Two major themes emerged from the participants’ experiences regarding COVID-19 vaccination, namely, barriers to vaccination and motivations for vaccination, which can be analyzed through factors at the four social levels considered under the CMA framework.
Individual level
At the individual level, the participants’ personal experiences and social networks strongly affected both their barriers to and incentives for vaccination. For those participants open to vaccination (n = 19), their trust in the vaccine, their desire to achieve a sense of security, and positive experiences with the vaccine among members of their social networks were significant motives. This group of participants tended to have a strong belief that COVID-19 vaccines have been developed for the good of the people. Those participants who refused (n = 6) or were hesitant (n = 6) to be vaccinated, by contrast, exhibited more distrust in the safety and efficacy and expressed a negative view of the vaccine due to weak social and family networks. The hesitant participants frequently noted that they would delay their decision to be vaccinated until others had received the vaccine. This result is consistent with findings from previous research [31]. Some of the hesitant participants wished to delay their COVID-19 vaccination because they wanted to spend time deciding on the “best” vaccine, that is, the vaccine with the highest efficacy and the fewest side effects.
Vaccine hesitancy has been widely documented in the literature [32, 33]. Vaccine acceptance should be interpreted on a continuum spanning from complete acceptance of all vaccines to complete refusal of all vaccines, with hesitancy in between [7]. The 3C model, consisting of complacency (which arises from perceptions that the risks from diseases preventable through vaccination are low), convenience (concerning the physical availability and financial affordability of the vaccine), and confidence (regarding trust in the safety and effectiveness of the vaccine), has been proposed as a method to understand vaccine hesitancy [7]. This model was later modified and extended to the 5C model for the psychological antecedents of vaccination: confidence, complacency, constraints (availability, affordability, and accessibility), calculation (engagement in seeking information), and collective responsibility (willingness to protect others) [34]. However, because the causes and mechanisms underlying the elements of the models remain unknown, both the 3C and 5C models are inadequate for developing a robust understanding of vaccine hesitancy. Based on the results of the analysis, it can be asserted that social, cultural, economic, and political factors influence peoples’ perceptions of and behavior regarding vaccination.
Studies have presented conflicting results on the influence of prior exposure to the seasonal influenza vaccine with respect to their motivation to receive the COVID-19 vaccine. Wang et al. [35] reported that having previously received vaccinations against seasonal influenza enhanced motivation to receive the COVID-19 vaccine in China, whereas Malik et al. [36] observed no association in their study in the United States. The results of this study do not reveal a clear association between the two types of vaccination. Of the 19 participants who were willing to receive a COVID-19 vaccination, only 5 had previously received seasonal influenza vaccinations. Of the 12 participants who refused (n = 6) or were hesitant (n = 6) to receive COVID-19 vaccination, 6 had received vaccination against seasonal influenza. A prior experience of receiving a seasonal influenza vaccine did not guarantee a greater acceptance of COVID-19 vaccination among the study participants. Although both vaccines are provided free of charge to older adults in Hong Kong (seasonal influenza vaccine is provided with government subsidies to those who are aged 50 or above under the Vaccination Subsidy Scheme), the vaccination rates for both vaccines remain low. The vaccination rates for seasonal influenza among people aged 65 or older made up 45.8%, 44.7%, and 39.3% of that population in 2019/2020, 2020/2021, and 2021/2022, respectively [37]. Older adults have the lowest rate of COVID-19 vaccination in Hong Kong; in July 2021, only 26% of adults aged 60 years or older had received their first dose [6]. Although the COVID-19 vaccination rate among older adults has increased dramatically in 2022 (85.25% for those 60–69 years old, 74.16% for those 70–79 years old, and 45.07% for those 80 years old or older have been vaccinated with the first shot as of late February 2022), the vaccination rate is still among the lowest at the time of this article when compared to younger age groups (excluding the 3 to 11 age group, which only received approval for vaccination in February 2022) [23]. Some of the participants indicated that the free vaccination was an incentive for receiving vaccination, but the results suggest that financial factors are not the sole motivator for obtaining a vaccination among older adults.
Trust in the vaccine has been identified as a major factor in individuals’ decisions regarding vaccination [38], and trust and confidence in the COVID-19 vaccine were identified as key determinants of motivations for and barriers to vaccination for the participants in this study. The participants’ confidence in the COVID-19 vaccine was undermined by its novel nature and short development time. The participants who refused or were hesitant toward the vaccine perceived that the short development timeline of the vaccine indicated potential harmful effects, such as adverse vaccination events. “I can’t possibly know what will happen to me [if I get vaccinated]” was a common concern among the participants. The hesitant participants stated that they would delay COVID-19 vaccination to observe its effects in others. Similar perceptions are prevalent in the U.S., where vaccine skepticism remains a major obstacle to achieving herd immunity [39]. Among the participants with high acceptance of COVID-19 vaccination, trust in the vaccine, in medical experts, and in the government was commonly expressed. These participants typically believed that the COVID-19 vaccine was developed to help rather than to harm the public.
Consistent with the findings of studies on motivations for vaccination [40, 41], social support networks comprised of peers and family members could provide both incentives for and barriers to vaccination. Vaccine acceptance by peers and family members in particular contributed to strong motivation for receiving vaccination. The participants who refused or were hesitant toward vaccination had peers and family members who were hesitant about receiving the vaccine. Furthermore, the participants with fragile family networks were often hesitant to receive vaccination because they were concerned that they would not be able to obtain assistance and would be left alone if they experienced side effects or sequelae. The fear of burdening family members in the event of experiencing severe side effects or chronic sequelae was also a notable barrier to vaccination. Overall, the participants’ social support networks were critical in both increasing and decreasing their levels of vaccine acceptance. In 2018, 15.7% of individuals aged 65 years or older in Hong Kong lived alone [42], and the fragile family and social networks of this group of older adults may contribute to their low levels of vaccination. Furthermore, a recent report noted that the “hidden elderly,” or those without family and social support, are vulnerable to isolation during the pandemic, making obtaining support regarding vaccination difficult [43]. The participants in this study were from lower socioeconomic classes, which are shown to be closely associated with poor social support networks [44]. Governmental health authorities and public health practitioners must consider social support as a key factor when promoting COVID-19 vaccination in older adults. Strengthening social support networks for older adults or providing additional support after vaccination may reduce this population’s hesitancy toward vaccination and increase their motivation to receive the vaccine.
Microsocial level
At the microsocial level, stigma regarding health care workers and perceptions that these individuals were dangerous due to potential contact with the COVID-19 virus were notable demotivating factors. The participants who refused or were hesitant to receive COVID-19 vaccinations perceived contact with health care workers during the ongoing COVID-19 pandemic to be risky. Specifically, health care workers were stigmatized by these participants as “dirty” (in cultural and non-physical terms) because they work in hospital environments, which the participants perceived as contaminating. If people are considered “dirty” or “unclean,” they may be ostracized by others [45]. The stigma attached to health care workers therefore served as a barrier to vaccination for those opposed to or hesitant toward receiving the vaccine.
Intermediate-social level
At the intermediate-social level, political factors related to trust in the government influenced the participants’ decisions to receive vaccinations. Acceptance of the vaccine was higher among the participants with high levels of trust in the government, and a lack of trust in the government was noted as a demotivating factor by those opposed to or were hesitant toward the vaccine. Purity, liberty, and antiauthority are values associated with vaccine hesitancy, with liberty and antiauthority specifically relating to a lack of trust in the government [46]. Past studies note that the political affiliation of the past presidents of the United States can have a significant impact on its citizens’ vaccine acceptance or hesitancy. One study noted that endorsement of the COVID-19 vaccine by then-U.S. President Donald Trump did little to encourage vaccine acceptance among the U.S. public [47]. Another national survey conducted in the U.S. observed that public confidence in and acceptance of the vaccine increased after one of former President Barack Obama’s daughters received the vaccination [48]. This study also reveals the contribution of political factors to vaccination behavior. The participants who expressed lower levels of trust in the government also had doubts about the authenticity of the vaccine. Furthermore, although the Hong Kong government has established an expert committee to investigate adverse events following COVID-19 vaccination [49], some of the participants continued to doubt the safety and effectiveness of the vaccine. They believed that the adverse events experienced by some individuals after receiving the vaccine had been dismissed as being explainable by those individuals’ pre-existing chronic conditions. These participants believed that neither the government nor medical experts were held accountable for occurrences of adverse effects related to the vaccine and that neither were willing to award monetary compensation for these effects. This idea undermined the participants’ confidence in the vaccine, contributing to their negative perceptions of it. In sum, the attribution of adverse events arising after COVID-19 vaccination to the pre-existing chronic conditions of those affected was perceived by these participants as an excuse and a refusal of responsibility for harm done by the government.
Macrosocial level
At the macrosocial level, the participants’ cultural perceptions of vaccines help explain their hesitancy to receive vaccination. The results align with the finding presented in a systematic review by Wilson et al. [50], who found that cultural factors may serve as barriers to vaccination. The participants who refused or were hesitant toward vaccination viewed vaccines as “toxic” (i.e., dangerous). This perception is common in Chinese societies [16, 51] and was reinforced by these participants’ past experiences of feeling ill after vaccination.
Studies have reported that a sense of responsibility to society has been a key motivator of individuals’ infection control behavior during the ongoing COVID-19 pandemic [9, 34, 52]. Awareness of the social consequences of COVID-19 can encourage people to adopt prosocial and altruistic behaviors, such as receiving vaccination [53]. Moral obligations can also strengthen justifications for vaccination policies [54], thereby further promoting vaccination. This leaning is reflected in the findings, given that a sense of civic responsibility and unwillingness to cause trouble for others were two strong incentives for vaccination in participants willing to receive the vaccine. The participants believed that they had a collective and civic responsibility to not only avoid infection but also to take action (i.e., receive vaccination) to prevent infection and illness and enable society to return to normal. Per Hong Kong’s infection control policy (as of February 2022), people who come into close contact with COVID-19 patients (e.g., family members living in the same household, colleagues working in the same office, or dining partners) must quarantine at the Penny’s Bay Quarantine Centre. Individuals living in the same building as individuals with COVID-19 must also be quarantined, albeit less strictly, and undergo compulsory viral testing. This feeling of collective responsibility therefore serves as an effective measure for containing infection and as a motivator for vaccination. Furthermore, some of the participants perceived vaccination as a means to protect themselves from the moral blame that they could experience if they contracted COVID-19 and caused those around them to undergo quarantine procedures.
The COVID-19 vaccination rate among older adults increased dramatically in 2022 when the fifth wave of COVID-19 hit Hong Kong; 85.25% of those 60–69 years old, 74.16% of those 70–79 years old, and 45.07% of those 80 years old and older have been vaccinated with the first shot as of late February 2022 [23]. This increase in vaccination is due in part to the Hong Kong government’s recent implementation of policies to address the barriers to and enhance the motivators for vaccination at various social levels. For example, support networks for older adults living in residential care premises have been introduced by health care providers (individual-level management). These health care providers provide proactive physical evaluations for these older adults living in residential care premises, which helps increase their trust in health care workers (microsocial level management). Measures to encourage the general public to get vaccinated can also promote a positive atmosphere around vaccination, serving to exert peer pressure on older adults (individual level management). Furthermore, the introduction of the Vaccine Pass on February 24, 2022 [55] enhances peer pressure regarding vaccination (individual level management) and reinforces the idea that receiving COVID-19 vaccination is a civic responsibility (macrosocial level management). These measures to tackle the barriers to and enhance the motivators for vaccination at different social levels of the CMA framework may serve to increase the acceptance of vaccination in the older adult population.
Limitations
These findings should be interpreted with caution, because they are based on interviews with a small sample of older adults (31 participants) who were recruited from two NGOs located in five districts of Hong Kong. Although data saturation was achieved, the findings of this study have limited generalizability and thus cannot represent the older adult populations of other communities. Confidence in the results can be strengthened through follow-up studies involving a greater number of participants recruited from more sites.
Given that the data for this study were collected between November 2020 and February 2021, the rising vaccination rate among older adults seen in 2022, when the fifth wave COVID-19 hit Hong Kong, is not reflected.
