ABSTRACT
The COVID-19 pandemic has caused negative impacts both on populations’ health worldwide. COVID-19 vaccines are currently developed and tested in clinical trials. However, limited studies have investigated the willingness to get COVID-19 vaccines in populations. Therefore, the study aimed to determine the individual’s willingness to accept and pay for COVID-19 vaccines, and knowledge, attitude, and perceptions (KAP) of COVID-19 vaccines, which hopefully will be available soon. Non-pregnant Chinese adults aged ≥18 years were asked to complete a self-administered KAP COVID-19 vaccine questionnaire distributed between March and May 2020. A total of 1179 participants (574 males and 605 females) were included and the mean age was 36.0 ± 11.5 years. Both the willingness to be vaccinated against COVID-19 and pay for COVID-19 vaccines were high (77.4% and 81.1%), respectively. Also, the most acceptable price range of COVID-19 vaccine was ¥501-1000 (US $ 75–149). Education and willingness to be vaccinated were significantly associated with some of the responses in KAP (P < .05). In conclusion, our study reported high willingness to be vaccinated against COVID-19 and pay for COVID-19 vaccines in Chinese population. Our findings also provided some important contributions for public health policy makers to formulate appropriate vaccination programs.
Introduction
COVID-19 pandemic is a global threat. A systematic review and meta-analysis of 30 studies (n = 53,000 COVID-19 patients) by Zhao et al. reported that the mortality was 3.1%.Citation1 In addition, the COVID-19 mortality increased significantly in the elderly and individuals with comorbidities including chronic disease and cardiovascular disease (CVD).Citation2 Currently, there are no specific drug therapies approved by the US Food and Drug Administration (FDA) for COVID-19 patients.Citation3 Therefore, the COVID-19 vaccines are considered one of the most promising strategies to combat COVID-19 pandemic.
Immunization is one of the important public health measures to protect individuals from contracting serious infectious diseases.Citation4 Especially when dealing with the coronavirus diseases 2019 (COVID-19) pandemic, the development and deployment of COVID-19 vaccines is crucial in limiting the spread of the COVID-19 pandemic before the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) acquired increased antiviral resistance.Citation5 However, high vaccination coverage is needed to stop the spread of the COVID-19 pandemic. Although some studies have been conducted to explore the vaccines against some emerging infectious diseases including Zika, Ebola, and dengue,Citation6–8 there are limited studies that have been conducted to assess the acceptance of COVID-19 vaccines.Citation3,Citation9 The results of such studies are very important for the health authorities to formulate the best suitable approach to implement COVID-19 vaccination programme, especially in developing countries.
In China, some vaccine uptakes including influenza vaccines have been reported to be lower (25%) than those of developed countries including United Kingdom (50%), Spain (51%), and the United States of America (USA) (79%).Citation10–13 Therefore, the study aimed to determine the individual’s willingness to accept and pay for COVID-19 vaccines, which are hopefully to be available soon. In addition, the knowledge, attitude, and perceptions (KAP) about COVID-19 vaccines amidst the COVID-19 pandemic were also investigated in Chinese population.
Methods
A cross-sectional study was conducted in China between March 2020 and May 2020 using mixed sampling process (i.e., convenience and snowball samplings). The target population was non-pregnant Chinese adults aged ≥18 years who were willing to provide informed consent for participating in the study. The study procedure were approved by the Ethics Committee of the Jinzhou Medical University, and performed following The Code of Ethics of the World Medical Association (Declaration of Helsinki) and CHERRIES statement.Citation14
KAP regarding COVID-19 vaccines
Participants were asked to report their responses in a validated modified KAP COVID-19 vaccine questionnaire on a 5-point Likert scale.Citation9,Citation15–19 Questions included were: “how contagious is SARS-CoV-2?”, “can the COVID-19 vaccine cause COVID-19?”, “do you think you are at risk to get COVID-19?”, “all adults should get vaccinated against COVID-19”, and “the COVID-19 vaccine is safe and effective in preventing COVID-19”. In addition, participants were asked to complete questions regarding their attitudes and perceptions toward COVID-19 vaccination. These questions included “immunizations do more good than harm”, “trust immunizations that have been around for a while”, “immunisation protects vulnerable individuals from getting diseases from unimmunized individuals”, immunization requirements went against freedom of choice”, “immunizations get safer and better all of the time”, “perceived severity of COVID-19 effect to own life”, and “perceived risk of getting COVID-19”.
Participants were inquired if they would accept or refuse COVID-19 vaccines when these vaccines would be available soon with their reasons. Also, questions based on a 5-point Likert scale such as willingness to pay for COVID-19 vaccines were included in the questionnaire.
Sources of vaccine information
Participants were first asked to indicate how they usually received the vaccine information, followed by an evaluation of the quality of the main sources of vaccine information listed in the questionnaire.Citation18 For example, family members, friends, Internet (reliable websites such as the World Health Organization), visits to healthcare providers, mass media, alternative healthcare providers, vaccine industry and companies, and printed materials from healthcare providers. The response options for these questions ranged from 1 (very poor quality) to 5 (excellent quality).Citation18
Statistical analysis
All the statistical analyses were conducted using SPSS ver. 24.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to present sociodemographic data including age. Participant responses were calculated and reported as the percentages of cases. Analyses of covariance (ANCOVA) and Chi-square tests were used to compare differences between continuous and categorical data, respectively. Multiple logistic regression analyses were conducted to determine the factors potentially associated with the willingness to accept COVID-19 vaccines. The level of statistical significance was set to P < .05.
Results
Participant characteristics
Of the 2300 adults who responded to the survey, 48.7% reported that they were not interested (including: no time to complete the survey and the length of the survey was too long); therefore, only 1179 (51.3%) valid responses were retained in the final data analysis (). The mean age of participants was 36.0 ± 11.5 years and both sexes had a similar mean age (P = .386). Majority of participants were married (81.1%), from high-risk regions (96.0%), did not have any religious beliefs (96.6%) and had earned a higher educational level (86.8%) at the time of study. Only 7.0% and 21.5% of participants worked as healthcare workers and had chronic diseases. More than half of participants reported no perceived increased risk of contracting COVID-19 (53.7%) and severity of effect of COVID-19 to own life (52.1%). Only 1.0% of participants were previously diagnosed with COVID-19.
Table 1. Sociodemographic characteristics of participants
Majority of participants reported that they would be willing to be vaccinated against COVID-19 (77.4%) and pay for a COVID-19 vaccine (81.1%) (). Reasons provided for the willingness to be vaccinated against COVID-19 were because of the recommendations from health authorities (25.5%), followed by “protective” (27.7%), “safe” (27.3%), “effectiveness” (16.1%), and “affordable” (3.4%). On the other hand, reasons provided for not willing to be vaccinated against COVID-19 were “concerned about vaccine side effects” (52.2%), “vaccines not safe (39.3%), “afraid of injections” (5.9%), and “prefer to natural and traditional remedies (2.6%). Also, majority of participants reported the acceptable price range of COVID-19 vaccine ranging from ¥501-1000 (US 75–149 USD) (36.9%), followed by ¥1001-1500 (US 150–224 USD) (27.8%), <¥500 (<US 75 USD) (24.3%), and >¥1500 (>US 224 USD) (10.9%).
Knowledge, attitude and perceptions (KAP) regarding vaccination
Overall, more than half of participants (73.8%) disagreed that a COVID-19 vaccine can cause SARS-CoV-2 infection (). Education level was significantly associated with the response for the statement“COVID-19 vaccine can cause SARS-CoV-2 infection” (P < .001). In addition, majority of participants (76.3%) agreed that COVID-19 vaccine is safe and effective for preventing COVID-19. Although majority of participants (69.3%) agreed that they were at risk of getting COVID-19, only half of participants (50.0%) agreed that all adults should get vaccinated against COVID-19. The willingness to be vaccinated against COVID-19 was significantly associated with the positive response that all adults should be vaccinated against COVID-19 (P = .002) and they were at risk of getting COVID-19 (P = .013).
Table 2. Knowledge, attitudes and perceptions (KAP) regarding vaccination among participants
In addition, majority of participants reported that COVID-19 was very contagious (81.2%), followed by “somewhat contagious” (12.4%), and “minimally contagious” (6.4%). More than half of participants agreed that everyone could potentially spread COVID-19 to others (77.8%), trusted the immunizations that had been around for a while (60.3%), immunizations were better and safer all the time (67.5%) and immunizations did more good than harm (70.1%). Education level was significantly associated with the response for the statements “immunizations were better and safer all the time” (P = .004) and “immunizations did more good than harm” (P < .001).
More than half of participants (67.6%) did not oppose to immunizations. In addition, majority of participants agreed that immunization protected immunized adults from getting diseases from unimmunized adults (74.2%). The willingness to be vaccinated against COVID-19 was significantly associated with the positive response that immunization protected immunized adults from getting diseases from unimmunized adults (P = .007).
COVID-19 vaccine information sources
Overall, majority of participants (32.7%) reported using media to obtain COVID-19 vaccine information, followed by Internet (19.8%), visits to healthcare providers (15.4%), family members (12.1%), friends (8.3%), printed materials from healthcare providers (6.2%), alternative healthcare providers (3.6%), and vaccine companies and industry (1.9%) (). Factors including the willingness to be vaccinated against COVID-19 vaccine and education level were significantly associated with the types of COVID-19 vaccine information sources (P < .05).
Table 3. Perceptions of SARS-CoV-2 vaccine information sources among participants
More than 85.0% of participants rated all COVID-19 vaccine information sources as good/excellent sources except for vaccine companies and industry (28.8%). No differences in perceptions of COVID-19 vaccine information sources were reported for sex and education level (all P > .05). There were no differences in perceptions of COVID-19 vaccine information sources for the willingness to be vaccinated against COVID-19 except media (P < .001), visits to healthcare providers (P < .001), and vaccine companies and industry (P = .017).
Discussion
As of October 2020, the COVID-19 virus SARS-CoV-2 has infected tens of millions of people worldwide, resulting in more than one million deaths.Citation20 The COVID-19 pandemic has negatively impacted on the quality of life and health of the populations including pregnant women.Citation21–23 Hence, clinical research laboratories and research institutions are working to develop a COVID-19 vaccine which is important to reduce the mortality and health costs associated with the COVID-19 treatment. However, it is unclear how much the general population would value the COVID-19 vaccine and understand the KAP regarding COVID-19 vaccination. This is because in order to achieve herd immunity, it is important to have higher vaccination rate.Citation24 Our study was therefore designed to assess these research questions regarding COVID-19 vaccination in a sample of Chinese population when the COVID-19 vaccines are available.
Currently, there have been at least 137 vaccine candidates in preclinical phases and 23 candidates in clinical evaluation phases.Citation25 Effective and safe COVID-19 vaccines will be expected to play a leading role in curbing the transmission of COVID-19. The development of any vaccines including COVID-19 vaccines is costly and lengthy.Citation25 In our study, majority of participants reported that the acceptable price range of COVID-19 vaccine should be ranging from ¥501-1000. In addition, our study reported that 81.1% of participants were willing to pay for a COVID-19 vaccine. Our findings were consistent with the findings by Garcia and Cerda.Citation26 The authors reported that 90.6% of the Chilean adults (n = 566) would be willing to pay for a COVID-19 vaccine.Citation26 However, it is important to ensure that COVID-19 vaccines are made affordable, especially to some population groups with lower socioeconomic status. Therefore, price control can be one of the approaches to ensure that effective COVID-19 vaccines are widely affordable to all different population groups.Citation27
Our study reported that 77.4% of participants were willing to be vaccinated against COVID-19, which was higher than the percentage of participants who were willing to be vaccinated against COVID-19 according to a European survey by Neumann‑Böhme (73.9%). In addition, the major reason why our participants were willing to be vaccinated against COVID-19 was because of the recommendations from health authorities. On the other hand, the major reason why participants were unwilling to be vaccinated against COVID-19 was because they were concerned about vaccine side effects. Therefore, it is imperative to highlight and emphasize the benefits of COVID-19 vaccination, which can reflect on strengthening trust in COVID-19 vaccines among the population. In addition, it is important to note that the avoidance of COVID-19 vaccination can lead to a lower COVID-19 vaccination rate among the population and increase the risk of SARS-CoV-2 infection. Therefore, in order to further improve the vaccination rate, the relevant health authorities need to design and develop health education programs emphasizing the importance of vaccination.
Despite of high willingness of participants to be vaccinated against COVID-19, majority of participants in our study reported no perceived increased severity of effect of COVID-19 to own life and risk of contracting COVID-19. Several studies reported that high-perceived risk for contracting an infection was associated with increased vaccine acceptance in populations.Citation28–30 In addition, a study by Harapan et al. reported that a higher perceived risk to be infected with COVID-19 was associated with higher willingness to be vaccinated against COVID-19 in a sample of Indonesian adults.Citation3 Therefore, the relationships between perceived risk and vaccine acceptance may be complicated.Citation3 In our study, although more than half of our participants did not have perceived increased risk, they still would want to obtain COVID-19 vaccines. Therefore, future studies should investigate the potential factors including the effectiveness of COVID-19 vaccines and compliance with social distancing measures associated with COVID-19 vaccine acceptance in populations.
In addition, majority of participants in our study reported using media and Internet to obtain COVID-19 vaccine information. Online sources have been reported to be one of the important sites for individuals to seek for health-related information especially in the 21st century. Therefore, online sources can be one of the important factors that can influence health behaviors and attitudes in individuals. On the other hand, if these online resources contain some misinformation details that may negatively influence health behaviors and attitudes, this can cause some adverse effects on the individual health status. For example, majority of individuals received vaccination information via online sources which have become the primary source of information.Citation31 Future studies should include the components of health literacy or eHealth literacy for COVID-19 vaccination survey.
Several strengths in our study included a larger sample of Chinese adults. In addition, to our knowledge, our study was one of the first studies to lead the characterization of willingness to accept and pay for COVID-19 vaccines, and KAP regarding COVID-19 vaccines among the general population in China. Nevertheless, our study had limitations which were needed to be addressed. For example, the sampling techniques used in our study might have left out some under-representation of vulnerable communities including elderly and individuals with lower sociodemographic characteristics. In addition, our study only assessed the COVID-19 acceptance using a questionnaire, which may differ from the preferences of participants in real-life situation when the COVID-19 vaccines are available. Future studies should also consider investigating if there are differences in the COVID-19 vaccination rate between different provinces, regions (e.g. urban vs. rural) and population groups (e.g. pregnant women and elderly). In addition, future studies should consider investigating the COVID-19 vaccination rate in refugees and migrants from war zones.Citation32
In conclusion, our study reported high willingness to be vaccinated against COVID-19 and pay for COVID-19 vaccines in Chinese population. The COVID-19 pandemic has presented several significant challenges including the willingness to be vaccinated against COVID-19 vaccines. Hopefully, the unprecedented outbreak would concede momentum and room for the health authorities to address these critical issues from a global perspective, especially in vulnerable populations.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
Author contributions
Conceptualization, Yutong Zhang and Zheng Feei Ma; Formal analysis, Yutong Zhang, Xiaoqin Luo, and Zheng Feei Ma; Methodology, Yutong Zhang and Zheng Feei Ma; Writing – original draft, Yutong Zhang; Writing – review & editing, Yutong Zhang, Xiaoqin Luo, and Zheng Feei Ma.
Additional information
Funding
References
- Zhao X, Zhang B, Li P, Ma C, Gu J, Hou P, et al. Incidence, clinical characteristics and prognostic factor of patients with COVID-19: a systematic review and meta-analysis. MedRxiv. 2020. doi:10.1101/2020.03.17.20037572.
- Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Peña R, Holguin-Rivera Y, Escalera-Antezana JP, Alvarado-Arnez LE, Bonilla-Aldana DK, Franco-Paredes C, Henao-Martinez AF, et al. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect Dis. 2020;34:101623. doi:10.1016/j.tmaid.2020.101623.
- Harapan H, Wagner AL, Yufika A, Winardi W, Anwar S, Gan AK, Setiawan AM, Rajamoorthy Y, Sofyan H, Mudatsir M, et al. Acceptance of a COVID-19 Vaccine in Southeast Asia: A cross-sectional study in Indonesia. Front Public Health. 2020;8:381. doi:10.3389/fpubh.2020.00381.
- Schlipköter U, Flahault AJPHR. Communicable diseases: achievements and challenges for public health. Public Health Rev. 2010;32:90–119. doi:10.1007/BF03391594.
- Del Rio C, Malani P. COVID-19—new insights on a rapidly changing epidemic. JAMA. 2020;323(14):1339–40. doi:10.1001/jama.2020.3072.
- Harapan H, Anwar S, Setiawan AM, Sasmono RT. Dengue vaccine acceptance and associated factors in Indonesia: A community-based cross-sectional survey in Aceh. Vaccine. 2016;34(32):3670–75. doi:10.1016/j.vaccine.2016.05.026.
- Mudatsir M, Anwar S, Fajar JK, Yufika A, Ferdian MN, Salwiyadi S, Imanda AS, Azhars R, Ilham D, Timur AU, et al. Willingness-to-pay for a hypothetical Ebola vaccine in Indonesia: A cross-sectional study in Aceh. F1000Res. 2019;8:1441. doi:10.12688/f1000research.20144.2.
- Harapan H, Mudatsir M, Yufika A, Nawawi Y, Wahyuniati N, Anwar S, Yusri F, Haryanti N, Wijayanti NP, Rizal R, et al. Community acceptance and willingness-to-pay for a hypothetical Zika vaccine: A cross-sectional study in Indonesia. Vaccine. 2019;37(11):1398–406. doi:10.1016/j.vaccine.2019.01.062.
- Neumann-Böhme S, Varghese NE, Sabat I, Barros PP, Brouwer W, van Exel J, et al. Once we have it, will we use it? A European survey on willingness to be vaccinated against COVID-19. Eur J Health Econ. 2020;21(7):977–82. doi:10.1007/s10198-020-01208-6.
- Domínguez A, Godoy P, Castilla J, María Mayoral J, Soldevila N, Torner N, Toledo D, Astray J, Tamames S, García-Gutiérrez S, et al. Knowledge of and attitudes to influenza in unvaccinated primary care physicians and nurses. Hum Vaccin Immunother. 2014;10(8):2378–86. doi:10.4161/hv.29142.
- Bekkat-Berkani R, Romano-Mazzotti L. Understanding the unique characteristics of seasonal influenza illness to improve vaccine uptake in the US. Vaccine. 2018;36(48):7276–85. doi:10.1016/j.vaccine.2018.10.027.
- Pereira M, Williams S, Restrick L, Cullinan P, Hopkinson NS. Healthcare worker influenza vaccination and sickness absence - an ecological study. Clin Med. 2017;17(6):484–89. doi:10.7861/clinmedicine.17-6-484.
- Rong H, Lai X, Ma X, Hou Z, Li S, Jing R, Zhang H, Peng Z, Feng L, Fang H, et al. Seasonal influenza vaccination and recommendation: the difference between general practitioners and public health workers in China. Vaccines. 2020;8(2):265. doi:10.3390/vaccines8020265.
- Eysenbach G. Improving the quality of web surveys: the checklist for reporting results of internet e-surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34. doi:10.2196/jmir.6.3.e34.
- Chor JSY, Ngai KLK, Goggins WB, Wong MCS, Wong SYS, Lee N, Leung T-F, Rainer TH, Griffiths S, Chan PKS, et al. Willingness of Hong Kong healthcare workers to accept pre-pandemic influenza vaccination at different WHO alert levels: two questionnaire surveys. BMJ. 2009;339:b3391. doi:10.1136/bmj.b3391.
- Liu H, Tan Y, Zhang M, Peng Z, Zheng J, Qin Y, Guo Z, Yao J, Pang F, Ma T, et al. An internet-based survey of influenza vaccination coverage in healthcare workers in China, 2018/2019 season. Vaccines. 2019;8(1):6. doi:10.3390/vaccines8010006.
- Canning HS, Phillips J, Allsup S. Health care worker beliefs about influenza vaccine and reasons for non-vaccination - a cross-sectional survey. J Clin Nurs. 2005;14(8):922–25. doi:10.1111/j.1365-2702.2005.01190.x.
- Jones AM, Omer SB, Bednarczyk RA, Halsey NA, Moulton LH, Salmon DA. Parents’ source of vaccine information and impact on vaccine attitudes, beliefs, and nonmedical exemptions. Adv Prev Med. 2012;2012:932741. doi:10.1155/2012/932741.
- Martinello RA, Jones L, Topal JE. Correlation between healthcare workers‘ knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003;24(11):845–47. doi:10.1086/502147.
- WHO. Coronavirus disease (COVID-2019) situation reports. 2020.
- Ma ZF, Zhang Y, Luo X, Li X, Li Y, Liu S, Zhang Y. Increased stressful impact among general population in mainland China amid the COVID-19 pandemic: A nationwide cross-sectional study conducted after Wuhan city’s travel ban was lifted. Int J Soc Psychiatry. 2020;66(8):770–79. doi:10.1177/0020764020935489.
- Zhang Y, Ma ZF. Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: a cross-sectional study. Int J Environ Res Public Health. 2020;17(7):2381. doi:10.3390/ijerph17072381.
- Zhang Y, Ma ZF. Psychological responses and lifestyle changes among pregnant women with respect to the early stages of COVID-19 pandemic. Int J Soc Psychiatry. 2020:002076402095211. doi:10.1177/0020764020952116.
- Britton T, Ball F, Trapman PJS. A mathematical model reveals the influence of population heterogeneity on herd immunity to SARS-CoV-2. Science. 2020;369(6505):846–49. doi:10.1126/science.abc6810.
- Forman R, Anderson M, Jit M, Mossialos E. Ensuring access and affordability through COVID-19 vaccine research and development investments: A proposal for the options market for vaccines. Vaccine. 2020;38(39):6075–77. doi:10.1016/j.vaccine.2020.07.068.
- García LY, Cerda AA. Contingent assessment of the COVID-19 vaccine. Vaccine. 2020;38(34):5424–29. doi:10.1016/j.vaccine.2020.06.068.
- Karim SA. COVID-19 vaccine affordability and accessibility. Lancet. 2020;396(10246):238. doi:10.1016/S0140-6736(20)31540-3.
- Rajamoorthy Y, Radam A, Taib NM, Rahim KA, Wagner AL, Mudatsir M, Munusamy S, Harapan H. The relationship between perceptions and self-paid hepatitis B vaccination: A structural equation modeling approach. PLoS One. 2018;13(12):e0208402. doi:10.1371/journal.pone.0208402.
- Rajamoorthy Y, Radam A, Taib NM, Rahim KA, Munusamy S, Wagner AL, Mudatsir M, Bazrbachi A, Harapan H. Willingness to pay for hepatitis B vaccination in Selangor, Malaysia: A cross-sectional household survey. PLoS One. 2019;14(4):e0215125. doi:10.1371/journal.pone.0215125.
- Sundaram N, Purohit V, Schaetti C, Kudale A, Joseph S, Weiss MG. Community awareness, use and preference for pandemic influenza vaccines in Pune, India. Hum Vaccin Immunother. 2015;11(10):2376–88. doi:10.1080/21645515.2015.1062956.
- Melovic B, Jaksic Stojanovic A, Vulic TB, Dudic B, Benova E. The impact of online media on parents’ attitudes toward vaccination of children-social marketing and public health. Int J Environ Res Public Health. 2020;17(16):5816. doi:10.3390/ijerph17165816.
- Mipatrini D, Stefanelli P, Severoni S, Rezza G. Vaccinations in migrants and refugees: a challenge for European health systems. A Systematic Review of Current Scientific Evidence Pathog Glob Health. 2017;111(2):59–68. doi:10.1080/20477724.2017.1281374.