Vaccines | Free Full-Text | COVID-19 Vaccine Booster Hesitancy among the Elderly in Malaysian Residential Care Homes: A Cross-Sectional Study in Klang Valley
4.1. Factors Associated with Hesitancy toward a Second Booster of the COVID-19 Vaccine
This study has examined the factors that influence hesitancy toward the second booster of the COVID-19 vaccine among elderly people from residential care homes. Some recent reviews have highlighted factors frequently reported as influencing vaccine booster uptake [25,26,27]. Factors investigated include demographics of which age has been found to be more relevant in the context of vaccine booster hesitancy. However, it has been noted that the result of this association is conflicting between different studies [25]. In an extensive systematic review by Kadafar et al. [28], which looked at vaccine hesitancy in the general population, younger age was identified as one of the demographic factors positively associated with vaccine hesitancy in general. However, it does not negate our observation of the association of vaccine hesitancy with increasing age, as our study group specifically involved the elderly from residential care facilities. Hence, it is not appropriate to carry out a comparison with respect to this factor.
Other factors often quoted across studies are adverse events following the vaccine, perceived usefulness or lack thereof of the booster, perceived level of susceptibility for COVID-19, vaccination recommendations from various sources, and the level of trust in these recommendations [25,26,27]. Of these reported factors, the only one found to be significantly associated with vaccine hesitancy in the present context, based on our multivariate analysis, was adverse events (death) among close contacts/family members post-vaccination.
The Malaysian government mandates require the administration of both the first and second vaccine doses, the refusal of which may result in restricted mobility. The launching of the first booster, which was encouraged, resulted in fairly widespread acceptance, an observation which could be attributed to frequent news about the emergence of new variants. As the vaccination efforts progressed, many individuals, including those in social groups, reported tolerable mild reactions. However, instances of individuals succumbing to serious reactions following the COVID-19 vaccine, though rare, were also known. The awareness and fear of the potential risk of death associated with the COVID-19 vaccine could pose a strong disincentive, or more likely lead to regretting the decision to get vaccinated in the first place; this regret might influence the choice to take the optional second booster dose [29], possibly underlying our finding that there is an association between vaccine-related deaths among close contact/family members and vaccine booster hesitancy.
Secondly, negative messaging in the form of concerns about the potential harm associated with the booster shot expressed by caregivers, friends, or family members is another predictor of second-booster hesitancy among the elderly in residential care homes. This finding is particularly relevant due to the culture of collectivism which is prevalent in Malaysia, where elderly individuals residing in care homes often have limited access to information and are surrounded by individuals who often echo prevailing sentiments. Moreover, they may have a restricted understanding of the cause-and-effect relationship between the vaccine and potential health risks. In such environments, where the elderly may rely heavily on the subjective norms of those around them, the dissemination of negative information and mistrust regarding booster shots can instil fear and reluctance among listeners [30,31]. Caregivers, close friends, and family members play a crucial role in influencing the perspectives of the elderly, often holding greater sway than influential lobbies from the government and healthcare practitioners. The impact of the culture of collectivism in Malaysia accentuates the importance of these interpersonal relationships in shaping the attitudes of the elderly population in care homes towards COVID-19 booster shots.
Conversely, this study also identified that positive messages regarding the booster dose, disseminated by government officials and caregivers, friends, and family members, constitute significant factors in mitigating second booster hesitancy. In stark contrast to negative influences, the support and endorsement from these trusted sources play a crucial role in encouraging acceptance and willingness among individuals who may have initially harboured hesitancy. This is in line, with the principles of the Social Influence Theory, which posits that a person’s thoughts, feelings, and behaviours are influenced by the presence or actions of others [32]. Therefore, recognizing the impactful role of positive messaging from trusted community figures highlights the importance of targeted communication strategies to promote vaccine acceptance, particularly in the context of booster doses.
Indian ethnicity was identified as another risk factor for hesitancy, possibly due to the fact that the elderly Indian individuals in this study comprise the highest proportion (4.4%) experiencing serious adverse reactions from the first or second vaccine dose. This is coupled with the finding that this ethnic group made up a higher proportion of those who did not have chronic illness (26.7%) and were not on medication for chronic illness (31.3%) compared to the other ethnic groups [28,33,34]. In summary, the association between Indian ethnicity and vaccine hesitancy appears to be due to the combination of a higher incidence of critical reactions and possibly complacency due to the relatively low frequency of chronic illnesses, findings supported by Limbu et al. [25], in their review that highlighted adverse events, perceived susceptibility and health status as among thirteen key factors that influence booster hesitancy.
Having Sinovac as the first booster was identified as a predictor of hesitancy towards receiving a second booster among the elderly in care homes. This could be attributed to more cases who required treatment and/or hospitalization (14.6%) and death (12.4%) among close friends and immediate family members after the first dose of Sinovac vaccine compared to the other vaccine brands. Likewise, with the second dose of Sinovac, with 15.9% needing treatment/hospitalization and 13.6% deaths. However, the first booster using Sinovac, while also associated with relatively high rates of treatment/hospitalization (14.3%) and deaths (11.9%), was second to AstraZaneca with rates of 17.4% and 21.7%, respectively. Nevertheless, mild reactions after the Sinovac booster were most common among the elderly recipients interviewed. In the present context, the common occurrence of mild reactions among Sinovac-booster recipients, coupled with reports of hospitalization and critical reactions among their close contacts (i.e., friends and immediate family members) who received Sinovac as the initial doses, could collectively contribute to the hesitancy among individuals who have previously received the Sinovac vaccine to take a second booster dose. This observation can, at least in part, be understood on the basis of social cognition constructs, highlighted by Hagger MS, et.al., 2022 [35]. The authors of this paper found that perceptions of control and risks influence vaccine acceptance, although less so compared to attitudes and subjective norms.
4.2. Implications
The findings of the present study could conceivably provide information with public health significance for policymakers and healthcare practitioners. First, as increasing age among the elderly is a notable predictor of second-booster hesitancy, the development of personalized communication strategies is recommended, with reference to this high-risk group.
Second, culturally sensitive education efforts are also relevant. Healthcare practitioners could collaborate with community leaders to enhance vaccine education and acceptance within particular ethnic groups, such as the Indian elderly community in the current context.
Third, transparent communication from vaccine brands is important when hesitancy is tied to a particular vaccine brand. Public awareness campaigns should incorporate detailed information about various vaccine brands to foster transparency, address specific concerns, and maintain public trust.
Fourth, empathy-infused communication and mental health support is necessary to address the emotional impact of losing loved ones and close contacts post-vaccination. Recognition of the emotional aspects of vaccine hesitancy should prompt the incorporation of mental health support services within vaccination programs.
Fifth, given the impact of the culture of collectivism, caring for vaccine recipients with adverse outcomes should actively involve caregivers, friends, and family members. Community-focused campaigns that leverage the influence of key public figures in disseminating positive information and addressing negative sentiments could help to address and counteract factors contributing to hesitancy.
Lastly, in the context of the elderly under residential care, collaborative efforts with elderly residential care homes represent a pivotal strategy. These initiatives could include educational campaigns, direct engagement with residents, and support from caregivers. Addressing concerns about critical reactions, potential side effects, and the emotional toll of losing close contacts post-vaccination should be central to these initiatives.
4.3. Limitations and Future Directions
It is acknowledged that there are limitations within this study. First, this study is an initial examination of an evidence-based empirical study on hesitancy surrounding vaccine booster doses, an area that has received relatively little research scrutiny. The participants are elderly residents from a random sample of care homes within the Klang Valley, a geographically limited region of the country. Hence, the results are non-representative and thus do not fully capture the diversity of perspectives of the elderly from residential care homes in other regions of the country. The ethnic composition of the sample is another limitation, as the participating care homes, primarily Chinese-based, resulted in a two-third dominance of Chinese elderly participants. This imbalance may introduce selection bias and potentially affect the generalizability of the findings. Further studies, encompassing a larger and more representative sample of the elderly, would provide more comprehensive and representative data.
Additionally, the study identifies associations between various factors and hesitancy toward the second booster. The cross-sectional nature of the research design limits the ability to infer causal relationships between identified predictors and hesitancy. Longitudinal studies would be necessary to establish a more robust understanding of causative factors. Moreover, evaluating the effectiveness of targeted interventions would provide valuable insights for public health policies and practices.
