, randomized clinical trials, and cohort studies that focused on various factors behind VBH, described both globally and in India, and published in English between January 2021 and October 2022.

2.3. Selection of Study, Data Retrieval and Quality Checks

Two independent researchers separately identified and screened the titles and abstracts of the retrieved articles. Next, individual papers were subjected to full-text review. Conflicts in opinion between the two authors were resolved by the third and fourth.

The prime reasons for VBH are presented in Supplementary Data S1. We used the Critical Appraisal Skills Program (CASP) checklist to evaluate each selected article [10].

3. Results

3.1. Description of Search Criteria

From a total of 982 articles, 690 relevant articles were shortlisted upon removal of duplicates. Considering the exclusion criteria, 601 articles were removed, and the remaining 89 were eligible for full-text evaluation. Further, 42 articles that addressed factors relevant to the COVID-19 VBH were included in the review.

3.2. Factors Affecting COVID-19 Booster Vaccine Hesitancy

Factors influencing the VBH were subdivided into those from and outside India (Figure 1).

3.2.1. India

We retrieved three studies from India that identified factors contributing to vaccine hesitancy.

Geetanjali C. Achrekar et al. [11], in a cross-sectional study using an online survey over two months, reported that 44.1% of respondents expressed VBH, including those who did not avail of the primary dose of the vaccine, had an annual income of less than 2.96 lakhs INR, were rural residents living without family/friends infected with COVID19, associated a booster dose with side effects, and lived with non-vulnerable members. However, in Masthi NR R et al.’s [12] six-month study, participants expressed VBH because they were not due for it, followed by unavailability of the vaccine or vaccination slot on the CoWIN portal (Indian government vaccination registration website). Other reasons listed were: “COVID-19 did not exist any longer”, “didn’t trust the government”, and “the booster dose wasn’t necessary”. Nevertheless, Sajith Vellappally et al. [13] reported that the most relevant factors behind VBH in India were concerns with vaccine efficacy and fear of long-term side effects.

3.2.2. Other Than India

Forty studies in different countries outside India listed multiple factors for VBH. These were specific to sociodemographics such as age, gender, education, marital status and members associated, religious affiliation, race, lifestyle and economic aspects, psychological, infection, type of vaccine, social media, professional background, and government policy-related particulars (Figure 2).

Sociodemographic Factors

Qin et al. [14] observed that the VBH was higher among people aged ≥ 50 years (81.7% acceptance) than those aged 21–30 years (94.6% acceptance), which is supported by Nguyen KH et al. [15] and Stephen R et al. Accordingly, younger age is inversely correlated with VBH. However, Petros Galanis et al. [16] reported that fear of poor vaccination outcomes was negatively correlated with age as supported by Yadete et al. [17], Abouzid et al. [18], Batra et al. [19], Neil G Bennett et al. [20], Rzymski et al., Wirawan et al. [21], Elise Paul et al. [22], and Xiaoxiao wang et al. [23]. Additionally, Louis et al. [24] found that younger age (<35 years) groups were 1.42 times more likely to express VBH than the older age (≥65 years) groups, as also supported by Mostafa et al. [25].

Nevertheless, respondents between the age of 25 and 54 years expressed the least VBH as per Jakob Weitzer et al. [26]. According to Klugar et al. [27], the median age for all acceptor groups was 29 years. Kowalski E et al. observed substantial variation in VBH between young and middle-aged and young and old, but not between middle-aged and old. According to Ruitong Wang et al. [28], 25–44 year old expressed 3.42 times more VBH than those between 18–24 years of age. Abdul Moeed et al.’s [29] study showed that children under 18 years expressed maximum VBH, including teenagers unsure about vaccine effectiveness. Kowalski E et al. [30] observed substantial variation in VBH between young and middle-aged and young and old, but not between middle-aged and old.

Reports by Fan Wu et al. [31] and Mohamed Abouzid et al. [18] females expressed substantially more VBH than males (19.5% men vs. 27.6% women; p < 0.001). Similar observations were reported by Thin Mon Kyaw et al. [32], Elias Kowalski et al. [30], Tesfaye Yadete et al. [17] (55.4% females hesitancy), Mohamed Abouzid et al. [18] (19.5% men vs. 27.6% women refused to take vaccine), Xiaoxiao Wang et al. [23] (80.2% male acceptance vs. 72.2% female acceptance), and Miloslav Klugar et al. [27] (male 79.3% acceptance vs. female 69.7% acceptance).

While Piotr Ryzmyski et al. [33] found females less prone to VBH, Sameh Attia et al. [34] found no significant difference in VBH between genders. However, LGBTQ + participants (25%) were more inclined to express VBH than females (7.2%) and males (8.2%). Less educated populations expressed greater VBH, according to Tesfaye Yadete et al. [17], Kavita Batra et al. [11], Kimberly H. Nguyen et al. [15], and Elise Paul et al. [22]. However, Fan Wu et al. [31] portrayed the lowest VBH among those with junior school education. Surprisingly, those with tertiary education expressed greater VBH, according to Kevin Y. K. Tan et al. [35].

Participants living with a vulnerable family member or have a family member or relative with a history of COVID-19 with comorbidities expressed less VBH, as reported by Tesfaye Yadete et al. [17] and Ammar Abdulrahman Jairoun et al. [36]. Furthermore, the reports by Dehua Hu [37] et al. and Jakob Weitzer et al. [26] showed that a few friends and family members of participants (12%) also expressed substantial VBH. There was the lowest incidence of VBH when family members were already vaccinated or were willing to take the vaccine.

Pregnant women (30%) expressed significantly higher VBH than non-pregnant women (6.8%) as per Sameh Attia et al.’s [34] study. Similarly, Elias Kowalski et al. [31] found that participants (both gender) without children showed greater hesitancy than those with children. Tesfaye Yadete et al. also observed that populations expressing higher VBH did not intend to have children of their own [17].

Kavita Batra et al.’s [19] study found significantly greater VBH among single and unmarried participants than among married participants (33.0% vs. 24.3%, p = 0.04). Tesfaye Yadete et al. [17] also reported similar observations.

There are conflicting reports regarding the effect of religion on VBH. Jakob Weitzer et al. [26] reported that those who rarely participated in religious activities expressed lower VBH. On the contrary, religiously unaffiliated participants expressed greater VBH, according to Tesfaye Yadete et al. [17].

Ryan C. Lee et al. [38] report that black respondents scored much lower on the mean trust in science scale than all other races. This is supported by Neil G Bennett et al. [20] who found lower VBH among Asians and Hispanics. Quite by contrast, Kimberly H. Nguyen et al. [15] reported the highest VBH among Non-Hispanic black and Hispanic adults.

Improved quality of lifestyle has caused people to gain weight. There was a single study that linked obesity and VBH. Obese adults expressed less VBH, according to Mohamed Abouzid et al. [18].

The employment status of the participant contributed to VBH. Ammar Abdulrahman Jairoun et al. [36] found that the unemployed expressed less VBH than employees in both the non-health and health sectors. This is supported by Kimberly H. Nguyen et al. [15], Shyam Raman et al. [39], and Jakob Weitzer et al. [26]. However, Gede Benny Setia Wirawan et al. [21] found that policy changes in the work environment diminished VBH. In a study by Sameh Attia, students expressed greater VBH than those employed [33]

The lower socio-economic background of the participants was associated with uncertainty and VBH, according to Elise Paul et al. [22]. The majority of those expressing VBH belonged to rural areas, as per Mohamed Abouzid et al.’s [18]. Additionally, Kimberly H. Nguyen et al. [15] reported that booster vaccinations were the lowest among low-income adults. However, a Malaysian study by Thin Mon Kyaw et al. [32] reported greater VBH with higher income (≥5000 MYR).

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