Abstract
Introduction/Objectives:
Addressing vaccine hesitancy has become an increasingly important public health priority in recent years. There is a paucity of studies that have focused on vaccine hesitancy among older adults, who are known to be at greater risk of complications from infections such as COVID-19. We aim to explore the attitudes and beliefs of older adults regarding COVID-19 and influenza vaccines in Toronto, Ontario.
Methods:
Older adults enrolled in the Student Senior Isolation Prevention Partnership (SSIPP) program at the University of Toronto were contacted to participate in a phone survey and semi-structured interview. Survey data was analyzed descriptively, and attitude toward vaccination was compared between sociodemographic groups by using Fisher’s exact test. Interview audio files were transcribed verbatim and analyzed inductively for themes and sub-themes.
Results:
All thirty-three (100%) older adults reported that they had received the first and second doses of the COVID-19 vaccine. Twenty-six (78.8%) participants reported intent to get vaccinated against influenza or had already received the influenza vaccine that year. Notably, only 2 out 7 (28.6%) individuals who did not plan to get vaccinated against influenza believed that vaccines offered by health providers are beneficial and only 3 out of 7 (42.9%) agreed that getting vaccines is a good way to protect oneself from disease. No other significant differences in attitudes among participants were found when compared by gender, ethnicity, or education level. The qualitative data analysis of interview transcripts identified 5 themes that impact vaccine decision making: safety, trust, mistrust, healthcare experience, and information dissemination and education.
Conclusions:
Our data showed that older adults in the SSIPP program generally had positive views toward vaccination, especially toward the COVID-19 vaccines. However, several concerns regarding the effectiveness of the vaccines were brought up in interviews, such as the speed at which the vaccines were produced and the inconsistency in government messaging.
Introduction
Vaccine hesitancy was defined by the World Health Organization as a “delay in acceptance or refusal of vaccines despite availability of vaccine services.” 1 Although it is not a new phenomenon, addressing vaccine hesitancy has become an increasingly important public health priority as the Coronavirus disease 2019 (COVID-19) pandemic has both strained healthcare systems and catalyzed public concerns over vaccine safety and efficacy.2,3 Early in the COVID-19 pandemic, older adults in the Greater Toronto Area (GTA), Ontario were lagging behind the younger population in terms of COVID-19 vaccine uptake, especially among seniors over 80 years old.4,5 This was concerning as older adults were more likely to develop severe COVID-19 infection, and those over 65 years of age had a 23-fold greater risk of death than those under 65. 6 More recently however, adults in the 50 to 69 age group had an 88% primary COVID-19 series uptake and those 70 years and older had an 84% primary COVID-19 series uptake. 7
Influenza vaccination rates during the COVID-19 pandemic saw marginal increases but have not kept pace with near ubiquitous uptake of COVID-19 vaccines.8,9 Prior to the pandemic, 2019 data showed influenza vaccination coverage at 36.6% for the general Ontario population and 67.1% for persons over age 65. 8 In the 2020 influenza season, the coverage increased to 42.2% of Ontario residents over age 12 and 71.3% for over age 65. Ontario-specific data for the same time period is not available for 2021, but Canada-wide rates were 39% for the general population and 71% for adults over age 65. 10 It is not clear which factors have driven these marginal increases in influenza vaccination in recent years, however, literature has shown clear correlations between attitudes regarding COVID-19 and influenza vaccination.11,12 A survey-based study comparing data from before and during the COVID-19 pandemic identified factors associated with influenza vaccine uptake with strongest predictors being history of influenza vaccine and self-reported worry about COVID-19. 11 It has also been shown that rates of COVID-19 vaccine hesitancy were significantly higher among individuals who received 2 or fewer influenza vaccines in the previous 5 years. 12 While these studies have captured valuable correlations, there is a paucity of studies that have focused on vaccine hesitancy among older adults and incorporated interview-based methods to qualitatively characterize attitudes toward both COVID-19 and influenza vaccines. Our study therefore aims to explore the attitudes and beliefs of older adults regarding COVID-19 and influenza vaccines, as a similar study has not been done yet in Canada to our knowledge.
Methods
Study Design
We conducted a multi-methods study using a cross-sectional survey and individual semi-structured interviews.
Setting and Participants
The study was conducted in the GTA in Ontario, Canada. Participants were recruited from the Student Senior Isolation Prevention Partnership (SSIPP) program at the University of Toronto Temerty Faculty of Medicine. The SSIPP is an initiative where student volunteers make weekly calls to older adults in the community who are at-risk of social isolation, and who have been referred to the program by their primary care providers, to provide companionship and emotional support. Participants were eligible for our study if they were aged 65 years or older, English-speaking, capable of providing consent and were active in the SSIPP program during the 2021 to 2022 academic year.
Study Instruments
We developed the survey questionnaire (see Supplemental Material) based on review of similar studies.13,14 The first section of the questionnaire collected sociodemographic information including age, gender, ethnicity, highest level of education, and type of home/living arrangement. The second section of the survey included questions on whether the participants had received a first and second dose of the COVID-19 vaccine, and whether or not they intended to receive or had received an influenza vaccine that year. The third section included Johnson et al.’s modified version of the SAGE Group’s validated 24-item “Vaccine Hesitancy” survey and contained questions about attitudes toward all vaccines, COVID-19 vaccines and influenza vaccines. 14 Each question was scored on a five-point Likert scale, ranging from “strongly disagree” to “strongly agree.” The individual semi-structured phone interview guide (see Supplemental Material) was developed by the research team in accordance with Patton’s approach 15 and contained a set of open-ended questions and prompts intended to elicit participants’ perception on COVID-19, COVID-19 vaccines, and influenza vaccines.
Data Collection
Eligible participants were contacted by phone and invited to participate in our study by 5 research team members, who followed a recruitment script. Those who were interested were emailed or mailed a consent form, which was reviewed at a later date with one of our research team members over the phone. Once verbal informed consent was obtained, the research team member proceeded with the survey questionnaire guide over the phone and recorded the participants’ answers in a secure and de-identified electronic database. At the end of the survey, respondents were invited to participate in a semi-structured individual phone interview to further explore their views on the topic. Among those who agreed, a purposeful sample of participants, based on age, gender, and ethnicity and vaccination status, was called again at a later date to conduct the interview, until data saturation was achieved. The interviews were audio-recorded and then transcribed verbatim by a professional transcriptionist. Transcripts were compared to the audio-recording of the interviews to ensure completeness. The surveys were completed from September 2021 to January 2022 and the interviews from May 2022 to June 2022.
Data Analysis
Categorical variables were calculated as frequency counts (n, %) using Microsoft Excel for all questions of the survey. For the attitude questions of the third section of the survey, frequency counts were reported for participants who had answered “strongly agree” and “agree” to each statement. These frequency counts were compared between several groups: those who had received the annual influenza vaccine versus those who had not, men versus women, White ethnicity versus Black or Asian ethnicities, high school diploma versus higher education level (college, university or graduate degrees), by calculating Fisher’s exact test using RStudio version 1.1.463. Any difference was considered statistically significant at P-value < .05.
Interview transcripts were read in their entirety several times by 2 research team members (CM and AC) for data immersion. There was an inductive approach to open coding followed by complete conventional content analysis and constant comparative method to identify clusters of codes (sub-themes) and themes that emerged from the data, until “saturation” was achieved or when no additional themes were identified. 16 The coding was performed independently by 2 study team members (CM and AC) and the themes were agreed upon by 3 team members (CM, AC, and MM).
Ethics
The study was approved by the University Health Network Research Ethics Board (REB) and the University of Toronto Health Sciences REB.
Results
Survey Questionnaire
We contacted and sent informed consent forms with study information to 57 English-speaking older adults that had been enrolled in the SSIPP program at the time. Thirty-three participants consented to the study and answered the phone-administered survey (response rate of 57.9%). The majority of participants were women (72.7%), of White ethnicity (66.7%) and lived in an apartment/condominium (66.7%) (Table 1). Most of the participants (63.6%) were between the ages of 70 and 79. Six out of the 33 (18.2%) participants only had a high school degree while the remainder of the participants had a college degree or higher educational level. All participants reported that they had received the first and second doses of the COVID-19 vaccine. Twenty-six (78.8%) of the participants reported intent to get vaccinated against influenza or had already received the influenza vaccine that year. Six older adults did not plan to receive the influenza vaccine and 1 older adult was unsure at the time of survey completion (Table 1).
Participant Demographic Characteristics and Vaccination Status/Intent.
Attitudes Toward All Vaccines, COVID-19 Vaccines and Influenza Vaccines
Our analysis demonstrated an association between influenza vaccination status and attitudes toward vaccination across several domains. Participants who had received (or intended to receive) the influenza vaccine in the current season were significantly more likely to strongly agree/agree with positive statements regarding influenza vaccines, including feeling that influenza vaccines are beneficial to oneself and others, having few concerns about side effects, and considering healthcare providers to be reliable and trustworthy sources of information on the topic (Table 2). When asked if “The flu vaccine is effective,” 21 out of the 26 participants (80.8%) who were vaccinated strongly agreed/agreed compared to 3 out of the 7 participants (42.9%) who had not received the influenza vaccine, but the difference between the 2 groups was not statistically significant (P = .068).
Proportion of Participants Who “Strongly Agree/Agree” With Statements, by Immunization Status and Demographic Characteristics.
Questions above based on survey developed by Johnson et al. 14
Denominator is N-1 for these questions as one participant declined to answer these questions.
Bold values indicate statistical significance of P-value < .05.
Similar results were obtained when questioned about attitudes on vaccines in general, with influenza-vaccinated participants agreeing significantly more that vaccines are beneficial and safe, that information provided by their healthcare providers is credible, and that vaccines are important to one’s own health. Interestingly, no difference was found between the 2 groups when asked whether vaccines in general are important to the health of others, and once again, whether vaccines in general are effective.
When asked about COVID-19 vaccine-related attitudes, there was no significant difference found between the influenza-vaccinated group and the influenza-unvaccinated group for most of the statements. The influenza-unvaccinated participants disagreed more that the COVID-19 vaccine is beneficial, the information received from their healthcare provider is reliable and the COVID-19 vaccine is effective, even if they had all received at least 2 doses of the COVID-19 vaccine. More participants in general agreed that the COVID-19 vaccines are effective (93.9%) compared to influenza vaccine (72.7%).
When comparing attitudes by gender, ethnicity, and education level, we did not find any significant difference between men and women, between White and Asian/Black participants, and between participants with a high school diploma and those with a higher education degree (Table 2). The only exception was that among White participants, 59.1% agreed that the flu vaccine is effective, compared to 100% of Asian/Black participants (P-value = .032).
Semi-Structured Individual Interviews
Out of the 33 survey participants, 8 were interviewed. The qualitative data analysis of the interview transcripts identified 5 themes which influenced vaccine uptake: safety, trust, mistrust, healthcare experience, and information dissemination and education. Each theme and its sub-themes are described below, and illustrative quotes are summarized in Table 3.
Themes and Illustrative Quotes From Interviews.
Safety
Safety was a common theme among participants, citing perceived risk of contracting infections when unvaccinated, personal safety, the safety of others, vaccine side effects, and incomplete vaccine effectiveness. Older adults discussed the importance of protecting others as well as protecting themselves from severe disease or even death. Issues such as the influenza vaccine strain “guessing game” and getting COVID-19 despite being vaccinated were brought up. Participants also endorsed concerns that individuals had side effects or reactions to the COVID-19 vaccine, such as blood clots or allergic reactions which impacted their decision-making process.
Trust
Several participants discussed their trust in experts, mainstream media, government and science. The sharing of information by the government was identified as a positive factor that impacted vaccine uptake. Older adults discussed having strong confidence in the science and the research behind the COVID-19 vaccines. Many participants endorsed consuming information about the vaccines from television news broadcasts and other forms of news media which reinforced their positive opinions. Participants expressed trust in the doctors who recommended the vaccines and expressed favor in following the public health guidelines.
Mistrust
The theme of mistrust represents some study participants’ lack of trust in mainstream media and the government as well as experts on the topic of vaccination, which contributed to their hesitancy toward vaccines. Sentiments included opinions that the media was biased by government or manufacturer incentives to promote the COVID-19 vaccine and suppress dissenting opinions and that the media were purposefully underreporting deaths and adverse effects related to the COVID-19 vaccine. Concerns regarding the unclear origin of the COVID-19 infection lead to doubts regarding COVID-19 information.
Healthcare experience
Several participants cited routine healthcare experiences that influenced vaccine uptake. Getting the flu shot every year was a routine that they kept up with and discussed how readily accessible both the COVID-19 and influenza vaccine are. Previous positive vaccine experiences, such as with polio and smallpox, positively impacted vaccine uptake. Participants identified their therapeutic relationship with their family physician as a source of reliable information that influenced decision making. Paternalistic medicine impacted participants as several seniors endorsed getting vaccinated to follow doctors’ orders. Distrust of the healthcare system by Black individuals who experienced generational trauma lead to hesitancy toward vaccines.
Information dissemination and education
This theme captured initial skepticism about COVID-19 vaccination due to inconsistent guidelines and inadequate evidence. Specifically, there was confusion about the constantly changing recommendations for the interval time between first and second doses of the COVID-19 vaccine as well as the lack of testing of the vaccines. Participants reported being motivated to educate themselves by listening to the news and reading about the guidelines, the research and the science behind the vaccines. Some individuals also highlighted the impact of positive social influence on vaccine decision-making when others around them were getting vaccinated. On the other hand, some participants mentioned the influence of close friends or family members who were outspoken about their hesitancy and refusal to get vaccinated.
Discussion
Our results showed that older adults participating in SSIPP had an overall positive view toward vaccination, especially toward the COVID-19 vaccines. All participants had received at least 2 doses of the COVID-19 vaccine and nearly all agreed that they are effective and beneficial to both themselves and the community. This is higher than the reported COVID-19 primary series vaccination coverage in Ontario of 80.9% (as of April 2023), although closer to values seen in the 60+ Ontario population, which was over 90%. 17 As for the influenza vaccine, 21.2% of our participants reported not having received or not intending to receive it in the year of the study, which is slightly lower than the 29.5% who reported not receiving an influenza vaccination in the past 12 months in the Canadian Longitudinal Study on Aging. 18 This could be the result of the small sample size but could also be explained by the selection bias of our sample.
All participants in our study were actively engaged with their primary care provider and, based on our interviews, trusted them. Only 1 individual indicated that they did not trust information regarding vaccines from their family doctor and only 2 individuals indicated that they do not do what their healthcare providers recommend regarding vaccination. This trust may not reflect the overall Canadian population and there may be a higher degree of vaccine hesitancy in those individuals who do not engage with primary care providers or do not trust their healthcare providers. Gravagna et al. found that lack of recent contact with a family doctor was associated with non-influenza vaccination. 18 Another study of parents and their views on vaccinating their children reported that parents who found their healthcare provider influential in their decision to vaccinate their children were twice as likely to respond that vaccines were safe for children, indicating that healthcare providers have a positive influence on a patient’s decision regarding vaccination. 19 It is possible that individuals who are more distrusting of vaccination may also be more distrusting of the healthcare system overall and would not participate in programs such as SSIPP and would therefore not be represented within our study population.
Interestingly, although the overall view toward vaccines was largely positive, there was more hesitancy and perceived lack of importance toward influenza vaccination, as only 75.8% of our participants agreed that the influenza vaccine is important for their health, compared to 90.9% for the COVID-19 vaccine. Similarly, 72.7% of participants agreed that the flu vaccine is effective, compared to 93.9% who thought the same about the COVID-19 vaccine, indicating more trust in the COVID-19 vaccine compared to the influenza vaccine. In the early phases of the pandemic, 2 studies looking at the impact of the COVID-19 pandemic on older adults’ attitudes to influenza vaccination in the United Kingdom 20 and in Canada 21 found that the pandemic had positively shifted influenza vaccination intent, but that concerns for potential risks associated with vaccine also increased. Our data was collected toward the end of the second year of the pandemic. It would be relevant to do further studies on the impact of the pandemic on influenza vaccination intent and uptake in the current post-pandemic times to inform continued public health efforts to increase annual vaccination coverage.
We did not identify significant differences in attitude between ethnic groups in the survey results, which is likely due to our small sample size, but during the interviews, it was mentioned that multigenerational trauma within the Black community may have affected initial views toward the COVID-19 vaccines. A qualitative study of vaccine attitudes and intentions among African American participants of a faith-based wellness program found that vaccine hesitancy was partly related to historical mistrust of government and pharmaceutical companies conducting unethical healthcare research among Black populations. 22 These might be sentiments shared by other groups across Canada and may be possible reasons why certain Canadians have not decided to be vaccinated or delayed getting vaccinated. Understanding and addressing concerns that prevent Canadians from getting vaccinated will be crucial in raising vaccination rates in the future, especially in the case of another pandemic.
The most common reasons for vaccine hesitancy in our study appeared to be similar to what has been found in other studies in other age groups. 23 In a study studying COVID-19 and influenza vaccine hesitancy in college students, researchers found that the 3 biggest vaccine-related concerns in their cohort were safety, effectiveness and limited information. 24 Similarly, Johnson et al. found that the main reasons for vaccine hesitancy were the potential side effects, fear of getting sick from the vaccine, and absence of vaccine recommendations at the time. 14 One study by researchers looking at vaccine hesitancy specifically in Thai seniors found that 44.3% of their participants were hesitant to receive the COVID-19 vaccines at the time, citing reasons such as low education, lack of confidence in the healthcare system’s ability to treat patients with COVID-19, being offered a vaccine from an unexpected manufacturer, and a low number of new COVID-19 cases per day. 13 Notably, reasons for vaccine hesitancy that were identified in our study seem to be similar to those identified in a systematic literature review of influenza and COVID-19 vaccine hesitancy in adults. 25 The 4 major themes identified in their review were concerns over safety, lack of trust, lack of need for vaccination and cultural reasons, with concerns for safety being the only concern identified in all studies included in the review.
We acknowledge that there are several limitations to our study. One limitation is that our study participants were chosen from a convenience sample of individuals who were referred to the student-led SSIPP initiative by their healthcare providers and who chose to participate in regular check-ins by healthcare professional students at the University of Toronto. It is likely that these individuals are more motivated about their health and well-being and are better informed about vaccines. They were found to be overall trusting of their healthcare providers regarding vaccination and thus more likely to hold positive views regarding vaccination. Another limitation is the sample size, which was limited by the virtual nature of our study due to the COVID-19 pandemic and limited numbers enrolled in the SSIPP program. In addition, as time has passed, vaccination rates have changed. As of September 11, 2022, 97.9% of individuals 80+ have now completed a primary series of COVID-19 vaccinations. Although the vaccination rate in the older age groups have caught up, the fact that they initially lagged behind remains true. Understanding the reason for the lag remains important to understand as continuing vaccinations beyond the initial primary series will likely continue to be important throughout the ongoing pandemic. Lastly, a limitation of the phone-based data collection is that there may have been response bias due to individuals wanting to answer in a way that conforms to the beliefs of the students who were performing the survey/interviews. This may have resulted in responses not truly reflective of their true opinions and to be more favorable toward vaccination overall.
Future studies should expand on the patient population in order to better capture individuals who have not received their vaccinations. Additionally, exploring views and hesitancy toward additional doses beyond the primary series in different age groups may reveal important information that could be addressed and used to improve vaccination rates.
Conclusions
Our study described the unique attitudes of isolated older adults participating in the SSIPP program in Toronto, Ontario on topics such as COVID-19 and influenza vaccines as well as their trust in government, science and healthcare practitioners and experts. Our results point toward the importance of continued patient education by their primary healthcare providers about the effectiveness of vaccines in general to help increase vaccine confidence. Further public education through mainstream media should also focus on the safety, importance, and effectiveness of influenza vaccines.
Supplemental Material
sj-pdf-1-jpc-10.1177_21501319231214127 – Supplemental material for Perspectives of Older Adults on COVID-19 and Influenza Vaccination in Ontario, Canada
Supplemental material, sj-pdf-1-jpc-10.1177_21501319231214127 for Perspectives of Older Adults on COVID-19 and Influenza Vaccination in Ontario, Canada by Milena Music, Nicholas Taylor, Christopher McChesney, Christian Krustev, Alexandra Chirila and Catherine Ji in Journal of Primary Care & Community Health
Footnotes
Acknowledgements
We would like to thank Jordan Deneau and Natalie Pitch for their ideas and contributions to the initial study design; and Stefanie Ivkovic and Sandra Sabongui for their help with the phone survey data collection.
List of Abbreviations
COVID-19: Coronavirus disease 2019
GTA: Greater Toronto Area
REB: Research Ethics Board
SSIPP: Student Senior Isolation Prevention Partnership
Author Contributions
All authors contributed to the study conception and design. Material preparation and data collection were performed by Milena Music, Nicholas Taylor, Christopher McChesney, Christian Krustev and Alexandra Chirila. Quantitative data analysis was performed by Milena Music, Christopher McChesney, and Catherine Ji. Qualitative data analysis was performed by Christopher McChesney, Alexandra Chirila, and Milena Music. The first draft of the manuscript was written by Milena Music, Nicholas Taylor, and Christian Krustev, and all authors reviewed and commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CJ has received a research grant from Pfizer Canada “Assessment of on-time immunization coverage in children under 2 years of age in Canada” (Competitive Grant Program) from November 2020 to November 2021 (grant number #63478895), which is unrelated to this publication. All the other authors do not have any competing interest.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received financial support from the Dr. Thomas Geleff Fund through the University Health Network Foundation and Department of Family and Community Medicine to help cover the transcription fees and Article Processing Charge for the publication of this article.
Ethics Approval and Consent to Participate
The study was approved by the University Health Network Research Ethics Board (REB) and the University of Toronto Health Sciences REB. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee (University Health Network REB #21-5660, and the University of Toronto Health Sciences REB #41572). Informed consent was obtained from all individual participants included in the study.
Consent for Publication
Not applicable
Availability of Data and Material
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
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