Fear of COVID-19 disease and vaccination as predictors of vaccination status.

Vaccination rates are still insufficient to prevent the spread of COVID-19, so immunity must be increased among the population in order to reduce the virus' spread and the associated medical and psychosocial effects. Although previous work has identified various factors associated with a low willingness to get vaccinated, the role of emotions such as fear of vaccination (FVAC) or fear of COVID-19 (FCOV), vaccination as a subjective norm (SN), psychological factors like general control beliefs (CB) or psychological resilience, and their interaction have been investigated less intensively. We used data from three cross-sectional waves of the German Panel COSMO (November 2021, N = 1010; February 2022, N = 1026; March 2022, N = 1031) and multiple logistic regression analyses to test whether vaccination rates are moderated by those factors. After controlling for covariates (age, sex, confidence in own intuition, optimism, well-being), we found that CB was no significant predictor of vaccination status. Higher FCOV and higher ratings in SN, however, were associated with an increased likelihood of being vaccinated. In contrast, higher FVAC was associated with a decreased likelihood of being vaccinated. Psychological resilience did not consistently moderate the associations between fear and vaccination status.

Filter Questions in Symptom Assessment Affect the Prevalence of (A)Symptomatic COVID-19 Cases.

BACKGROUND: It has been reported that a substantial number of COVID-19 infections are asymptomatic, with both symptomatic and asymptomatic infections contributing to transmission dynamics. Yet, the share of asymptomatic cases varies greatly across studies. One reason for this could be the measurement of symptoms in medical studies and surveys. DESIGN: In 2 experimental survey studies (total N > 3,000) with participants from Germany and the United Kingdom, respectively, we varied the inclusion of a filter question on whether participants who tested positive for COVID-19 had experienced symptoms prior to presenting a checklist of symptoms. We measured the reporting of asymptomatic (versus symptomatic) COVID-19 infections. RESULTS: The inclusion of a filter question increased the reporting of asymptomatic (versus symptomatic) COVID-19 infections. Particularly mild symptoms were underreported when using a filter question. CONCLUSIONS AND IMPLICATIONS: Filter questions affect the reporting of (a)symptomatic COVID-19 cases. To account for such differences in the estimation of population infection rates, future studies should transparently report the applied question format. HIGHLIGHTS: Both symptomatic and asymptomatic infections are important for COVID-19 transmission dynamics.In previous research, symptoms have been assessed either with or without a filter question prior to presenting a symptom list.We show that filter questions reduce the reporting of asymptomatic infections.Particularly mild symptoms are underreported when using a filter question.

The association between vaccination status identification and societal polarization.

Public discord between those vaccinated and those unvaccinated for COVID-19 has intensified globally. Theories of intergroup relations propose that identifying with one's social group plays a key role in the perceptions and behaviours that fuel intergroup conflict. We test whether identification with one's vaccination status is associated with current societal polarization. The study draws on panel data from samples of vaccinated (n = 3,267) and unvaccinated (n = 2,038) respondents in Germany and Austria that were collected in December 2021 and February, March and July 2022. The findings confirm that vaccination status identification (VSI) explains substantial variance in a range of polarizing attitudes and behaviours. VSI was also related to higher psychological reactance toward mandatory vaccination policies among the unvaccinated. Higher levels of VSI reduced the gap between intended and actual counterbehaviours over time by the unvaccinated. VSI appears to be an important measure for predicting behavioural responses to vaccination policies.

Situational pathogen avoidance mediates the impact of social connectedness on preventive measures during the COVID-19 pandemic.

During the COVID-19 pandemic, physical distancing was one of the more important behaviours for reducing the spread of the virus. The present study investigated the influence on pathogen avoidance of familiarity with other people at private gatherings. Based on the social identity model of risk taking and the theory of the behavioural immune system, we assumed that greater familiarity with others would make people feel more connected with one another and decrease situational pathogen avoidance. This could result in lower perceptions of the risk of contracting COVID-19 and fewer protective behaviours. Two experiments (n1 = 1022, n2 = 994) showed that the negative influence of greater familiarity on the perceived risk of infection and protective behaviour is explained by an increased feeling of connectedness and less feeling of situational pathogen avoidance. In an additional survey, the participants (n = 23,023) rated the quality of their past social contacts. The correlational analyses showed that the familiarity of the other person was more important in explaining variance in protective behaviours than attitudes toward those behaviours or the pandemic situation itself. Understanding the process that result in an explosive increase in infection after social gatherings can improve infection control in the future.

Different Interventions for COVID-19 Primary and Booster Vaccination? Effects of Psychological Factors and Health Policies on Vaccine Uptake.

BACKGROUND: Mitigation of the COVID-19 pandemic requires continued uptake of SARS-CoV-2 vaccines. To increase vaccination intention and uptake, key determinants of primary and booster vaccination need to be understood and potential effects of vaccination policies examined. DESIGN: Using experimental data collected in Germany in February 2022 (N = 2701), this study investigated 1) predictors of primary and booster vaccination and 2) potential effects of policies combining vaccination mandates and monetary incentives. RESULTS: Compared with unvaccinated participants, those with primary vaccination were less complacent, more often understood the collective protection afforded by vaccination, and less often endorsed conspiracy-based misinformation. Compared with participants with primary vaccination, boosted individuals were even less complacent, exhibited fewer conspiracy-based beliefs, perceived fewer constraints by prioritizing vaccination over other things, and more often favored compliance with official vaccination recommendations. Support for and reactance about vaccination mandates depended on vaccination status rather than policy characteristics, regardless of mandate type or incentives (up to 500 EUR). While unvaccinated individuals rejected policy provisions and declined vaccination, boosted individuals indicated mid-level support for mandates and showed high vaccination intention. Among vaccinated individuals, higher incentives of up to 2000 EUR had a considerable positive effect on the willingness to get boosted, especially in the absence of a mandate. CONCLUSIONS: While mandates may be needed to increase primary vaccination, our results indicate that financial incentives could be an alternative to promote booster uptake. However, combining both measures for the same target group seems inadvisable in most cases. HIGHLIGHTS: Unvaccinated individuals and people with primary and booster vaccinations differ on psychological dimensions, calling for tailored immunization campaigns.Vaccination intentions depend on vaccination status rather than on mandatory or incentivizing policies.Incentives are unlikely to persuade unvaccinated individuals but may increase booster uptake.Positive effects of incentives decrease when vaccination is mandatory, advising against combination.

From delta to omicron: The role of individual factors and social context in self-reported compliance with pandemic regulations and recommendations.

As SARS-CoV-2 spreads especially when larger groups gather (e.g., at the workplace), it is crucial to understand compliance with regulations and recommendations in such settings. Using data from adults in Germany (N = 29,355) assessed between October 2021 and February 2022, we investigated factors associated with self-reported compliance in both private and working life and how these relate to each other. The results indicate that private compliance was stronger among older individuals and females; among those who worried more about the pandemic situation and assumed that infection was more severe; among those who trusted the government more; and among those who did not perceive public health measures as exaggerated. Private compliance was also associated with personality traits; in particular, individuals who followed regulations and recommendations were likely to be more introverted, conscientious, open, and agreeable. Compliance at work related to both private compliance and colleagues' behaviors. Individuals whose private compliance was high also complied at work. However, when private compliance was low, compliance at work aligned with colleagues' behaviors; that is, compliance at work was high when colleagues complied and low when they did not. The observed effects were stable over time. In summary, they suggest that compliance with regulations and recommendations depends on individual risk perception, trust in government, perception of required or recommended measures, and social norms. To promote protective behaviors in contexts where larger groups gather (including workplaces), making positive social norms more salient (e.g., by supporting role models) may prove especially useful.

Crowdsourcing interventions to promote uptake of COVID-19 booster vaccines.

Background: COVID-19 booster vaccine uptake rates are behind the rate of primary vaccination in many countries. Governments and non-governmental institutions rely on a range of interventions aiming to increase booster uptake. Yet, little is known how experts and the general public evaluate these interventions. Methods: We applied a novel crowdsourcing approach to provide rapid insights on the most promising interventions to promote uptake of COVID-19 booster vaccines. In the first phase (December 2021), international experts (n = 78 from 17 countries) proposed 46 unique interventions. To reduce noise and potential bias, in the second phase (January 2022), experts (n = 307 from 34 countries) and representative general population samples from the UK (n = 299) and the US (n = 300) rated the proposed interventions on several evaluation criteria, including effectiveness and acceptability, on a 5-point Likert-type scale. Findings: Sanctions were evaluated as potentially most effective but least accepted. Evaluations by expert and general population samples were considerably aligned. Interventions that received the most positive evaluations regarding both effectiveness and acceptability across evaluation groups were: a day off work after getting vaccinated, financial incentives, tax benefits, promotional campaigns, and mobile vaccination teams. Interpretation: The results provide useful insights to help governmental and non-governmental institutions in their decisions about which interventions to implement. Additionally, the applied crowdsourcing method may be used in future studies to retrieve rapid insights on the comparative evaluation of (health) policies. Funding: This study received funding from the Austrian Science Fund (SFB F63) and the University of Vienna.

Payments and freedoms: Effects of monetary and legal incentives on COVID-19 vaccination intentions in Germany.

Monetary and legal incentives have been proposed to promote COVID-19 vaccination uptake. To evaluate the suitability of incentives, an experiment with German participants examined the effects of payments (varied within subjects: 0 to 10,000 EUR) and freedoms (varied between subjects: vaccination leading vs. not leading to the same benefits as a negative test result) on the vaccination intentions of previously unvaccinated individuals (n = 782) in April 2021. While no effect could be found for freedoms, the share of participants willing to be vaccinated increased with the payment amount. However, a significant change required large rewards of 3,250 EUR or more. While monetary incentives could increase vaccination uptake by a few percentage points, the high costs of implementation challenge the efficiency of the measure and call for alternatives. As the data suggest that considering vaccination as safe, necessary, and prosocial increases an individual's likelihood of wanting to get vaccinated without payment, interventions should focus on these features when promoting vaccination against COVID-19.

A lay perspective on prioritization for intensive care in pandemic times: Vaccination status matters

During a pandemic, demand for intensive care often exceeds availability. Experts agree that allocation should maximize benefits and must not be based on whether patients could have taken preventive measures. However, intensive care units (ICUs) are often overburdened by individuals with severe COVID-19 who have chosen not to be vaccinated to prevent the disease. This article reports an experiment that investigated the German public's prioritization preferences during the fourth wave of the coronavirus pandemic (N?=?1014). In a series of scenarios, participants were asked to decide on ICU admission for patients who differed in terms of health condition, expected treatment benefits, and vaccination status. The results reveal an in-group bias, as vaccinated individuals preferred to allocate more resources to the vaccinated than to the unvaccinated. Participants also favored admitting a heart attack patient rather than a COVID-19 patient with the same likelihood of benefiting from ICU admission, indicating a preference for maintaining regular ICU services rather than treating those with severe COVID-19. Finally, participants were more likely to admit a patient to intensive care when this meant withholding rather than withdrawing care from another patient. The results indicate that lay prioritizations violate established allocation principles, presaging potential conflicts between those in need of intensive care and those who provide and allocate it. It is therefore recommended that allocation principles should be explained to enhance public understanding. Additionally, vaccination rates should be increased to relieve ICUs and reduce the need for such triage decisions.

Attitude toward a mandatory COVID-19 vaccination policy and its determinants: Evidence from serial cross-sectional surveys conducted throughout the pandemic in Germany.

BACKGROUND: Mandating vaccination against COVID-19 is often discussed as a means to counter low vaccine uptake. Beyond the potential legal, ethical, and psychological concerns, a successful implementation also needs to consider citizens' support for such a policy. Public attitudes toward vaccination mandates and their determinants might differ over time and, hence, should be monitored. METHODS: Between April 2020 and April 2021, we investigated public support for mandatory vaccination policies in Germany and examined individual correlates, such as vaccination intentions, confidence in vaccine safety, and perceived collective responsibility, using a series of cross-sectional, quota-representative surveys (overall N = 27,509). RESULTS: Support for a vaccination mandate declined before the approval of the first vaccine against COVID-19 in December 2020 and increased afterwards. However, at the end of April 2021, only half of respondents were in favor of mandatory regulations. In general, mandates were endorsed by those who considered the vaccines to be safe, anticipated practical barriers, and felt responsible for the collective. On the contrary, perceiving vaccination as unnecessary and weighing the benefits and risks of vaccination was related to lower support. Older individuals and males more often endorsed vaccination mandates than did younger participants and females. Interestingly, there was a gap between vaccination intentions and support for mandates, showing that the attitude toward mandatory vaccination was not only determined by vaccination-related factors such as vaccine safety or prosocial considerations. CONCLUSIONS: Because of low public support, mandatory vaccination against COVID-19 should be considered a measure of last resort in Germany. However, if removing barriers to vaccination and educational campaigns about vaccine safety and the societal benefits of high vaccination uptake are not sufficient for increasing vaccination uptake to the required levels, mandates could be introduced. In this case, measures to ensure and increase acceptance and adherence should be taken.

Caregivers' Willingness to Vaccinate Their Children against Childhood Diseases and Human Papillomavirus: A Cross-Sectional Study on Vaccine Hesitancy in Malawi.

BACKGROUND: Vaccines are among the most effective and cost-efficient public health interventions for promoting child health. However, uptake is considerably affected by vaccine hesitancy. An example is Malawi, with a decline in second vaccine doses and the highest cervical cancer incidence and mortality rate in Sub-Saharan Africa. Understanding vaccine hesitancy is especially important when new vaccines are introduced. This study explores factors contributing to vaccine hesitancy for routine childhood immunization and the human papillomavirus vaccine in Malawi. METHODS: The study used a cross-sectional survey design targeting caregivers of children under five years old and adolescent girls. The sample population was derived using three inclusion criteria: one district with low vaccine uptake (Dowa), one district with high vaccine uptake (Salima), and one district where human papillomavirus vaccine was piloted earlier (Zomba). A convenience sample of one primary and one secondary health facility was selected within each district, and participants were systematically included (n = 600). The measures were based on 5C scale for measuring vaccine hesitancy. Multiple regression analyses were performed to explore vaccination intention predictors. RESULTS: Confidence in vaccine safety was the strongest predictor of routine childhood immunization, followed by constraints due to everyday stress. Caregivers had lower confidence in vaccine safety and efficacy when they believed rumors and misinformation and were unemployed. Confidence was higher for those who had more trust in healthcare workers. Age, gender, religion, education, employment, belief in rumors, and trust in healthcare workers were considered predictors of vaccination intention. A husband's positive attitude (approval) increased childhood vaccination intention. For human papillomavirus, vaccination intentions were higher for those with lower education, more trust in healthcare workers, lower complacency, and a lower tendency toward calculating the benefits and risks of vaccination. Knowledge of human papillomavirus did not increase vaccination intention, but the need to attain a husband's approval did. Being a young adult and unemployed increased belief in rumors, while trust in healthcare workers reduced the belief. CONCLUSIONS: This study provides good insights into the drivers of vaccine hesitancy across different contexts in Malawi. However, further studies are necessary to understand low risk perception among elderly people and the declining trend in second vaccine doses.

Money is not everything: experimental evidence that payments do not increase willingness to be vaccinated against COVID-19.

Rapid, large-scale uptake of new vaccines against COVID-19 will be crucial to decrease infections and end the pandemic. In a recent article in this journal, Julian Savulescu argued in favour of monetary incentives to convince more people to be vaccinated once the vaccine becomes available. To evaluate the potential of his suggestion, we conducted an experiment investigating the impact of payments and the communication of individual and prosocial benefits of high vaccination rates on vaccination intentions. Our results revealed that none of these interventions or their combinations increased willingness to be vaccinated shortly after a vaccine becomes available. Consequently, decision makers should be cautious about introducing monetary incentives and instead focus on interventions that increase confidence in vaccine safety first, as this has shown to be an especially important factor regarding the demand for the new COVID-19 vaccines.

Attitudes towards the economic costs associated with measures against the spread of COVID-19: Population perceptions from repeated cross-sectional data of the nationally representative COVID-19 Snapshot Monitoring in Germany (COSMO).

INTRODUCTION: Our aim was to examine attitudes of the general population towards reasonableness of these costs, as well as the degree to which these costs are shared across society (solidarity financing) and to determine the factors associated with them. METHOD: Repeated cross-sectional data from a nationally representative online-survey. More precisely, data from wave 8 (21-22 April 2020) and wave 16 (7-8 July 2020) were used (in wave 8: analytical sample with n = 976, average age was 47.0 years (SD: 15.3 years), ranging from 18 to 74 years, 51.8% female; in wave 16: analytical sample with n = 978, average age was 46.1 years (SD: 15.9 years), ranging from 18 to 74 years, 50.9% female). After a short introduction emphasizing considerable economic costs associated with the measures against the spread of the coronavirus, individuals were asked to rate the following statements (outcome measures), in each case from 1 = strongly disagree to 7 = strongly agree: "These economic costs are currently reasonable in relation to the objective pursued" (reasonableness of costs), "These economic costs should be borne jointly by all citizens and depending on income" (solidarity financing). RESULTS: In wave 8 (wave 16 in parentheses), the average rating for the attitude towards reasonableness of costs was 4.3, SD: 1.8 (wave 16, average: 4.2, SD: 1.8) and the average rating for the attitude towards solidarity financing was 3.7, SD: 1.9 (wave 16, average: 3.3, SD: 2.0). In wave 8, more positive attitudes towards the reasonableness of costs and solidarity financing were associated with being male, higher education, not being in a partnership/being unmarried, higher affect regarding COVID-19 and higher presumed severity with respect to COVID-19. Furthermore, more positive attitudes towards the reasonableness of costs were associated with having a migration background. More positive attitudes towards solidarity financing was associated with higher age groups. Mainly similar findings were observed in wave 16. DISCUSSION: Agreement with reasonableness of costs of preventative measures as well as solidarity financing was moderately high. Knowledge of these attitudes is important to ensure social cohesion during the fight against COVID-19.

The four weeks before lockdown during the COVID-19 pandemic in Germany: a weekly serial cross-sectional survey on risk perceptions, knowledge, public trust and behaviour, 3 to 25 March 2020.

BackgroundDuring the COVID-19 pandemic, public perceptions and behaviours have had to adapt rapidly to new risk scenarios and radical behavioural restrictions.AimTo identify major drivers of acceptance of protective behaviours during the 4-week transition from virtually no COVID-19 cases to the nationwide lockdown in Germany (3-25 March 2020).MethodsA serial cross-sectional online survey was administered weekly to ca 1,000 unique individuals for four data collection rounds in March 2020 using non-probability quota samples, representative of the German adult population between 18 and 74 years in terms of age × sex and federal state (n = 3,910). Acceptance of restrictions was regressed on sociodemographic variables, time and psychological variables, e.g. trust, risk perceptions, self-efficacy. Extraction of homogenous clusters was based on knowledge and behaviour.ResultsAcceptance of restrictive policies increased with participants' age and employment in the healthcare sector; cognitive and particularly affective risk perceptions were further significant predictors. Acceptance increased over time, as trust in institutions became more relevant and trust in media became less relevant. The cluster analysis further indicated that having a higher education increased the gap between knowledge and behaviour. Trust in institutions was related to conversion of knowledge into action.ConclusionIdentifying relevant principles that increase acceptance will remain crucial to the development of strategies that help adjust behaviour to control the pandemic, possibly for years to come. Based on our findings, we provide operational recommendations for health authorities regarding data collection, health communication and outreach.

Willingness to bear economic costs of measures against SARS-CoV-2 in Germany.

BACKGROUND: The aim of this study was to assess the willingness of the general population in Germany to bear the economic costs of measures against the spread of SARS-CoV-2. METHODS: Repeated cross-sectional data were taken from three waves of a nationally representative survey of individuals aged 18 to 74 years (wave 8: 21-22 April 2020, N = 976; wave 16: 7-8 July 2020, N = 977; wave 38: 9-10 March 2021). The willingness to accept a reduction of annual household income in order to bear the economic costs of the measures against SARS-CoV-2 served as outcome measure. Two-part models were used including explanatory variables on sociodemographic and (subjectively assessed) potential health hazard caused by COVID-19. RESULTS: 65.5% (61.6%; 56.9%) of respondents in wave 8 (wave 16; wave 38) were willing to accept a reduction of income, with the likelihood for accepting a reduction of income being positively associated with higher affect (i.e. emotional reaction) and presumed severity regarding COVID-19 in all three waves. The mean maximum percentage of income participants were willing to give up was 3.3% (95% CI: 2.9 to 3.7%) in wave 8, 2.9% (95% CI: 2.5 to 3.3%) in wave 16 and 4.3% (95% CI: 3.6 to 5.0%) in wave 38, with presumed severity of COVID-19 being positively associated with this percentage in all three waves. CONCLUSIONS: The majority of respondents indicated willingness to sacrifice income in order to bear the costs of measures against the spread of SARS-CoV-2, with the potential health hazard caused by COVID-19 being consistently associated with this willingness. However, the proportion of individuals who were willing to give up income slightly decreased throughout the pandemic.

Vaccination policy reactance: Predictors, consequences, and countermeasures.

Ending the COVID-19 pandemic will require rapid large-scale uptake of vaccines against the disease. Mandating vaccination is discussed as a suitable strategy to increase uptake. In a series of cross-sectional quota-representative surveys and two preregistered experiments conducted in Germany and the US (total N = 4629), we investigated (i) correlates of individual preferences for mandatory (vs voluntary) COVID-19 vaccination policies; (ii) potential detrimental effects of mandatory policies; and (iii) interventions potentially counteracting them. Results indicate that reactance elicited by mandates can cause detrimental effects, such as decreasing the intention to vaccinate against influenza and adhere to COVID-19 related protective measures.

Protective and Risk Factors for Mental Distress and Its Impact on Health-Protective Behaviors during the SARS-CoV-2 Pandemic between March 2020 and March 2021 in Germany.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is posing a global public health burden. These consequences have been shown to increase the risk of mental distress, but the underlying protective and risk factors for mental distress and trends over different waves of the pandemic are largely unknown. Furthermore, it is largely unknown how mental distress is associated with individual protective behavior. Three quota samples, weighted to represent the population forming the German COVID-19 Snapshot Monitoring study (24 March and 26 May 2020, and 9 March 2021 with >900 subjects each), were used to describe the course of mental distress and resilience, to identify risk and protective factors during the pandemic, and to investigate their associations with individual protective behaviors. Mental distress increased slightly during the pandemic. Usage of cognitive reappraisal strategies, maintenance of a daily structure, and usage of alternative social interactions decreased. Self-reported resilience, cognitive reappraisal strategies, and maintaining a daily structure were the most important protective factors in all three samples. Adherence to individual protective behaviors (e.g., physical distancing) was negatively associated with mental distress and positively associated with frequency of information intake, maintenance of a daily structure, and cognitive reappraisal. Maintaining a daily structure, training of cognitive reappraisal strategies, and information provision may be targets to prevent mental distress while assuring a high degree of individual protective behaviors during the COVID-19 pandemic. Effects of the respective interventions have to be confirmed in further studies.

Good night: Experimental evidence that nighttime curfews may fuel disease dynamics by increasing contact density.

BACKGROUND: Nighttime curfews have been discussed and implemented in many countries as a means of controlling the COVID-19 pandemic. However, there is evidence that such curfews have little or no effect on disease dynamics when other measures such as bans on gatherings or business and school closures are already in place. There are two possible explanations for this. First, nighttime curfews may elicit reactance-a feeling of anger that drives non-adherence; second, nighttime curfews may motivate people to shift activities from night to daytime, thereby increasing contact density. METHODS: A survey experiment was conducted with German participants (N = 997) to investigate public perceptions of nighttime curfews and possible detrimental effects on contact behaviors. RESULTS: Most participants perceived nighttime curfews as ineffective. The introduction of a hypothetical curfew did not affect intentions to reduce private contacts but instead elicited reactance, motivating participants to violate curfew hours or to shift a fictitious dinner meeting to an earlier time rather than cancelling it. CONCLUSIONS: When people do not support nighttime curfews or do not understand the rationale behind them, introduction of this measure may fuel the spread of the disease. For that reason, nighttime curfews should be a measure of last resort and should be accompanied by a public communication campaign explaining the importance of contact reduction during both nighttime and daylight hours.