PSYCHOSOCIAL FACTORS VACCINE HESITANCY Author Note I would like to acknowledgment the individuals who supervised and assisted me with this project: Drs. Elizabeth Larsen, Justin Hackett, Joel Press, Craig Fox, and Mr. Loring Prest Correspondence concerning this article should be addressed to Dillon L. Shash at sha9901@calu.edu 1 PSYCHOSOCIAL FACTORS VACCINE HESITANCY 2 Abstract Background: The COVID-19 pandemic has caused millions of deaths worldwide. Fortunately, multiple vaccines now exist and are readily available to the majority of people. While all the available vaccines demonstrate high efficacy rates, some reporting above 90% protection from infection, any vaccine is only effective if it is accepted. Thus, vaccine hesitancy poses a threat to the success of controlling and mitigating the pandemic. While vaccine hesitancy is multidimensional, the related psychosocial factors are arguably the most crucial to understand and address. Unfortunately, due largely to the novelty of the situation, the determinants of COVID19 vaccine hesitancy are not well studied. Therefore, the objectives of this study are: (1) to understand the psychological and sociological factors that contribute to COVID19 vaccine hesitancy; (2) systemically review and report the current literature on the topic of interest. Methods: A systematic literature review was conducted on March 14, 2021 to identify articles of interest. Search terms included those related to covid-19 and vaccine hesitancy. Multiple databases were utilized including PsycINFO, SocINDEX, MEDLINE Complete, and others. Original research studies that were relevant to the topic of interest were included in the review. The search was limited by date range, including articles published from 20192021. Results: This review followed PRISMA guidelines. Given the search terms and limitations, 122 articles were reviewed. Ultimately, 42 articles were included in the PSYCHOSOCIAL FACTORS VACCINE HESITANCY study. Discussion: Gender, SES, political influence, and social media, were commonly reported social factors. Health beliefs, perceptions of COVID-19 and/or the vaccines, and trust in healthcare providers and science were commonly reported psychological factors. 3 PSYCHOSOCIAL FACTORS VACCINE HESITANCY 4 Introduction The COVID-19 pandemic has caused mass mortality around the world. Vaccines will largely be responsible for the success of mitigating and controlling the virus. However, vaccine hesitancy will serve as a prominent barrier to against mass vaccination efforts. This systematic review uses the World Health Organization’s model of vaccine hesitancy to understand the psychosocial factors that currently relate to COVID-19 vaccine hesitancy. It should be noted that vaccine hesitancy is not synonymous with anti-vaccination and thus the focus of this review is specifically interested in vaccine hesitancy. Methods To better understand and organize the current literature on the psychosocial factors related to COVID-19 vaccine hesitancy, a systematic review was performed. Such a review allows the researcher and the eventual consumer to conceptualize the literature as a collective whole. The methods described below allow a researcher to follow the same search and review process used in this article to then produce the same results, and also allow the consumer to understand the exact methodology used. It is important to note that this review followed PRISMA guidelines, a structured method for reporting systematic reviews, and thus is organized as such (Page et al., 2021). Additionally, a model of vaccine hesitancy provided in a report by the Strategic Advisory Group of Experts on Immunization serves as the basis for study inclusion as well as the presentation of results (Eskola et al., 2014). The model is presented in Figure 1. PSYCHOSOCIAL FACTORS VACCINE HESITANCY Figure 1 SAGE Working Group Determinants of Vaccine Hesitancy Matrix 5 PSYCHOSOCIAL FACTORS VACCINE HESITANCY 6 Information Sources and Search Strategy A search was performed on March 14, 2021 using online resources offered through the library’s website of California University of Pennsylvania. It total, six databases were utilized in the search: APA PsycArticles, APA PsycInfo, MEDLINE Complete, Psychology and Behavioral Sciences Collection, SocINDEX with Full Text, and Sociological Collection. Due to the psychosocial focus on the review, the author considered these databases as the most capable of providing an extensive list of relevant articles. Search terms were divided between two search fields. The first search field pertained to terms related to COVID-19, and was formatted as follows: “covid19” or “coronavirus” or “2019-ncov” or “sars-cov-2” or “cov-19”. The second search field included terms related to vaccine hesitancy with an “AND” separating it from the first search field and was formatted as follows: “vaccine hesitancy” or “vaccine refusal” or “vaccine acceptance” or “anti-vaccine” or “anti-vaccination”. Quotation marks were included around each search term or phrase to ensure it would be searched for exactly as written. In both search fields, the terms were limited to the abstract of the articles. This step was taken to enhance the relevancy of the resulting articles. The search was also limited by date, including articles only from the range of 2019 to 2021. This step was taken to also enhance relevancy as the COVID-19 pandemic began in the year 2019. Due to the nature of the review, the search was also limited to peer reviewed journal articles. It should be noted that as an expander, items were searched within the full-text of the article. Finally, duplicate articles were removed automatically. Synthesis and Selection of Studies PSYCHOSOCIAL FACTORS VACCINE HESITANCY The final number of articles that resulted from the library search were then exported as a CSV file which was then converted and uploaded to Microsoft Excel (Microsoft 365, Version 2104). The articles were automatically formatted to include available information such as the article title, authors, DOI, abstract, and various other fields. All articles were there reviewed to determine inclusion. Original research articles with a major focus on the psychosocial factors related to COVID-19 vaccine hesitancy were included in the review. However, numerous articles did not meet this inclusion criteria and were thus excluded from this review. Despite limitations present in the search, multiple non-empirical articles were included in the final set. Such articles included commentaries, clinical opinion/guidelines, systematic and metaanalytic reviews, and any other format that was not an original research study were excluded. Additionally, any article deemed irrelevant to the topic of interest was also excluded. Specifically, this review was interested only with factors contributing to vaccine hesitancy concerning COVID-19 vaccines. As stated previously, vaccine hesitancy is not synonymous with anti-vaccination and thus articles discussing such were excluded. Also, those lacking a focus on COVID-19 related vaccine hesitancy in major part or in full were excluded. Finally, articles that were not in the English language and did not provide information for a translated article were excluded due to the lingual limitations of the author. Quality and Bias Assessment The author of this review served as the sole researcher and thus was responsible for conducting the library search, synthesizing the studies, determining 7 PSYCHOSOCIAL FACTORS VACCINE HESITANCY 8 study inclusion and exclusion, and performing the quality assessment. To reduce bias and increase consistency, articles were reviewed multiple times and on different occasions. Specific software or instruments to assist in quality assessment were not utilized in this review. However, numerous characteristics of the studies reviewed were considered when assessing quality. Such characteristics include: sample size and demographics, presence of validated measures, statistical analysis/analyses used, author reported limitations, and definitions of key terms. General characteristics of research studies and statistical interpretation used to assess quality were also considered (e.g. larger sample sizes increase the generalizability of the study). Finally, it should be noted that the author corresponded with and received guidance from the individuals referenced in the acknowledgment while completing this article. Results This review ultimately included 42 studies from six different databases. This final count started from an original search total of 518 results, which was then reduced to 122 after the search limitations were applied. The process of how the final number of studies were chosen for inclusion is represented in Figure 2. Ultimately, all 42 included articles represented original research studies with a grand total sample size of n = 121,013 (Females n = 75,032; Males n = 32,972; Non-binary n = 32; Other categories n = 12,977). A vaccine hesitancy rate was explicitly reported in 17 studies (M = 31 %; SD = 18% CI {13, 49}). Studies mainly took place in the United States, but numerous countries were represented in all: China, Egypt, Cameroon, France, England, Japan, Kuwait, Turkey, Italy, Qatar, Jordan, United Kingdom, Dominican Republic, among others. PSYCHOSOCIAL FACTORS VACCINE HESITANCY Figure 2 PRISMA 2020 Flow Diagram Identification Identification of studies via databases Records identified from: Databases (n = 518) Records removed before screening: Records removed from limit to peer reviewed (n = 84) Records removed from limit to dates 2019-2021 (n = 21) Records removed from limit to abstract first search field (n = 162) Records removed from limit to abstract second search field (n = 118) Duplicate records removed (n = 11) Included Screening Records screened (n = 122) Reports assessed for eligibility (n = 122) Studies included in review (n = 4) Reports excluded: Relevancy (n = 39) Non-empirical (n = 28) Strength of Focus (n = 11) Article withdrawn (n = 2) 9 PSYCHOSOCIAL FACTORS VACCINE HESITANCY 10 Contextual Influences Contextual influences include the social, political, cultural, and economic factors related to vaccine hesitancy (Eskola et al., 2014). For a full description of the facets listed below, see the Appendix. In total, this section includes 41 entries. Communication and Media Environment A total of seven studies were included in this facet, all of which found that media consumption has a significant effect on vaccine intention. Six of the studies reported that consumption of information via social media was related to negative attitudes towards a COVID- 19 vaccine and thus an overall increased rate of hesitancy (Alabdulla et al., 2021; Dinga et al., 2021; Murphy et al., 2021; Romer & Jamieson 2020; Saied et al., 2021; Sallam et al., 2021). In contrast, one study reported a positive effect of consumption of mainstream news sources on vaccine acceptance (Salali & Uysal, 2020). Influential leaders, immunization program gatekeepers and anti- or pro-vaccination lobbies Only one study was included in this facet. The study found that opinions on COVID-19 vaccines produced by the World Health Organization and the US Centers for Disease Control were correlated with higher acceptance rates than when compared to opinions coming from US President Donald Trump (Kreps et al., 2020). PSYCHOSOCIAL FACTORS VACCINE HESITANCY 11 Religion/culture/gender/socio-economic Table 1 Article findings for Religion/culture/gender/socio-economic facet Author(s) Gender Ethnicity Income Religion AlMohaithef & Padhi (2020) Alqudeimat Male** et al. (2021) Bell et al. (2020) Callaghan et Female al. (2021) * Chen et al (2021) NS Detoc et al. Male** (2020) Ditekemena NS et al. (2021) Freeman et Female al. (2020) * GagneuxBrunon et al. (2021) Gerussi et al. (2021) Hursh et al. (2020) Khubchanda ni et al. (2021) Male** - - - Marital Status Married** - NS - Married** Lower income*; Higher income* * Higher income* * Higher income* * - - Non-white* Black* NS - Black and mixed* Middle income* *; High income* * Lower income* Religiosity * - Education level Postgraduate or higher** NS - - Higher education** - - Lower education** - - - NS NS NS Not single or widowed* - Lower education* - - - - NS NS NS - - - Male** NS - - - - Female * AfricanAmericans*; Hispanics* - NS Lower income* - Lower education* PSYCHOSOCIAL FACTORS VACCINE HESITANCY Kreps et al. Female (2020) * Kuter et al. Male** (2021) Latkin et al. Female (2021) * Malik et al. (2020) Meier et al. (2021) Mercadante & Law (in press) Male** Montagni et al. (2021) Murphy et al. (2021) Olagoke et al. (2020) Pogue et al. (2020) Female * Female * NS Male** Nonbinary* NS Roozenbeek Male* et al. (2020) Salali & Male** Uysal (2020) Sallam et al. Male** (2021) Schwarzinge r et al. (2021) Scott et al. (2021) Shekhar et al. (2021) Skjefte et al. (2021) Female * Female * - Black* Black*; Hispanic*; Multiple/Oth er races* Black*; Hispanic* Asian**; Black* Non-Black** NS - Higher income* * - Black*; American Indian**; Alaska Native**; Asian/South Asian** - Lower income*; Higher income* * Non-Irish* Lower income* NS Black* NS NS - - Swartzentrub er Amish* Black*; Lantinx* - - Higher income* * Higher income* * - Higher income* Lower income* 12 NS - Religious belief* - Higher education** Postgraduate ** - NS Lower education* - - - - - - - NS - NS - NS Religiosity NS * - NS Higher education** Higher education** Higher education** - - NS - - - - Higher education* Higher education** - - - - - NS - Single* Lower education* Higher education* Lower education* PSYCHOSOCIAL FACTORS VACCINE HESITANCY Unroe et al. Male** White** (2021) Wang et al. Male** (2021) Yigit et al. Female (2021) * Yoda & Male** Katsuyama (2021) Note. NS = Not significant *Increased vaccine hesitancy **Increased vaccine acceptance - Religiosity * Unmarried ** Religiosity * Religiosity * 13 NS Higher education* - A total of 33 studies were included in this facet and are outlined in Table 1. Of them, 24 concluded that gender was a significant factor relating to vaccine hesitancy and acceptance. Within these articles, 14 report male gender as the predominant factor with 13 articles finding it related to increased vaccine acceptance. In contrast, 10 articles reported female gender as the predominant factor, all of which finding related to increases in vaccine hesitancy. One article reported non-binary participants as the predominant gender related to increases vaccine hesitancy. Regarding race, 15 articles reported significant correlations to vaccine hesitancy. African American/Black participants most commonly reported attitudes and behaviors indicative of vaccine hesitancy in 10 of the articles. In terms of income, 13 articles reported significant correlations with six finding low incomes most strongly related to vaccine hesitancy. Six articles mention religion and religious beliefs as playing a role in attitudes and behaviors indicative of vaccine hesitancy. Only five articles found marital status as a significant factor and the results are mixed when considering its relationship to vaccine uptake. Finally, 17 articles reported education level as a significant factor with highly consistent results of lower education levels leading to increased vaccine PSYCHOSOCIAL FACTORS VACCINE HESITANCY 14 hesitancy and higher levels leading to increased acceptance. Individual and Group Influences Individual and Group Influences include the social psychological factors that relate to vaccine hesitancy (Eskola et al., 2014). For a full description of the facets listed below, see the Appendix. In total, this section includes 19 articles. Beliefs, attitudes about health and prevention Five articles were included in this facet. Three of the articles found that participants with certain beliefs about health and prevention, such as a preference for natural immunity via exposure as well as support for various forms of non-empirical medical treatments like homeopathy, were positively correlated with vaccine hesitancy (Alabdulla et al., 2021; Alqudeimat et al., 2021; Čavojová et al., (2020). Additionally, another study found that external health locus of control was positively correlated with vaccine hesitancy (Olagoke et al., 2020). In contrast, health engagement was positively correlated with vaccine acceptance (Graffigna et al., 2020). Health system and providers-trust and personal experience Table 2 Article findings for Health system and provider-trust and personal experience facet Authors Health Government/Institutions Vaccines Experts/Scientists System Al-Mohaithef High trust & Padhi increased (2020) vaccine acceptance Bell et al. High trust increased Low trust increased (2020) vaccine acceptance vaccine hesitancy PSYCHOSOCIAL FACTORS VACCINE HESITANCY Callaghan et al. (2021) - - Ditekemena et al. (2021) - - Freeman et High mistrust al., (2020) increased vaccine hesitancy Lucia et al. (2020) - - 15 - Low trust increased vaccine hesitancy High mistrust increased vaccine hesitancy - Murphy et al. Low trust (2021) increased vaccine hesitancy Palamenghi et al. (2020) Low trust increased vaccine hesitancy Pogue et al. Low trust (2020) increased vaccine hesitancy Prati (2020) - Low trust increased vaccine hesitancy - Low trust increased vaccine hesitancy Low trust increased vaccine hesitancy - Roozenbeek et al. (2020) - Shekhar et al. Low trust (2021) increased vaccine hesitancy Skjefte et al. (2021) Wong et al. High trust (2021) increased vaccine acceptance - - - High trust increased vaccine acceptance - - High trust increased vaccine acceptance Low trust increased vaccine hesitancy High trust increased vaccine acceptance - - - Low trust increased vaccine hesitancy - High trust increased vaccine acceptance - Low trust increased vaccine hesitancy High trust increased vaccine acceptance - High trust increased vaccine acceptance A total of 14 articles were included in this facet and are outlined in Table 2. Six studies found that trust in the health system was correlated with vaccine uptake where PSYCHOSOCIAL FACTORS VACCINE HESITANCY 16 high trust correlated with acceptance and low trust with hesitancy. Seven studies reported significant correlations with trust in government and institutions with five of the studies finding low trust increased vaccine hesitancy and the remaining two studies finding high trust increased acceptance. Four studies report trust in vaccines themselves as the related variable to vaccine intention, three of which finding low trust increased hesitancy and one finding high trust increased acceptance. Finally, six studies referenced trust in experts or scientists where high trust increased vaccine acceptance in four of the studies and low trust increased hesitancy in two. Discussion This systematic review highlights the diversity and significance of the psychosocial factors related to vaccine hesitancy. Specifically, this review outlines the psychological and sociodemographic factors related to vaccine hesitancy as it pertains to COVID-19 vaccines. To this regard, there are numerous sociodemographic factors related to vaccine hesitancy including race, gender, religion, and socioeconomic status (see table 1). Social media appears to be related to vaccine hesitancy in a number of ways. In the most general sense, social media use has been associated with negative views about vaccines including that they are unsafe and ineffective (Wilson & Wiysonge, 2020). Additionally, social media is used as a medium to spread antivaccine views and gather supporters of the anti-vaccine movement (Johnson et al., 2020). Race is yet another factor greatly contributing to vaccine hesitancy as shown by a preprint article of over one million participants that found African Americans to have the highest rates of hesitancy (Nguyen et al., 2021). Of course, many psychological factors are also involved in accepting vaccines. Belief and trust in healthcare providers, PSYCHOSOCIAL FACTORS VACCINE HESITANCY science, politicians, vaccines, and a host of other sources seem to play a significant role (Hamel et al., 2020). This review is not without its limitations. Search limitations and study selection may have removed articles that would have otherwise been included and contributed to the review. Additionally, due to the author’s status as the sole researcher and reviewer there is an inherent, perhaps moderate level of bias. In conclusion, future reviews should include studies and data about vaccine hesitancy after COVID- 19 vaccines are widely available. 17 PSYCHOSOCIAL FACTORS VACCINE HESITANCY References Alabdulla, M., Reagu, S. M., Al‐Khal, A., Elzain, M., & Jones, R. M. (2021). COVID‐19 vaccine hesitancy and attitudes in Qatar: A national cross‐sectional survey of a migrant‐ majority population. 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Pediatric Infectious Disease Journal, 40(4), e134–e136. https://doi.org/10.1097/inf.0000000000003042 Yoda, T., & Katsuyama, H. (2021). Willingness to Receive COVID-19 Vaccination in Japan. Vaccines, 9(1), 48. https://doi.org/10.3390/vaccines9010048 27 PSYCHOSOCIAL FACTORS VACCINE HESITANCY Appendix Figure A1 Description of Contextual Influences (Eskola et al., 2014) 28 PSYCHOSOCIAL FACTORS VACCINE HESITANCY Figure A2 Description of Individual and Group Influences (Eskola et al., 2014) 29