Abstract
In this online survey of 1,733 US adults in December-2021, respondents believed COVID-19 vaccines are less beneficial and less safe for someone who had already had COVID-19. Those who experienced COVID-19 after being vaccinated believed that the vaccines are less beneficial and less safe than those who had not. Findings highlight the need to better communicate evolving evidence of COVID-19 vaccine benefit and safety and to tailor communications to peoples’ COVID-19 history and vaccination status.
Keywords: COVID-19, vaccine uptake, Health Behavior
Graphical abstract
Introduction
COVID-19 vaccinations significantly reduce disease severity, hospitalizations, and deaths,1 but as of April 2023, 30% of the population have not been vaccinated with primary doses and 83% of those eligible have not received a booster dose.2 Perceptions about the benefit and safety of COVID-19 vaccines are important determinants of vaccine uptake3 and therefore represent an important area of research. This remains particularly important given that research evidence regarding the protection against COVID-19 offered via different types of immunity (e.g., infection-induced/vaccine-induced/hybrid) is ever-changing.4 However, public perceptions of this changing body of evidence and the extent to which they may influence vaccination perceptions and intentions has been understudied.
In this study, we examined whether people think COVID-19 vaccination is less beneficial or safe for someone who has already had COVID-19 compared to someone who has not. We also examined whether COVID-19 vaccine benefit and safety perceptions and intentions (for primary and booster doses) vary based on a person’s own COVID-19 infection history and vaccination status.
Methods
We conducted an English-language, online survey, which was deemed exempt by the University of Utah IRB and follows AAPOR guidelines. Respondents were enrolled and compensated by Qualtrics (December 8–23, 2021).5
Respondents first self-reported their COVID-19 infection history and vaccination status. Unvaccinated respondents reported their intentions to receive a COVID-19 vaccine. Respondents who were eligible for, but had not received, a booster vaccine reported their intentions to receive a booster vaccine. Vaccinated respondents with prior COVID-19 infection reported when they had COVID-19 relative to their primary vaccination series. Next, all respondents reported their perceptions of the benefit and safety of a COVID-19 vaccine for “a person who had already had COVID-19” and “a person who had not had COVID-19” (hereafter referred to as “for someone else with prior COVID-19 infection” and “for someone else without prior COVID-19 infection”). The rest of the survey contained items for unrelated studies, individual differences, and demographics.5
We first compared within-respondents perceptions of the benefit and safety of COVID-19 vaccination for someone else with prior COVID-19 infection vs. for someone else without prior COVID-19 infection. Among vaccinated respondents, we compared benefit and safety perceptions between-respondents based on whether they reported having experienced COVID-19 post-vaccination or not. Next, we conducted between-respondent comparisons for COVID-19 vaccination intentions among unvaccinated respondents (based on whether they had experienced COVID-19 or not) and booster intentions among respondents eligible for one (based on whether they had experienced COVID-19 post-vaccination or not). Analyses were conducted using R-Studio Version-1.4.1106; these are secondary analyses from a larger study5 and were not preregistered.6
Results
Our sample (n=1,733) had a mean age of 41±15 years, 66.4% were non-Hispanic White, and 66.0% were female. Half (53.1%) of respondents reported having received ≥1 dose of a COVID-19 vaccine and 27.6% reported prior COVID-19 infection. Full sample characteristics are reported elsewhere.5
Within-respondents comparison: Respondents’ benefit/safety perceptions of COVID-19 vaccination for someone else with prior COVID-19 infection vs. for someone else without Across all respondents, COVID-19 vaccination was seen as less beneficial and less safe for someone else with prior history of COVID-19 infection than for someone else without prior COVID-19 infection (Figure 1). Over 40% of respondents felt that a COVID-19 vaccine did not even offer a moderate benefit for someone else with prior history of COVID-19 infection and 30% felt that a COVID-19 vaccine was unsafe.
Figure 1.
Within-respondents comparisons of COVID-19 vaccine benefit (N=1367) and safety perceptions (N=1280) for someone else with and without prior COVID-19 infection shown both as mean differences and as proportions.
Between-respondents comparison 1: Vaccinated respondents’ benefit/safety perceptions of COVID-19 vaccination according to the respondents’ COVID-19 infection history Vaccinated respondents who had personally experienced COVID-19 post-vaccination perceived COVID-19 vaccines as less beneficial and less safe for someone else compared to vaccinated respondents who had not personally experienced COVID-19 post-vaccination (Table 1). This was found both when asking about COVID-19 vaccination for someone else with prior COVID-19 infection and for someone else without prior COVID-19 infection.
Table 1.
Between-respondents comparisons of COVID-19 vaccine benefit and safety perceptions among vaccinated respondents only (December 2021).
| Group 1: Had personally experienced | Group 2: Had not personally experienced | Mean difference estimate (95% CIs) | ||
|---|---|---|---|---|
| COVID-19 post-vaccination (n=78) a | COVID-19 post-vaccination b (n=653) | |||
| Perceived benefit of a COVID-19 | ||||
| vaccine… | ||||
| For someone else without a prior COVID-19 infection |
3.28±0.92 | vs | 3.58±0.74 | −0.31 (−0.53 to −0.09) |
| For someone else with a prior COVID-19 infection |
2.89±1.00 | vs | 3.36±0.90 | −0.48 (−0.72 to −0.23) |
| Perceived safety of a COVID-19 | ||||
| vaccine… | ||||
| For someone else without a prior COVID-19 infection |
3.27±0.93 | vs | 3.61±0.63 | −0.34 (−0.55 to −0.12) |
| For someone else with a prior COVID-19 infection |
3.19±0.89 | vs | 3.50±0.64 | −0.31 (−0.53 to −0.09) |
Response scales: for benefit questions (1=No benefit at all, 2=A small benefit, 3=A moderate benefit, 4=A lot of benefit), for safety questions (1=Very unsafe, 2=Unsafe, 3=Safe, 4=Very safe)
Plus–minus values are means ±SD. Confidence intervals which do not include zero are highlighted with bolded text.
Group includes vaccinated respondents who experienced COVID-19 post-vaccination and those who experienced COVID-19 both pre-vaccination and post-vaccination.
Group includes vaccinated respondents who had not personally experienced COVID-19 and those who experienced COVID-19 pre-vaccination. We did not conduct comparisons with respondents who were unsure of their COVID-19 history or who reported having had COVID-19 pre-and-post vaccine due to low numbers in these sub-groups.
Between-respondents comparison 2: Respondents’ vaccine intentions according to the respondents’ COVID-19 infection history There were no statistically significant differences in unvaccinated respondents’ primary dose COVID-19 vaccine intentions based on whether they had experienced COVID-19 or not (M=2.08±1.30 vs. 1.91±1.24, difference, 0.16[95%CI, −0.04 to 0.37]) or in respondents’ booster vaccination intentions based on whether they had experienced COVID-19 post-vaccination or not (M=3.96 ±1.19 vs. 4.12±1.12, difference, −0.17[95%CI, −0.54 to 0.20]). (Appendix).
Discussion
Our findings suggest that US adults believe that COVID-19 vaccines are less beneficial and less safe for someone who has already had a COVID-19 infection. Vaccinated respondents who personally experienced COVID-19 post-vaccination perceived the vaccine as less beneficial and less safe than those who had not. Intentions to receive primary and booster doses among those eligible did not differ based on the respondents’ prior COVID-19 infection history, possibly due to stronger or more immediate influences of other demographic or cognitive factors.
Limitations of this study include a non-representative sample from an online survey. In addition, further information regarding the characteristics of the potential vaccine recipient (e.g., their age or health status) and other contextual information such as the type (i.e., SARS-CoV-2 variant), timing, and severity of prior infection might also influence vaccine perceptions and intentions but were not assessed.
Despite these limitations, there are several important public health implications. Evidence indicates that COVID-19 vaccination is highly beneficial, including for individuals who have previously experienced COVID-19.4,7 To address low uptake, these findings highlight the need to more effectively communicate changes in clinical understanding of COVID-19 immunity as the public appear to underestimate the benefits and safety of COVID-19 vaccination for those who have had a COVID-19 infection.8,9 These findings also speak to the importance of tailoring communications to peoples’ COVID-19 history and vaccination status.
Furthermore, the lower benefit and safety perceptions reported by respondents who experienced COVID-19 post-vaccination are an important reminder for health communicators not to overstate the efficacy of COVID-19 vaccination. Misperceptions about the protection offered by COVID-19 vaccination, perhaps heightened by overoptimistic vaccine-related health communications, may explain why those who experienced a COVID-19 infection post-vaccination were less positive about the benefit and safety of the vaccines afterwards. Moving forward, communicators should be mindful not to convey overoptimistic information about vaccine efficacy when promoting vaccines for COVID-19 and other diseases.8–10
Supplementary Material
Funding:
Dr. ---- was supported in part by grant No. 51300302 from the American Heart Association Children’s Strategically Focused Research Network fellowship. Dr. ---- was supported by a K01 (1K01AG065440-2) awarded from the National Institute on Aging/National Institutes of Health. Funding for the study was provided by Dr. ----.
Footnotes
Conflicts of interest: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Ethics: This study was approved (deemed exempt) by the ------- IRB by (Ref: IRB_00147032)
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Data availability statement:
The data underlying this article will be shared on reasonable request to the corresponding author.
References
- 1.Accorsi EK, Britton A, Fleming-Dutra KE, et al. Association between 3 doses of mRNA COVID-19 vaccine and symptomatic infection caused by the SARS-CoV-2 Omicron and Delta variants. Jama. 2022;327(7):639–651. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.CDC. COVID Data Tracker Weekly Review. Centers for Disease Control and Prevention. Published November 4, 2022. Accessed April 22, 2023. https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html [Google Scholar]
- 3.Paul E, Steptoe A, Fancourt D. Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. The Lancet Regional Health – Europe. 2021;1. doi: 10.1016/j.lanepe.2020.100012 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Sette A, Crotty S. Immunological memory to SARS-CoV-2 infection and COVID-19 vaccines. Immunological Reviews. 2022;310(1):27–46. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Levy AG, Thorpe A, Scherer LD, et al. Misrepresentation and nonadherence regarding covid-19 public health measures. JAMA Network Open. 2022;5(10):e2235837-e2235837. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Althouse AD. Adjust for Multiple Comparisons? It’s Not That Simple. The Annals of Thoracic Surgery. 2016;101(5):1644–1645. doi: 10.1016/j.athoracsur.2015.11.024 [DOI] [PubMed] [Google Scholar]
- 7.Cavanaugh AM. Reduced Risk of Reinfection with SARS-CoV-2 After COVID-19 Vaccination — Kentucky, May–June 2021. MMWR Morb Mortal Wkly Rep. 2021;70. doi: 10.15585/mmwr.mm7032e1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Han PKJ, Scharnetzki E, Scherer AM, et al. Communicating Scientific Uncertainty About the COVID-19 Pandemic: Online Experimental Study of an Uncertainty-Normalizing Strategy. J Med Internet Res. 2021;23(4):e27832. doi: 10.2196/27832 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Gretton JD, Meyers EA, Walker AC, Fugelsang JA, Koehler DJ. A brief forewarning intervention overcomes negative effects of salient changes in COVID-19 guidance. Judgment & Decision Making. 2021;16(6). [Google Scholar]
- 10.Thorpe A, Fagerlin A, Drews FA, et al. Communications to Promote Interest and Confidence in COVID-19 Vaccines. Am J Health Promot. 2022;36(6):976–986. doi: 10.1177/08901171221082904 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article will be shared on reasonable request to the corresponding author.