https://orcid.org/0000-0002-5576-402X
ABSTRACT
The worldwide effort to recover from the COVID-19 crisis is now at its pinnacle with the putative vaccine against SARS-CoV-2. To reach herd immunity, it has become an urgent global need to understand the emotional factors that drive people’s choice to get vaccinated. Therefore, this exploratory study examined emotional motivations as predictors of the decision to receive the vaccine. The sample (N = 627) included adult (18+) participants in Israel who were recruited by a snowball sampling. The participants filled out an online survey when the vaccines have become widely available in Israel. Within the entire sample, as well as among people who did not receive the vaccine yet, hope was the only factor that was associated with their willingness to be vaccinated; higher levels of hope were related to willingness to be vaccinated. The results of the study indicate that hope is an important factor related to motivation to receive the SARS-CoV-2 vaccine.
The worldwide endeavor to recuperate from the COVID-19 crisis is now at its peak with the vaccines against SARS-CoV-2. To reach herd immunity, the vaccination rate would need to range between 60% and 100%, depending on its effectivenessCitation1, and therefore the public’s acceptability of the immunization is critical.Citation1,Citation2 Nevertheless, a few research groups have already demonstrated a worrisome hesitancy among populations to receive the vaccine.Citation2–8 In France, 26% of the survey participants expressed refusal to be vaccinated;Citation5 in Italy, 15.3% of the respondents reported they would refuse to be vaccinated, and 26.2% indicating hesitancy.Citation3 In the US 31.6% respondents in an adult representative sample were hesitant, and 10.8% did not intend to be vaccinated.Citation4 In Ireland 35% of a representing sample expressed vaccine hesitancy, and in the United Kingdom 31% were hesitant.Citation9 In these studies, the reasons for the vaccination hesitancy were lack of trust in authorities, the concerns about long-term side effects and about the vaccination’s safety. A recent study found that social norms were a significant predictor of vaccine hesitancy.Citation6
Based on these concerning findings, it has become an urgent public health need to understand the motivational and emotional factors that influence vaccination behavior, and help leaders and policymakers communicate the benefits of the vaccine in order to enhance these motivations and promote vaccination rate.Citation1,Citation2,Citation5 Many of the studies have focused mostly on demographic characteristics as predictors of willingness to be vaccinated, e.g., age, education level, and socioeconomic status (SES). In these studies, it was found that younger age, having lower education and SES predicted higher SARS-CoV-2 vaccine hesitancy.Citation2–5 In addition, it was found that lower health literacy was a predictor of lower willingness to be vaccinated.Citation2,Citation6 However, looking only at demographic factors or specific attitudes may limit the understanding of what are the underlying psychological and emotional motivations that drive people to receive the SARS-CoV-2 vaccine. The existing literature indicates that there are several psychological characteristics, including personality traits, locus of control, cognitive styles, and political attitudes, that are related to vaccination hesitancy.Citation9 These studies are important; however, they are focused on more stable psychological or social characteristics, that are harder to modify or to impact. Additionally, very few studies focused on positive emotions as motivators that predict willingness to be vaccinated. One study found that triggering altruism increased the willingness to get vaccinated more than other internal motives such as self-protection.Citation10 Therefore, there is still an urgent need to identify situational emotional motivators or positive motivations, that could be impacted to promote willingness to be vaccinated.
In response to this need, this exploratory study examined situational emotional motivations alongside demographic factors as predictors of the decision to receive the SARS-CoV-2 vaccine. Specifically, it was examined whether fear of COVID-19Citation11–15 and hope specifically related to the vaccine may possibly impact this decision. Fear of COVID-19 could motivate people who want to avoid the infection or its complications. Hope is an important emotional motivation and a vital coping resource that could lead to proactive health behaviors.Citation11 Hope is defined as a state of positive motivation based on determination to achieve one’s objectives and goals.Citation12 Moreover, hope is also a modifiable factor, which can be developed and increased using education.Citation13 Studies exploring vaccines hesitancy rarely asked about vaccine-related hope as a predictor of vaccine uptake. For example, a large study conducted in the UK and in IrelandCitation9 (N = 3,066), explored vaccine hesitancy related psychological factors such as trust and altruism. Another study conducted in the US (N = 1,000),Citation4 found that reasons for vaccine hesitancy included vaccine concerns, a need for more information, antivaccine beliefs, and a lack of trust. However, in these studies, hope as an emotional motivator was never assessed, although it could be a powerful motivator for vaccine uptake.
In light of the limited literature about hope related to the vaccine uptake and the existing literature about other related demographic factors, this study advanced two research hypotheses. The first research hypothesis predicted that older age, higher education level, higher SES, having risk for COVID-19 complications and being a health care professional will be related to higher levels of willingness to be vaccinated. The second hypothesis predicted that higher levels of fear of COVID-19 and higher levels of hope regarding the vaccine will be related to higher levels of willingness to be vaccinated.
After receiving an ethics approval from the Helsinki committee at the Shalvata Mental Health Center (approval number: 0012–20-SHA), an online survey was administered in Israel during January 1st–6th, 2021 approximately two weeks after the vaccination operation has commenced. Israel is one of the leading countries in COVID-19 vaccination rates, with 62.84% of the population already vaccinated (May 2021).Citation14 Since in Israel the vaccines have become gradually available for everyone who chooses to receive it, with older people and healthcare workers receiving it first, examining willingness to be vaccinated in Israel is not a hypothetical question, but rather a realistic and timely question for the study participants. The sample was recruited using a virtual snowball sampling method and all participants signed an informed consent document. No incentive was offered to the participants. To allow broad and diverse sampling of the Israeli society, the virtual snowball sampling was conducted through advertising widely in social media, including Facebook pages and groups with thousands of followers in different professions. To ensure that the sample is not biased in terms of the participants’ attitudes toward vaccination, Facebook groups focused on vaccine support or vaccine hesitancy were avoided. In addition, and to broaden the sample, an invitation to participate in the study was sent to large listservs of physicians (e.g.: the Israel medical association listserv), other healthcare workers, and the general population. In the current sample (N = 627), aged 18+ participants, who were healthcare and non-healthcare workers, were asked whether they had received the vaccine, and if not, whether they were willing to receive it in the future. Furthermore, participants were asked, in an open-ended question, to state the main reason(s) for their decisions, and to complete the validated fear of COVID-19 scaleCitation15 translated to Hebrew.Citation16 The total score of the fear of COVID-19 scale ranges between 7 and 35, with a higher sum score indicating higher levels of fear of COVID-19. The participants also completed a demographic questionnaire. They indicated their age, their gender, their education level, their socioeconomic status, and whether they have any health risk factors that may put them at risk for COVID-19 complications. The participants were also asked to state their occupation and whether they were healthcare workers or not.
Finally, the participants were asked how hopeful they felt about the COVID-19 vaccination (on a Likert scale ranging between 1 – feeling very unhopeful to 6 – feeling very hopeful). This single item measurement was chosen since no other scales for this specific hope are known, and since single-item self reported measurements are common in positive psychology (e.g.: the single-item Satisfaction with Life ScaleCitation17). In addition, participants who stated that they received the vaccine or were willing to receive it were asked to openly share in writing what were their main reasons for their decision to receive the vaccine. The demographic data of the study sample are presented in .
Table 1. Demographic characteristics of the sample by groups (N = 627)
To examine which factors were related to the willingness to be vaccinated, a multiple logistic regression was conducted with demographic variables (age, gender, education level, SES, risk for COVID-19 complications), and emotional variables (fear of COVID-19, and hope levels) as independent variables, and the willingness to take the vaccine as a dependent variable. Across all analyses, we used alpha criteria of below 0.05 as a threshold for significant results. The qualitative data was analyzed using thematic content analysis,Citation18 following these stages: generating initial codes, searching for themes, reviewing themes, defining and naming the themes, and producing the report.
Before running the multiple logistic regression, we examined the levels of multicollinearity between the independent variables. All Variance Inflation Factors (VIF) values were lower or equal to 1.442, indicating very small levels of multicollinearity in the data. Hence, we conducted the multiple logistic regression with all the aforementioned variables. The results of the logistic regression analysis are presented in . The first hypothesis wasn’t confirmed. Within the entire sample, only age and being a health worker were significantly related to willingness to vaccinate. However, as can be seen from the odds ratios and confidence intervals, age’s odds ratio (OR = .98) indicates that there is no real difference in willingness to vaccinate between the different ages. The confidence interval for being a health care worker (95%CI[.33,.93]) suggests that the effect for being an healthcare worker might be random. Therefore, while these effects are significant, they might be meaningless, hence we prefer to not further discuss them. All the other demographic variables were not related to the willingness to be vaccinated.
Table 2. Logistic regression coefficients for the entire sample analysis
The second research hypothesis was partially confirmed. Hope was the only additional factor that was significantly and strongly associated with willingness to be vaccinated (OR = .43, 95%CI[.35,.52], p < .001), indicating that higher levels of hope were related to willingness to be vaccinated. The fear of COVID-19 was not related to the willingness to get vaccinated (OR = .99, 95%CI[.94,1.04], p = .66). Importantly, Fear of COVID-19 was uncorrelated to hope (r = .065, p = .10), suggesting that these two constructs are independent from each other, and their association can not explain these results.
To ensure that the relationships between hope and willingness to be vaccinated are not biased by those who already got vaccinated, we further examined only those who have not been vaccinated yet (n = 328). As vaccination was given in Israel based on age and with priority to healthcare workers and people with health risk factors for Covid-19 complications, no wonder that (as can be seen in ) those who still haven’t got the vaccine were younger in average (t(570.32) = 6.99, p < .001), less educated (χ2(4) = 64.11, p < .001), and in a lower SES (χ2(4) = 30.28, p < .001), and that there have been less healthcare workers (χ2 (1) = 124.56, p < .001) or people who have risks from COVID-19 (χ2 (1) = 4.47, p = .038) among this group. However, these two groups did not differ in their levels of fear from COVID-19 (t(622) = .367, p = .714) or genderFootnote1 (χ2 (4) = 5.76, p = .218), suggesting that they are only differ on age-related variables.
Although the non-vaccinated group was differed in the demographic data comparing to the vaccinated group, using the same variables and analysis had arisen a similar pattern of results. Hope was the only variable that has been strongly associated with willingness to get vaccinated OR = .45, 95%CI[.36, .56], p < .001). None of the other factors were found to be meaningful or significantly related, see .
Table 3. Logistic regression coefficients for those who still haven’t been vaccinated
The thematic analysis revealed that participants who received the vaccine, or were willing to receive it, mainly expressed these reasons for their decision: (1) The belief in the vaccine as a way to protect themselves and others in their communities, as one of the participants stated: “I believe that this is the best way that I can protect myself.” (2) The hope to be back to personal routines (e.g., meeting family members, traveling abroad). For example, one of the participants stated: “I believe that the vaccine is our only hope to live our life fully again,” or as another participants stated: “I am hoping to have my life back!” and “I wish to have social life again, having culture, vocational activities and vacations in my life.” Lastly, (3) Participants expressed the hope and belief that the vaccine would be the solution for the COVID-19 societal crisis, this is an example of how a participant expressed this hope: “I strongly believe that this will be the way to end this pandemic.” Healthcare professionals commented about their hope to help and protect their clients by taking the vaccines, for example one of the healthcare workers stated: “I am working as a physician, and am exposed to covid patients, I wouldn’t like to pass it on to my family or my patients,” and another healthcare worker commented: “I hope that the vaccine will help me to avoid transmitting the virus, I wouldn’t like to transmit it to others.” These qualitative findings suggest that people were hopeful about the possibility that the vaccines will become a “game changer,” that they will allow improvement on both personal and societal life.
Most studies in this area stressed the centrality of negative feelings in relation to vaccine uptake,Citation8 this study found that addressing positive feelings such as hope is important when considering vaccination choices. This exploratory short report sheds some light on the importance of emotional motivators in relation to the willingness to be vaccinated with the SARS-CoV-2 vaccine. The Israeli population was an excellent setting to examine the impact of emotions on the willingness to be vaccinated, since the COVID-19 vaccines are widely available, and therefore the decision is tangible and realistic for the participants and not hypothetical as was measured in previous studies in this area.Citation2,Citation5
The first research hypothesis was not confirmed, although in previous studies, age was a predictor of willingness to be vaccinated, and older people were more willing to be vaccinated than younger people, in this study age was not a meaningful factor among the entire sample, and was not a meaningful nor significant factor among people who were not vaccinated yet. Additionally, in previous studies, being a health worker predicted willingness to vaccinate, related to health workers’ trust in health authorities, literacy in health, and wanting to protect themselves, relatives and their service users. In this study it was not meaningfully related to willingness to get vaccinated. These two results may be attributed to the fact that most of the older population and healthcare workers were already vaccinated in this sample, and therefore when looking at the unvaccinated group only, it included younger people who are not healthcare workers. As opposed to previous studies, other demographic variables (including education level, SES), were not predictors of the decision to be vaccinated. We believe that this difference could be attributed to the fact that the Pfizer vaccines are offered free of charge and equally all over Israel and therefore are very accessible. Israel is geographically small, which allows people to easily approach clinics and hospitals to receive the vaccines if they chose to receive them. It could be that the accessibility of the vaccines eliminated the impact of socioeconomic status. This finding suggests that making the vaccines accessible is an important factor related to their uptake.
In line with the second research hypothesis, hope was the strongest predictor for willingness to be vaccinated. Within the sample of people who were not vaccinated, and in the context of the study and the specific measured variable, hope was the only meaningful predictor of willingness to vaccinate. The findings about hope are novel and reflect the importance of studying emotions as motivators for willingness to receive the SARS-CoV-2 vaccine. Other studies in this field tested related variables,Citation1,Citation2 but did not assess hope related to willingness to be vaccinated. This novel finding could be explained by the fact that the studies cited explored willingness to take the Covid-19 vaccines, as a hypothetical question. The current study was conducted in a very special timing, at the actual time when the participants either had already made a choice and got vaccinated or needed to make a choice shortly. This is because the vaccines became widely available and highly accessible for all (with older people, people at risk for Covid-19 complications, and HCP’s having a priority, and shortly after the whole population having free access to vaccinations).
The hypothesis that fear of COVID-19 would be related to the decision to be vaccinated was not confirmed. This is a surprising finding, as it was expected that fears would lead to willing to be vaccinated. This finding could be explained by the stronger impact of hope, that was expressed by participants who were willing to be vaccinated, as was indicated in the qualitative findings.
The difference between our findings and previous studies that found fear and anxiety as important emotional factors related to vaccine uptake, could be that most of these studiesCitation2–4,Citation6,Citation7 were conducted when the SARS-CoV-2 vaccines were not yet available, and the responses of the participants about willingness to be vaccinated were hypothetical. This study was conducted while all the participants had, or would have had shortly, free access to the vaccine, and therefore in an actual position of taking action.
It is important to state that taking an action is what makes hope related to the vaccines different than optimism. Both optimism and hope reflect the extent to which one believes that the future will be positive.Citation19 However, optimism is defined as general positive outcome expectations,Citation20 and hope is a cognitive set that is based on a sense of a successful agency to meet the goal. Therefore, hope is directly concerned with the actions one can take to create a successful future.Citation21 Simply put, the optimistic person believes that somehow – the pandemic will be over eventually. The hopeful person, on the other hand, believes that taking an action and be vaccinated is the pathway to end the pandemic, or at the very least be more protected or protect others. It is interesting to note, that overoptimism was related to low willingness to be vaccinated,Citation7 whereas in our study, hope regarding the vaccine was related to willingness to be vaccinated.
This study attempted to address an important and timely concern about the hesitancy of people to receive the SARS-CoV-2 vaccine, and it has some limitations. One limitation is that the sample was based on a non-probability snowball sample, which could have caused selection bias, and pose a threat to external validity. Additionally, within the limitations of this study we did not measure other variables such as optimism, trust, or feelings of being pressured to vaccinated by the workplace (such as healthcare settings). Future studies may compare between more stable personality traits such as optimism and trust, and more situational variables such as hope, and workplace pressure to be vaccinated. In future studies it is also important to explore how hope may be experienced in different ways for people who are already vaccinated and those who are not. Lastly, it is hard to determine the causality between reported emotions and actual behavior, future longitudinal studies may need to follow levels of hope and actual vaccine uptake over time.
Nevertheless, these results also indicate the importance of hope held by individuals and societies in promoting vaccination rates. Hope, unlike demographic variables, might be more easily modifiable;Citation13 education and building trust regarding the vaccine might raise hope. Additionally, with the ongoing debate about human rights in times of the pandemic, finding positive motivations rather than using punitive means to increase the vaccinations rate is imperative. Future studies in this area may need to test if hope is modifiable among people who experience low hope, and what could be the impactful means to modify hope.
It is important to note that hope could be also manipulated in negative ways as well positively strengthened. This makes it crucial that the efforts to encourage hope will be directed toward encouraging vaccine uptake. Therefore, it may be beneficial for public health policymakers and leaders to encourage vaccinations rates by including strategies that nurture the hope that vaccination offer for individuals and communities. With due caution, and as vaccines become more available to larger populations in different countries, our results, focused on psychological motivations, may be relevant elsewhere.
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Notes
1. Gender included five options: “female”, “male”, “non-binary”, “other” or “prefer not to say”.
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