key: cord-0846619-0y64lui8
authors: Sherman, Susan M.; Sim, Julius; Cutts, Megan; Dasch, Hannah; Amlôt, Richard; Rubin, G James; Sevdalis, Nick; Smith, Louise E.
title: COVID-19 vaccination acceptability in the UK at the start of the vaccination programme: a nationally representative cross-sectional survey (CoVAccS – wave 2)
date: 2021-10-18
journal: Public Health
DOI: 10.1016/j.puhe.2021.10.008
sha: 15945462051ce6d9bff9ccd464e02034fbdce083
doc_id: 846619
cord_uid: 0y64lui8

Objectives To investigate factors associated with intention to have the COVID-19 vaccination following initiation of the UK national vaccination programme. Study Design 1,500 adults completed an online cross-sectional survey (13th–15th January 2021). Methods Linear regression analyses were used to investigate associations between intention to be vaccinated for COVID-19 and sociodemographic factors, previous influenza vaccination, attitudes and beliefs about COVID-19, and attitudes and beliefs about COVID-19 vaccination and vaccination in general. Participants’ main reasons for likely vaccination (non-)uptake were also solicited. Results 73.5% of participants (95% CI 71.2%, 75.7%) reported being likely to be vaccinated against COVID-19, 17.3% (95% CI 15.4%, 19.3%) were unsure, and 9.3% (95% CI 7.9%, 10.8%) reported being unlikely to be vaccinated. The full regression model explained 69.8% of the variance in intention. Intention was associated with: having been/intending to be vaccinated for influenza last winter/this winter; stronger beliefs about social acceptability of a COVID-19 vaccine; the perceived need for vaccination; adequacy of information about the vaccine; and weaker beliefs that the vaccine is unsafe. Beliefs that only those at serious risk of illness should be vaccinated and that the vaccines are just a means for manufacturers to make money were negatively associated with vaccination intention. Conclusions Most participants reported being likely to get the COVID-19 vaccination. COVID-19 vaccination attitudes and beliefs are a crucial factor underpinning vaccine intention. Continued engagement with the public with a focus on the importance and safety of vaccination is recommended.

One year on from the emergence of COVID-19 in China in December 2019, there have been more than 112 million cases of COVID-19 and nearly 2.5 million deaths worldwide. 1 While countries have implemented a variety of public health measures to try to prevent the spread of the virus, scientists across the world have worked on developing effective vaccines. On 2nd

December 2020, the United Kingdom (UK) became the first country to approve a COVID- 19 vaccine that had been through a large-scale trial 2 and on 8th December, the first dose of the Pfizer/BioNTech vaccine was administered. 3 This was swiftly followed by UK approval of the Oxford/AstraZeneca vaccine on 30th December 2020 and the Moderna vaccine on 8th January 2021. Given the severity of the pandemic and associated clinical outcomes, it is imperative that COVID-19 vaccination uptake is maximized so that, alongside ongoing protective public health practices, the spread of infection can be reduced. 4 To achieve this, we need to understand the factors that affect people's willingness to have a vaccine.

The existing peer-reviewed research exploring the acceptability of a COVID-19 vaccination was all conducted before a vaccination was available, 5, 6, 7, 8 when details about the actual vaccination were still a matter of speculation. For example, in a survey of 1,500 UK adults that we conducted in July 2020, 5 64% of participants reported being very likely to be vaccinated against COVID-19, 27% were unsure, and 9% reported being very unlikely to be vaccinated. Intention to be vaccinated was associated with: more positive general COVID-19 vaccination beliefs and attitudes; weaker beliefs that the vaccination would cause side effects or be unsafe; greater perceived information sufficiency to make an informed decision about COVID-19 vaccination; greater perceived risk of COVID-19 to others; older age; and having been vaccinated for influenza the previous year. Studies conducted before a vaccine was available provided useful data with which to start planning communication strategies about vaccine rollout. With national vaccination programmes currently underway internationally, further research is needed to understand how COVID-19 vaccine acceptance and factors affecting acceptance might have changed now that vaccination has materialized.

Contextual factors such as news stories and media coverage also influence vaccine acceptance. 9 The approval of the COVID-19 vaccines and the rollout of the vaccination programme has been accompanied by considerable press reporting of the differences between the vaccines, including the type of technology used (mRNA vs viral vector 10 ), speculation about levels of efficacy observed in clinical trials, and potential variation in effectiveness in a public health context. 11 There was coverage related to two doctors in the UK who had an J o u r n a l P r e -p r o o f allergic reaction to the vaccine 12 and some controversy over the deviation from prior clinical trial administration of the required 2 doses of each vaccine 3 weeks apart so that they were administered 12 weeks apart, 13 as well as the potential to mix vaccine types. 14 These issues may also have influenced COVID-19 vaccine acceptance.

The aim of this study was to investigate associations between COVID-19 vaccination intention and sociodemographic, psychological, and contextual factors in a demographically representative sample of the UK adult population at the start of the COVID-19 vaccination programme rollout.

We conducted an online cross-sectional survey (13 th to 15 th January 2021), hosted on Qualtrics.

Participants (n=1,500) were recruited through Prolific's online research panel and were eligible for the study if they were aged eighteen years or over, lived in the UK, and had not completed our previous survey 5 (n>31,000 eligible participants). Prolific set quotas based on UK census data to ensure respondents were broadly representative of the UK population in terms of age, sex and ethnicity. Of 1,508 people who began the survey, 1,503 completed it (99.7% completion rate). Three participants were excluded from the sample as they did not meet quality control checks (specifically, they failed to correctly answer 2 or more of 3 attention check questions). Participants were paid £2 for a completed survey.

Full survey materials are available online. 15 Most items were the same as those in the UK survey reported above 5 , which was conducted in July 2020 and consisted of items that were based on previous literature. [16] [17] [18] [19] [20] Some further items were added, and some removed or amended to reflect the availability of specific COVID vaccinations and the timing of the survey.

J o u r n a l P r e -p r o o f

We asked participants to report their age, gender, ethnicity, religion, highest educational or professional qualifications, current working situation, and total household income. We also asked participants what UK region they lived in, how many people lived in their household, whether they or someone else in their household (if applicable) had a long-standing illness, disability or infirmity and, if so, whether they had received a letter from the NHS recommending that they took extra precautions against coronavirus ('shielding') or whether they had a chronic illness that made them clinically vulnerable to serious illness from COVID-19. We also asked whether they or anyone they lived with were classified as obese or were pregnant, and if they worked or volunteered in roles considered critical to the COVID-19 response ('key worker' roles).

Lastly, we asked participants whether they had been vaccinated for seasonal influenza last winter and/or had (or intended to be) this winter (yes/no).

Participants were asked to what extent they thought "coronavirus poses a risk to" people in the UK and to themselves personally, on a five-point scale, from "no risk at all" to "major risk". They were asked if they thought they "have had, or currently have, coronavirus".

Participants could answer "I have definitely had it or definitely have it now", "I have probably had it or probably have it now", "I have probably not had it and probably don't have it now", and "I have definitely not had it and definitely don't have it now". They were also asked if they personally knew anyone who had had COVID-19 (yes/no).

Further, we asked participants a series of eight questions about their attitudes towards COVID-19. They were asked whether, as far as they knew, they were in one of the groups that had so far been offered the vaccine. Participants were then asked if they had been vaccinated (yes, I've had one/two doses/no) and if they answered yes, they were asked which vaccine they had received (Pfizer-BioNTech/Oxford University-AstraZeneca). All participants were then asked 21 questions about COVID-19 vaccination. Statements measured theoretical constructs including perceived susceptibility to COVID-19, severity of COVID-19, benefits of a COVID-19 vaccine, barriers to being vaccinated against COVID-19, ability to be vaccinated (self-efficacy), subjective norms, behavioural control, anticipated regret, knowledge, trust in the Government, and trust in the NHS. These items also investigated concerns about commercial profiteering, and participants' beliefs about J o u r n a l P r e -p r o o f vaccination allowing life to get back to 'normal' and having to follow social distancing and other restrictions for COVID-19 if vaccinated. Participants rated the statements on an elevenpoint scale (0-10) from "strongly disagree" to "strongly agree". We adjusted the wording to make the grammatical tense either retrospective for those who had received the vaccine or prospective for those who had not. Participants who had not yet received a vaccine were additionally asked how likely they thought it was that they would get side effects from a coronavirus vaccine. We also asked participants if the coronavirus vaccination had been recommended to them by a health care professional and whether their employer did/would want them to have the COVID-19 vaccination. Order of items was quasi-randomized.

To measure vaccination intention, we asked participants who had not yet been vaccinated to state how likely they would be to have a COVID-19 vaccination "now that a coronavirus vaccination is available" on an eleven-point scale from "extremely unlikely" (0) to "extremely likely" (10).

We additionally asked participants to report the main reason why they were likely or unlikely to have a coronavirus vaccination in an open-text comment box.

Ethical approval for this study was granted by Keele University's Research Ethics Committee 

A target sample size of 1500 was chosen to provide a high ratio of cases to estimated parameters in order to avoid overfitting and loss of generalizability in the regression model. 21

To identify variables associated with an intention to have the COVID-19 vaccination in those who had not yet been vaccinated, we constructed a linear regression model. Ordinal and multinomial predictors were converted to dummy variables. To aid interpretation of the model, and to achieve a more parsimonious set of predictor variables, we ran principal component analyses 22 To analyse open-ended responses for reasons why participants were likely or unlikely to have a coronavirus vaccination, we conducted a content analysis using an emergent coding approach, whereby codes were identified from the data rather than a priori. 23 Two authors (MC and HD) jointly coded a small sample of statements to understand the scope of the data.

They then each independently coded sufficient responses that they achieved a run of 15 statements without encountering any new emerging codes. At this point they compared the codes they had generated and discussed any discrepancies. They then independently applied these codes to the rest of the statements, after which they checked that they had applied the same codes across the statements and discussed and resolved any additional codes and any discrepancies. This process was first applied to those participants who were uncertain about whether they would have the vaccine, then to those who were unlikely to have it, and finally to those participants who were likely to have it. 

Participants' vaccination intention (in participants who had not already received one or both doses) is presented in Figure 1 . Vaccination intention exhibited a marked negative skew (mean=8.13, standard deviation=2.96, median=10.00). In order to categorize respondents in terms of their vaccination intention, we applied a priori cut-points to the 0-10 scale (with scores of zero to two as "very unlikely", three to seven as "uncertain" and eight to ten as "very likely", as per our July 2020 survey [5] (Table 4) . 

Of the 1470 participants who had not yet received a vaccine and were asked to give a reason for the score provided on the likelihood of having the vaccination question, 1461 participants (99.4%) provided a response. Answers ranged from one word to 455 words (mean=20.3, SD=20.6). The content analysis generated 102 unique codes. The codes were then further organized into themes and these, along with a frequency count of comments per theme, are presented in Table 5 . A breakdown of codes and themes is provided in Supplementary Materials 3. The two most frequently cited reasons to support the score participants gave on the likelihood question related to protecting themselves or others. These were primarily reasons given by participants who indicated they were likely to have the vaccine. In comparison, the most J o u r n a l P r e -p r o o f frequently provided reasons provided by participants who were uncertain or unlikely to have the vaccine were related to safety concerns about the COVID-19 vaccine.

The UK government has set a target of offering a first dose of a COVID-19 vaccine to all adults in the UK by the end of July 2021. 24 In this study conducted in January 2021 threequarters of participants reported being very likely to have the vaccination. This is higher than the 64% who reported being very likely to have the vaccination in our study conducted in July 2020 xx and is consistent with increases in vaccination intention reported elsewhere. For example, in a recent (March 2021) YouGov poll in the UK, 86% of respondents had either already been vaccinated or reported that they would get the vaccine. 25 Despite the relatively high intention reported in our study and recent polling, we cannot be complacent about uptake. News stories are emerging almost every week about different variants of the virus as well as issues around differential uptake of individual vaccines across the world 26 and it is important to understand the factors associated with intention in order to maximize uptake and offset any adverse media reporting, social media misinformation, and the like.

Our results indicate that greater intention to have the COVID-19 vaccination was associated with having been vaccinated for influenza last or this winter or intending to be this winter. This is consistent with our previous findings 5 as well as with findings from the US 27 and Europe. 28 However, several of the COVID-19 vaccination beliefs and attitudes explained a more substantial proportion of the variance in vaccination intention. Intention was associated with greater perceived social norms around COVID-19 vaccination and greater perceived necessity of vaccination. These items map onto theoretical constructs that have previously been shown to influence uptake of health behaviours: subjective norms and perceived susceptibility 5 . Previous studies exploring vaccine intentions have also found high levels of positive social norms favouring the vaccine 29 and that intention is associated with increased levels of concern related to the risks of the disease. 28, 30 We also found that lower intention was associated with reduced belief in the safety of the vaccine, and this has been found consistently across studies exploring COVID-19 vaccine intentions 7,8 and vaccine hesitancy. 8 This was also reflected in the content analysis of participants' open-ended responses, in which issues related to vaccine safety were the most frequently identified reason for lower vaccination intention in the participants we classified as uncertain or very unlikely to have the vaccine. This is also consistent with the free text responses given in an English J o u r n a l P r e -p r o o f study exploring vaccine acceptability conducted April to May 2020. 7 Since there was less than a year between the genetic code of COVID-19 being made public and the first COVID-19 vaccine being approved, this belief is perhaps unsurprising. However, it does make it essential that there is sufficient engagement with the public's concerns and that good-quality and credible information continues to be made available about the vaccine. This recommendation is reinforced by the association in our data of perceived adequacy of information about the vaccine to facilitate an informed decision with vaccination intention.

Since free-text responses related to safety were the most frequent category of response from uncertain responders, it is likely that any reporting of safety concerns in the media may well shift the balance in favour of not being vaccinated, as has been observed previously 31 J o u r n a l P r e -p r o o f vaccine. 34 We recruited a demographically representative sample based on age, gender, and ethnicity. However, the relatively low number of participants from ethnic minority backgrounds necessitated collapsing our data across these categories, which may explain why ethnicity was not associated with intention in our study. The lack of an association with age is also unexpected, especially since by 19th September 2021, 73.9% of 18-24-year-olds had had at least one dose of the vaccine compared to 98.3% of 75-79-year-olds. 35 The age difference in actual uptake may in part be due to the way the vaccine was rolled out to the population, with the vaccine being distributed first to older age groups (25 to 29 year olds first invited 6 months after distribution to residents in care homes and those aged 80 years and over) 36 . The percentage of participants in our sample who indicated they were very likely to have the vaccine (73.5%) was lower than the percentage of the UK population who actually did (89.0% had had one dose and 82.9% had 2 doses by 19th September 2021 35 ).

This may reflect the fact that our study was conducted when the vaccine was first rolled out and was not yet available to most of our participants. As the roll-out gathered pace, subjective norms and perceived susceptibility, both of which are shown to be important determinants of vaccine willingness in our study, may well have increased for older adults, with high uptake fuelling subjective norms, and the disparity in reported health outcomes for vaccinated versus unvaccinated adults fuelling perceived susceptibility. Furthermore, the UK government and NHS have been proactive in providing mass vaccination centres, invitations, reminders, and messaging. A recent study found that younger adults in the UK demonstrated more vaccine hesitancy and resistance, 37 which may have prevented the same inflation in uptake relative to reported likelihood that we have seen in older adults. Studies using appropriate sampling techniques are required to capture and quantify uptake and associated attitudinal differences across different population cohorts. As the vaccination is made available to all those who want it, future research could also usefully focus on those who are uncertain or unlikely to be vaccinated.

Our regression model explained 70% of the variance in vaccination intention, similar to the figure of 76% in our previous study; 5 the remaining unexplained variance will represent predictors that we did not measure and random measurement error. Given that social science research in general, 38 and public opinion surveys in particular, 39 do not characteristically yield high R 2 values owing to the likely multiple and complex determinants of individuals' beliefs and attitudes, we believe that our model demonstrates good explanatory power.

Finally, intention to have the COVID-19 vaccine was associated with a weaker belief that widespread coronavirus vaccination is just a way to make money for vaccine manufacturers. This is consistent with research from Hong Kong 40 in which higher levels of trust in the vaccine manufacturer were associated with increased willingness to have the COVID-19 vaccine.

Limitations of this study include that we measured self-reported intention rather than actual uptake. Intention is usually higher than uptake; however, vaccine intention predicts vaccine uptake and so acts as a useful proxy in the early stages of vaccination rollout. The survey is cross-sectional, so we are unable to infer causality between attitudinal factors and intention. Although our sample was broadly representative across the dimensions of age, sex, and ethnicity, representativeness was not specifically sought in the quota sampling for other dimensions such as location in the UK or socio-economic status.

To our knowledge, this is the first peer-reviewed study investigating intention to receive a COVID-19 vaccination in a demographically representative sample of the UK population since the COVID-19 vaccination rollout began in December 2020. Three-quarters of our sample reported being very likely to have the COVID-19 vaccination. However, since vaccine uptake may well be lower than vaccine intention, it is important to understand the factors associated with intention and to ensure that communication and engagement strategies related to the vaccination are informed by those factors. Going forward, it is not yet known for how long COVID-19 vaccines confer immunity or how effective they will continue to be against emerging strains as the virus mutates and, consequently, whether booster vaccines may be required. 24 In order to ensure the success of the current vaccination rollout and any 

The authors affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned have been explained.

Data are available online XX [redacted for peer review].

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