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There are concerns that vaccine hesitancy may impede COVID-19 vaccine rollout and prevent the achievement of herd immunity. Vaccine hesitancy is a delay in acceptance or refusal of vaccines despite their availability.
We aimed to identify which people are more and less likely to take a COVID-19 vaccine and factors associated with vaccine hesitancy to inform public health messaging.
A Canadian cross-sectional survey was conducted in Canada in October and November 2020, prior to the regulatory approval of the COVID-19 vaccines. Vaccine hesitancy was measured by respondents answering the question “what would you do if a COVID-19 vaccine were available to you?” Negative binomial regression was used to identify the factors associated with vaccine hesitancy. Cluster analysis was performed to identify distinct clusters based on intention to take a COVID-19 vaccine, beliefs about COVID-19 and COVID-19 vaccines, and adherence to nonpharmaceutical interventions.
Of 4498 participants, 2876 (63.9%) reported COVID-19 vaccine hesitancy. Vaccine hesitancy was significantly associated with (1) younger age (18-39 years), (2) lower education, and (3) non-Liberal political leaning. Participants that reported vaccine hesitancy were less likely to believe that a COVID-19 vaccine would end the pandemic or that the benefits of a COVID-19 vaccine outweighed the risks. Individuals with vaccine hesitancy had higher prevalence of being concerned about vaccine side effects, lower prevalence of being influenced by peers or health care professionals, and lower prevalence of trust in government institutions.
These findings can be used to inform targeted public health messaging to combat vaccine hesitancy as COVID-19 vaccine administration continues. Messaging related to preventing COVID among friends and family, highlighting the benefits, emphasizing safety and efficacy of COVID-19 vaccination, and ensuring that health care workers are knowledgeable and supported in their vaccination counselling may be effective for vaccine-hesitant populations.
In the fall of 2020, regions of Canada were experiencing a second wave of COVID-19 with rising case counts, hospitalizations, and deaths [
Although there was great optimism about the potential emergence of safe and effective vaccines against SARS-CoV-2, COVID-19 vaccine hesitancy was becoming evident in the summer and fall of 2020 [
Several studies have looked at the risk factors for vaccine hesitancy in populations around the world and have found that many different factors, including sociodemographic variables and concerns about efficacy and safety of COVID-19 vaccines, may contribute to COVID-19 vaccine hesitancy [
In the summer of 2020, we designed a mixed methods study to examine COVID-19 attitudes, beliefs, and behaviors among Canadians with an overreaching goal of informing targeted public health messaging to improve adherence to NPIs and vaccine uptake. We have previously published the initial phases of this mixed methods study including a pilot survey [
Based on the findings from the initial work in our mixed methods study [
We used a cross-sectional survey to assess the attitudes and beliefs about vaccines and vaccine hesitancy among adults aged 18 years or older living in Canada. The survey was administered online by the Angus Reid Institute [
This study was approved by the Conjoint Health Research Ethics Board at the University of Calgary (REB20-1228). Informed consent was obtained from each participant prior to commencing the survey, and participation was voluntary. Responses were deidentified at the time of collection to ensure participant anonymity and privacy. If participants started the survey but did not complete it, it was assumed that consent was withdrawn and their survey responses were not saved. Consistent with Angus Reid Forum policy [
The main outcome measure was vaccine hesitancy. Survey participants were asked what they would do if a COVID-19 vaccine were available to them and given the following 4 options: (1) get a vaccine as soon as possible, (2) eventually get a vaccine, but wait a while first, (3) not get a vaccine, or (4) not sure. Vaccine hesitancy was defined as any of the latter 3 responses consistent with the SAGE Working Group definition of vaccine hesitancy [
We considered factors that could be associated with vaccine hesitancy in each of the domains of the SAGE framework (contextual influences, individual and group influences, and vaccine-specific factors) [
Descriptive statistics (percentage frequencies) were calculated for all participant characteristics, adherence to NPIs, attitudes toward COVID-19 and COVID-19 vaccines, and trusted sources of COVID-19 information. Respondents were excluded if they did not answer all survey questions, and therefore, there were no missing data. Negative binomial regression models were used to estimate crude prevalence ratios (PRs) for factors associated with being vaccine hesitant compared to not being vaccine hesitant. Each PR was reported with the associated 95% CI. We used multiple models to examine the association between vaccine hesitancy and each of the following: (1) sociodemographic characteristics, (2) attitudes toward COVID-19 vaccine, (3) adherence toward NPIs, (4) attitudes toward COVID-19, and (5) trusted sources of COVID-19 information. We also calculated adjusted prevalence ratios (aPRs) by using sociodemographic characteristics identified through a literature search [
To identify data-driven patterns in survey responses with respect to vaccine hesitancy, we used cluster analysis. The cluster analysis was based on intention to take a COVID-19 vaccine, beliefs about COVID-19 and COVID-19 vaccine, and adherence to NPIs. The K-means algorithm was used to partition the data set into distinct clusters. This iterative algorithm assigns observations to a cluster such that within each cluster, the sum of the squared distance between observations and the arithmetic mean of all observations is minimized. Cluster analysis was used to integrate COVID-19 vaccine intention, COVID-19 beliefs, and adherence to NPIs into similar like-minded groupings to identify insights that can be utilized for targeted messaging and interventions. By using several exposures to establish these clusters, we aimed to create clusters with greater similarity in motivations and attitudes for vaccine intention and gain a deeper understanding of vaccine hesitancy. Negative binomial regression was used to estimate crude PRs and 95% CI comparing sociodemographic characteristics between each of the clusters with cluster 2 as the reference. Analyses were conducted using STATA Version 15.1 (Stata Corp). A
Of the 14,887 survey invitations distributed, 5893 (39.6%) invitations were accepted in the 7 days the survey was available. Of those, 4498 (76.3%) participants completed the survey and were included in the analysis (
Participant characteristics and association with COVID-19 vaccine hesitancy in October to November 2020 (N=4498).
Characteristic | Total, n (%) | Vaccine hesitancy, n (%) | Prevalence ratioa (95% CI) | Adjusted prevalence ratiob (95% CI) | |||||||||
No | Yes |
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Participants | 4498 (100) | 1622 (36.1) | 2876 (63.9) | N/Ac | N/A | ||||||||
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Female | 2294 (51) | 815 (35.5) | 1479 (64.5) | Refd | Ref | |||||||
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Male | 2204 (49) | 807 (36.6) | 1397 (63.4) | 0.98 (0.91-1.06) | 0.93 (0.86-1.01) | |||||||
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18-34 | 1341 (29.8) | 505 (37.7) | 836 (62.3) | Ref | Ref | |||||||
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35-54 | 1585 (35.2) | 504 (31.8) | 1081 (68.2) | 1.09 (1.00-1.20) | 1.04 (0.95-1.14) | |||||||
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55+ | 1572 (35) | 613 (39) | 959 (61) | 0.98 (0.89-1.07) | 0.90 (0.82-0.99) | |||||||
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Alberta | 1998 (44.4) | 672 (33.6) | 1326 (65.4) | Ref | Ref | |||||||
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British Columbia | 502 (11.2) | 176 (35.1) | 326 (64.9) | 0.98 (0.87-1.10) | 1.04 (0.92-1.17) | |||||||
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Prairie provincese | 445 (9.9) | 156 (35.1) | 259 (58.2) | 0.98 (0.76-1.11) | 0.95 (0.84-1.08) | |||||||
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Ontario | 800 (17.8) | 311 (38.9) | 489 (61.1) | 0.92 (0.83-1.02) | 0.96 (0.87-1.07) | |||||||
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Quebec | 502 (11.2) | 203 (40.4) | 299 (59.6) | 0.90 (0.79-1.02) | 0.97 (0.85-1.10) | |||||||
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Atlantic provincese | 251 (5.6) | 104 (41.4) | 147 (58.6) | 0.88 (0.74-1.05) | 0.95 (0.80-1.13) | |||||||
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<$50,000 | 1030 (22.9) | 342 (33.2) | 688 (66.8) | Ref | Ref | |||||||
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$50,000-$99,999 | 1353 (30.1) | 486 (35.9) | 867 (64.1) | 0.96 (0.87-1.06) | 0.97 (0.88-1.08) | |||||||
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$100,000-$199,999 | 1300 (28.9) | 511 (39.3) | 789 (60.7) | 0.91 (0.82-1.01) | 0.93 (0.84-1.04) | |||||||
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≥$200,000 | 229 (5.1) | 102 (44.5) | 127 (55.5) | 0.83 (0.69-1.00) | 0.85 (0.70-1.03) | |||||||
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Rather not say | 586 (13) | 181 (30.9) | 405 (69.1) | 1.03 (0.92-1.17) | 1.02 (0.90-1.15) | |||||||
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High school graduate or less | 897 (19.9) | 256 (28.5) | 641 (71.5) | Ref | Ref | |||||||
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Some college or trade school | 840 (18.7) | 240 (28.6) | 600 (71.4) | 1.00 (0.89-1.12) | 1.01 (0.90-1.13) | |||||||
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College or trade school | 996 (22.1) | 301 (30.2) | 695 (69.8) | 0.98 (0.88-1.09) | 0.98 (0.88-1.10) | |||||||
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Some university | 454 (10.1) | 185 (40.7) | 269 (59.3) | 0.83 (0.72-0.96) | 0.85 (0.73-0.97) | |||||||
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University degree | 1311 (29.1) | 640 (48.8) | 671 (51.2) | 0.72 (0.64-0.80) | 0.73 (0.65-0.81) | |||||||
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Caucasian | 3862 (85.9) | 1430 (37) | 2432 (63) | Ref | Ref | |||||||
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Indigenous/First Nations/Metis/Inuit | 228 (5) | 68 (29.8) | 160 (70.2) | 1.11 (0.95-1.31) | 1.09 (0.93-1.27) | |||||||
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Asian | 193 (4.3) | 65 (33.7) | 128 (66.3) | 1.05 (0.88-1.26) | 1.15 (0.96-1.37) | |||||||
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Caribbean/African/South American | 70 (1.6) | 19 (27.1) | 51 (72.9) | 1.16 (0.88-1.53) | 1.16 (0.88-1.54) | |||||||
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Other | 145 (3.2) | 40 (27.6) | 105 (72.4) | 1.15 (0.95-1.40) | 1.10 (0.91-1.34) | |||||||
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Liberal | 1841 (40.9) | 936 (50.8) | 905 (49.2) | 0.73 (0.66-0.80) | 0.74 (0.67-0.82) | |||||||
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Moderate/middle of the road | 1029 (22.9) | 334 (32.5) | 695 (67.5) | Ref | Ref | |||||||
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Conservative | 1628 (36.2) | 352 (21.6) | 1276 (78.4) | 1.16 (1.06-1.27) | 1.18 (1.07-1.29) |
aPrevalence ratio is the prevalence of vaccine hesitancy compared with the prevalence of planning to take a COVID-19 vaccine.
bAdjusted for sex, age, province of residence, household income, education level, ethnicity, and political leaning.
cN/A: not applicable.
dRef: reference value.
ePrairie provinces include Saskatchewan and Manitoba; Atlantic provinces include Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador.
fCAD $1=US $0.75.
Participant demographic and socioeconomic characteristics are presented in
More than half of the participants (2501/4498, 55.6%) felt that the benefits of taking a vaccine outweigh its risks, while 969 (22%) were unsure and 1028 (22%) disagreed (
Associations between COVID-19 vaccine hesitancy and attitudes toward COVID-19 vaccines in October to November 2020 (N=4498).
|
Total, n (%) | Vaccine hesitancy, n (%) | Prevalence ratioa (95% CI) | Adjusted prevalence ratiob (95% CI) | |||||||||
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No | Yes |
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Participants | 4498 (100) | 1622 (36.1) | 2876 (63.9) | N/Ac | N/A | ||||||||
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Agree | 3293 (73.2) | 1603 (48.7) | 1690 (51.3) | Refd | Ref | ||||||
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Disagree | 810 (18) | 17 (2.1) | 793 (97.9) | 1.91 (1.75-2.08) | 1.77 (1.62-1.94) | ||||||
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Not sure | 395 (8.8) | 2 (0.5) | 393 (99.5) | 1.94 (1.74-2.16) | 1.85 (1.66-2.07) | ||||||
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Agree | 1265 (28.1) | 691 (54.6) | 574 (45.4) | Ref | Ref | ||||||
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Disagree | 2214 (49.2) | 587 (26.5) | 1627 (73.5) | 1.62 (1.47-1.78) | 1.54 (1.40-1.70) | ||||||
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Not sure | 1019 (22.7) | 344 (33.8) | 675 (66.2) | 1.46 (1.31-1.63) | 1.43 (1.28-1.61) | ||||||
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Agree | 2523 (56.1) | 1301 (51.6) | 1222 (48.4) | Ref | Ref | ||||||
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Disagree | 1901 (42.3) | 301 (15.8) | 1600 (84.2) | 1.74 (1.61-1.87) | 1.67 (1.55-1.80) | ||||||
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Not Sure | 74 (1.6) | 20 (27) | 54 (73) | 1.51 (1.15-1.98) | 1.50 (1.14-1.97) | ||||||
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Agree | 2583 (57.4) | 533 (20.6) | 2050 (79.4) | Ref | Ref | ||||||
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Disagree | 1443 (32.1) | 922 (63.9) | 521 (36.1) | 0.45 (0.41-0.50) | 0.47 (0.43-0.52) | ||||||
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Not Sure | 472 (10.5) | 167 (35.4) | 305 (64.6) | 0.81 (0.72-0.92) | 0.83 (0.73-0.93) | ||||||
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Agree | 2703 (60.1) | 542 (20.1) | 2161 (79.9) | Ref | Ref | ||||||
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Disagree | 1294 (28.8) | 881 (68.1) | 413 (31.9) | 0.40 (0.36-0.44) | 0.42 (0.38-0.46) | ||||||
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Not sure | 501 (11.1) | 199 (39.7) | 302 (60.3) | 0.75 (0.67-0.85) | 0.78 (0.69-0.88) | ||||||
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Agree | 1985 (44.1) | 162 (8.2) | 1823 (91.8) | Ref | Ref | ||||||
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Disagree | 1874 (41.7) | 1248 (66.6) | 626 (33.4) | 0.36 (0.33-0.40) | 0.38 (0.35-0.42) | ||||||
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Not sure | 639 (14.2) | 212 (33.2) | 427 (66.8) | 0.73 (0.65-0.81) | 0.75 (0.67-0.83) | ||||||
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Agree | 2501 (55.6) | 1457 (58.3) | 1044 (41.7) | Ref | Ref | ||||||
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Disagree | 1028 (22.9) | 40 (3.9) | 988 (96.1) | 2.30 (2.11-2.51) | 2.17 (1.98-2.38) | ||||||
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Not sure | 969 (21.5) | 125 (12.9) | 844 (87.1) | 2.09 (1.91-2.28) | 2.02 (1.85-2.22) | ||||||
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Agree | 1681 (37.4) | 745 (44.3) | 936 (55.7) | Ref | Ref | ||||||
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Disagree | 2296 (51) | 717 (31.2) | 1579 (68.8) | 1.24 (1.14-1.34) | 1.17 (1.08-1.27) | ||||||
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Not sure | 521 (11.6) | 160 (30.7) | 361 (69.3) | 1.24 (1.10-1.41) | 1.21 (1.07-1.37) | ||||||
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Agree | 2775 (61.7) | 1422 (51.2) | 1353 (48.8) | Ref | Ref | ||||||
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Disagree | 1319 (29.3) | 131 (10) | 1188 (90.1) | 1.85 (1.71-2.00) | 1.73 (1.59-1.87) | ||||||
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Not sure | 404 (9) | 69 (17.1) | 335 (82.9) | 1.70 (1.51-1.92) | 1.65 (1.46-1.86) |
aPrevalence ratio is the prevalence of vaccine hesitancy compared with the prevalence of planning to take a COVID-19 vaccine.
bAdjusted for sex, age, province of residence, household income, education level, ethnicity, and political leaning.
cN/A: not applicable.
dRef: reference value.
Those who disagreed had higher prevalence of vaccine hesitancy compared with those who agreed (aPR 2.17, 95% CI 1.98-2.38;
Participants reported that they would be more likely to take a COVID-19 vaccine if it was recommended by a family doctor, pharmacist, or public health nurse (2775/4498, 61.7%) or if their friends or family took a vaccine (1681/4498, 37.4%). However, the prevalence of vaccine hesitancy was higher in participants who disagreed that they would take a vaccine if their friends/family do (aPR 1.17, 95% CI 1.08-1.27) or if it was recommended by a family doctor, pharmacist, or public health nurse (aPR 1.73, 95% CI 1.59-1.87). Numerous participants (3293/4498, 73.2%) said they would take a COVID-19 vaccine to protect their family; participants who disagreed with this statement had a higher prevalence of vaccine hesitancy compared with those who agreed (aPR 1.77, 95% CI 1.62-1.94). Many participants were concerned about the short-term side effects (2583/4498, 57.4%) and long-term side effects (2703/4498, 60.1%). Participants (1874/4498, 41.7%) who disagreed with the statement that vaccines were developed too fast had a lower prevalence of vaccine hesitancy compared with those who agreed (aPR 0.38, 95% CI 0.35-0.42).
The majority of the participants reported physical distancing (3782/4498, 84.1%), wearing face masks (3873/4498, 86.1%), avoiding crowded spaces (3517/4498, 78.2%), and staying home when sick (3857/4498, 85.7%) all or most of the time (
Associations between COVID-19 vaccine hesitancy, adherence to public health measures, and attitudes toward COVID-19 in October to November 2020 (N=4498).
Characteristic | Total, n (%) | Vaccine hesitancy, n (%) | Prevalence ratioa (95% CI) | Adjusted prevalence ratiob (95% CI) | |||
No | Yes | ||||||
Participants | 4498 (100) | 1622 (36.1) | 2876 (63.9) | N/Ac | N/A | ||
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All the time/most of the time | 3777 (84) | 1523 (40.3) | 2254 (69.7) | Refd | Ref |
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Sometimes | 457 (10.2) | 68 (14.9) | 389 (85.1) | 1.43 (1.28-1.59) | 1.32 (1.18-1.48) |
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Rarely/never | 264 (5.8) | 31 (11.7) | 233 (88.3) | 1.48 (1.29-1.69) | 1.31 (1.13-1.50) |
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All the time/most of the time | 3868 (86) | 1566 (40.5) | 2302 (69.5) | Ref | Ref |
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Sometimes | 274 (6.1) | 36 (13.1) | 238 (86.9) | 1.46 (1.28-1.67) | 1.34 (1.16-1.54) |
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Rarely/never | 356 (7.9) | 20 (5.6) | 336 (94.4) | 1.59 (1.41-1.78) | 1.38 (1.22-1.56) |
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All the time/most of the time | 3513 (78.1) | 1434 (40.8) | 2079 (59.2) | Ref | Ref |
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Sometimes | 457 (10.2) | 129 (28.2) | 328 (71.8) | 1.21 (1.08-1.36) | 1.16 (1.03-1.31) |
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Rarely/never | 528 (11.7) | 59 (11.2) | 469 (88.8) | 1.50 (1.36-1.66) | 1.35 (1.21-1.50) |
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All the time/most of the time | 3852 (85.6) | 1505 (39.1) | 2347 (60.9) | Ref | Ref |
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Sometimes | 232 (5.2) | 47 (20.3) | 185 (79.7) | 1.31 (1.13-1.52) | 1.22 (1.05-1.42) |
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Rarely/Never | 414 (9.2) | 70 (16.9) | 344 (83.1) | 1.36 (1.22-1.53) | 1.27 (1.13-1.42) |
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No | 4385 (97.5) | 1583 (36.1) | 2802 (63.9) | Ref | Ref |
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Yes | 113 (2.5) | 39 (34.5) | 74 (65.5) | 1.02 (0.81-1.29) | 1.05 (0.83-1.32) |
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No | 3162 (70.3) | 1101 (34.8) | 2061 (65.2) | Ref | Ref |
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Yes | 1336 (29.7) | 521 (39) | 815 (61) | 0.94 (0.86-1.01) | 0.98 (0.90-1.06) |
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Mild or no symptoms | 1085 (24.1) | 201 (18.5) | 884 (81.5) | Ref | Ref |
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Manageable symptoms | 1940 (43.1) | 747 (38.5) | 1193 (61.5) | 0.75 (0.69-0.82) | 0.80 (0.73-0.86) |
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Severe symptoms | 1026 (22.8) | 452 (44.1) | 574 (55.9) | 0.69 (0.62-0.76) | 0.73 (0.66-0.82) |
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Possible death | 447 (9.9) | 222 (49.7) | 225 (50.3) | 0.62 (0.53-0.72) | 0.65 (0.56-0.76) |
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Not concerned | 1204 (26.8) | 165 (13.7) | 1039 (86.3) | Ref | Ref |
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Concerned | 3294 (73.2) | 1457 (44.2) | 1837 (55.8) | 0.65 (0.60-0.70) | 0.70 (0.64-0.76) |
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No | 2649 (58.9) | 874 (33) | 1775 (67) | Ref | Ref |
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Yes | 1849 (41.1) | 748 (40.5) | 1101 (59.5) | 0.89 (0.82-0.96) | 0.89 (0.83-0.97) |
aPrevalence ratio is the prevalence of vaccine hesitancy compared with the prevalence of planning to take a COVID-19 vaccine.
bAdjusted for sex, age, province of residence, household income, education level, ethnicity, and political leaning.
cN/A: not applicable.
dRef: reference value.
A small proportion of participants had tested positive for COVID-19 (113/4498, 3%) and almost one-third (1336/4498, 29.7%) knew someone who had tested positive for COVID-19 (
Participants who trusted chief medical officers of health (aPR 0.54, 95% CI 0.47-0.61) and public health websites (aPR 0.68, 95% CI 0.59-0.77) had lower prevalence of vaccine hesitancy compared with participants who did not (
Associations between COVID-19 vaccine hesitancy, trusted sources of COVID-19 information, and trust in institutions in October to November 2020 (N=4498)a.
Sources | Total (N) | Vaccine hesitancy, n (%) | Prevalence ratiob (95% CI) | Adjusted prevalence ratioc (95% CI) | |||||
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No | Yes |
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Chief Medical Officer of Health | 1933 | 904 (46.8) | 1029 (53.2) | 0.76 (0.70-0.82) | 0.80 (0.73-0.86) | |||
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Public health websites | 1754 | 778 (44.4) | 976 (55.6) | 0.83 (0.77-0.90) | 0.86 (0.80-0.94) | |||
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Health care provider | 1239 | 514 (41.5) | 725 (58.5) | 0.91 (0.84-1.00) | 0.93 (0.85-1.01) | |||
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Television/radio news | 607 | 233 (38.4) | 374 (61.6) | 0.98 (0.88-1.10) | 0.96 (0.86-1.07) | |||
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Internet searches (eg, Google) | 529 | 81 (15.3) | 448 (84.7) | 1.43 (1.29-1.58) | 1.34 (1.21-1.49) | |||
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Friends and family | 159 | 33 (20.8) | 126 (79.2) | 1.28 (1.07-1.53) | 1.16 (0.97-1.39) | |||
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Print newspaper | 134 | 55 (41) | 79 (59) | 0.94 (0.75-1.18) | 0.96 (0.77-1.21) | |||
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2167 | 778 (35.9) | 1389 (64.1) | 1.00 (0.93-1.08) | 0.98 (0.91-1.06) | ||||
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YouTube | 976 | 297 (30.4) | 679 (69.6) | 1.12 (1.02-1.22) | 1.08 (0.99-1.17) | |||
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797 | 342 (42.9) | 455 (57.1) | 0.87 (0.79-0.96) | 0.91 (0.82-1.00) | ||||
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450 | 144 (32) | 396 (88) | 1.07 (0.95-1.21) | 1.09 (0.96-1.22) | ||||
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407 | 196 (48.2) | 211 (51.8) | 0.79 (0.69-0.91) | 0.84 (0.72-0.97) | ||||
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Trust | 3370 | 1440 (42.7) | 1930 (57.3) | Refd | Ref | ||
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Neutral | 828 | 154 (18.6) | 674 (81.4) | 1.42 (1.30-1.55) | 1.33 (1.22-1.45) | ||
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Do not trust | 300 | 28 (9.3) | 272 (90.7) | 1.58 (1.39-1.80) | 1.43 (1.25-1.62) | ||
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Trust | 1401 | 744 (53.1) | 657 (46.9) | Ref | Ref | ||
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Neutral | 1414 | 569 (40.2) | 845 (59.8) | 1.27 (1.15-1.41) | 1.24 (1.12-1.38) | ||
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Do not trust | 1683 | 309 (18.4) | 1374 (81.6) | 1.74 (1.59-1.91) | 1.61 (1.46-1.78) | ||
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Trust | 579 | 261 (45.1) | 318 (54.9) | Ref | Ref | ||
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Neutral | 1707 | 648 (38) | 1059 (62) | 1.13 (1.00-1.28) | 1.15 (1.01-1.30) | ||
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Do not trust | 2212 | 713 (32.2) | 1499 (67.8) | 1.23 (1.09-1.39) | 1.22 (1.08-1.38) | ||
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Trust | 1325 | 537 (40.5) | 788 (59.5) | Ref | Ref | ||
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Neutral | 1824 | 641 (35.1) | 1183 (64.9) | 1.09 (1.00-1.19) | 1.09 (0.99-1.19) | ||
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Do not trust | 1349 | 444 (32.9) | 905 (67.1) | 1.12 (1.03-1.24) | 1.14 (1.03-1.25) |
aParticipants could pick more than one most trusted source from each list.
bPrevalence ratio is the prevalence of vaccine hesitancy compared with the prevalence of planning to take a COVID-19 vaccine.
cAdjusted for sex, age, province of residence, household income, education level, ethnicity, and political leaning.
dRef: reference value.
Three distinct nonoverlapping clusters were identified through cluster analysis (
Willingness of the survey participants, by cluster, to take the COVID-19 vaccine when available.
Participant characteristics by cluster (N=4498) in October to November 2020.
Characteristic | Total, n (%) | Cluster, n (%) | Prevalence ratioa (95% CI) | |||||||||||
Cluster 1: |
Cluster 2: Waiting | Cluster 3: Not |
Cluster 1 versus Cluster 2 | Cluster 3 versus Cluster 2 | ||||||||||
Participants | 4498 (100) | 1652 (36.7) | 2099 (46.7) | 747 (16.6) | N/Ab | N/A | ||||||||
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Female | 2294 (51) | 837 (36.5) | 1171 (51) | 286 (12.5) | Refc | Ref | |||||||
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Male | 2204 (49) | 815 (37) | 928 (42.1) | 461 (20.9) | 1.12 (1.02-1.24) | 1.69 (1.46-1.96) | |||||||
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18-34 | 1341 (29.8) | 511 (38.1) | 621 (46.3) | 209 (15.6) | Ref | Ref | |||||||
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35-54 | 1585 (35.2) | 516 (32.5) | 741 (46.8) | 328 (20.7) | 0.91 (0.80-1.03) | 1.22 (1.02-1.45) | |||||||
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55+ | 1572 (34.9) | 625 (39.8) | 737 (46.9) | 210 (13.3) | 1.02 (0.890-1.14) | 0.88 (0.73-1.06) | |||||||
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Alberta | 1998 (44.4) | 684 (34.2) | 836 (41.8) | 478 (23.9) | Ref | Ref | |||||||
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British Columbia | 502 (11.2) | 185 (36.9) | 273 (54.4) | 44 (8.8) | 0.90 (0.76-1.06) | 0.38 (0.28-0.52) | |||||||
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Prairie provincesd | 445 (9.9) | 158 (35.5) | 215 (48.3) | 72 (16.2) | 0.94 (0.79-1.12) | 0.69 (0.54-0.88) | |||||||
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Ontario | 800 (17.8) | 318 (39.7) | 404 (50.5) | 78 (9.8) | 0.98 (0.86-1.12) | 0.44 (0.35-0.57) | |||||||
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Quebec | 502 (11.2) | 202 (40.2) | 250 (49.8) | 50 (10) | 0.99 (0.85-1.16) | 0.46 (0.34-0.61) | |||||||
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Atlantic provincesd | 251 (5.6) | 105 (41.8) | 121 (48.2) | 25 (10) | 1.03 (0.84-1.27) | 0.47 (0.31-0.70) | |||||||
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<$50,000 | 1030 (22.9) | 341 (33.1) | 532 (51.7) | 157 (15.2) | Ref | Ref | |||||||
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$50,000-$99,999 | 1353 (30.1) | 489 (36.1) | 644 (47.6) | 220 (16.3) | 1.10 (0.96-1.27) | 1.12 (0.91-1.37) | |||||||
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$100,000-$199,999 | 1300 (28.9) | 532 (40.9) | 559 (43) | 209 (16.1) | 1.25 (1.09-1.43) | 1.19 (0.97-1.47) | |||||||
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≥$200,000 | 229 (5.1) | 100 (43.7) | 87 (38) | 42 (18.3) | 1.37 (1.10-1.71) | 1.43 (1.02-2.01) | |||||||
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Rather not say | 586 (13) | 190 (32.4) | 277 (47.3) | 119 (20.3) | 1.04 (0.87-1.24) | 1.32 (1.04-1.67) | |||||||
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High school graduate or less | 897 (19.9) | 262 (29.2) | 433 (48.3) | 202 (22.5) | Ref | Ref | |||||||
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Some college or trade school | 840 (18.7) | 240 (28.6) | 421 (50.1) | 179 (21.3) | 0.96 (0.81-1.15) | 0.94 (0.77-1.15) | |||||||
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College or trade school | 996 (22.1) | 304 (30.5) | 491 (49.3) | 201 (20.2) | 1.01 (0.86-1.20) | 0.91 (0.75-1.11) | |||||||
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Some university | 454 (10.1) | 190 (41.8) | 197 (43.4) | 67 (14.8) | 1.30 (1.08-1.57) | 0.80 (0.61-1.05) | |||||||
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University degree | 1311 (29.2) | 656 (50) | 557 (42.5) | 98 (7.5) | 1.43 (1.24-1.66) | 0.47 (0.37-0.60) | |||||||
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Caucasian | 3862 (85.9) | 1455 (37.7) | 1765 (45.7) | 642 (16.6) | Ref | Ref | |||||||
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Indigenous/First Nations/Metis/Inuit | 228 (5.1) | 71 (31.1) | 107 (46.9) | 50 (21.9) | 0.88 (0.70-1.12) | 1.19 (0.90-1.59) | |||||||
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Asian | 193 (4.3) | 67 (34.7) | 115 (59.6) | 11 (5.7) | 0.81 (0.64-1.04) | 0.33 (0.18-0.59) | |||||||
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Caribbean/African/South American | 70 (1.5) | 16 (22.9) | 43 (61.4) | 11 (15.7) | 0.60 (0.37-0.98) | 0.76 (0.42-1.39) | |||||||
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Other | 145 (3.2) | 43 (29.6) | 69 (47.6) | 33 (22.8) | 0.85 (0.63-1.15) | 1.21 (0.85-1.72) | |||||||
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Liberal | 1841 (40.9) | 971 (52.7) | 821 (44.6) | 49 (2.7) | 1.48 (1.30-1.68) | 0.29 (0.21-0.40) | |||||||
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Moderate/middle of the road | 1029 (22.9) | 327 (31.8) | 565 (54.9) | 137 (13.3) | Ref | Ref | |||||||
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Conservative | 1628 (36.2) | 354 (21.7) | 713 (43.8) | 561 (34.5) | 0.91 (0.78-1.05) | 2.26 (1.87-2.72) |
aDetermined using negative binomial regression.
bN/A: not applicable.
cRef: reference value.
dPrairie provinces include Saskatchewan and Manitoba; Atlantic provinces include Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador.
eCAD $1=US $0.75.
Compared with participants in Cluster 2 (the vaccine waiting and NPI-accepting cluster), participants in Cluster 3 (the vaccine and NPI nonaccepting cluster) were more likely to be male (PR 1.69, 95% CI 1.46-1.96), 35-54 years of age (PR 1.22, 95% CI 1.02-1.45), have a household income of CAD $200,000 (USD $150,200; CAD $1=US $0.75) or more (PR 1.32, 95% CI 1.04-1.67), and report a conservative political leaning (PR 2.26, 95% CI 1.87-2.72). Participants in Cluster 1 (the vaccine and NPI-accepting cluster) were more likely to be Liberal leaning (PR 1.48, 95% CI 1.30-1.68), have some university education (PR 1.30, 95% CI 1.08-1.57), or a university degree (PR 1.43, 95% CI 1.24-1.66), have an annual household income of CAD $100,000-$199,999 (PR 1.25, 95% CI 1.09-1.43) or CAD $200,000 or more (PR 1.37, 95% CI 1.10-1.71), and male (PR 1.12, 95% CI 1.02-1.24) compared with participants in Cluster 2 (the vaccine-waiting and NPI-accepting cluster).
In this national cross-sectional survey completed in the fall of 2020 prior to the approval of COVID-19 vaccines in Canada, we found that 63.9% (2876/4498) of the participants reported COVID-19 vaccine hesitancy, ranging from delaying vaccine administration when offered to not planning to take a vaccine. Vaccine hesitancy was associated with several sociodemographic factors including (1) younger age (18-39 years), (2) lower education, and (3) non-Liberal political leaning. Participants who reported vaccine hesitancy had higher prevalence of reporting being concerned about vaccine side effects, did not believe that a COVID-19 vaccine would end the pandemic or that the benefits of a COVID-19 vaccine outweighed the risks, and had lower prevalence of reporting being influenced by peers or health care professionals. We identified 3 distinct participant clusters: (1) participants who reported adherence to NPIs and did not have vaccine hesitancy, (2) individuals who reported adherence to NPIs but did have vaccine hesitancy, and (3) individuals who reported less adherence to NPIs and vaccine hesitancy.
The 3 distinct clusters of vaccine acceptance can inform targeted vaccination campaign messaging in a novel way by directing messages to address cluster-specific concerns with respect to vaccine hesitancy. The majority of the participants in Cluster 2 (the vaccine waiting and NPI-accepting cluster) planned to delay taking a vaccine when offered, while the majority in Cluster 3 (the vaccine and NPI nonaccepting cluster) did not intend to take a vaccine at all. Messaging related to preventing COVID among friends and family, highlighting the benefits, and ensuring health care workers are knowledgeable and supported in their vaccine counselling may be more helpful for those in Cluster 2 relative to those in Cluster 3. Participants in Cluster 3 were more likely to be male, 35-54 years of age, have an annual household income of CAD $200,000 or more, report Conservative political leaning, and live in Alberta compared with participants in Cluster 2. The characteristics of Cluster 3 are consistent with current trends in vaccine uptake in that less uptake has been seen among Albertans, males, and individuals aged 18 to 59 years as of October 23, 2021 [
As of October 27, 2021, more than 1,700,000 Canadians have been infected with COVID-19 and more than 28,000 Canadians have died [
While there has been a decrease in vaccine hesitancy over time, many of the underlying predictors of hesitancy have remained stable over time [
We did not find an association between ethnicity and COVID-19 vaccine hesitancy, although an association has been reported in several other studies [
The influences of COVID-19 vaccine characteristics and administration of COVID-19 vaccines on vaccine hesitancy are unique compared to annual influenza campaigns or childhood immunization schedules. In response to the COVID-19 pandemic, the scientific community has come together to develop safe and effective vaccines [
Trust in government has been identified as a factor associated with acceptance of a COVID-19 vaccine [
The major limitation of this cross-sectional study was that it represents one snapshot in time in the fall of 2020 prior to the approval of COVID-19 vaccines in Canada and as the country was entering the second wave of the pandemic; therefore, the responses provided by participants at that time have evolved. The survey recruited participants from an existing voluntary nationwide panel designed to be representative of the Canadian population; however, by using a panel, there will be a component of selection bias as participants have volunteered to partake in research surveys through an electronic platform, which may lead to increased selection of individuals with higher socioeconomic status or education level leading to an underestimation of vaccine hesitancy. We included all provinces and territories in our sampling strata; however, we did oversample Alberta, which could lead to bias in the results and make these findings less generalizable to the Canadian population. To minimize this bias, province of residence was included in all adjusted analyses. Response bias should also be considered as individuals who chose to respond to the web-based survey may differ systematically from those who chose not to respond.
COVID-19 vaccines are an important tool in the fight against the COVID-19 pandemic; yet, vaccine hesitancy is a concern. We have identified population segments that are associated with vaccine hesitancy (eg, younger age, lower education level) that can be targeted with public health messaging as well as attitudes toward COVID-19, COVID-19 vaccines, and NPIs that can inform messaging content. Effectively addressing vaccine hesitancy is important to increase vaccine uptake.
Survey questions.
Cluster analysis.
adjusted prevalence ratio
nonpharmacologic intervention
prevalence ratio
Strategic Advisory Group of Experts
Strengthening Reporting of Observational Studies in Epidemiology
This study was funded by a COVID-19 Rapid Response Funding Grant from Alberta Innovates (grant 202100489).
JLB, RL, OA, BS, HS, MM, MMF, TT, BJM, DAM, JH, and RJO were all involved in study design. RL, JLB, BS, HS, MM, MMF, TT, BJM, DAM, JH, and RJO developed the survey. JLB, OA, BS, and RJO performed the analysis. JLB, OA, and RL wrote the initial draft of the paper. All authors reviewed the final manuscript.
None declared.