Sociodemographic predictors of COVID-19 vaccine hesitancy and main reasons against the vaccines in eastern Oslo: A cross-sectional study

Abstract

Background: Vaccines are an essential public health strategy to curb viral infection spreading and hinge on vaccine uptake which may be threatened by vaccine hesitant individuals. This study therefore aims to address sociodemographic predictors of vaccine hesitancy, main reasons for vaccine hesitancy, and how these reasons are explained by sociodemographic characteristics during the COVID-19 pandemic.

Methods: A cross-sectional study (N = 5 442) was carried out in June 2021 among six eastern Oslo districts with high infection pressure. Sociodemographic variables included gender, age, country of birth, education, and household income. Binary logistic regression models were used to explore predictors of both vaccine hesitancy and specific reasons. Main reasons for vaccine hesitancy were assessed through descriptive statistics.

Results: Vaccine hesitancy was overall low (5.8%). Findings stress the vulnerable position of younger age, participants born outside of Norway, lower education, and lower household income in relation to vaccine hesitancy proneness. Hesitancy was mainly grounded in confidence barriers such as fear of side effects (55.8%) and little experience with the vaccines (50.2%). Otherwise, complacency barriers such as not feeling to belong to a risk group (46.1%), not needing the vaccines (39.1%), and wanting the body to develop natural immunity (29.3%) were frequently present. Results indicated overall high trust in health authorities and professionals. Women and participants born in Norway were more likely hesitant due to a lack of confidence in the vaccines. Complacency barriers were less likely present among older age (60+) and participants born outside of Norway.

Conclusions: Varying determinants of vaccine hesitancy and barrier trends among population groups emphasize the importance of clear public health communication about the risks, benefits, and importance of vaccines. Future studies with a larger sample should verify current findings and further explore the prevalence of convenience barriers. Norwegian health authorities should take these results into account and develop different public health strategies targeted at vulnerable population groups during the current and forthcoming pandemics to increase vaccine uptake and reach sufficient immunization.

Background

Vaccines are an essential public health strategy to curb viral infection spreading that hinge on vaccine uptake (1, 2). Vaccine hesitancy may however greatly threaten this. Vaccine hesitancy is defined by the WHO as either delayed acceptance or refusal of a vaccine despite its availability. It has been addressed as one of top ten major global health threats which may undermine global efforts to control the viral spreading of disease and efforts to reach sufficient immunization, referred to as herd immunity (3, 4). Vaccine hesitancy is however a complex problem as it continuously evolves across context, time, place, and different vaccines (2, 5).

Previous literature has identified several sociodemographic factors contributing to vaccine hesitancy. Overall, women show more vaccine hesitancy than men (6–16). As public health messages have emphasized the increased vulnerability for severe COVID-19 outcomes for older adults (especially 60+) and those with underlying health conditions compared to others (17–19), vaccine hesitancy is mostly found among younger age groups (7, 10–12, 14, 15, 20, 21). Increased vaccine hesitancy is also found among ethnic minorities even though they have shown prone to disproportionate suffering from COVID-19 (12–14, 16, 21–26). Additionally, the majority of literature has found associations between vaccine hesitancy and low education (7, 9–11, 13–16, 21, 25, 27–29), as well as low-income levels (7, 12–14, 16, 25, 28, 29). Moreover, both low education and income are associated with low health literacy which may contribute to vaccine hesitancy. Still, many inconsistent results across studies demonstrate that sociodemographic predictors of vaccine hesitancy cannot be assumed (5).

The WHO’s Strategic Advisory Group of Experts (SAGE) developed the “3Cs” model which categorizes reasons for vaccine hesitancy among three main factors: confidence, complacency, and convenience (2, 3). Confidence barriers refer to worries about the safety and effectiveness of the vaccine. Complacency encompasses individuals with low self-perceived risk of a disease that may be prevented by vaccination where other life or health values weigh heftier (2). Self-efficacy may be high, where individuals may have high confidence in personal abilities for prevention, viewing vaccines as an unnecessary preventive measure (30). Matters such as availability, accessibility, affordability, and the widespread reach and understanding of health messages (health literacy) from authorities about the vaccine contribute to vaccine convenience. Although COVID-19 vaccines have been actively offered to all Norwegian residents free of charge, convenience barriers resulting from low health literacy or language barriers cannot be excluded due to the high migrant density in eastern Oslo (3, 30, 31).

As current literature has primarily focused on measuring hypothetical vaccine intention, few studies have assessed sociodemographic predictors of vaccine hesitancy after the arrival of the COVID-19 vaccines. Due to its continuous evolution, research across- and within countries on a subnational and regional level is crucial to identify predictors and address specific barriers in vaccine uptake to identify vulnerable population groups and react deftly with more tailored and nuanced approaches (2, 12–14, 24). In March 2021, several municipalities in Norway received extra vaccine doses due to consistent high COVID-19 infection rates (31, 32). In Oslo, these were mostly assigned to six eastern districts with high infection pressure. Although vaccine acceptance is expected to be high in Norway due to generally high levels of trust in Norwegian authorities (33–36), eastern Oslo is known as a deprived area relative to other parts of the city with high ethnic minority density where vaccine hesitancy is suspected (37). Therefore, by using survey data collected during the COVID-19 pandemic from these prioritized districts, this study aims to investigate sociodemographic predictors of vaccine hesitancy, explore what main reasons for vaccine hesitancy are, and how these reasons are predicted by sociodemographic characteristics. This may enable the identification of vulnerable subgroups and in turn aid the development of tailored public health strategies targeted accordingly to increase vaccine uptake (11, 14, 20, 21, 24, 27, 38). Furthermore, this study shall address vaccine hesitancy after the arrival of the vaccines, thus adding to the current underrepresentation of Norway in related literature. This may be of substantial importance for public health responses in the current and forthcoming pandemics.

Methods

This cross-sectional study used primary data from a survey database developed between researchers at OsloMet’s Center for Research on Pandemics & Society (PANSOC) and the Pandemic Center at the University of Bergen. The survey was administered by an external firm, Kantar, and conducted online in June 2021 among residents in six eastern districts of Oslo (Alna, Bjerke, Gamle Oslo, Grorud, Søndre Nordstrand, and Stovner). With access to all phone numbers from a population database, 59 978 texts were sent out to residents in the six districts. The sample was recruited proportionately according to the population in the different districts. These areas were also chosen due to high migrant density as one goal of the overall project was to investigate disparities based on migrant status. Additionally, the survey was translated into six different languages (English, Somali, Arabic, Urdu, Polish, and Norwegian) to encourage participation among ethnic minorities. Response rates were low (9.1%) and 5 447 participants completed the survey. Six respondents were excluded during the data cleaning processes due to rapid survey completion, unclarity of open-ended questions, or a large number of skipped questions. This resulted in a total sample of 5 442 respondents.

Sociodemographic characteristics included gender, age, born in Norway, education, and household income (see Table 1). Hesitant individuals are the sum of those who show no intention or are unsure about taking the vaccine (2). Vaccine hesitant participants were subsequently asked about their main motivations against taking the vaccine (multiple options). Only reasons chosen by more than 15% of the hesitant sample were considered as main reasons for further analyses.

Results

Discussion

Several sociodemographic predictors of vaccine hesitancy were identified. Increasing age (45+) predicted lower likelihood of vaccine hesitancy compared to younger participants. Contrastingly, using country of birth as indicator for ethnic minorities, participants born outside of Norway reported higher likelihood of vaccine hesitancy compared to those born in Norway. Although results align with an abundance of literature (7, 10–16, 20, 21, 25, 26), both older age and ethnic minorities have increased vulnerability to severe COVID-19 outcomes (17–19, 22, 23). Whilst results suggest a suitable reaction among older adults regarding their vulnerable position, the opposite may be claimed for ethnic minorities which magnifies their vulnerability. Furthermore, higher education (university) and high household income (> 1 400 000 NOK) predicted lower likelihood of vaccine hesitancy compared to lower education (primary) and low household income (< 200 000 NOK). This aligns with the majority of literature and indicates hesitancy proneness among lower education and income (7, 9–11, 13–16, 21, 25, 27–29). No significant gender differences in COVID-19 vaccine hesitancy were found.

Vaccine hesitancy was mainly due to confidence and complacency concerns as grouped by the “3Cs” model (2, 3). Findings suggest that barriers relating to convenience were successfully reduced by actively offering the COVID-19 vaccines to all Norwegian residents without costs. As such, confidence concerns were predominantly grounded in fear of side effects and little experience with the vaccines. Taking into account that data collection took place not long after the introduction of the rapidly developed COVID-19 vaccines, these results are conceivable. Relating to complacency, participants mostly did not feel like they belonged to a risk group, felt no need for the vaccine, and/or wanted their body to develop natural immunity. This may result from a lack of evidence at the time related to how long immunity following infection persists and the risk of re-infection. Few participants stated that they had no need to protect themselves, family, and their community which aligns with low observed hesitancy rates. Furthermore, results showed little distrust in health authorities and professionals which supports high trust in Norwegian authorities compared to other nations (33–36). Still, in an area where vaccine hesitancy was anticipated to be high, observed rates of hesitancy were nearly twice as low as anticipated in Norway (33), which may indicate an underestimation of vaccine hesitancy. Furthermore, hesitancy due to religious reasons was least present. As Oslo has the highest density of religious groups in Norway (39), this was unanticipated and may reflect an underrepresentation of ethnic minorities.

Findings show that women are more likely hesitant due to confidence barriers such as the risk of side effects and little experience with the COVID-19 vaccines than men. Although participants born outside of Norway were more likely vaccine hesitant, they predicted lower likelihood of hesitancy due to confidence barriers compared to those born in Norway. This may denote convenience barriers among ethnic minorities in which health information is misunderstood or not accessed, possibly resulting from barriers in health literacy or language (3, 30, 31, 37). Complacency barriers seemed least present among older age (45+), participants born outside of Norway and household income. This further suggests successful public health communication and good health literacy among participants concerning age-related risk factors of COVID-19. Due to the high number of missing values on income, the reliability of results can be argued and may explain why findings do not allow for any concluding trends on this variable. Although education significantly predicted vaccine hesitancy likelihood, no significant relations were found with any of the main reasons. This may also denote convenience barriers linked to health literacy as education is identified as a robust predictor of vaccine hesitancy (7, 9–11, 13–16, 21, 25, 27–29).

Conclusion

Results highlight the vulnerability of younger age, ethnic minorities, lower education, and lower household income in relation to COVID-19 vaccine hesitancy proneness. Varying barrier trends among subgroups emphasize the importance of clear public health communication about the risks, benefits and importance of vaccines. Norwegian health authorities should consider these findings when developing tailored strategies targeted at hesitant subgroups during the COVID-19 pandemic to increase vaccine uptake and reach sufficient immunization.

Abbreviations

Declarations

Ethics approval and consent to participate
 The study’s methods were conducted in compliance with the relevant guidelines and regulations. This study was granted ethical approval by the Regional Ethics Committee for Medical Health and Research Ethics (REK, approval number 250310). All respondents were given contact information. Informed consent to participate was obtained from participants prior to starting the survey.

Consent for publication
 Not applicable. 

Availability of data and materials
 The datasets generated and/or analysed during the current study are not publicly available due to wishes of an OsloMet Centre of Research; the Centre for Research on Pandemics and Society (PANSOC), but are available from the corresponding author on reasonable request. 

Competing interests
 The author declares that there are no competing interests. 

Funding
 Funding was provided by PANRISK: Socioeconomic risk groups, vaccination, and pandemic influenza (Research Council of Norway grant agreement No 302336). 
 The Centre for Research on Pandemics & Society (PANSOC) – an OsloMet Centre of Research. Excellence studying the societal aspects of pandemics has provided a stipend to the article’s author to fund this research.

Author’s contribution
 OsloMet’s Center for Research on Pandemics & Society (PANSOC) and the Pandemic Center at the University of Bergen collaborated to develop the survey and conceptualized the study. Lara Steinmetz, the author of this manuscript conceptualized the study, did the literature review, conducted the analysis and wrote the interpretation.

Acknowledgments
 I like to thank PANSOC for the provision of data and guidance throughout this study. 

Author information
 Lara Steinmetz. 
 [email protected]
 Oslo Metropolitan University.

References

1. European Centre for Disease Prevention and Control. COVID-19 vaccination 2022 [Available from: https://www.ecdc.europa.eu/en/covid-19/prevention-and-control/vaccines.
2. World Health Organization. Report of the SAGE Working Group on Vaccine Hesitancy.; 2014.
3. MacDonald NE, SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161–4.
4. World Health Organization. World health statistics overview 2019: monitoring health for the SDGs: WHO; 2019.
5. World Health Organization. Summary WHO SAGE conclusions and recommendations on Vaccine Hesitancy. 2015.
6. Alabdulla M, Reagu SM, Al-Khal A, Elzain M, Jones RM. COVID-19 vaccine hesitancy and attitudes in Qatar: A national cross-sectional survey of a migrant-majority population. Influenza and other respiratory viruses. 2021;15(3):361–70.
7. Graeber D, Schmidt-Petri C, Schröder C. Attitudes on voluntary and mandatory vaccination against COVID-19: Evidence from Germany. PLoS One. 2021;16(5):1–18.
8. Kasrine Al Halabi C, Obeid S, Sacre H, Akel M, Hallit R, Salameh P, et al. Attitudes of Lebanese adults regarding COVID-19 vaccination. BMC Public Health. 2021;21(1):1–7.
9. Magadmi RM, Kamel FO. Beliefs and barriers associated with COVID-19 vaccination among the general population in Saudi Arabia. BMC Public Health. 2021;21(1):1–8.
10. Rodríguez-Blanco N, Montero-Navarro S, Botella-Rico JM, Felipe-Gómez AJ, Sánchez-Más J, Tuells J. Willingness to Be Vaccinated against COVID-19 in Spain before the Start of Vaccination: A Cross-Sectional Study. International journal of environmental research and public health. 2021;18(10).
11. Fisher KA, Bloomstone SJ, Walder J, Crawford S, Fouayzi H, Mazor KM. Attitudes Toward a Potential SARS-CoV-2 Vaccine. Annals of Internal Medicine. 2020;173(12):964–73.
12. Murphy J, Vallières F, Bentall RP, Shevlin M, McBride O, Hartman TK, et al. Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom. Nature Communications. 2021;12(1):29.
13. Paul E, Steptoe A, Fancourt D. Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. The Lancet Regional Health - Europe. 2021;1:100012.
14. Cascini F, Pantovic A, Al-Ajlouni Y, Failla G, Ricciardi W. Attitudes, acceptance and hesitancy among the general population worldwide to receive the COVID-19 vaccines and their contributing factors: A systematic review. EClinicalMedicine. 2021;40:101113.
15. Edwards B, Biddle N, Gray M, Sollis K. COVID-19 vaccine hesitancy and resistance: Correlates in a nationally representative longitudinal survey of the Australian population. PLoS One. 2021;16(3):e0248892.
16. Mondal P, Sinharoy A, Su L. Sociodemographic predictors of COVID-19 vaccine acceptance: a nationwide US-based survey study. Public Health. 2021;198:252–9.
17. World Health Organization. COVID-19: vulnerable and high risk groups 2022 [Available from: https://www.who.int/westernpacific/emergencies/covid-19/information/high-risk-groups.
18. Centers for Disease Control and Prevention (CDC). COVID-19 Risks and Vaccine Information for Older Adults 2021 [Available from: https://www.cdc.gov/aging/covid19/covid19-older-adults.html.
19. Helsedirektoratet. Risikogrupper: Helse Norge; 2022 [Available from: https://www.helsenorge.no/koronavirus/risikogrupper/.
20. Luk TT, Zhao S, Wu Y, Wong JY-h, Wang MP, Lam TH. Prevalence and determinants of SARS-CoV-2 vaccine hesitancy in Hong Kong: A population-based survey. Vaccine. 2021;39(27):3602–7.
21. Robertson E, Reeve KS, Niedzwiedz CL, Moore J, Blake M, Green M, et al. Predictors of COVID-19 vaccine hesitancy in the UK household longitudinal study. Brain, Behavior, and Immunity. 2021;94:41–50.
22. Vist GE, Arentz-Hansen EH, Vedøy TF, Spilker RS, Hafstad EV, Giske L. Incidence and severe outcomes from COVID-19 among immigrant and minority ethnic groups and among groups of different socio-economic status: A systematic review. Oslo: Norwegian Institute of Public Health; 2021.
23. Hildreth JEK, Alcendor DJ. Targeting COVID-19 Vaccine Hesitancy in Minority Populations in the US: Implications for Herd Immunity. Vaccines. 2021;9(5):489.
24. Dubé E, Gagnon D, Nickels E, Jeram S, Schuster M. Mapping vaccine hesitancy—Country-specific characteristics of a global phenomenon. Vaccine. 2014;32(49):6649–54.
25. Khubchandani J, Sharma S, Price JH, Wiblishauser MJ, Sharma M, Webb FJ. COVID-19 Vaccination Hesitancy in the United States: A Rapid National Assessment. Journal of Community Health. 2021;46(2):270–7.
26. Crawshaw AF, Deal A, Rustage K, Forster AS, Campos-Matos I, Vandrevala T, et al. What must be done to tackle vaccine hesitancy and barriers to COVID-19 vaccination in migrants? Journal of Travel Medicine. 2021;28(4).
27. Abedin M, Islam MA, Rahman FN, Reza HM, Hossain MZ, Hossain MA, et al. Willingness to vaccinate against COVID-19 among Bangladeshi adults: Understanding the strategies to optimize vaccination coverage. PLoS One. 2021;16(4):1–17.
28. Tahir MJ, Saqlain M, Tariq W, Waheed S, Tan SHS, Nasir SI, et al. Population preferences and attitudes towards COVID-19 vaccination: a cross-sectional study from Pakistan. BMC Public Health. 2021;21(1):1–12.
29. Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012. Vaccine. 2014;32(19):2150–9.
30. World Health Organization. Vaccination and trust. How concerns arise and the role of communication in mitigating crises. 2017.
31. Stoksvik M. Oslo får flere vaksiner: – En gledens dag. NRK. 2021, March 2.
32. Holmes MCS, & Fausko, L. Oslo får 18.000 vaksiner neste uke – minst 13.000 går til Oslo øst. VG. 2021, March 13.
33. Ebrahimi OV, Johnson MS, Ebling S, Amundsen OM, Halsøy Ø, Hoffart A, et al. Risk, Trust, and Flawed Assumptions: Vaccine Hesitancy During the COVID-19 Pandemic. Frontiers in Public Health. 2021;9(849).
34. Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, et al. Coronavirus Pandemic (COVID-19): Published online at OurWorldInData.org.; 2020 [Available from: https://ourworldindata.org/coronavirus.
35. Helsingen LM, Refsum E, Gjøstein DK, Løberg M, Bretthauer M, Kalager M, et al. The COVID-19 pandemic in Norway and Sweden – threats, trust, and impact on daily life: a comparative survey. BMC Public Health. 2020;20(1):1597.
36. Edlund J. Trust in government and welfare regimes: Attitudes to redistribution and financial cheating in the USA and Norway. European Journal of Political Research. 1999;35(3):341–70.
37. Capar R-I. Vaccination: Priority districts in Oslo are struggling to reach the immigrant population. Norway Today. 2021, July 5.
38. Goodman T, Heidari S. Critical sex and gender considerations for equitable research, development and delivery of COVID-19 vaccines. 2021.
39. Taule L. Hva forteller statistikkene om religion, tro og livssyn i Norge? Samfunnsspeilet. 2012;1.
40. Bryman A. Social research methods. 5th ed. ed. Oxford: Oxford University Press; 2016 2016. XXXV, 747 s. p.

Tables

Table 5 is available in the Supplemental Files section.