HCA COVID-19 Vaccine Survey December 2020

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COVID-19

VACCINE SURVEY

Analysis of Responses

by Supervisory District

EXECUTIVE SUMMARY The Orange County Health Care Agency (HCA) conducted a vaccine hesitancy survey in order to determine which concerns about vaccination were more important to different demographic groups within Orange County (OC). The survey measured willingness to be vaccinated plus attitudes in five areas:

Concerns about safety.

Lack of appreciation of the severity of the disease.

Stress and inconvenience of being vaccinated.

Whether one weighed benefits and risks in making a decision about vaccination.

Concern about protecting other people by being vaccinated.

The survey was distributed by email using a non-representative convenience sample by asking members of the OC COVID-19 Vaccine Taskforce to email their constituents. An additional 1,232 responses were obtained from low income central OC residents via face-to-face and telephone interviews. A total of 26,324 surveys were completed. Analysis of the results by supervisory district yielded the following results:

n Willingness to be vaccinated for COVID-19 differed as much as 11 percentage points between districts.

n Highly educated respondents were more positive about the vaccine, although those without a high school diploma were also.

n Districts 3 and 5 were most willing to be vaccinated and were less concerned across most questions.

n Asians and non-Hispanic Whites were more positive than Hispanics and non-Hispanic Blacks.

n District 4 was least willing to be vaccinated.

n Age was positively related to favorable attitudes toward vaccination; 35-54 year old respondents were least positive about vaccination.

n Vaccine willingness and positive attitudes toward the vaccine tended to be related to the demographics of respondents for each district.

n Younger respondents valued getting vaccinated in order to protect others.

Messaging to counter vaccine hesitancy: n Females; 35-54 year olds; Hispanics; and non-Hispanic Blacks should be targeted for messaging. n Safety of the vaccine needs to be addressed in all groups.

n Weighing benefits and risks should be addressed in messaging. n Within supervisory districts messaging can be tailored to demographics.

Vaccine hesitancy has been defined by the World Health Organization as “the delay in the acceptance or refusal to vaccinate despite the availability of vaccine services.” It went on to say that, “vaccine hesitancy is a complex, context-specific phenomenon that varies in time, places, and in regard to specific vaccines.”

Succi, 2018

In terms of factors that influence vaccine hesitancy, these have been shown to include:

 concerns about the safety and efficacy  lack of concern about the disease  whether one has health care coverage or the ability to pay for vaccination;

 trust in the system  personal attributes including level of education, gender, race or ethnicity

 occupation

The model that is most used in developing explaining vaccine hesitancy and developing strategies to overcome hesitancy is called the 5-C model, originally developed (as the 3-C model) by the SAGE Working Group on Vaccine Hesitancy from the World Health Organization. The five concerns that influence vaccine acceptance, hesitancy, or refusal are as follows: 1) CONFIDENCE:

trust in the effectiveness and safety of vaccines, the system that delivers them, including the reliability and competence of the health services and health professionals, and the motivations of policymakers who decide on the need of vaccines.

2) COMPLACENCY:

perceived risks of vaccine-preventable diseases are low and vaccination is not deemed a necessary preventive action.

3) CONSTRAINTS:

physical availability, affordability and

willingness-to-pay, geographical accessibility, ability to understand (language and health literacy) and appeal of immunization service.

4) CALCULATION:

engagement in extensive information searching. We assume that individuals high in calculation evaluate risks of infections and vaccination to derive a good decision.

5) COLLECTIVE RESPONSIBILITY:

the willingness to protect others by one’s own vaccination by means of herd immunity.

There is an assessment tool to go along with the 5-C model, which can be given either as a long-form scale of 15 items, or a short-form scale of 5 items. (Betsch et al, 2018) Our aim was to find out which concerns about vaccination were more important to different groups within Orange County, so we could tailor messages aimed at countering vaccine hesitancy to the concerns of each group.

We used the short-form of the 5-C assessment tool by Betsch et al., modifying only one item to make it specific to COVID-19.

Items were answered using a 7-choice scale ranging from strongly disagree to strongly

agree for each item in accordance with the method of Betsch et al. In addition, we added an item, “If a COVID-19 vaccine is available, I plan to be vaccinated,” to assess the likelihood of getting vaccinated. We also added two yes/no questions about the flu vaccine: “Last year I got a flu shot,” and “I plan to or have already gotten a flu shot this year,” in

order to compare how they felt about getting a COVID-19 vaccine to how they felt about getting a flu shot. We also asked respondents to indicate their status on demographic questions about city and ZIP Code of residence, age, gender, race/ethnicity, level of education, primary language and occupation. A copy of the survey is attached. (Appendix A)

The Survey and the Sample A survey of vaccine hesitancy was created in order to determine which concerns about vaccination were more important to different demographic and occupational groups within Orange County, so that messages promoting COVID-19 vaccination could be tailored to each group’s greatest concerns. The survey used was a 5-item, short-form version of the 5-C Scale of Psychological Antecedents to Vaccination developed by Cornelia Betsch and her colleagues (Betsch, 2018).

Demographic items also asked about gender, age, ethnicity, primary language, education, occupation, city and ZIP Code of residence.

The 5-items measured concerns about safety, lack of severity of the disease, stress and inconvenience of being vaccinated, whether one weighed benefits and risks in making a decision about vaccination, and concern about protecting other people by being vaccinated. Willingness to be vaccinated and prior vaccination with the flu vaccine were also assessed.

The survey was distributed by email using a non-representative convenience sample

by asking members of the OC COVID-19 Vaccine Taskforce and their contacts to send it to their constituents. An additional 1,232 responses from low-income central Orange County residents were obtained via faceto-face and telephone interviews. A total of 26,324 surveys were completed.

The sample over-represented females, non-Hispanic Whites, college educated, English-speaking residents working in office, professional, educational or health care occupations (Appendix B). Because of the large number of responses, even most of the less well-represented groups produced an adequate number of responses to allow reliable estimates of their choices within a margin of error of 1-4 percentage points, depending on the size of the group. Those groups that did not have an adequate number of respondents included those who designated their gender as “other,” non-Hispanic Blacks, those whose primary language was designated as Arabic, Khmer or Farsi, and workers in construction, landscaping, housecleaning or janitorial professions.

Results from Overall Sample Across the whole sample, agreement to receive a COVID-19 vaccine was 58.1% (Figure 1). This is very similar to the 58% of U.S. residents who would accept a vaccine as reported in a Gallup survey from October 19-November 1 (Reinhart, 2020). The area of greatest concern was the safety of the vaccine. Willingness to be vaccinated for COVID-19 was substantially less than for the flu vaccine. Males were more likely to agree to be vaccinated and were less concerned about vaccination across nearly all items (there were not enough “other�

gender responses to include). Asians and non-Hispanic Whites were the most positive about being vaccinated and Hispanics and non-Hispanic Blacks least, with the number of the latter (n=265) low enough to interpret it with caution (margin of error = 6%).

Vaccine acceptance increased with age with the exception that the 35-54 year olds were the least positive about being vaccinated.

Generally, the higher the level of education the more positive and the fewer concerns a respondent had about being vaccinated.

Figure 1. Agree to Take Vaccine - Across Different Demographic Groups

Vaccine -- Yes Vaccine Yes 80% 70% 60% 50% 40% 30% 20% 10% 0%

Vaccine - Yes

In terms of agreeing that a vaccine is safe (Figure 2), the responses across various groups mirrored the responses to the question with regard to agreeing to take the vaccine. Again, the “other� category for

gender did not have enough respondents to include the data and the number of respondents in the non-Hispanic Black number needs to be interpreted with caution.

Figure 2. Agreement Across Questions for Supervisory Districts (margin of error 1-2%)

Vaccines are Safe

Vaccines are Safe 80% 70% 60% 50% 40% 30% 20% 10% 0%

Vaccines are safe

Analysis of Responses by Supervisory District Responses by supervisory district were examined by using ZIP Codes to group responses by district. This method resulted in 17 out of 89 ZIP Codes appearing in more than one district.

Respondents from different districts differed significantly by age, ethnicity, education, primary language, and less so by occupation.

Female respondents predominated in all districts (See Appendix C).

The map in Figure 3 shows the rate of agreement to be vaccinated by district using a map of the five Orange County districts.

Figure 3. Covid-19 Vaccine Hesitancy Survey in Orange County

Comparing districts (Figures 3 & 4), District 4 had the lowest vaccine acceptance (52.6%) and Districts 3 and 5 the highest (61.8% & 63.9%, respectively), mirroring the results for flu vaccine. The main demographic differences between these districts was that Districts 3 and 5 had the highest number of respondents with graduate degrees and the lowest numbers with a high school diploma or less. These two districts also had the highest percentages of combined Asian and non-Hispanic White respondents. District 5 also had the oldest and most likely to be non-Hispanic White respondents. District 4, with lower

vaccine acceptance, did not appear to stand out demographically from other districts in any particular way. Safety was the greatest concern across all districts, with Districts 1 and 4 being more likely to view everyday stresses as deterring vaccination, and also agreeing less that COVID-19 is serious enough to merit vaccination. Respondents in each District were generally agreed that self-vaccination was important in protecting others, although District 4 was slightly lower on this item. Within districts, the more positive acceptance of vaccines by males was uniform across all districts.

Figure 1. Agree to Take Vaccine - AcrossbyDifferent Demographic % Agreement Supervisory District Groups

% Agreement by Supervisory District

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Va cc

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-Y es

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Andrew Do District 1

Michelle Steel District 2

Doug Chaffee District 4

Lisa A. Bartlett District 5

Andrew Do_District 1

Michelle Steel_District 2

Doug Chaee_District 4

Lisa A. Bartle�_District 5

Donald P. Wagner District 3

Donald P. Wagner_District 3

District 1 Although they had small numbers (n=62) and considerable caution needs to accompany interpreting their responses, older adults in District 1 were more likely to agree to be vaccinated and less concerned about the vaccine’s safety, although they said everyday stresses were a greater hindrance for them in getting vaccinated. Young adults were more concerned about protecting others. With the largest percentage of Asians and Hispanics in the sample, Asian residents in District 1

were most positive about being vaccinated and Hispanics least, excluding non-Hispanic Blacks because of low numbers (n=16).

District 1 had the highest number of respondents with less than a high school diploma (10.7% of their respondents), and they were more positive than other educational groups with regard to being vaccinated. On most of the other questions greater positivity was directly relate to greater education.

District 2 In District 2, older adults were also most positive about being vaccinated and least concerned about other issues related to the vaccine. Their 204 responses were 3.1% of those from District 2, but still few enough to require caution in interpreting this result.

35-54 year olds were least positive about vaccination and young adults 18-35 were as concerned about protecting others as were older adults. Asians and non-Hispanic Whites were most positive about being

vaccinated, and Hispanics least, with not enough non-Hispanic Blacks (n=53) to make a reliable estimate. There was no clear relationship between level of education and willingness to be vaccinated in District 2, but otherwise, greater education was related to fewer concerns about the vaccine, with the exception of agreeing that self-vaccination protected others, which showed an inconsistent relationship to education.

District 3 District 3 was unique in that young adults, who were 20% of the district’s respondents, were the most accepting of the vaccine across several questions especially related to the seriousness of the virus and concern for protecting others and were nearly as willing to be vaccinated (68%) as older adults. This probably reflects a large number of students (n=455) from this district, which is the home of the University of California, Irvine. Across all districts, 74% of students agreed to be vaccinated. 35-54 year olds were, as in other groups, least positive about being vaccinated.

As in other districts, Asians and non-Hispanic Whites were most accepting of the vaccine with Hispanics least and too few non-Hispanic Blacks (n=53) to make a reliable estimate. Greater education was linearly related to vaccine acceptance, except that those with less than a high school education were more willing to be vaccinated and less concerned about safety, but the low numbers in this group (n=58) require caution in interpreting the result, although it agrees with that found in other districts.

District 4 District 4 had the lowest overall acceptance of the vaccine and lowest willingness to be vaccinated and some of the relationships between demographic variables and acceptance were less clear in this district.

There was no direct relationship between age and willingness to be vaccinated or any of the other concerns about vaccination. Relationships between ethnicity and vaccine acceptance were similar to other districts with Asians and non-Hispanic Whites being most willing to vaccinate and having the least concerns about vaccination, while Hispanics were less willing and more

concerned with not enough non-Hispanic Blacks (n=50) to make reliable estimates.

Although their numbers were low enough to require caution in their interpretation, respondents with less than a high school diploma were more willing to be vaccinated than all but those with a graduate degree. This was similar to respondents in District 1, which had the highest number of those without a high school diploma as well as in to respondents in District 3. Across most measures, greater education was directly related to fewer concerns about the vaccine.

District 5 District 5 had the oldest population of respondents of any district (and the highest number retirees) and, although their number was still small enough that the margin of error was 6 percentage points, older adults were more willing to be vaccinated and had fewer concerns with vaccination. Except for the question about protecting others through vaccination, on which young adults were more concerned, and the greater concern among 35-54 year olds across most questions, lack of concern on most questions was positively related to age. District 5 also had the highest percentage of non-Hispanic White respondents by a considerable amount. They and Asian respondents were most willing to be vaccinated and least concerned about

the safety of the vaccine, as well as least concerned across most of the other questions. Hispanics differed less from Asians and non-Hispanic Whites across most questions than they did in other districts. Non-Hispanic Blacks were, again too few to generate reliable estimates. In terms of education, District 5 had too few respondents without a high school education (n=13) to make an estimate and even those with a high school diploma were a small number (n=145) so their estimate has to be treated with caution.

Otherwise, greater education was associated with more willingness to be vaccinated and fewer concerns about vaccination, as in other districts, and this district had the highest education levels among its respondents.

Conclusions and Implications

A

lthough the sample of Orange County residents who took the survey is not demographically representative of the county, the overall willingness to be vaccinated for COVID-19 across the sample is remarkably similar to national estimates of vaccine hesitancy. Individual supervisory districts differed by as much as 11 percentage points in terms of willingness to be vaccinated for COVID-19 and 10 percentage points on their perception of the safety of the vaccine, safety being the main concern across all districts and groups.

The main contributing factors to differences between districts were the education level of the respondents and their ethnicity.

In general, more highly educated respondents were more positive about the vaccine, although those without a high school education were more willing than other educational groups, and Asians and non-Hispanic Whites were more positive than Hispanics.

Non-Hispanic Blacks were least positive about vaccination, although their low numbers require caution in interpretation.

Age was generally positively related to favorable attitudes toward vaccination although the number of adults age 75 or greater was small, but still within a 4% margin of error across the whole sample. Younger respondents, age 18-34 were routinely more positive than middle-age respondents age 35-54 and younger respondents also tended to value getting vaccinated in order to protect others. District 3, in particular had young respondents who were very positive toward vaccination and many of them were students.

Although response patterns within districts

tended to be based on the demographic makeup of respondents from each district, the exception was District 4, which showed the lowest overall positive attitudes toward vaccination, but whose responses were not as clearly linked to demographic factors as in other districts.

In terms of messaging to counter vaccine hesitancy, it is clear that females should be a target, since they view vaccination less favorably than males. Also, middle age, 35-54 year olds are less favorable and should receive more attention as should Hispanics and non-Hispanic Blacks. Education was positively related to favorable attitudes toward vaccination, but the majority of the sample had at least a 4 year college degree and still had a willingness to be vaccinated of under 60%, suggesting that even the more highly educated need to be targeted. Those without a high school diploma also tended to be more willing to be vaccinated. Safety of the vaccine is the overwhelming concern for everyone.

Not taking COVID-19 seriously was not as big a concern as safety and a substantial percentage of respondents, particularly young people ages 18-34 were favorable toward an argument that self-vaccination is a way to protect others. Nearly everyone said they weigh the benefits and risks before deciding on a vaccine, so reasoned messages with information about benefits and risks should be most useful. Within supervisory districts messaging can be tailored to the district or even neighborhood demographics in terms of age, ethnicity and education and the concerns that are related to those factors within each district.

References Betsch C, Schmid P, Heinemeier D, Korn L, Holtmann C, BĂśhm R (2018), Beyond confidence: Development of a measure assessing the 5-C psychological antecedents of vaccination. PLoS ONE 13(12): e0208601. https://doi.org/ 10.1371/journal.pone.0208601.

Reinhart, RJ, More Americans Now Willing to Get COVID-19 Vaccine, Gallup, November 17, 2020. https://news.gallup.com/poll/325208/americans-willing-covid-vaccine.aspx.

Succi, RC deM., Vaccine refusal – what we need to know, Jornal de Pediatria, Volume 94, Issue 6, 2018, Pages 574-581, ISSN 0021-7557, https://doi.org/10.1016/j.jped.2018.01.008. (http://www.sciencedirect.com/science/article/pii/S0021755717310045).

APPENDIX A Instruction: “Please evaluate how much you disagree or agree with the following statements 1) If a Covid-19 vaccine is available, I plan to be vaccinated.

1 Strongly disagree

2

3

4

5

6

7

Moderately disagree

Slightly disagree

Neutral

Slightly agree

Moderately agree

Strongly agree

2) I am completely confident that vaccines are safe.

1 Strongly disagree

2

3

4

5

6

7

Moderately disagree

Slightly disagree

Neutral

Slightly agree

Moderately agree

Strongly agree

3) Covid-19 is not so severe that I should get vaccinated.

1 Strongly disagree

2

3

4

5

6

7

Moderately disagree

Slightly disagree

Neutral

Slightly agree

Moderately agree

Strongly agree

4) Everyday stresses prevent me from getting vaccinated.

1 Strongly disagree

2

3

4

5

6

7

Moderately disagree

Slightly disagree

Neutral

Slightly agree

Moderately agree

Strongly agree

5) When I think about getting vaccinated, I weigh benefits and risks to make the best decision possible.

1 Strongly disagree

2

3

4

5

6

7

Moderately disagree

Slightly disagree

Neutral

Slightly agree

Moderately agree

Strongly agree

6) I get vaccinated because I can also protect other people from getting infected.

1 Strongly disagree

2

3

4

5

6

7

Moderately disagree

Slightly disagree

Neutral

Slightly agree

Moderately agree

Strongly agree

What City do you live in?______________________________________________________ What zip code do you live in?__________________________________________________ Last year I got a flu shot (circle)

Yes No

I plan to or have already gotten a flu shot this year (circle)

Yes No

Please check all those that apply to you: 1) My Gender is: Female _______ Male _______ Other (specify) _______ 4) My age is: 18-34 years old 35-54 years old 55-74 years old 75 and older

_______ _______ _______ _______

5) My race/ethnicity is Non-Hispanic White Hispanic/Latinx Non-Hispanic Black Asian/Pacific Islander Mixed/other (specify)

_______ _______ _______ _______ _______

6) My highest level of education is Less than high school _______ High school diploma _______ Community college/some college _______ College degree (4-year) _______ Graduate Degree _______ 7) My primary language is English Spanish Vietnamese Farsi Chinese Cambodian/Khmer Other (specify)

_______ _______ _______ _______ _______ _______ _______

8) Which best describes your current occupation?

Healthcare worker (e.g. doctor, nurse) __ First _______ responder (e.g. fire, police) Retail/Food Service/ Restrnt/Delivery _______ Education (Teacher, Administrator) _______ Student _______ Construction//Maint./ Landscape/Trade _______ Office/Professional/Technical _______ Housekeeping/Cleaning/Janitorial _______ Homemaker _______ Retired _______ Disabled/Unemployed _______ _______ Other (specify)

APPENDIX B Demographic Information for Whole Sample

Variable

Gender

Age

Race/ Ethnicity

Value

Frequency

Percent

Cumulative Percent

Other

141

0.5

0.5

Female

18,963

72.8

73.3

Male

6,957

26.7

100.0

18-34 Years

5,350

20.5

20.5

35-54 Years

13,402

51.3

71.8

55-74 Years

6,593

25.3

97.1

75 and older

760

2.9

100.0

Other

1,368

5.3

5.3

Non-Hispanic White

13,313

51.6

56.9

Hispanic

6,533

25.3

82.2

265

1.0

83.2

4,335

16.8

100.0

608

2.3

2.3

High school diploma

1,590

6.1

8.4

Community college/some college

5,801

22.3

30.7

College degree (4-year)

8,109

31.1

61.8

Graduate degree

9,942

38.2

100.0

544

2.1

2.1

22,785

87.1

89.2

Non-Hispanic Black Asian Less than high school Highest Level of Education

Primary Language

Other English

Variable

Frequency

Percent

Cumulative Percent

1,694

6.5

95.7

Vietnamese

585

2.2

97.9

Farsi

100

0.4

98.3

Chinese

343

1.3

99.6

Cambodian/Khmer

107

0.4

100.0

Other

2,413

9.2

9.2

Health care worker

2,902

11.1

20.4

First responder

810

3.1

23.5

Retail/Food Services

894

3.4

26.9

Education

6,350

24.3

51.2

Student

1,474

5.6

56.9

358

1.4

58.2

6,897

26.4

84.7

145

0.6

85.2

Homemaker

1,570

6.0

91.2

Retired

1,902

7.3

98.5

388

1.5

100.0

Value Spanish

Primary Language

Occupation

Construction/Maintenance/ Landscape Office/Professional/Technical Housekeeping/Cleaning/ Janitorial

Disabled/Unemployed

APPENDIX C Demographics by District