key: cord-0741525-rd17m0sq authors: Ousseine, Youssoufa M.; Vaux, Sophie; Vandentorren, Stéphanie; Bonmarin, Isabelle; Champenois, Karen; Lydié, Nathalie; Velter, Annie title: Predictors of Uncertainty and Unwillingness to Receive the COVID-19 Vaccine in Men Who Have Sex with Men in France date: 2022-04-28 journal: Int J Environ Res Public Health DOI: 10.3390/ijerph19095372 sha: 8960bed0ced4039438dbf5b7af3f5b9d413fb10d doc_id: 741525 cord_uid: rd17m0sq The development of vaccines against COVID-19 has given hope to populations. Public acceptability of vaccination is a major driver in containing the disease. However, in marginalized and stigmatized populations, uncertainty and unwillingness may be a challenge. This study aimed to analyze the factors associated with uncertainty and unwillingness to vaccinate against COVID-19 in men who have sex with men (MSM) living in France. The data used came from Rapport au Sexe (ERAS) 2021, a voluntary, cross-sectional, anonymous, self-administered, online survey conducted from 26 February to 11 April 2021. Among the 15,426 respondents included in the analysis, 60.5% were willing to vaccinate (these included persons already vaccinated), 17.5% were not, and 22% were uncertain. Factors independently associated with uncertainty and unwillingness were lower education level, low health literacy level, financial hardship, being under 30 years of age, and living in a rural area. HIV-positive MSM were less likely to report vaccination uncertainty and unwillingness than HIV-negative MSM and those with unknown serostatus. Although more impacted by COVID-19, socioeconomically vulnerable MSM were the sub-group most unwilling to vaccinate. To improve acceptability of COVID-19 vaccination in MSM, policy makers and researchers must increase access to and understanding of medical information by considering the general public’s health literacy when developing information sources. Moreover, a dedicated global care approach, which ensures these populations can be reached, is necessary. In December 2019, an unusually high number of cases of viral pneumonia were reported in Wuhan, China. The rapid spread of the associated virus SARS-CoV-2, and the consequent infection COVID-19, quickly became a concern for global health authorities. The WHO declared a pandemic on 11 March 2020. The lack of a cure or vaccine at the time, and the high transmissibility of the infection led to protective measures, such as national lockdowns and curfews. Meanwhile, scientists put all their efforts into developing a COVID-19 vaccine. For the first time in modern medical history, mRNA-based vaccines were rapidly developed in less than a year. By the end of 2020, studies had shown the safety and efficacy of the Moderna and Pfizer/BioNtech mRNA vaccines [1, 2] . Furthermore, the AstraZeneca vaccine (ChAdOx1 nCoV-19 vaccine-AZD1222) using viral vector technology 2 of 12 had shown positive safety and efficacy results [3] . A study confirmed the effectiveness of these COVID-19 vaccines [4] . In France, the vaccination strategy began on 27 December 2020; it consisted of phased vaccination, first prioritizing the elderly and/or those weakened by morbidity factors, in order to protect people most likely to develop a serious form of the disease. Priority was also given to health professionals. Only from 12 May 2021 was vaccination extended to people under 50 years old. Vaccination is a crucial driver in containing the COVID-19 pandemic. However, unwillingness to be vaccinated is widespread worldwide [5] . In June 2020, intention to vaccinate against COVID-19 differed greatly between countries. France, Poland, and Russia had the lowest rates worldwide (58.9%, 56.3%, and 54.9%, respectively) [6] . Previous studies showed gender differences in unwillingness to be vaccinated against COVID-19, with significant unwillingness in women [7, 8] . Several factors have been associated with uncertainty or unwillingness, including age, education level, socioeconomic status, perceived seriousness of COVID-19, and sexual orientation [6, 7, [9] [10] [11] . For example, in Puerto Rico, gay self-identity was associated with greater intention to be vaccinated [9] . Marginalization and systematic discrimination of sexual minorities led to inequalities of all kinds. The COVID-19 health crisis has had a greater impact on sexual minorities than the general population, particularly men who have sex with men (MSM) [12] . It has highlighted pre-existing vulnerabilities specific to MSM in terms of health, isolation, socioeconomics, and mental health [12] [13] [14] [15] [16] . These vulnerabilities may have exacerbated stigma and internalized homonegativity (feelings of guilt, inferiority, and low self-esteem), two factors associated with low utilization of care and poor preventive behaviors [17, 18] . In addition, the rapid development of COVID-19 vaccines, and the divergent medical information regarding these vaccines and the pandemic, may have triggered or reinforced COVID-19 vaccine hesitancy in people with low health literacy [19, 20] . While several studies have documented factors associated with intention to vaccinate in the general population, few have focused on sexual minorities [21, 22] . Knowing that the binary consideration of gender and the omission of sexual orientation in access to care could be a source of inequality, we must make efforts to build an inclusive environment for equity. This study aimed to investigate factors associated with intention to vaccinate against COVID-19 in the MSM population in France. We used data from Rapport au Sexe 2021, a large, cross-sectional online survey of MSM in France conducted between 26 February and 11 April 2021. Respondents who self-identified as homosexual or bisexual or have had sex with a man in their lifetime are considered MSM. The survey was anonymous, self-administered, and voluntary. Participants were recruited through different digital media. Banners were posted directly on gay dating websites, gay geolocation dating applications, gay affinity news sites, and social media networks (Facebook). They were also posted via programmatic platforms targeting men aged 18 years old and over and on browsing pages containing keywords related to homosexuality and male dating. By clicking on these banners, people were directed to the survey site, where information about its objectives was presented as well as the conditions of participation and data confidentiality. By clicking on a button containing the text "I have read and understood the information above", the participant provided informed consent and was directed to the online questionnaire. No IP address was collected. No financial incentive was given. The only inclusion criterion was being aged 18 years and older. Intention to vaccinate against COVID-19 was measured using the following question: "Do you intend to be vaccinated against Coronavirus? Yes/I have already been vaccinated against the Coronavirus in the last few weeks/I do not know/No". Respondents were then classified into three groups: willing (already vaccinated or intended to), uncertain (were unsure about vaccination), or unwilling (did not want to be vaccinated). The following socioeconomic and demographic characteristics were collected: age, place of birth, area of residence, having a steady relationship with a man, education level, occupational situation, perceived financial situation, and health literacy. Perceived financial situation was measured with the question "Would you say that financially . . . " ('you are comfortable'; 'you get by'; 'you have to be careful'; 'you find it difficult to make ends meet'; and 'you can't make ends meet without incurring debt'). Response categories were merged to form a three-level variable: comfortable (which covered 'comfortable' and 'you get by'; need to be careful; difficulty and debt). Health literacy was evaluated using the Health Literacy Questionnaire (HLQ) scale 'having sufficient information to manage my health' [23, 24] . This scale contains four items, each scored on a 4-point Likert scale. The total score is calculated as the average of the four item scores, and ranges from 1 to 4. Participants were categorized into two groups: low (score ≤ 2.8 1st quartile) and adequate (score > 2.8) health literacy. Respondents also reported their vaccination history (hepatitis A and hepatitis B) and their HIV status. Furthermore, COVID-19-related information was collected, such as COVID-19-like symptoms or signs (yes/no) and diagnosed with COVID-19 (yes/no). In addition to these individual factors, respondents could report the reasons for their unwillingness to be vaccinated from a list of suggestions (COVID-19 vaccines are unsafe and side effects are not really known, doubts about vaccine effectiveness, COVID-19 is not a very dangerous disease, vaccine hesitant in general, not liking injections, other reasons). We performed univariate analyses to describe respondents' characteristics. Median and interquartile range (IQR) were computed for continuous variables. Categorical variables were expressed as proportions. Chi-squared tests were used to compare categorical data. To identify factors associated with intention to vaccinate against COVID-19, multinomial logistic models were used. A backward procedure was employed to select statistically significant factors in the multivariate models (entry threshold, p < 0.20). Only factors with a p < 0.05 were kept in the final multivariate model. Statistical analyses were performed using Stata software version 15 (StataCorp, College Station, TX, USA). Of the 36,648 people who started the questionnaire, 18,474 (50%) completed and validated it ( Figure 1 ). Respondents who discontinued the questionnaire were younger on average than those who completed it (32.2 vs. 34.7 years). They had lower than the upper secondary school certificate (39.8 vs. 32.1) and were more heterosexual or refused to self-identify (54.8 vs. 21.3) than respondents completed questionnaire. Among the latter, 3048 were excluded because they lived outside France (401) or were not MSM (2647). The majority of the sample (80%) had connected to the survey via social networks. Most of the respondents were born in France (94.6%), lived in an urban area (82.8%), and had a third-level education level (68.2%). Just under a third (31.1%) had a low level of health literacy, and 14% perceived their financial situation as difficult. With regard to COVID-19, 42.5% of respondents reported having COVID-19-like symptoms or signs, and 9.7% had been diagnosed with the disease. At the time of the study (February to April 2021), 60.5% of respondents were already COVID-19 vaccinated or intended to vaccinate, 17.5% did not intend to vaccinate, and 22% were uncertain about vaccinating (Table 1 ). Most of the respondents were born in France (94.6%), lived in an urban area (82.8%), and had a third-level education level (68.2%). Just under a third (31.1%) had a low level of health literacy, and 14% perceived their financial situation as difficult. With regard to COVID-19, 42.5% of respondents reported having COVID-19-like symptoms or signs, and 9.7% had been diagnosed with the disease. At the time of the study (February to April 2021), 60.5% of respondents were already COVID-19 vaccinated or intended to vaccinate, 17.5% did not intend to vaccinate, and 22% were uncertain about vaccinating (Table 1) . In univariate analyses, uncertainty and unwillingness were associated with age, occupation, area of residence (i.e., urban versus rural) and vaccination for hepatitis A and B diseases ( Table 2 ). MSM aged 25-29 years old were more likely to report unwillingness to vaccinate (22.3%) than other age groups (18-24 years: 20.7%, 30-44 years: 18%, and ≥45 years: 10.2%, p < 0.001). Unemployed, inactive, and retired MSM were also more likely to be unwilling to vaccinate. In addition, the relationships between education level, health literacy, financial situation, and intention to vaccinate revealed a socioeconomic gradient. More specifically, MSM with a lower level of education (i.e.,