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Recent concerns have been raised about waning protection against coronavirus disease 2019 (COVID-19) after completing the two-dose primary vaccination series (1). Cancer patients have been found to have higher mortality from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) than the general population, but only 52% [95% confidence interval (CI): 35%–70%] of this population were willing to accept the COVID-19 vaccine (2). To date, no study has evaluated the hesitancy of cancer patients to receive the booster doses of the COVID-19 vaccines in China. A multicenter cross-sectional study was conducted in four Chinese cities. Medical staff approached all cancer inpatients aged 18 years or above, and 893 patients completed a face-to-face interview. This study was based on a sub-sample of 525 participants who completed the primary vaccination series. Logistic regression models were fitted to identify the factors associated with vaccine hesitancy. Among the participants, 32.0% and 56.4% were hesitant to receive the first and second COVID-19 vaccine booster doses. Positive attitudes, perceived support from significant others and perceived behavioral control related to the booster dose, higher exposure to COVID-19 vaccination information, and thoughtful consideration about the veracity of COVID-19-specific information were associated with lower hesitancy to receive the booster doses. Vaccination fatigue was positively associated with vaccine hesitancy. Cancer patients in China were more hesitant than the general population to receive COVID-19 vaccine booster doses. Health sectors should advocate the benefits of vaccination with COVID-19 booster doses to cancer patients, which would improve the coverage and promote health.
In Chinese mainland, the National Guideline recommends a third dose of COVID-19 vaccine as a booster for cancer patients six months after completing the two-dose primary vaccination series (3). Many cancer patients may be hesitant to receive the booster doses. A previous study identified some factors associated with hesitancy to complete the primary vaccination series among cancer patients (4). Vaccine fatigue, which is defined as people’s inaction towards vaccine instruction due to perceived burden and burnout (5), could be a factor in this hesitancy. Thoughtful consideration of the veracity of the information may mitigate the negative impact of misinformation related to COVID-19 and COVID-19 vaccination. This study examined the effects of sociodemographics, cancer-related characteristics, perceptions, vaccine fatigue, and media influences associated with vaccine hesitancy.
This was a multicenter, cross-sectional study of cancer patients in four Chinese cities from four Provincial Level Administrative Divisions (PLADs) (Changzhi, Hohhot, Urumqi, and Shenzhen) conducted between May and June 2022. All study sites adhered to the national guideline and recommended a third dose of the COVID-19 vaccine as a booster for cancer patients (3).
Participants of the original study were included if they met the following criteria: 1) cancer patients who were hospitalized in the four participating hospitals during the study period, 2) aged 18 years or above, and 3) willing to provide written informed consent to complete the survey. Exclusion criteria included: 1) critical illness or intensive care unit admission, 2) a diagnosis of lymphoma, leukemia, mental illness, or taking medication for mental illness, or 3) dementia or inability to communicate effectively with the investigators. Medical staff from the selected hospitals approached all cancer inpatients, screened their eligibility, briefed them about the study, and invited them to participate in a face-to-face interview. No incentives were provided. The data collection procedures are shown in Figure 1. Ethics approval was obtained from the Institutional Review Board of Changzhi Medical College (reference: RT2022027).
Figure 1.The data collection procedures of this study.
Participants reported sociodemographic information, and medical staff extracted cancer-related characteristics and presence of other chronic diseases from medical records. We first asked whether participants had received the first booster dose, and for those who had not, we further asked their likelihood of receiving it (response categories: 1=very unlikely, 2=unlikely, 3=neutral, 4=likely, and 5=very likely). Since China has not yet provided the second booster dose, we asked all participants their likelihood of receiving it if it is available (response categories: 1=very unlikely, 2=unlikely, 3=neutral, 4=likely, and 5=very likely). Vaccine hesitancy was defined as “very unlikely,” “unlikely,” or “neutral.” We used the Theory of Planned Behavior (TPB) to measure perceptions related to COVID-19 vaccine booster dose (6). We used the 3-item Positive Attitude Scale and modified the 5-item Negative Attitude Scale, both of which were validated in older Chinese adults (7). In addition, perceived subjective norm and perceived behavioral control were measured by two single-item scales validated in the Chinese population (8). Vaccine fatigue was measured by a single item (“You are tired of receiving COVID-19 vaccination over and over again”). We adopted four items validated in the Chinese population to measure media influences related to COVID-19 and COVID-19 vaccination (8). A validated single item assessed the frequency of thoughtful consideration about the veracity of COVID-19 specific information. The Cronbach’s alpha of the Positive Attitude Scale, Negative Attitude Scale, and the Media Exposure Scale was 0.90, 0.84, and 0.90, respectively.
Frequency distributions of all variables were measured, and the mean and standard deviation (SD) of the scale and item scores were presented. Reliability tests were used to obtain the Cronbach's alpha for the scales. Hesitancy to receive the first and second COVID-19 vaccine booster doses were used as dependent variables, and univariate logistic regression models were used to examine significant associations between background characteristics and dependent variables. Perceptions, vaccine fatigue, and media influence were used as independent variables, and associations between one of these independent variables and the dependent variables with adjustments for significant background characteristics were assessed using adjusted odds ratios (AORs) and their corresponding CIs. There were no missing values for the participants who completed the primary vaccination series. Data analysis was conducted using IBM SPSS Statistics (version 26.0, IBM Corp., Armonk, NY, USA) and P<0.05 was considered statistically significant.
A total of 893 participants provided written informed consent and completed the interview. Of the 525 eligible cancer patients who completed primary COVID-19 vaccination, 41.8% were over 60 years old and 55.8% were male. The most common type of cancer was lung cancer (20.8%), followed by colorectal cancer (18.5%), and 6.7% had metastatic cancers. Most participants (93.0%) were under cancer treatment. In addition to cancers, 21.5% had at least one other chronic disease (Table 1). Of the participants, 49.9% had received the first COVID-19 booster dose. Of those who had not yet received the first booster dose, 36.1% intended to get vaccinated. The prevalence of hesitancy to receive the first and the second booster doses was 32.0% and 56.4%, respectively (
Supplementary Table S1 ).Background characteristic No. of participants Percentage (%) Sociodemographic characteristics Age group in years 18–45 87 16.6 46–60 219 41.7 61–75 194 37.0 >75 25 4.8 Gender Male 293 55.8 Female 232 44.2 Ethnicity Han majority 426 81.1 Other ethnic minority groups 99 18.9 Education level Junior high school and below 338 64.4 High school education or equivalent 102 19.4 College-level and above 85 16.2 Relationship status Single/divorced/widowed 39 7.4 Married 486 92.6 Employment status Full-time 138 26.3 Part-time/self-employed/unemployed/retired/students 387 73.7 Characteristics of cancer Type of cancer Lung cancer 109 20.8 Gastric cancer 66 12.6 Liver cancer 15 2.9 Breast cancer 30 5.7 Colorectal cancer 97 18.5 Esophageal cancer 26 5.0 Ovarian cancer 43 8.2 Other types of cancer 139 26.5 Metastatic cancers No 490 93.3 Yes 35 6.7 Current treatment for cancer Untreated patients 17 3.2 Chemotherapy only 338 64.4 Radiotherapy only 89 17.0 Immunotherapy only 12 2.3 Chemotherapy and radiotherapy 34 6.5 Immunotherapy and chemotherapy/radiotherapy 15 2.9 Treatment completion 20 3.8 Presence of other chronic diseases Diabetes mellitus 30 5.7 Hypertension and/or hyperlipidemia 73 13.9 Chronic cardiovascular diseases 13 2.5 Chronic respiratory diseases 4 0.8 Chronic liver and/or kidney diseases 7 1.3 Other chronic diseases 15 2.9 Table 1. Background characteristics of 525 participants who completed the primary COVID-19 vaccination series.
In the univariate analysis, cancer patients who were ethnic minorities had lower hesitancy to receive the first COVID-19 vaccine booster dose (
Supplementary Table S2 ). After adjusting for significant background characteristics listed inSupplementary Table S2 , positive attitudes toward the booster dose (AOR: 0.83 & 0.66), perceived higher support from significant others (AOR: 0.55 & 0.40), perceived higher behavioral control to take up the booster dose (AOR: 0.51 & 0.25), higher exposure to information related to COVID-19 vaccination (AOR: 0.94 & 0.90), and thoughtful consideration about the veracity of COVID-19-specific information (AOR: 0.65 & 0.52) were associated with lower hesitancy to receive the first and the second booster doses (Table 2). Vaccination fatigue was also positively associated with hesitancy to receive the first and second booster doses (AOR: 1.36 & 1.52). Additionally, hesitancy to receive the first booster dose was associated with higher hesitancy for the second booster dose (AOR: 14.05).Characteristic Hesitancy to receive the
third dose of COVID-19 vaccineHesitancy to receive the
fourth dose of COVID-19 vaccineOR (95% CI) P value AOR*
(95% CI)P value OR (95% CI) P value AOR*
(95% CI)P value Individual-level variables Positive attitude scale 0.83
(0.76, 0.92)<0.001 0.83
(0.76, 0.92)<0.001 0.65
(0.60, 0.74)<0.001 0.66
(0.60, 0.74)<0.001 Negative attitude scale 1.01
(0.97, 1.06)0.553 1.01
(0.97, 1.06)0.560 1.03
(0.99, 1.08)0.147 1.03
(0.99, 1.08)0.195 Perceived subjective norms 0.54
(0.43, 0.67)<0.001 0.55
(0.44, 0.69)<0.001 0.39
(0.30, 0.49)<0.001 0.40
(0.31, 0.51)<0.001 Perceived behavioral control 0.54
(0.43, 0.67)<0.001 0.51
(0.40, 0.63)<0.001 0.25
(0.19, 0.34)<0.001 0.25
(0.19, 0.34)<0.001 Vaccination fatigue (tired of receiving COVID-19 vaccination over and over again) 1.34
(1.18, 1.58)<0.001 1.36
(1.18, 1.58)<0.001 1.48
(1.28, 1.71)<0.001 1.52
(1.31, 1.78)<0.001 Hesitancy to receive the third dose of COVID-19 vaccine NA NA NA NA 14.05
(7.94, 24.79)<0.001 14.05
(8.05, 24.52)<0.001 Interpersonal variables Media exposure scale 0.93
(0.89, 0.99)0.012 0.94
(0.89, 0.99)0.033 0.90
(0.85, 0.95)<0.001 0.90
(0.85, 0.95)<0.001 Frequency of thoughtful consideration about veracity of COVID-19-specific information 0.64
(0.53, 0.77)<0.001 0.65
(0.54, 0.79)<0.001 0.51
(0.42, 0.62)<0.001 0.52
(0.43, 0.64)<0.001 Abbreviation: OR=crude odds ratio; AOR=adjusted odds ratio; CI=confidence interval; NA=not applicable.
* Adjusted for significant background characteristics listed inSupplementary Table S2 .Table 2. Factors associated with hesitancy to receive the first and second booster doses of the COVID-19 vaccine (N=525).
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This is the first study to investigate hesitancy to receive the first and second COVID-19 vaccine booster doses among cancer patients. This study has several strengths, including its coverage of different geographic regions in China, its large sample size, and its examination of potential determinants at different levels. The level of hesitancy to receive the first COVID-19 vaccine booster dose among our participants was much higher than that of the general population in China (9).
This study provided practical implications for developing health promotion. Addressing vaccination fatigue may be beneficial for future health promotion for cancer patients. Rapid changes in policies and recommendations related to COVID-19 booster doses caused confusion among the general public (5). This confusion was further exacerbated when health authorities recommended the second booster dose. Modifying perceptions related to COVID-19 vaccine booster doses is also important. Updated evidence of booster doses in reducing mortality and severe consequences caused by COVID-19 among cancer patients should be disseminated in an accessible manner. Future programs might consider involving significant others of cancer patients to create a subjective norm favoring COVID-19 vaccine booster doses uptake. Healthcare workers may facilitate cancer patients to form a plan to receive a booster dose during clinical visits, which may help to improve perceived behavioral control. Higher exposure to topics related to COVID-19 vaccination and the Omicron variant was associated with lower hesitancy to receive booster doses. Health authorities should consider using these mass media channels to disseminate messages promoting booster doses. Similar to the findings among the general population in China, thoughtful consideration played an essential role in reducing hesitancy to receive booster doses. Thoughtful consideration could mitigate the negative impacts of misinformation on vaccine hesitancy (8).
This study has several limitations. First, our findings could not be generalized to all cancer patients, as we only targeted inpatients. Second, the sample was selected conveniently and could not represent all cancer patients in China. Third, we could not obtain the characteristics of cancer patients who refused to join the study, leading to selection bias. Additionally, this was a cross-sectional survey and could not establish a causal relationship. To address vaccination fatigue, modify perceptions related to booster doses, disseminate booster dose promotion messages through mass media, and improve thoughtful consideration of the veracity of COVID-19-related information might be helpful strategies.
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