Effectiveness of chatbots on COVID vaccine confidence and acceptance in Thailand, Hong Kong, and Singapore.

Chatbots have become an increasingly popular tool in the field of health services and communications. Despite chatbots' significance amid the COVID-19 pandemic, few studies have performed a rigorous evaluation of the effectiveness of chatbots in improving vaccine confidence and acceptance. In Thailand, Hong Kong, and Singapore, from February 11th to June 30th, 2022, we conducted multisite randomised controlled trials (RCT) on 2,045 adult guardians of children and seniors who were unvaccinated or had delayed vaccinations. After a week of using COVID-19 vaccine chatbots, the differences in vaccine confidence and acceptance were compared between the intervention and control groups. Compared to non-users, fewer chatbot users reported decreased confidence in vaccine effectiveness in the Thailand child group [Intervention: 4.3 % vs. Control: 17%, P = 0.023]. However, more chatbot users reported decreased vaccine acceptance [26% vs. 12%, P = 0.028] in Hong Kong child group and decreased vaccine confidence in safety [29% vs. 10%, P = 0.041] in Singapore child group. There was no statistically significant change in vaccine confidence or acceptance in the Hong Kong senior group. Employing the RE-AIM framework, process evaluation indicated strong acceptance and implementation support for vaccine chatbots from stakeholders, with high levels of sustainability and scalability. This multisite, parallel RCT study on vaccine chatbots found mixed success in improving vaccine confidence and acceptance among unvaccinated Asian subpopulations. Further studies that link chatbot usage and real-world vaccine uptake are needed to augment evidence for employing vaccine chatbots to advance vaccine confidence and acceptance.

Effect of a mobile app chatbot and an interactive small-group webinar on COVID-19 vaccine intention and confidence in Japan: a randomised controlled trial.

INTRODUCTION: We investigated the effect of social media-based interventions on COVID-19 vaccine intention (VI) and confidence in Japan. METHODS: We conducted a three-arm randomised controlled trial between 5 November 2021 and 9 January 2022 during a low incidence (<1000/day) of COVID-19 in Japan in the midst of the second and the third waves. Japanese citizens aged ≥20 who had not received any COVID-19 vaccine and did not intend to be vaccinated were randomly assigned to one of the following three groups: (1) a control group, (2) a group using a mobile app chatbot providing information on COVID-19 vaccines and (3) a group using interactive webinars with health professionals. VI and predefined Vaccine Confidence Index (VCI) measuring confidence in the importance, safety and effectiveness were compared before and after the interventions under intention-to-treat principle. Logistic regression models were used to investigate the effect of each intervention on postintervention VI and changes of VCI compared with control. RESULTS: Among 386 participants in each group, 359 (93.0%), 231 (59.8%) and 207 (53.6%) completed the postsurvey for the control, chatbot and webinar groups, respectively. The average duration between the intervention and the postsurvey was 32 days in chatbot group and 27 days in webinar group. VI increased from 0% to 18.5% (95% CI 14.5%, 22.5%) in control group, 15.4% (95% CI 10.8%, 20.1%) in chatbot group and 19.7% (95% CI 14.5%, 24.9%) in webinar group without significant difference (OR for improvement=0.8 (95% CI 0.5, 1.3), p=0.33 between chatbot and control, OR=1.1 (95% CI 0.7, 1.6), p=0.73 between webinar and control). VCI change tended to be larger in chatbot group compared with control group without significant difference (3.3% vs -2.5% in importance, OR for improvement=1.3 (95% CI 0.9, 2.0), p=0.18; 2.5% vs 1.9% in safety, OR=1.1 (95% CI 0.7, 1.9), p=0.62; -2.4% vs -7.6% in effectiveness, OR=1.4 (95% CI 0.9, 2.1), p=0.09). Improvement in VCI was larger in webinar group compared with control group for importance (7.8% vs -2.5%, OR=1.8 (95% CI 1.2, 2.8), p<0.01), effectiveness (6.4% vs -7.6%, OR=2.2 (95% CI 1.4, 3.4), p<0.01) and safety (6.0% vs 1.9%, OR=1.6 (95% CI 1.0, 2.6), p=0.08). CONCLUSION: This study demonstrated that neither the chatbot nor the webinar changed VI importantly compared with control. Interactive webinars could be an effective tool to change vaccine confidence. Further study is needed to identify risk factors associated with decreased vaccine confidence and investigate what intervention can increase VI and vaccine confidence for COVID-19 vaccines. TRIAL REGISTRATION NUMBER: UMIN000045747.

Applications of Social Media and Digital Technologies in COVID-19 Vaccination: Scoping Review.

BACKGROUND: Social media and digital technologies have played essential roles in disseminating information and promoting vaccination during the COVID-19 pandemic. There is a need to summarize the applications and analytical techniques of social media and digital technologies in monitoring vaccine attitudes and administering COVID-19 vaccines. OBJECTIVE: We aimed to synthesize the global evidence on the applications of social media and digital technologies in COVID-19 vaccination and to explore their avenues to promote COVID-19 vaccination. METHODS: We searched 6 databases (PubMed, Scopus, Web of Science, Embase, EBSCO, and IEEE Xplore) for English-language articles from December 2019 to August 2022. The search terms covered keywords relating to social media, digital technology, and COVID-19 vaccines. Articles were included if they provided original descriptions of applications of social media or digital health technologies/solutions in COVID-19 vaccination. Conference abstracts, editorials, letters, commentaries, correspondence articles, study protocols, and reviews were excluded. A modified version of the Appraisal Tool for Cross-Sectional Studies (AXIS tool) was used to evaluate the quality of social media-related studies. The review was undertaken with the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. RESULTS: A total of 178 articles were included in our review, including 114 social media articles and 64 digital technology articles. Social media has been applied for sentiment/emotion analysis, topic analysis, behavioral analysis, dissemination and engagement analysis, and information quality analysis around COVID-19 vaccination. Of these, sentiment analysis and topic analysis were the most common, with social media data being primarily analyzed by lexicon-based and machine learning techniques. The accuracy and reliability of information on social media can seriously affect public attitudes toward COVID-19 vaccines, and misinformation often leads to vaccine hesitancy. Digital technologies have been applied to determine the COVID-19 vaccination strategy, predict the vaccination process, optimize vaccine distribution and delivery, provide safe and transparent vaccination certificates, and perform postvaccination surveillance. The applied digital technologies included algorithms, blockchain, mobile health, the Internet of Things, and other technologies, although with some barriers to their popularization. CONCLUSIONS: The applications of social media and digital technologies in addressing COVID-19 vaccination-related issues represent an irreversible trend. Attention should be paid to the ethical issues and health inequities arising from the digital divide while applying and promoting these technologies.

Vaccines and the social amplification of risk.

In 2019, the World Health Organization (WHO) named "Vaccine Hesitancy" one of the top 10 threats to global health. Shortly afterward, the COVID-19 pandemic emerged as the world's predominant health concern. COVID-19 vaccines of several types have been developed, tested, and partially deployed with remarkable speed; vaccines are now the primary control measure and hope for a return to normalcy. However, hesitancy concerning these vaccines, along with resistance to masking and other control measures, remains a substantial obstacle. The previous waves of vaccine hesitancy that led to the WHO threat designation, together with recent COVID-19 experience, provide a window for viewing new forms of social amplification of risk (SAR). Not surprisingly, vaccines provide fertile ground for questions, anxieties, concerns, and rumors. These appear in new globalized hyperconnected communications landscapes and in the context of complex human (social, economic, and political) systems that exhibit evolving concerns about vaccines and authorities. We look at drivers, impacts, and implications for vaccine initiatives in several recent historical examples and in the current efforts with COVID-19 vaccination. Findings and insights were drawn from the Vaccine Confidence Project's decade long monitoring of media and social media and its related research efforts. The trends in vaccine confidence and resistance have implications for updating the social amplification of risk framework (SARF); in turn, SARF has practical implications for guiding efforts to alleviate vaccine hesitancy and to mitigate harms from intentional and unintentional vaccine scares.

Erratum: Author Correction: Mapping global acceptance and uptake of COVID-19 vaccination: a systematic review and meta-analysis.

[This corrects the article DOI: 10.1038/s43856-022-00177-6.].

Effectiveness of a pay-it-forward intervention compared with user-paid vaccination to improve influenza vaccine uptake and community engagement among children and older adults in China: a quasi-experimental pragmatic trial.

BACKGROUND: China has low seasonal influenza vaccination rates among priority populations. In this study, we aimed to evaluate a pay-it-forward strategy to increase influenza vaccine uptake in rural, suburban, and urban settings in China. METHODS: We performed a quasi-experimental pragmatic trial to examine the effectiveness of a pay-it-forward intervention (a free influenza vaccine and an opportunity to donate financially to support vaccination of other individuals) to increase influenza vaccine uptake compared with standard-of-care user-paid vaccination among children (aged between 6 months and 8 years) and older people (≥60 years) in China. Recruitment took place in the standard-of-care group until the expected sample size was reached and then in the pay-it-forward group in primary care clinics from a rural site (Yangshan), a suburban site (Zengcheng), and an urban site (Tianhe). Participants were introduced to the influenza vaccine by project staff using a pamphlet about influenza vaccination and were either asked to pay out-of-pocket at the standard market price (US$8·5-23·2; standard-of-care group) or to donate any amount anonymously (pay-it-forward group). Participants had to be eligible to receive an influenza vaccine and to have not received an influenza vaccine in the past year. The primary outcome was vaccine uptake. Secondary outcomes were vaccine confidence and costs (from the health-care provider perspective). Regression methods compared influenza vaccine uptake and vaccine confidence between the two groups. This trial is registered with ChiCTR, ChiCTR2000040048. FINDINGS: From Sept 21, 2020, to March 3, 2021, 300 enrolees were recruited from patients visiting three primary care clinics. 55 (37%) of 150 people in the standard-of-care group (40 [53%] of 75 children and 15 [20%] of 75 older adults) and 111 (74%) of 150 in the pay-it-forward group (66 [88%] of 75 children and 45 [60%] of 75 older adults) received an influenza vaccine. People in the pay-it-forward group were more likely to receive an influenza vaccine compared with those in the standard-of-care group (adjusted odds ratio [aOR] 6·7 [95% CI 2·7-16·6] among children and 5·0 [2·3-10·8] among older adults). People in the pay-it-forward group had greater confidence in vaccine safety (aOR 2·2 [95% CI 1·2-3·9]), importance (3·1 [1·6-5·9]), and effectiveness (3·1 [1·7-5·7]). In the pay-it-forward group, 107 (96%) of 111 participants donated money for subsequent vaccinations. The pay-it-forward group had a lower economic cost (calculated as the cost without subtraction of donations) per person vaccinated (US$45·60) than did the standard-of-care group ($64·67). INTERPRETATION: The pay-it-forward intervention seemed to be effective in improving influenza vaccine uptake and community engagement. Our data have implications for prosocial interventions to enhance influenza vaccine uptake in countries where influenza vaccines are available for a fee. FUNDING: Bill & Melinda Gates Foundation and the UK National Institute for Health Research.

Mapping global acceptance and uptake of COVID-19 vaccination: A systematic review and meta-analysis.

Background: The COVID-19 pandemic exit strategies depend on widespread acceptance of COVID-19 vaccines. We aim to estimate the global acceptance and uptake of COVID-19 vaccination, and their variations across populations, countries, time, and sociodemographic subgroups. Methods: We searched four peer-reviewed databases (PubMed, EMBASE, Web of Science, and EBSCO) for papers published in English from December 1, 2019 to February 27, 2022. This review included original survey studies which investigated acceptance or uptake of COVID-19 vaccination, and study quality was assessed using the Appraisal tool for Cross-Sectional Studies. We reported the pooled acceptance or uptake rates and 95% confidence interval (CI) using meta-analysis with a random-effects model. Results: Among 15690 identified studies, 519 articles with 7,990,117 participants are eligible for meta-analysis. The global acceptance and uptake rate of COVID-19 vaccination are 67.8% (95% CI: 67.1-68.6) and 42.3% (95% CI: 38.2-46.5), respectively. Among all population groups, pregnant/breastfeeding women have the lowest acceptance (54.0%, 46.3-61.7) and uptake rates (7.3%, 1.7-12.8). The acceptance rate varies across countries, ranging from 35.9% (34.3-37.5) to 86.9% (81.4-92.5) for adults, and the lowest acceptance is found in Russia, Ghana, Jordan, Lebanon, and Syria (below 50%). The acceptance rate declines globally in 2020, then recovers from December 2020 to June 2021, and further drops in late 2021. Females, those aged < 60 years old, Black individuals, those with lower education or income have the lower acceptance than their counterparts. There are large gaps (around 20%) between acceptance and uptake rates for populations with low education or income. Conclusion: COVID-19 vaccine acceptance needs to be improved globally. Continuous vaccine acceptance monitoring is necessary to inform public health decision making.

Geographic social inequalities in information-seeking response to the COVID-19 pandemic in China: longitudinal analysis of Baidu Index.

The outbreak of the COVID-19 pandemic alarmed the public and initiated the uptake of preventive measures. However, the manner in which the public responded to these announcements, and whether individuals from different provinces responded similarly during the COVID-19 pandemic in China, remains largely unknown. We used an interrupted time-series analysis to examine the change in Baidu Search Index of selected COVID-19 related terms associated with the COVID-19 derived exposure variables. We analyzed the daily search index in Mainland China using segmented log-normal regressions with data from Jan 2017 to Mar 2021. In this longitudinal study of nearly one billion internet users, we found synchronous increases in COVID-19 related searches during the first wave of the COVID-19 pandemic and subsequent local outbreaks, irrespective of the location and severity of each outbreak. The most precipitous increase occurred in the week when most provinces activated their highest level of response to public health emergencies. Search interests increased more as Human Development Index (HDI) -an area level measure of socioeconomic status-increased. Searches on the index began to decline nationwide after the initiation of mass-scale lockdowns, but statistically significant increases continued to occur in conjunction with the report of major sporadic local outbreaks. The intense interest in COVID-19 related information at virtually the same time across different provinces indicates that the Chinese government utilizes multiple channels to keep the public informed of the pandemic. Regional socioeconomic status influenced search patterns.

Changes in Parental Attitudes Toward COVID-19 Vaccination and Routine Childhood Vaccination During the COVID-19 Pandemic: Repeated Cross-sectional Survey Study.

BACKGROUND: It was reported that one in four parents were hesitant about vaccinating their children in China. Previous studies have revealed a declining trend in the vaccine willingness rate in China. There is a need to monitor the level of parental vaccine hesitancy toward routine childhood vaccination and hesitancy toward the COVID-19 vaccine during the ongoing COVID-19 pandemic. OBJECTIVE: This study aims to assess changes in trends of parental attitudes toward routine childhood vaccines and COVID-19 vaccinations across different time periods in China. METHODS: Three waves of cross-sectional surveys were conducted on parents residing in Wuxi City in Jiangsu Province, China from September to October 2020, February to March 2021, and May to June 2021. Participants were recruited from immunization clinics. Chi-square tests were used to compare the results of the three surveys, controlling for sociodemographic factors. Binary and multivariable logistic regression analysis was used to examine factors related to parental vaccine hesitancy and COVID-19 vaccine willingness. RESULTS: Overall, 2881, 1038, and 1183 participants were included in the survey's three waves. Using the Vaccine Hesitancy Scale, 7.8% (225/2881), 15.1% (157/1038), and 5.5% (65/1183) of parents showed hesitancy to childhood vaccination (P<.001), and 59.3% (1709/2881), 64.6% (671/1038), and 92% (1088/1183) of parents agreed to receive a COVID-19 vaccine themselves in the first, second, and third surveys, respectively (P<.001). In all three surveys, "concerns about vaccine safety and side effects" was the most common reason for refusal. CONCLUSIONS: There has been an increasing acceptance of COVID-19 vaccination in Wuxi City, China. Effective interventions are needed to mitigate public concerns about vaccine safety.

Challenges to evidence-informed decision-making in the context of pandemics: qualitative study of COVID-19 policy advisor perspectives.

INTRODUCTION: The exceptional production of research evidence during the COVID-19 pandemic required deployment of scientists to act in advisory roles to aid policy-makers in making evidence-informed decisions. The unprecedented breadth, scale and duration of the pandemic provides an opportunity to understand how science advisors experience and mitigate challenges associated with insufficient, evolving and/or conflicting evidence to inform public health decision-making. OBJECTIVES: To explore critically the challenges for advising evidence-informed decision-making (EIDM) in pandemic contexts, particularly around non-pharmaceutical control measures, from the perspective of experts advising policy-makers during COVID-19 globally. METHODS: We conducted in-depth qualitative interviews with 27 scientific experts and advisors who are/were engaged in COVID-19 EIDM representing four WHO regions and 11 countries (Australia, Canada, Colombia, Denmark, Ghana, Hong Kong, Nigeria, Sweden, Uganda, UK, USA) from December 2020 to May 2021. Participants informed decision-making at various and multiple levels of governance, including local/city (n=3), state/provincial (n=8), federal or national (n=20), regional or international (n=3) and university-level advising (n=3). Following each interview, we conducted member checks with participants and thematically analysed interview data using NVivo for Mac software. RESULTS: Findings from this study indicate multiple overarching challenges to pandemic EIDM specific to interpretation and translation of evidence, including the speed and influx of new, evolving, and conflicting evidence; concerns about scientific integrity and misinterpretation of evidence; the limited capacity to assess and produce evidence, and adapting evidence from other contexts; multiple forms of evidence and perspectives needed for EIDM; the need to make decisions quickly and under conditions of uncertainty; and a lack of transparency in how decisions are made and applied. CONCLUSIONS: Findings suggest the urgent need for global EIDM guidance that countries can adapt for in-country decisions as well as coordinated global response to future pandemics.

Willingness and uptake of the COVID-19 testing and vaccination in urban China during the low-risk period: a cross-sectional study.

BACKGROUND: Regular testing and vaccination are effective measures to mitigate the ongoing COVID-19 pandemic. Evidence on the willingness and uptake of the COVID-19 testing is scarce, and the willingness and uptake of vaccination may change as the pandemic evolves. This study aims to examine willingness and uptake of COVID-19 testing and vaccination during a low-risk period of the COVID-19 pandemic in urban China. METHODS: A cross-sectional online survey was conducted among 2244 adults in urban China. Descriptive analyses were performed to compare the respondents' willingness and uptake of COVID-19 testing and vaccination. Multivariate logistic regressions were fitted to investigate factors associated with the willingness and uptake of the two measures. RESULTS: In early 2021, about half (52.45%) of the respondents had received or scheduled a COVID-19 test at least once, and a majority (95.63%) of the respondents were willing to receive testing. About two-thirds (63.28%) of the respondents had received/scheduled or were willing to receive a COVID-19 vaccine. Willingness and uptake of COVID-19 testing were not associated with socio-demographic characteristics, except for occupation. Being of older age, migrants, having higher educational attainment and secure employment were associated with a higher uptake of COVID-19 vaccination among the surveyed respondents, while willingness to vaccinate was consistent across socio-demographic characteristics among those who had not been vaccinated. CONCLUSIONS: By early 2021, Chinese adults expressed almost universal willingness of COVID-19 testing and over half of adults have been tested, while the willingness and uptake of COVID-19 vaccination were relatively low at the low-risk period of the COVID-19 pandemic. Maintaining willingness of COVID-19 vaccination is critical and necessary, especially when the pandemic evolved into a low-risk period.

Delays in routine childhood vaccinations and their relationship with parental vaccine hesitancy: a cross-sectional study in Wuxi, China.

OBJECTIVES: This study aimed to examine childhood vaccination delay, explore the association between vaccination delay and parental vaccine hesitancy, and assess childhood vaccination delays during the coronavirus disease (COVID)-19 pandemic in China. METHODS: This cross-sectional survey was conducted in Wuxi City. Participants were recruited from local vaccination clinics. Questionnaires were used to collect information about socio-demographics, vaccine hesitancy, and immunization clinic evaluations. Vaccination records were obtained from the Jiangsu Information Management System of Vaccination Cases. RESULTS: Overall, 2728 participants were included. The coverage for seven category A vaccines (Expanded Program on Immunization (EPI)) was more than 95% at 24 months. The proportion of children vaccinated in a timely manner was the highest for the first dose of the hepatitis B vaccine (91.6%) and the lowest for the Bacillus-Calmette-Guerin vaccine (44.6%). More than 50% of the planned vaccinations were delayed in February and March 2020. The Vaccine Hesitancy Scale scores were not associated with vaccination delay (P = 0.842). Children's vaccination delays were negatively associated with parents who reported convenient access to clinics and satisfaction with immunization services (P = 0.020, P = 0.045). CONCLUSIONS: EPI is highly successful in China. Despite vaccination delays due to the COVID-19 pandemic, coverage was recovered after lockdown restrictions were eased.

Public Attitudes and Factors of COVID-19 Testing Hesitancy in the United Kingdom and China: Comparative Infodemiology Study.

BACKGROUND: Massive community-wide testing has become the cornerstone of management strategies for the COVID-19 pandemic. OBJECTIVE: This study was a comparative analysis between the United Kingdom and China, which aimed to assess public attitudes and uptake regarding COVID-19 testing, with a focus on factors of COVID-19 testing hesitancy, including effectiveness, access, risk perception, and communication. METHODS: We collected and manually coded 3856 UK tweets and 9299 Chinese Sina Weibo posts mentioning COVID-19 testing from June 1 to July 15, 2020. Adapted from the World Health Organization's 3C Model of Vaccine Hesitancy, we employed social listening analysis examining key factors of COVID-19 testing hesitancy (confidence, complacency, convenience, and communication). Descriptive analysis, time trends, geographical mapping, and chi-squared tests were performed to assess the temporal, spatial, and sociodemographic characteristics that determine the difference in attitudes or uptake of COVID-19 tests. RESULTS: The UK tweets demonstrated a higher percentage of support toward COVID-19 testing than the posts from China. There were much wider reports of public uptake of COVID-19 tests in mainland China than in the United Kingdom; however, uncomfortable experiences and logistical barriers to testing were more expressed in China. The driving forces for undergoing COVID-19 testing were personal health needs, community-wide testing, and mandatory testing policies for travel, with major differences in the ranking order between the two countries. Rumors and information inquiries about COVID-19 testing were also identified. CONCLUSIONS: Public attitudes and acceptance toward COVID-19 testing constantly evolve with local epidemic situations. Policies and information campaigns that emphasize the importance of timely testing and rapid communication responses to inquiries and rumors, and provide a supportive environment for accessing tests are key to tackling COVID-19 testing hesitancy and increasing uptake.

COVID-19-related stigma and its influencing factors: a nationwide cross-sectional study during the early stage of the pandemic in China.

OBJECTIVES: To describe the situation of COVID-19-related stigma towards patients with COVID-19 and people from the city of Wuhan in China and to assess the associations between COVID-19-related stigma, health literacy and sociodemographic characteristics during March 2020, the early stage of the pandemic. DESIGN: A cross-sectional online survey. SETTING: The study surveyed 31 provinces in China. PARTICIPANTS: This study surveyed 5039 respondents in China. OUTCOME MEASURES: Public stigma towards both patients with COVID-19 and Wuhan residents was measured. Binary logistic regression was used to identify the factors associated with public COVID-19-related stigma. RESULTS: Among the participants, 122 (2.4%) reported themselves and 254 (5.0%) reported the communities they lived in as holding a stigmatising attitude towards patients with COVID-19, respectively. Additionally, 114 (2.5%) and 475 (10.3%) reported that themselves and the communities they lived in, respectively, held a stigma against people from Wuhan, which was the most severely affected area in China. People aged over 40, lived in areas with severe epidemics (adjusted OR (aOR)=2.03, 95% CI (1.05 to 3.92)) and who felt it difficult to find and understand information about COVID-19 (aOR=1.91, 95% CI (1.08 to 3.37); aOR=1.88, 95% CI (1.08 to 3.29)) were more likely to stigmatise patients with COVID-19. People who were male, aged 41-50 and had difficulty understanding information (aOR=2.08, 95% CI (1.17 to 3.69)) were more likely to stigmatise people from Wuhan. CONCLUSIONS: Patients with COVID-19 and Wuhan residents suffered stigma at both the individual and the community levels. Those who had low health literacy, who lived in areas with a large number of COVID-19 cases and who were of ethnic minorities were more likely to stigmatise others. Tailored interventions are encouraged to improve health literacy and consequently to reduce public COVID-19-related stigma.

Factors related to perceived stress during the COVID-19 epidemic context among the general population in China: A cross-sectional nationwide study.

BACKGROUND: This study aimed to investigate factors related to high stress levels among the general population in China during the novel coronavirus disease (COVID-19) pandemic when its containment measures were in place and to identify the most stressed populations. METHODS: A nationwide study was conducted online among 5,039 adults in all 31 provinces in mainland China between March 1 and March 16, 2020. Bivariate analysis and multivariate logistic regressions were performed to explore the related factors of high perceived stress. RESULTS: Among all respondents, 36.0% reported a high level of stress. Respondents in Hubei province (the epicenter) were more likely to report high stress levels than those in low epidemic areas. Respondents who went outside every day or every other day reported greater odds of experiencing a high level of stress than those who went outside every 8-14 days. People with higher risk perceptions were more prone to report high stress levels. Respondents aged 16-35 were more likely to report high stress than respondents aged 46 or older. Lower household income and lower health literacy were related to increased odds of reporting high stress levels. LIMITATIONS: We used a convenience sample and self-reported survey data. CONCLUSIONS: We identified risk factors for high stress levels related to the epidemic (epidemic intensity in residential areas, risk perception, and frequency of going outside) and other vulnerabilities (younger age, low household income, low health literacy). Our findings can directly inform interventions and policies for mitigating stress among the general population for this or future epidemics.

The Influence of the COVID-19 Epidemic on Prevention and Vaccination Behaviors Among Chinese Children and Adolescents: Cross-sectional Online Survey Study.

BACKGROUND: The COVID-19 epidemic and the related containment strategies may affect parental and pediatric health behaviors. OBJECTIVE: The goal of this study was to assess the change in children's and adolescents' prevention and vaccination behaviors amid China's COVID-19 epidemic. METHODS: We conducted a cross-sectional online survey in mid-March 2020 using proportional quota sampling in Wuhan (the epidemic epicenter) and Shanghai (a nonepicenter). Data were collected from 1655 parents with children aged 3 to 17 years. Children's and adolescents' prevention behaviors and regular vaccination behaviors before and during the epidemic were assessed. Descriptive analyses were used to investigate respondents' characteristics, public health prevention behaviors, unproven protection behaviors, and vaccination behaviors before and during the COVID-19 epidemic. Univariate analyses were performed to compare differences in outcome measures between cities and family characteristics, using chi-square tests or Fisher exact tests (if expected frequency was <5) and analyses of variance. Multivariate logistic regressions were used to identify the factors and disparities associated with prevention and vaccination behaviors. RESULTS: Parent-reported prevention behaviors increased among children and adolescents during the COVID-19 epidemic compared with those before the epidemic. During the epidemic, 82.2% (638/776) of children or adolescents always wore masks when going out compared with 31.5% (521/1655) before the epidemic; in addition, 25.0% (414/1655) and 79.8% (1321/1655) had increased their frequency and duration of handwashing, respectively, although only 46.9% (776/1655) went out during the epidemic. Meanwhile, 56.1% (928/1655) of the families took unproven remedies against COVID-19. Parent-reported vaccination behaviors showed mixed results, with 74.8% (468/626) delaying scheduled vaccinations and 80.9% (1339/1655) planning to have their children get the influenza vaccination after the epidemic. Regarding socioeconomic status, children and adolescents from larger families and whose parents had lower education levels were less likely to improve prevention behaviors but more likely to take unproven remedies. Girls were less likely than boys to always wear a mask when going out and wash their hands. CONCLUSIONS: Prevention behaviors and attitudes toward influenza vaccination have improved during the COVID-19 epidemic. Public health prevention measures should be continuously promoted, particularly among girls, parents with lower education levels, and larger families. Meanwhile, misinformation about COVID-19 remains a serious challenge and needs to be addressed by public health stakeholders.