key: cord-0924242-a3hj98dq
authors: Al‐Amer, Rasmieh; Maneze, Della; Everett, Bronwyn; Montayre, Jed; Villarosa, Amy R.; Dwekat, Entisar; Salamonson, Yenna
title: COVID‐19 vaccination intention in the first year of the pandemic: A systematic review
date: 2021-07-06
journal: J Clin Nurs
DOI: 10.1111/jocn.15951
sha: 53a447eaac9aee34b2b0d04d4703eab29084d836
doc_id: 924242
cord_uid: a3hj98dq

AIMS AND OBJECTIVES: To synthesise evidence regarding vaccination intention, identify factors contributing to vaccine hesitancy among healthcare professionals and the general populations globally. BACKGROUND: As COVID‐19 vaccine becomes available worldwide, attention is being directed to community vaccine uptake, to achieve population‐wide immunity. A number of factors have been reported to influence vaccine intention. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, a systematic search of COVID‐19 vaccination intention related literature published on or before 31 December 2020 from seven databases was undertaken. RESULTS: Thirty articles were included in this systematic review. Overall COVID‐19 vaccination intention during the first year of the pandemic ranged from 27.7% to 93.3%. Findings highlighted that socio‐demographic differences, perceptions of risk and susceptibility to COVID‐19 and vaccine attributes influenced vaccination intention. Healthcare professionals particularly, nurses have higher vaccine hesitancy reportedly due to concerns regarding vaccine safety and efficacy and mistrust of health authorities. Negative information about COVID‐19 vaccines in the social media and low confidence in the health system were associated with lower acceptability among the community. Interestingly, cumulative increase in COVID‐19 caseloads of countries over time was not associated with vaccination intention. CONCLUSIONS: The significant variability in vaccine intention rates worldwide would hamper efforts to achieve immunity against COVID‐19. Nurses’ concerns about vaccine safety and efficacy need to be addressed to increase vaccine acceptance and maximise their influence on vaccination decision in the community. As misinformation through social media negatively impacts vaccination uptake, authoritative and reliable information on vaccine attributes, disease risks and vaccination benefits are needed. RELEVANCE TO CLINICAL PRACTICE: Concerns about vaccine safety and efficacy including misinformation are important contributors to vaccine hesitancy. Addressing these factors, particularly among nurses who are considered trusted influencers of vaccination decisions in the community is an important strategy for pandemic preparedness.

The emergence of SARS-CoV-2 in the latter part of 2019 is perhaps the biggest health threat in living memory. This novel coronavirus that causes COVID-19, remains a significant threat to life (Fauci et al., 2020) . The rapid spread of this disease has caused substantial burden on morbidity and mortality, particularly among older people, causing a need to quarantine and physical distance to reduce transmission. In addition, restriction measures have contributed to a major global economic downturn (Mehta, 2020) . The cataclysmic impact of the COVID-19 pandemic on health and economy globally has contributed to an unprecedented pace in COVID-19 vaccine development to gain herd immunity.

Effective vaccine development usually takes an average of 10 years, but in the case of COVID-19 vaccines, 10 were developed and were being tested in clinical trials by June 2020. Of these, two received Emergency Use Authorization in December 2020 to be rolled out before the end of 2020 (Mullard, 2020) . Despite this unprecedented success in vaccine development, convincing the population to accept vaccination against COVID-19 remains a major challenge (World Health Organization, 2021) . Vaccination intention can be broadly defined to include willingness to be vaccinated, vaccine acceptability including desirability, vaccine demand and positive attitudes towards the given vaccine, which is contrasted to vaccine resistance, the refusal to be vaccinated (Gates et al., 2021) . Of most concern to public health is the issue of vaccine hesitancy, which can be defined as indecision, reluctance or concerns regarding vaccination for oneself or loved ones or delay in the uptake of vaccines (Dubé et al., 2013) . This indecision or reluctance towards COVID-19 vaccination can severely jeopardise herd immunity, which is the indirect protection conferred on vulnerable populations when a sufficiently large number of individuals who are immune to the disease within a population (Randolph & Barreiro, 2020) . Therefore, as the race to COVID-19 vaccine development is reaching the finish line, attention is now focused on community vaccine uptake, to achieve population-wide immunity. Pivotal in this effort is vaccine acceptance among healthcare professionals, particularly nurses, who are at the frontline of health care to promote vaccine acceptance by the public.

A range of factors are known to influence vaccination intention, which include personal socio-demographic characteristics, individual beliefs and experiences, to broader external or organisational factors (Dube et al., 2015) . Among parents from minority populations, willingness to have their children vaccinated has been influenced by concerns regarding the threat of the infection, perceived susceptibility of their children and confidence of vaccine effectiveness (Frew et al., 2011) . In relation to COVID-19 vaccine uptake intention, there have been several studies published in 2020 alone, focusing on the general public, healthcare workers, as well as on specific at-risk groups. The aim of this review was to assess intention to receive a COVID-19 vaccine, and to identify factors shown to be associated with vaccine acceptability. Additionally, this review also aimed to examine if the vaccination intention among nurses and other healthcare professionals were significantly different from that of the community in general. Findings from this review will contribute to understanding the challenges related to vaccine hesitancy across all population groups, and explore strategies to overcome these challenges. | 3 AL-AMER Et AL. coronavirus), vaccine (vaccination, inoculation and immunisation) and intention (attitude, acceptance, barriers, hesitancy, perception, refusal, uptake, utilisation and willingness) were used. In total, seven databases were searched CINAHL, Cochrane Library, Google Scholar, ProQuest, PsycINFO, PubMed and Scopus. Database searches commenced from 17 December 2020, and the date of the last search was performed on 31 December 2020. The reference lists of included studies were also reviewed for inclusion, as well as recent citations of the included studies. Any alerts of studies published before 31 December 2020 were included.

Studies that aimed to investigate attitude and perceptions of people towards COVID-19 vaccine were included. These included studies that used cross-sectional, observational or qualitative approaches that focused on COVID-19 vaccination intention. In addition to the three key concepts vaccine and intention) , all population groups were included. Studies published in languages other than English and Arabic were excluded from this review. Pre-print references with no evidence of acceptance by peer-reviewed journals up to 31 December 2020 were excluded from this review.

All records retrieved from the seven databases that met the inclusion criteria were downloaded using the reference management software, EndNote Version X9.0. Following removal of duplicate references, two authors (DM and YS) screened to exclude irrelevant records, firstly by title and then by abstract. Upon F I G U R E 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart for the systematic review

Author, year and country completion of this process, the full text of the remaining references was sourced and screened for inclusion in this systematic review (Figure 1 ).

We developed and pilot tested a data extraction form, which was tested by three authors (BE, JM and YS (Goldsmith et al., 2007; Villarosa et al., 2019) . In total, 16 of 30 (54%) studies were rated to be above 80% (high quality), 10 of 30 (33%) studies were within the range of 60%-79% (moderate quality), and 3 of 30 (13%) studies were appraised as poor quality (30%-59%).

Characteristics of all studies were summarised, including country of study, sample, period of data collection, levels of COVID-19 vaccination intention and key factors influencing this intention. Due to the heterogeneity in measurement of vaccination intention, synthesis of this outcome measure was included in the results section. 

Except for one study that assessed preference for the types of hypothetical COVID-19 vaccines , the remaining 29 studies measured vaccination intention using a range of approaches.

Six studies used a two (e.g. 'Yes' or 'No') category response format Gagneux-Brunon et al., 2020; Goldman et al., 2020; Harapan et al., 2020; Kabamba Nzaji et al., 2020) , five studies used a three ( In total, 11 studies that used the 5-point Likert response format, eight collapsed the first two positive categories of a 5-point Likert response format to indicate vaccination intention Lazarus et al., 2020; Malik et al., 2020; Palamenghi et al., 2020; Pogue et al., 2020; Reiter et al., 2020; Szilagyi et al., 2020; Zhang et al., 2020) , two computed an average score to indicate vaccination intention percentages Freeman et al., 2020) , and one reported the scores of all five categories .

Two studies that used a 6-point Likert response format also did not collapse category scores and reported scores for all six categories Williams et al., 2020) , and three studies used a 7-point Likert response format and computed an average score to indicate vaccination intention percentages Head et al., 2020; Kreps et al., 2020) . One study used an 11-point Likert scale and aggregated the first 3 categories to indicate vaccination intention .

Overall vaccination intention percentages for COVID-19 ranged from as low as 27.7% to 93.3% . In the one USA study that examined national trends in acceptability of COVID-19 vaccine from April to November 2020, there was an overall decline in vaccination intention over time, from 74% to 56% .

Studies included in this review also identified factors influencing COVID-19 vaccine uptake intention, which were categorised into five categories: (a) socio-demographic differences; (b) health literacy and COVID-19 information sources; (c) perceived risk or perceived susceptibility of COVID-19; (d) vaccine attributes, and speed of vaccine development; and (e) regional increase in cumulative COVID-19 caseloads over time.

Of the 30 studies, 12 found that those in older age groups were more likely to express willingness to be vaccinated against COVID-19 (Al-

Mohaithef Fisher et al., 2020; Freeman et al., 2020; Gagneux-Brunon et al., 2020; Grech et al., 2020; Kabamba Nzaji et al., 2020; La Vecchia et al., 2020; Lazarus et al., 2020; Malik et al., 2020; Palamenghi et al., 2020; Sherman et al., 2020; Szilagyi et al., 2020) , in contrast, three studies found higher vaccine acceptance among those in the younger age group Harapan et al., 2020; Kreps et al., 2020) . In relation to gender, 11 studies found that men were more likely to express acceptance of COVID-19 vaccine compared to women Freeman et al., 2020; Gagneux-Brunon et al., 2020; Guidry et al., 2020; Kabamba Nzaji et al., 2020; Kreps et al., 2020; Malik et al., 2020; Reiter et al., 2020; Szilagyi et al., 2020; Wang et al., 2020) .

This was also the case if fathers were the designated respondents to a caregiver survey, about their intention to accept COVID-19 vaccine for their child . Among racial and ethnic groups, lower COVID-19 vaccination intention was reported among Black Americans and those of ethnic minority backgrounds Freeman et al., 2020; Guidry et al., 2020; Kreps et al., 2020; Malik et al., 2020; Reiter et al., 2020; Szilagyi et al., 2020) .

In contrast, two USA studies reported that those of Asian descent had higher intention to COVID-19 vaccination compared to other racial and ethnic minority groups Szilagyi et al., 2020) . In another study that sampled populations from 19 countries , respondents living in China reported the highest positive COVID-19 acceptance percentage (88.6%).

Among studies that assessed educational attainment, 10 reported COVID-19 vaccination intention was lower among those with lower education levels Dodd et al., 2020; Fisher et al., 2020; Freeman et al., 2020; Guidry et al., 2020; Head et al., 2020; Kreps et al., 2020; La Vecchia et al., 2020; Malik et al., 2020; Szilagyi et al., 2020) . Political affiliations were also found to be associated with vaccination intention in three studies, with higher acceptance of COVID-19 vaccine among those with moderate or liberal political leanings Kreps et al., 2020; Reiter et al., 2020) , although one study did not show any group difference between vaccine uptake and political affiliation .

Nine of the 30 studies included or exclusively focused on healthcare workers (HCWs). Of these, two reported no difference between those in healthcare and the non-healthcare groups . Although one study reported lower intent to be vaccinated among HCWs compared to the general public , another study reported higher vaccination intention among HCWs . Within HCW groups, physicians were consistently reported to have higher intention to be vaccinated against COVID-19 compared to trainees or other HCWs, including nurses Gagneux-Brunon et al., 2020; Grech et al., 2020; Kabamba Nzaji et al., 2020) . In the study that exclusively surveyed nurses, only 40% reported an intention to accept COVID-19 vaccination .

While inadequate health literacy has been shown to be related to COVID-19 vaccination hesitancy Sherman et al., 2020) , high exposure to negative information about COVID-19 vaccines in the media, particularly social media, was associated with lower acceptability of COVID-19 vaccination Malik et al., 2020; Zhang et al., 2020) .

Specifically, those with conspiracy beliefs about the vaccine Freeman et al., 2020) , and those who reported vaccine mistrust Guidry et al., 2020) , expressed reluctance to be vaccinated against COVID-19.

In contrast, those with high trust in their nation's health system , or trust in health-related information from government bodies Lazarus et al., 2020) , were more likely to report willingness to be vaccinated. One USA study reported that endorsements from the Centers for Disease

Control and Prevention and World Health Organization were associated with higher vaccination intention . Trust in information from scientific research and recommendation from their healthcare provider were also associated with willingness to vaccinate against COVID-19 (Head et al., 2020; Reiter et al., 2020) .

Although one study reported that HCWs had higher acceptance of the COVID-19 vaccine , other studies did not find higher vaccination intention among those working in the healthcare industry Kabamba Nzaji et al., 2020) . Of concern, certain health professional groups, including nurses and assistant nurses, consistently reported lower COVID-19 vaccine acceptance, when compared to the adult population, or other health professional groups Gagneux-Brunon et al., 2020; Kabamba Nzaji et al., 2020; Wang et al., 2020) .

Two studies showed that medical doctors were more likely to express willingness to be vaccinated against COVID-19 compared to medical trainees or other HCWs Kabamba Nzaji et al., 2020) .

Vaccine acceptance was higher among those who perceived themselves to be at greater risk or threat (e.g. HCWs who were exposed to COVID-19 patients) of acquiring the infection (Al-Mohaithef & Dror et al., 2020; Harapan et al., 2020; Reiter et al., 2020; Wang et al., 2020; Williams et al., 2020) . Additionally, those who perceived themselves to be vulnerable or at greater susceptibility to COVID-19 (e.g. older age groups or those with chronic health conditions), were also more likely to indicate increased vaccine acceptance Head et al., 2020; Malik et al., 2020; Sherman et al., 2020; Wang et al., 2020) .

Seven studies included vaccine intention among HCWs Gagneux-Brunon et al., 2020; Harapan et al., 2020; Head et al., 2020; Kabamba Nzaji et al., 2020; Wang et al., 2020) which ranged from 28% to 96%. Nurses were shown to have lower vaccine intention (28%-65%) in half of these studies Gagneux-Brunon et al., 2020; Wang et al., 2020) because of lower perception of personal risk, concerns regarding the vaccine and time constraints.

Seven studies reported higher acceptance of the COVID-19 vaccine if respondents had had influenza vaccine in the past Fisher et al., 2020; Gagneux-Brunon et al., 2020; Goldman et al., 2020; Grech et al., 2020; Sherman et al., 2020; Wang et al., 2020) . Among those from healthcare backgrounds, two studies reported that they were more likely to receive the influenza vaccine than the COVID-19 vaccine ; however, there was no group difference in COVID-19 vaccination intention between healthcare professionals and the general population . In two studies, concerns about vaccine novelty and the speed of COVID-19 vaccine development were reasons given for vaccine hesitancy Goldman et al., 2020) .

In relation to personal preference of hypothetical types of available COVID-19 vaccines and vaccination intention, respondents from eight studies indicated effectiveness of vaccine was an important factor influencing vaccine selection or vaccination intention Freeman et al., 2020; Harapan et al., 2020; Kreps et al., 2020; Palamenghi et al., 2020; Pogue et al., 2020; Reiter et al., 2020; Wang et al., 2020) , as was a vaccine with long duration of disease protection Kreps et al., 2020; Pogue et al., 2020) .

Vaccine safety, that is a vaccine with no or few adverse effects, was also a strong determinant influencing willingness to be vaccinated Freeman et al., 2020; Kreps et al., 2020; Pogue et al., 2020; Reiter et al., 2020; Sherman et al., 2020; Wang et al., 2020) . Furthermore, COVID-19 vaccines that were developed or manufactured in America or Europe received higher preference ratings compared to those developed in China or Russia Kreps et al., 2020; Pogue et al., 2020) . Interestingly, in one study, cost of the vaccine was found to be the least important factor in respondents' vaccine selection 3.3.6 | Regional increase in cumulative COVID-19 caseloads over time and vaccination intention recorded trend over time in a single country ;

were excluded in this plot (Figure 2) . The time series pattern showed low estimated R of −0.00042, indicating no relationship between cumulative increase in COVID-19 caseloads and respondents' vaccination intention. The same and consistent pattern was also found in the study by Lazarus et al. (2020) , which collected data from 19 countries in June 2020. Low correlation (R = −.0004) was found between vaccination intention in each country and the cumulative mean COVID-19 caseloads per 1 million people during the period of data collection in June 2020.

As world leaders and public health officials focus on securing sufficient COVID-19 vaccines and an effective vaccine roll-out strategy for their population, this review underscores another urgent challenge-to address the variability in COVID-19 acceptance across socio-demographic groups, and addressing barriers to vaccine acceptance. Findings of this review on COVID-19 vaccination intention are consistent with previously reported seasonal influenza vaccination uptake which showed that being older, ethnically White, and having higher educational attainment were associated with higher vaccine acceptance (Okoli et al., 2019) . Similarly, the finding that men were more receptive to the COVID-19 vaccine is consistent with previous investigation on gender differences and vaccine uptake (Flanagan et al., 2017) . Some of the reasons postulated were lower level of social support for women and being less open to healthcare recommendations and preventive measures (Jiménez-García et al., 2010) . In contrast to those who underestimated the severity of the disease or showed mistrust in authorities, those who had previously received vaccination for seasonal influenza, and/or expressed higher concern and belief in their susceptibility to the disease were understandably more willing to vaccinate against COVID-19 .

Vaccine attributes were also found to be crucial in the decision to vaccinate, including effectiveness of the vaccine, long duration of protective effects and optimum safety profile which were also consistent with previous findings, for example, in the study conducted on the H1N1 vaccine during the 2009 influenza A pandemic (Frew et al., 2011) . Confidence in the quality of the vaccine was reported to be strengthened by recommendations from reliable sources such as nurses and physicians highlighting the role of HCWs in building public trust. Another important factor that influenced vaccine hesitancy found in this review was the speed of vaccine development which was not surprising considering the novelty of the COVID-19

virus and the new technologies used, raising uncertainties about the adequacy of research and testing, adversely impacting on perceived efficacy and safety of vaccines .

Of concern, this review also highlighted a decline in vaccination intention over a 10-month span in 2020, which was borne out in two studies, one conducted in the USA and the other in Italy . This decline occurred during a period when confirmed COVID-19 cases in both countries were consistently among the 10 highest in the world (COVID-19 Coronavirus Pandemic, 2020, 2020). Nevertheless, this trend is consistent with findings of another study conducted during the 2009-2010 H1N1 pandemic (Gidengil et al., 2012) . Postulated reasons for this paradoxical trend of decline in vaccination intention over time could be (a) an overestimation of perceived risk in an unusual event , which declines as more comprehensive understanding of the threat emerges (Gidengil et al., 2012) ; (b) messaging fatigue, a status of weariness and desensitisation, due to repeated exposure to information about COVID-19 (Koh et al., 2020); infodemic, an oversupply of information making it difficult to distinguish between reliable information and misinformation (Zarocostas, 2020) . Findings from this review support a need to address the issue of potential 'crisis of public confidence' against COVID-19 vaccination, and to address specific concerns of subpopulation groups, with vaccination messages that are group-and context-specific, to restore confidence in COVID-19 vaccines (Larson et al., 2011) .

Although the WHO has established a new information platform to share information tailored for specific target groups since the declaration of the COVID-19 pandemic (Zarocostas, 2020) , findings from this review indicate more work is needed. This need is particularly important, as it has been shown empirically, that undecided or vaccine hesitant groups were more likely to be influenced by the views from minority but well-organised anti-vaccination groups, compared to those from pro-vaccination groups (Johnson et al., 2020) . One strategy that has been promoted is psychological inoculation, also known as pre-bunking, an approach of presenting anti-conspiracy arguments to counter misinformation about COVID-19 vaccination, before the general public is exposed to misinformation on vaccination conspiracy theories (van der Linden et al., 2020). Nevertheless, the effectiveness of this strategy against COVID-19 vaccination in-

tention has yet to be reported.

In addition to highlighting the issues of vaccine intention in different population groups, this review has also highlighted the need for standardisation in measuring vaccine uptake. Differences in terminology used to refer to vaccine intention, heterogeneity in measurement of vaccine acceptance and collapsing responses often into dichotomous categories limit the capacity to undertake precise quantitative comparisons among studies that measured the same construct of vaccination intention. A standardised measure of this construct will enhance accuracy to identify target areas to improve vaccination uptake.

We only included full-text articles of studies published up until

December 2020 and we excluded pre-print articles that had not yet been peer reviewed. Given the very high rate of COVID-19 research publications-estimated at 137 publications per day compared to 6 papers per day during the 2009/2010 H1N1 pandemic (Yeo-Teh & Tang, 2021), it may be that including papers available in pre-print but not peer-reviewed at the time of our search may have resulted in different conclusions being drawn. We also only included papers published in English because of the lack of resources to undertake translation which may limit the generalisability of these findings.

This review identified significant variability in vaccine intention rates across countries, ranging from 27.7% to 93.3%, which in some countries would hamper efforts to achieve herd immunity. Nevertheless, factors shown to be associated with vaccine acceptability included being older, male, having higher levels of education, previous receipt of influenza vaccination, perceiving oneself to be at greater risk of exposure or greater susceptibility to COVID-19, and having high levels of trust in health-related information from government bodies and healthcare providers. In contrast, high exposure to negative information about COVID-19 vaccines, particularly in social media, and certain health professional groups including nurses and nursing assistants were associated with lower vaccine acceptability. This review did not support COVID-19 caseload as a factor associated with vaccination intention rather, it has highlighted a decline in vaccination intention during a period when COVID-19 have been increasing.

More research is needed to understand why nurses have lower rates of vaccine acceptability particularly as they are at higher risk of exposure to COVID-19 and will be prioritised to receive the vaccine.

Addressing methodological issues of measuring vaccine acceptance would be an important step towards an improved evaluation of vaccine intention. Intensive population education programs, in concert with vaccination promotion efforts from health, social and political organisations to address the barriers reported in this review are needed to improve vaccination acceptance.

An important finding of this review was the number of studies showing lower vaccine acceptance among healthcare professionals, particularly among nurses. This is consistent with previous studies that showed that nurses had more concerns with vaccine efficacy and safety, and mistrust in health authorities (Wilson et al., 2020) .

Given that nurses are considered the most trusted professionals in the community (Milton, 2018) , more focus should be given to address their vaccine hesitancy concerns, to enable them to provide informed and authoritative recommendations to the public.

No conflict of interest has been declared by the authors. 

Data are in the table and figures included in the article (Table 1) .

Della Maneze https://orcid.org/0000-0001-6475-8804

Following the completion of the search and screening process, 30 studies met the criteria for inclusion in this review (Figure 1) and are summarised in Table 1. None of these were published in Arabic. Of the 30 studies, nine were undertaken in the United States

four in Italy

2020) and one each from Australia

2020), the remaining 29 studies used a cross-sectional survey design. Time periods of surveys varied from early during the COVID-19 pandemic up to

Four studies did not include the time period of data collection

Two-thirds (20 of 30) of the included studies focused on the general public living in each of the respective countries

Three focused on students in higher education

and two collected data exclusively from parents or caregivers, and focused on their intended uptake of vaccine for their children against COVID-19

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