27 participants finally completed the in-depth interviews to reach data saturation. Of these participants, 14 were aged 70-79 years and eight were above 80 years old, while the remaining were 60-69 years old. In total, eighteen participants reported having been diagnosed with at least one chronic disease. A summary of participants’ demographics is provided in Table 1.
Five research themes were identified to explain older adults’ decision making for refusing or delaying COVID-19 vaccination (Figure 1). During the interviews, we identified a spectrum of vaccine-resistant and vaccine-hesitant attitudes relating to COIVD-19 vaccines. Their vaccine-resistant and vaccine-hesitant attitudes were weaved into the contexts of lacking sufficient decisional support from doctors, family, and government, their attitude roots of negative perception of ageing, fatalistic risk attitudes, low health literacy, present time perspectives and negative value on western biomedicine, as well as reliance on peripheral processing of vaccine-related information. While participants delayed or refused vaccines, they turned to alternative coping strategies to regain self-control in the pandemic.
Insufficient social support in decision making
Participants generally received low support for their decision making regarding taking COVID-19 vaccination from doctors, family, and the government.
Lack of decisional support from doctors
Participants exhibited great trust but received limited support from doctors for COVID-19 vaccination decision. For most participants, lacking explicit recommendation or endorsement by doctors resulted in vaccine delay or refusal. Older adults generally take a less active role in their communication with doctors about the vaccines. Whilst perceiving lack of knowledge prompted older people to unconditionally believed in doctor’s judgement (including no recommendation for vaccine uptake), making the shared decision-making less possible.
None of the participants received doctor’s recommendation/advice for taking COVID-19 vaccination unless they initiated the discussion with doctors about the vaccines. Of these participants who proactively asked their doctors about their eligibility for COVID-19 vaccination, however, only one received a firm recommendation from his doctor. The others mentioned that they remained hesitant after talking to their doctors about COVID-19 vaccines because their doctors gave ambiguous advice.
“I proactively asked (about the vaccine-related issues) twice… for the first time, the doctor asked me not to get vaccinated now and wait for a while due to my blood issue…For the second time, he said my blood turns normal, but told me that I should decide on my own…” (EV10).
Most participants indicated that they would rather passively wait for doctor’s recommendation. One major reason for this was their concern that this would harm their long-term relationship with doctors.
“When I asked him (the doctor) ‘how is my illness?’, he was annoyed and unhappy. I am also worried about asking too many questions, which may make him feel unhappy… I would rather just take the medicine the doctor prescribed for me without asking questions…” (EV09).
Another reason for participants’ unwillingness to discuss with their doctors about vaccines was perceiving lacking professional knowledge to initiate such discussion.
“I never think about discussing (vaccine-related issues) with the doctor… Because I do not know much about this field, and I am not good at communicating… If I discuss with the doctor, I am afraid that the next medical consultation will be interrupted” (EV11)
Lack of family support for COVID-19 vaccination
Participants consistently indicated that their families tended to return the vaccination decision back to themselves. Most participants lived alone or merely with other old family members (e.g., spouse) and thereby lacked connectivity with other family members (e.g., their children).
“My daughter did not give me any response… I think she prefers a free choice, depending on my own decision. I think she has no opinion.” (EV07).
Lacking tangible support from family for getting to the vaccination site was also identified, especially for participants who had physical difficulties to travel to the vaccination venues.
“I asked my son to take me to (the vaccination venue), maybe he was not available… If my son accompanies me to get vaccination, then I will go with him…” (EV13)
Four participants, all of whom were female, worried about burdening other family if adverse effects occurred due to vaccination.
“If you take your old parents to take a vaccine and they really have some bad consequences, as their child, you won’t get peace…I understand their difficulty.” (EV06)
Insufficient decisional support from the government
As participants could not obtain clear recommendation from doctors and opinions from family, participants sought information from the government. However, information from the government was perceived to be confusing and insufficient, which prompted feeling of being “ignored” or not being involved in the vaccination decision-making process.
“The vaccination recommendation (from the government) is relatively uncommon... The government should show more concern and care for the elderly, telling us more vaccine-related information … We can only learn from the news through television and radio … We know little about other aspects about the vaccines… There are two types of vaccines available, one is Sinovac, and another is BioNTech. I don’t know which one is better, or which one is more suitable for the older people.” (EV15)
Attitude roots are factors relevant to older adults’ personal values and historical education, serving as the underlying psychological factors that shape older adults’ attitudes and preference for COVID-19 vaccination, and perception of personal risk from COVID-19. During the interviews, participants repeatedly identified themselves to have more vulnerable health condition due to ageing. The negative self-perception of ageing constantly linked to their fatalistic views on pandemic risk and perception of being more physically vulnerable to vaccine risk. Participants’ concerns about vaccine risk were also rooted in their low health literacy which resulted in various misunderstandings about COVID-19 vaccines, a tendency to value the present more than the future, and negative value on western biomedicine.
Negative self-perception of ageing
Participants repeatedly mentioned their attitudes to death though not being prompted by the interviewer. They perceived that death was acceptable and “inevitable” as they aged. These thoughts prompted fatalistic views on the pandemic risk.
“No matter alive or dead, (my life) has already come to an end… nothing scares me” (EV19)
Eight participants expressed concerns about their ineligibility for taking a novel vaccine because of perceiving themselves to be “special” and “different”. Such belief was prompted by social comparison with other healthy and younger people.
“Young people’s physical function is definitely different from mine…They don’t have big health issues, of course they can take a vaccine…But I am different, I am fear of taking one (vaccine)” (EV05).
Fatalistic views on the pandemic risk
Participants repeatedly expressed little control over the pandemic risk. Eleven participants mentioned a “go-with-flow” attitude towards risk and believed that avoiding thinking too much was a coping strategy.
“It is inevitable when the COVID-19 virus comes… I will go with my flow.” (EV17)
Some participants attributed the cause of COVID-19 to luck or supernature power, indicating perceiving low controllability over the pandemic.
“(The pandemic) is a natural phenomenon… The earth has so many rubbish that need to be cleared out…So this is God’s intention, some people should be wept out (from the pandemic) … it is unavoidable...” (EV02).
Low health literacy
During the interviews, some misunderstandings about COVID-19 vaccines were identified. These misunderstandings reflected generally low health literacy of the participants. For instance, participants perceived that COVID-19 vaccines were for treatment rather than prevention.
“Why should I take a vaccine, I have no illness and pain!” (EV11)
Some participants held the belief that COVID-19 vaccination could increase asymptomatic infections which accelerated transmission.
“If people get too many vaccines, then they will become asymptomatic even get infection…They won’t realize this problem and walk around, this may cause virus spread and let others get infected as well...” (EV26)
Some participants perceived that they had limited medical knowledge and thereby were not confident to make vaccination decision.
“According to the experts, it will be better to take a vaccine…But you know, my medical knowledge is limited so I feel hard to make a judgement on that…” (EV02)
Present-oriented time perspective
Participants who were above 70 years old exhibited a present-focused time perspectives, valuing the importance of living for the moment rather than the prevention of future risk. This can be partly attributed to their perception of ageing. The present time perspective may drive a greater attention to the proximal cost caused by vaccination than future pandemic risk.
“It (the pandemic) is not a present matter…I will only think about it when I get infected in future later…I cannot foresee how the future will be.” (EV20)
Participants frequently expressed contentment with present and a preference for status quo.
“Many old people at my age have to use a crutch and they walk slower than me…So you asked me about getting infection (with COVID-19), I will tell you I don’t care too much. Present is good enough…” (EV02).
Negative value on western biomedicine
During the interviews, some participants expressed their preference for traditional Chinese medicine over western biomedicine including vaccination, which shaped a negative attitude towards vaccination.
“I seldom go to see doctors of western medicine. I usually go to see doctors of Chinese medicine… it is very annoying to take western medicine and get vaccinated at old age.” (EV24).
Peripheral processing of vaccine-related information
Peripheral information processing refers to reliance on cues, affect and personal experience rather than logics and cognitive deliberation to make risk judgment (30). When informational support from doctors, family and the government was insufficient, attitude roots became salient to prime participants’ attention to the more affect-loaded negative vaccine-related information from news reports or peers but rejected government’s explanations for the potential vaccine adverse effects. That is, a greater reliance on the peripheral information processing to evaluate the vaccine risk. The negative vaccine-related information usually contained more contextual information to allow mental simulation and affective cues being prioritized compared with government’s response to the negative vaccine-related reports.
Simulation of negative news reports about COVID-19 vaccines
Sixteen participants expressed their concerns about news on sudden deaths immediately following COVID-19 vaccination. They mentioned the characteristics of those reported death cases, for instance, having an older age and chronic diseases, which facilitated mental simulation of an event happening to themselves.
“I watched TV news earlier saying that some old people died due to their chronic illnesses (after taking vaccination), I also suffer from chronic illnesses...” (EV05).
Dissatisfaction with government’s response to potential vaccination adverse events
Meanwhile, participants expressed high dissatisfaction with the government’s official declaration of “no link existed between vaccination and the death cases”. This prompted them to interpret government’s response as an excuse to avoid responsibility. Such dissatisfaction was partly arisen from insufficient support from the government and deteriorated trust.
“HKSAR government is absurd…they claimed that vaccination has nothing to do with any consequences, even the two death cases were not relevant to vaccination… I do not believe in such statement.” (EV21).
Prioritizing negative anecdotal vaccination information from peers
Participants particularly those had chronic diseases highly valued the negative anecdotal information. Anecdotal information was usually peers’ or family’s personal experience and storytelling, hence were perceived to be more persuasive to participants.
“One of my schoolmates is an asthma sufferer, he had already got vaccinated and afterwards he fainted on the street one day… Then I am more worried about vaccination after knowing about his faint… and thus I am not willing to get vaccination…” (EV09)
Vaccine-hesitant and vaccine-resistant attitudes
Participants exhibited a spectrum of vaccination attitudes ranging from complete vaccine refusal or wait-and-see due to doubting vaccine efficacy and necessity, concern about vaccine safety and side effects, insufficient incentives for taking vaccination and feeling disgust about vaccine passport, to growing acceptance. Participants’ vaccine-hesitant and vaccine-resistant attitudes were manifested in their understanding, attitudes and feeling about vaccine efficacy, necessity, vaccination benefits, vaccine safety and vaccine side effects, which were weaved into the context of lacking decisional support, attitude roots and the peripheral processing of vaccine-related information.
Complete vaccine refusal and distrust
Complete vaccine refusal resulted from complete distrust in vaccine efficacy, distrust in vaccine safety, distrust in the government, and fatalistic view on risk.
“I don’t believe (in the efficacy of the vaccines) and have no interest to take one…They (the government) claimed that you won’t fear anything after taking the vaccine…how that possible?” (EV01)
“Nothing can help…any vaccines are useless at my old age” (EV27).
Doubting vaccine efficacy and necessity
Most participants doubted the vaccine efficacy and necessity and thereby preferred wait-and-see. Doubting about vaccine efficacy was arisen from their impression that vaccines failed to protect against infections and insufficient understanding about the purposes of taking vaccine boosters. This was rooted in participants’ low health literacy and insufficient informational support for their vaccination decision making.
“Some people took two doses of vaccines but still got infected…then why should I take the vaccine?” (EV17)
“To be honest, I don’t fully believe vaccines can provide enough protection for me…Because even I take one, I still need the second dose and the third dose…” (EV08)
Concern about vaccine safety and side effects
Some participants raised their concerns about vaccine safety which linked to their peripheral processing of vaccine-related information and negative self-perception of ageing.
“The majority of older people are concerned about vaccination… they are worried about uncertain reactions after vaccination if they have any hidden illnesses…” (EV17).
Participants also raised their concerns about the vaccine novelty and quick development.
“I am more confident in the flu vaccine because it is mature…But the COVID-19 vaccines are just new products…” (EV18).
Participants who were more present-oriented mentioned their concerns about the immediate vaccination cost such as injection pain and discomfort.
Perceived insufficient incentives for taking vaccination
Some mentioned that current incentives for encouraging vaccination were personally irrelevant and would wait until the government gave more personally relevant incentives for vaccination.
“They (other people) preferred going to mainland China, they need to take a vaccine…I don’t have such plan, so I won’t think about it.” (EV01)
Feeling of being forced to accept the vaccines
Some participants raised their strong disgust about government’s vaccine passport policy that prohibited them from accessing to their cultural activity of having Chinese style breakfast (e.g., “Yum Cha”) and public venues without vaccination.
“If I don’t take a vaccine I cannot dine in the restaurant, then how should I do? Everyone won’t favor such policy!” (EV14)
Growing vaccine acceptance
Participants who perceiving an increasing norm of accepting the COVID-19 vaccines seemed to be reassured about the vaccine safety and indicated planning to accept the vaccines.
“I see more people take the vaccine now, I think there will be no big problems…I plan to take one later.” (EV25)
Strategies to regain self-control in the pandemic
While participants refused or delayed vaccines, they turned to various strategies to obtain a sense of self-control in the pandemic. These strategies are illustrated below.
Avoiding vaccination decision
Avoid deliberating the vaccine-related information and discussing about COVID-19 vaccination with others was a strategy to keep participants from being “bothered” by the vaccination decision.
“Discussing (vaccines) with others is useless, they cannot inject for you right? … So, I would leave myself quiet and don’t think too much on that.” (EV01)
Downplaying the pandemic risk
Many participants downplayed the pandemic risk to lower necessity or urgency for making the vaccination decision.
Such optimism was arisen from their past illness experiences:
“At this age, I am not worried about this virus… because I can actually suffer from any illnesses…So I would just go with flow.” (EV02).
Their experience of survival through the past pandemics:
“I do not find this COVID-19 pandemic severe… During SARS, nothing happened even though I did not wear masks…People at my old age cannot worry too much.” (EV04).
And pandemic situation comparison:
“I read the news reports worldwide…the probability of getting infection is so high! But Hong Kong is totally different, so I don’t feel worried in Hong Kong.” (EV22)
Contentment with nonpharmaceutical risk-reduction strategies
Almost all participants mentioned that they sticked with nonpharmaceutical measures such as avoiding the crowds and maintaining good personal hygiene and perceived this strategy to be within personal control and sufficient to protect against COVID-19.
“I am not too worried about the COVID-19 pandemic, since I have done well in my personal hygiene, and I avoid going to crowded places.” (EV10)
Waiting for “better” interventions
Participants indicated that they preferred to wait for better medical interventions, such as oral medication or one-shot COVID-19 vaccine.
“It would be better and more convenient to take oral medication. Vaccine components will enter the blood, while oral medication is absorbed through the digestion in stomach.” (EV09).