Willingness of The COVID-19 Vaccine Uptake: A Cross-Sectional Study of Community Residents in China


 Background

The pandemic of coronavirus disease 2019 (COVID-19) brought great disaster to the world. Vaccination for COVID-19 is one of the most important preventative measures to reduce the disease transmission. Our study aims to estimate residents’ willingness to accept COVID-19 vaccination and its influencing factors in the general adult population in Chinese community.
Methods

3000 questionnaires were posted from December,2020 to January,2021 to residents in Kaifeng with 89.60% response rate. Results of the 2688 respondents on their willingness to accept the COVID-19 vaccine were analyzed.
Results

89.06% of respondents were willing to accept a COVID-19 vaccine if vaccines were available. People who were 46–59 years old (OR = 0.311; 95% CI: 0.188–0.512), often live in the town (OR = 3.979; 95% CI: 2.473–6.402) and pay attention to the development of the COVID-19 vaccine (OR = 0.301; 95% CI: 0.203–0.447), and agreeing that the COVID-19 vaccine can prevent COVID-19 (OR = 0.106; 95% CI: 0.050–0.224) were significantly associated with their willingness to accept receive COVID-19 vaccination.
Conclusion

A high acceptance of COVID-19 vaccination had been shown among Chinese residents although it was not during the pandemic period, while concerns about vaccine safety and effectiveness might hinder the promotion of vaccine uptake.


Background
Around March 2020, the outbreak of COVID-19 caused by a new type of SARS-CoV-2 has spread all over the world, reaching the level of pandemic [1,2]. Global attention was soon focused on the situation because of the increasing number of new cases and the high rate of death associated with the infections [3]. Since COVID-19 has caused huge casualties and serious economic losses, posing a threat to the world, it is urgent to understand the current situation and formulate strategies to curb the spread of the virus [4]. However, there are currently no speci c antiviral treatments for COVID-19 [5], so immunization is one of the most successful and cost-effective health interventions to prevent infectious diseases. WHO has recommended several candidate vaccine viruses for the development of COVID-19 vaccines for the purpose of pandemic preparedness [5]. In December 2020, Polack's study showed that the BNT162b2 mRNA COVID-19 vaccine conferred 95% protection against COVID-19 in persons 16 years of age or older [6]. Therefore, vaccination is a critical part of COVID-19 pandemic preparedness [7].
Although the development of vaccine has made great progress, there are still important challenges regarding future immunization against COVID-19. For example, As of January 10, 2021, the Daily Mail and other media reported that there were two deaths of doctors vaccinated with the P zer COVID-19 vaccine in the United States; on January 14, 2021, the Norwegian drug administration said that 23 people in Norway who were vaccinated by P zer and BioNTech died. It has deepened the public's doubts and trust in the safety and effectiveness of the vaccine. Understanding residents' willingness to accept the COVID-19 vaccine and its main related factors may enable policy makers to take measures for vaccination coverage improvement. Five surveys had been conducted in China [8,9,10,11,12], four of them were in the research and development stage of the COVID-19 vaccine, while the other one focused on young adults preference for COVID-19 vaccines. The epidemic situation in China has been basically controlled and the developed vaccine is on the market now. Under the current situation, what are the willingness of Chinese community residents to be vaccinated with COVID-19 and its in uencing factors? At present, there is a lack of research. In this study, a questionnaire survey was conducted among 3000 residents in Kaifeng City to evaluate the willingness of community residents to receive COVID-19 vaccination, and to determine the related possible factors.

Research objects
In this study, residents were recruited by a multistage sampling approach [13]. Initially, two urban districts were randomly selected to be sampled. From each selected district, three towns or streets were randomly selected. And then two communities were randomly selected in each of these towns or streets. In total, 12 communities were con rmed as the survey locations. To meet the sample size requirement (3000 questionnaires), 250 families were randomly selected from each community, and each family was responsible for a questionnaire. We had gotten rid of people under the age of 18.

Research questionnaire
The survey was carried out using an anonymous questionnaire, which consisted of four sections: (1) Demographics information (gender, age, permanent residence, marital status, educational level, occupation, religious belief, per capita monthly income of family, a chronic underlying disease and available with the response options of 'yes' and 'no', meanwhile, the questionnaire also contains the reasons why the participants were willing or unwilling to be vaccinated and other related issues. All the questions were based on evidence in the existing literature.

Data collection
We conducted the survey from December,2020 to January,2021, and we had contacted general managers of the twelve communities to obtain approval to send questionnaires to their residents. Within each survey location, all the households were randomly numbered according to the address numbers. Then we use random number table method to select 250 families in each community, and an adult in each family is responsible for a questionnaire. 3000 anonymous questionnaires were posted to general managers of communities who then passed these questionnaires to the community residents, which will be mailed to us after lling in. All questionnaires were received within a 2-week period.

Statistical analysis
Descriptive results were cross-tabulated. χ 2 test was used to examine demographic characteristics between community residents who were willing to accept COVID-19 vaccination against those who were not willing to accept it. We conducted univariate analyses to identify apparent associations between perceptions regarding COVID-19 factors, perceptions regarding vaccines and the willingness to take a future COVID-19 vaccine. Logistic regression models were then performed to examine the factors associated with residents' willingness to accept a future COVID-19 vaccine. The level of statistical signi cance was set at a p-value of < 0.001.

Difference analysis of vaccination willingness
The demographic characteristics of respondents who were willing to accept COVID-19 vaccination and with those who were not willing to accept it were compared by χ 2 test and were presented Table 1.
Residents who were willing to receive the COVID-19 vaccine were different from those who were not willing to receive the COVID-19 vaccine with respect to "age, permanent residence and educational level".
There were no statistically signi cant differences in other characteristics as analyzed by chi-square test.
The relationship between demographic and other characteristics of the community residents and their willingness to accept vaccination were analyzed further using logistic regression (  In this cross-sectional study, residents showed that they had a high acceptance of COVID-19 vaccination, which was consistent with the survey results of Malik and Reiter [14,15]. The high acceptance of COVID-19 vaccination among the residents re ects the strong demand for the vaccine and the high awareness of the importance of the vaccine in controlling the epidemic. The reasons that affect the vaccination of residents are believing in the safety and effectiveness of the COVID-19 vaccine and worrying about being infected in the future and spreading the infection to people around you and being quarantined after being infected. It shows that the risk perception of residents was an important predictor for vaccination acceptance, as those who perceived a high risk of infection were more likely to get vaccinated as soon as possible.
As the majority of respondents had the intention of getting vaccinated, it is meaningful to identify barriers or facilitators to their vaccination decision on whether to accept vaccination. Public concerns about vaccine safety are often reported as a major obstacle to vaccination decisions, especially for new vaccines. Our study con rmed the positive role of belief in safety and effectiveness of the COVID-19 vaccine and the constant attention to the development of the COVID-19 vaccine in accepting COVID-19 vaccination, which was consistent with previous studies [9,11]. Our study found that residents who often live in the town were more willing to vaccination than those who live in the village. It may be because of the high mobility of urban population, they seldom stay at home and travel more. These behaviors may lead to their higher perceived risk of being infected with COVID-19, and may eventually lead to higher acceptance of the vaccine. Our study also found that both medical staffs and non-medical staffs were willing to get the COVID-19 vaccine, Perhaps the severity of the epidemic, the high infectivity of the virus and the publicity of the role of the vaccine by the media are the driving factors for them to decide to vaccinate [16]. Inconsistent results were shown in previous studies from the Indonesia, Turkey or the United States concerning the impact of demographic characteristics on the acceptance of the COVID-19 vaccine [14,15,17,18], and we found that, among the residents, respondents aged 46 to 59 were more likely to accept vaccination, while respondents' income or medical insurance may not in uence their intention as shown in the results of logistic regression analysis. This shows that people aged 46 to 59 are strongly aware that vaccines provide not only personal protection, but also family protection. However, the income and medical insurance have nothing to do with the willingness to vaccination, which may be free of charge for the COVID-19 vaccination in China, and Chinese medical insurance has basically reached universal coverage.
There are still a small proportion of residents who are not willing to accept a future COVID-19 vaccine. Similar to the nding of Polack [6], we showed that the main reason why residents don't want to be vaccinated with the COVID-19 vaccine was to worry about the side effects and the e cacy and safety of the new vaccine. At the same time, Dubé [19] found that the uncertainties about new vaccine would lower the vaccine con dence of the public; Henrich's research showed concerns about using new vaccines during a pandemic were to differ from those of established products in a non-crisis situation [20]. So we can infer that the actual coverage of COVID-19 vaccination would be lower than our estimate of 89.60% in residents' willingness to accept COVID-19 vaccination. Research shows that the higher the coverage rate of vaccination, the higher the level of preventing the spread of the disease [18]. Therefore, to make sure the COVID-19 vaccine fully covered, the health departments and other sectors should strengthen the regular vaccination education of the vaccine to improve overall vaccine con dence and the compliance of the public.
We conducted the investigation under the condition of stable epidemic situation in China, which can highlight the public's willingness to receive vaccination during the stable period. Meanwhile, we investigated the in uencing factors of residents' vaccination willingness, the exploration of barriers and facilitators of vaccination was helpful for government to design effective immunization strategies to increase the vaccine uptake in the prevention and control of COVID-19. A limitation of our study is that we have only one center, but considering the diverse epidemic strength, income levels and healthcare access across regions, we should adopt multicenter research. And compared with the general population of China, our sample is younger and has limited universality.

Conclusion
Our study re ected a high level of acceptance of COVID-19 vaccination among the community residents in China although it is not during the pandemic period. Concerns about vaccine safety and effectiveness by the public may hinder the promotion of vaccine uptake in the future. To expand vaccine uptake in response to prevent the spread of the disease, health education and communication from authoritative sources will be important to alleviate public concerns about vaccine safety.

COVID-19 coronavirus disease 2019
Declarations Ethics approval and consent to participate This study was conducted according to the guidelines that were laid down in the Declaration of Helsinki, and all procedures involving human subjects were approved by the Ethics Committee of Kaifeng CDC. In addition, those participants were informed about the purpose of the study, the importance of their participation, and their ability to withdraw at any time. Written consent was obtained prior to data collection.

Consent for publication
Individual respondent consent to participate in the study.