key: cord-0799027-cpw94tjh authors: Arbel, Yuval; Arbel, Yifat; Kerner, Amichai; Kerner, Miryam title: Covid 19 vaccination: Accessibility or literacy? Israel as a case study() date: 2022-01-13 journal: Int J Disaster Risk Reduct DOI: 10.1016/j.ijdrr.2022.102794 sha: 55a3309fcaba25740be829fe53420d81a2f3d4d1 doc_id: 799027 cord_uid: cpw94tjh Israel is ranked as the leading country in terms of prevalence of vaccination against SARS-COV-2 virus (persons vaccinated divided by total population). Based on updated data as of January 19, 2021, the objective of the current study is to assess the relationship between the prevalence of vaccination and population density. A-priori, given the better infrastructure of health services (more physicians and nurses per 1000 persons), one would anticipate a higher level of vaccination in denser cities. Surprisingly, the outcomes demonstrate an opposite relationship: a lower level in the per capita level of vaccination with higher population densities from 0.2144 for 2 persons per sq. Km. to a minimum of 0.007191 for 16,642 persons per sq. Km. Given the relatively good accessibility to vaccination centers and high spread of clinics and health centers in Israel, research findings thus stress the major importance of promoting the benefits of vaccination (vaccination literacy) to diversified populations. Coronavirus 2019 (COVID-19) is a declared global pandemic with multiple risk factors (WHO report: coronavirus). As of October 31, 2021, the official accumulated Covid-19 cases are 247,376,970 and deaths worldwide are approx. 5 million persons (Worldmeter) . A vaccine against the SARS-COV-2 virus became available as of December 20, 2020. In this context, Israel is an interesting case study. It is a country with a high per capita income along with an advanced health system and offers universal health-care insurance by law. To address inequalities in availability and access to health care, legislation providing for universal health-care insurance for all Israeli citizens was passed in 1995 (Porath and Lev, 1995) . This law provides a broad basket of high-quality preventive, curative, and rehabilitation healthcare services. Israel is ranked as the leading country in terms of prevalence of vaccination against SARS-COV-2 virus (persons vaccinated divided by total population). This, despite the cultural and ethnic diversity of Israel's population, and the existence of pockets of "vaccine hesitancy" (Levin-Zamir, and Baron-Epel, 2020) . From a public policy perspective, the maintenance of high levels of vaccine coverage (in Israel and globally) is necessary to avert a decline in herd immunity, which in turn prevents a reoccurrence of diseases that otherwise might be on the verge of extinction. (Levin-Zamir, and Baron-Epel, 2020). Muhsen et al. (2017) mention the large extent of independent programs, initiated by the various health plans, to reduce inequalities in health by a combination of policies. These include lowering copayments, focusing on at-risk populations, and adapting intervention measures to language, culture, literacy, and comprehension levels. Similar public-relation promotion J o u r n a l P r e -p r o o f programs were applied by the Israeli Ministry of Health to accelerate the COVID-19 vaccination campaign (e.g., Winter, 2021 An interesting related debate is the role of development density in the spread of pandemics. Dense areas facilitate more intensive human interaction and could lead to higher exposure to the infection, which make them the potential epicenter of the pandemic crisis (Glaeser 2011; Eubank et al. 2004) . At the same time, dense areas tend to enjoy superior health and educational systems that are more prepared to handle pandemics, leading to higher recovery rates and lower mortality rates (Dye 2008) . Densely developed areas also have the infrastructure to put in place more effective measures that foster social distancing, thus reducing actual rates of infection. Density also might make it easier to provide services for citizens in need at the time of social distancing orders (Bell et al. 2009 ). (Hamidi et al. 2020, 1-2; Arbel et al., 2021) Based on updated data as of January 19, 2021, the objective of the current study is to assess the relationship between the prevalence of vaccination and population density. According to Dagan et al. (2021) , until February 1, 2021 (12 days after the date of our cross-sectional study -January 19, 2021), at least 1,503,216 persons, 2 consisting of 16.26% of the Israeli population (= 1,503,216 9,246,000 ), and 24.11% of the Israeli population without children (= 1,503,216 9,246,000−3,011,000 ), have been vaccinated in two doses. 3 A-priori, given the better infrastructure of health services (more physicians and nurses per 1,000 persons), 4 one would anticipate a higher vaccination likelihood in denser cities. Surprisingly, the outcomes demonstrate an opposite relationship: a lower level in the per capita level of vaccination with higher population densities from 0.2144 for 2 persons per sq. km. to a minimum of 0.007191 for 16,642 persons per sq. km. Given the relatively good accessibility to vaccination centers and high spread of clinics and health centers in Israel, research findings thus stress the major importance of promoting the benefits of vaccination (vaccination literacy) to diversified populations. The remainder of this study is organized as follows. Section 2 provides the background. Section 3 describes the methodology, and sections 4 and 5 present the results and discussion. Finally, Section 6 concludes and summarizes. Israel is a high-income country with an advanced health system and offers universal health-care insurance by law. To address inequalities in availability and access to health care, legislation providing for universal health-care insurance for all Israeli citizens was passed in 1995 (Porath and Lev, 1995) . This law provides a broad basket of high-quality preventive, curative, and rehabilitation health-care services. Overall, the health status has improved steadily over recent decades. Between 1975 and 2014, life expectancy in Israel steadily grew and is currently above the average life expectancy for the Organization for Economic Co-operation and Development (OECD) countries (Muhsen et al., 2017) . In the context of COVID19 vaccinations, several researchers have raised concerns regarding COVID19 and vaccine literacy among different populations, and the need to elevate public awareness in an effort to optimise vaccine uptake MCaffery et al, 2020) . 5 MCaffery demonstrated that compared with Australians with adequate health literacy, those with inadequate health literacy had poorer understanding of COVID-19 symptoms (49% vs 68%; p < 0.001), were less prone to adopt appropriate behaviour to prevent infection (59% vs 72% p < 0.001), and experienced more difficulty finding information and understanding government messaging about COVID-19. In addition, people with inadequate health literacy were less likely to rate social distancing as important (6.1 vs 6.5; p < 0.001) and reported more difficulty with remembering and accessing medicines since lockdown (3.6 vs 2.7; p < 0.001). People with lower health literacy were also more likely to endorse misinformed beliefs about COVID-19 and vaccinations (in general) than those with adequate health literacy. The same pattern of results was observed among people whose primarily language at home was not English. Health literacy in the Israeli context is directly related to both health care and public health and is operationally defined as: "the development of the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health" (Nutbeam, 1998 https://www.cbs.gov.il/he/publications/doclib/2019/2.shnatonpopulation/02_01e.pdf). As the map in Appendix A2 demonstrates, the urbanization patterns vis á vis the spread of the COVID19 pandemic may pose a challege to health policy. This is because dense areas facilitate more intensive human interaction and might lead to higher exposure to the infection, which make them the potential epicenter of the pandemic crisis (Glaeser 2011; Eubank et al. 2004 ). On the other hand, dense areas tend to enjoy superior health and educational systems that are more prepared to handle pandemics, leading to higher recovery rates and lower mortality rates (Dye 2008) . Densely developed areas also have the infrastructure to put in place more effective measures that foster social distancing, thus reducing actual rates of infection. Density also could make it easier to provide services for citizens in need at the time of social distancing orders (Bell et al. 2009 Consider the following estimated maximum likelihood objective function of the fractional probit model (e.g., Amemiya, 1981 Amemiya, : 1484 Papke and Wooldrige (1996) ; Johnston and Dinardo (1997) : 61-63, 7 424-426; Wooldrige (2010)): (1) The likelihood function of the model: = + + may be defined as ( , , 2 ; ). The maximum likelihood estimators (MLE) ̂,̂,̂2 maximize the probability of obtaining the sample values that have actually been observed (Johnston and dinardo, 1997: 61-63) . The method gained a widespread popularity due to a range of desirable large sample asymptotic properties, including: consistency, asymptotic normality and efficiency, (Johnston and dinardo, 1997: 143-145). Where j is the index for each Local Authority ( = 1,2,3, ⋯ ,169); = √ (the square root of Local Authority population); = _ = where 0 ≤ < 1; ′ is a matrix whose dimensions are 169×4 ( ,1 ′ = 1 ⃗ for the constant term; The fractional probit model was pioneered and has been extensively used in biometrics applications (Amemiya, 1981 (Amemiya, : 1484 Johnston and Dinardo, 1997: 413) . It belongs to the family of discrete choice models. Biologists (medical researchers) employ this sort of model to measure the relationship between survival of an insect=1; otherwise=0 (patients recovery=1; non-recovery=0) and the dosage of insecticide (drugs). Consequently, it seems plausible to employ this model in a micro-individual level sample, where the limited dependent variable equals 1/0 if the person was vaccinated/not-vaccinated. Based on a sample of 169 local authorities, covering 80.11% of the Israeli population, 8 Table 1 reports the regression outcomes obtained via the fractional, probit and logit models. Given the difficulty of direct interpretation of parameters, Figure 2 gives the projected probabilities of vaccination rates from the population (obtained from column (1) of Table 1 ) as a function of population density squared and population density. 9 The outcomes demonstrate that projected likelihood of vaccination becomes lower from 0.2144 for a population density of 2 persons per sq. km. (the minimum) to 0.007191 for a population density of 16,642 persons per sq. km. Above this population density, projected likelihood of vaccination becomes slightly higher until 0.03268 for the maximum population density of 26,510 persons per sq. km. The outcomes in Table 1 Israel is considered to be a highly urbanized nation. According to the ICBD report (Israel Additional results demonstrate insignificant difference in the projected likelihood to get vaccinated based on socio-economic status of the city or town. A possible interpretation is elevated medical literacy with higher socio-economics status, which, in turn, raises the awareness to adverse effects of vaccinations. This may prevail over the expected benefit of the vaccine, according to the risk perception of vaccine hesitants. Referring to children vaccinations against diseases such as measles, these points were demonstrated in Lorini et al. (2018) and Levin-Zamir, and Baron-Epel. (2020) . The implication from the outcomes reported in this article might be that medical literacy is more important than accesibility. Despite the fact that denser cities have better accesibility to health care centers, where vaccinations are given, compared to peripheral towns, fewer persons arrive to these centers to get vaccinated. Consequently, more effort should be given to the provision of medical information regarding the benefits and costs of COVID19 vaccinations by medical professionals. This information should be given in simple terminology that could be understood by the broad public who lack medical training and education. J o u r n a l P r e -p r o o f Israel is ranked as the leading country in terms of prevalence of vaccination against SARS-COV-2 virus (persons vaccinated divided by population), and vaccinations are given freeof-charge. Based on updated data as of January 19, 2021, the objective of the current study is to assess the relationship between the prevalence of vaccination and population density. A-Priori, given the better infrastructure of health services (more physicians and nurses per 1,000 persons), Second, referring to existing cities, municipalities should develop emergency plans to address future pandemics. These plans may include publication and enforcements of guidlines, such as: 1) hygienic behaviour; 2) reduction in activity hours; 3) reduction of public transportation; 4) promotion of online trading. Finally, research findings emphasize the major importance of promoting vaccination literacy to diversified populations. Particularly, different publication strategies should be implemented based on socio-economics status of the city. More effort should be given to the provision of medical information regarding the benefits and costs of COVID19 vaccinations by professional medical doctors. This might convince those who are "vaccine hesitants" with higher medical literacy in high income cities. In all cities, this information should be given in simple J o u r n a l P r e -p r o o f Notes: Estimation outcomes are based on the fractional probit and logit regressions, where population weights (√ ) are included. Robust p-values are given in parentheses. *p<0.1,**p<0.05,***p<0.01. 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