Discussion

In this study, more than half of the participants indicated they would not hesitate to get vaccinated when necessary. In a study conducted among U.S. adults, half of the participants showed no hesitancy toward COVID-19 vaccines or vaccines (Nguyen et al., Reference Nguyen, Chung, McChesney, Vasudevan, Allen and Bednarczyk2024). While most people (55–75%) had a positive attitude toward vaccines, the exact prevalence of indecision remains unclear (Kader, Reference Kader2019).

Vaccination intent was higher among men, individuals aged 65 and older, university graduates (compared to high school graduates), those whose income exceeded their expenses, and those taking medications. No statistically significant difference was found regarding vaccination intent related to employment status, the presence of chronic illness, family history of chronic disease, or perceived health status. However, in the multivariate analysis, the only sociodemographic feature that stood out was having an income higher than expenses.

The higher vaccination intent among older individuals than younger adults may stem from concerns that their natural immunity might not sufficiently protect them from infectious diseases or from being less likely to encounter misinformation online.

In a large-scale study examining vaccination attitudes in 67 countries, socioeconomic status and income were found to influence vaccination intent, which is consistent with the findings of this study. Similarly, individuals from lower-income groups had less favorable attitudes toward vaccines than higher-income groups. People aged 65 and older were more likely to report that vaccines were effective. Holding a master’s or doctoral degree – considered the highest level of education – was not associated with more positive views on vaccine importance and effectiveness when compared to those with no education. (Larson et al., Reference Larson, de Figueiredo, Xiahong, Schulz, Verger, Johnston, Cook and Jones2016)

The study found no difference in vaccination intent between university and primary school graduates. However, individuals with university or higher education levels had greater vaccination intent compared to high school graduates. It is believed that those with lower education levels tend to accept health professionals’ vaccine recommendations without question; in contrast, university graduates and those with higher education are less indecisive because they base their vaccination decisions on reliable information. Individuals with intermediate education levels may research vaccines but struggle to distinguish accurate information from misinformation.

Existing research shows that in studies conducted in the United Arab Emirates and Saudi Arabia, participants with higher education levels were more skeptical of vaccines (Alsubaie et al., Reference Alsubaie, Gosadi, Alsaadi, Albacker, Bawazir, Bin-Daud, Almanie, Alsaadi and Alzamil2019; Nour et al., Reference Nour, Powell, Alnakhi, Mamdouh, Zidoun, Hussain, Al Suwaidi and Zary2022). A broad research found that higher education was a potential barrier to vaccination in China, Lebanon, Israel, Bangladesh, and the United States. In contrast, studies conducted in the Netherlands, Nigeria, Pakistan, and Greece showed that higher education was associated with greater support for vaccination (WHO Report of the Sage Working Group on Vaccine Hesitancy, 2014).

In Greece, vaccine hesitancy was associated with certain sociodemographic characteristics such as age, place of residence, education level, and individual annual income (Gialama et al., Reference Gialama, Kleisiaris, Malliarou, Papagiannis, Papathanasiou, Karavasileiadou, Almegewly and Tsaras2024). Other studies investigating vaccine hesitancy in various countries confirmed the relationship between age, education level, and hesitancy (Mohd Azizi et al., Reference Mohd Azizi, Kew and Moy2017; Sasse et al., Reference Sasse, Mahabir, Gkountouna, Crooks and Croitoru2024).

In a study among Asian Americans living in New Jersey, no statistically significant relationship was found between vaccine hesitancy and education level, employment status, employment type, or household income. However, men were found to be less likely than women to exhibit vaccine hesitancy (Rana et al., Reference Rana, Jimenez, Khan and Narayanan2024).

In a study representative of the French adult population, similar to the current study, the male gender was associated with the ‘non-hesitant’ group. These findings confirm that men tend to have more positive attitudes toward vaccines, while women are more likely to be hesitant (Khoury et al., Reference Khoury, Ward, Mancini, Gagneux-Brunon and Luong Nguyen2024).

In the multivariate model, having an income higher than expenses emerged as an essential factor. Previous research on per capita income has reported higher vaccine hesitancy among lower-income groups than their higher-income counterparts (Hughes et al., Reference Hughes, Wang, Grossman, Pun, Whiteman, Deng, Hallisey, Sharpe, Ussery, Stokley, Musial, Weller, Murthy, Reynolds, Gibbs-Scharf, Harris, Ritchey and Toblin2021; Guo et al., Reference Guo, Kaniuka, Gao and Sims2022; Sasse et al., Reference Sasse, Mahabir, Gkountouna, Crooks and Croitoru2024).

Individuals with higher socioeconomic status may have access to more accurate health information or know how to access reliable sources better. Even if vaccines are free, indirect costs like taking time off work or traveling to a vaccination site could deter some from getting vaccinated. Income inequality likely affects people’s health-related attitudes and decision-making processes.

Vaccination intent was higher among those who had received the COVID-19 vaccine, those who had at least one flu shot, those not afraid of injections, and those who had persuaded a hesitant relative to get vaccinated.

In the multivariate model, receiving the COVID-19 vaccine emerged as the most significant determinant of general vaccination intent. This aligns with findings from Aggarwal et al., highlighting that vaccination behaviors during the COVID-19 pandemic remain crucial for understanding vaccine hesitancy and its behavioral determinants (Aggarwal et al., Reference Aggarwal, Singh, Alam, Sharma, Saroj, Zaman, Usman, Kant and Chaturvedi2024).

In a study by Yang et al., which evaluated the relationship between vaccine hesitancy and vaccination behavior, individuals with vaccine hesitancy had a higher risk of not getting vaccinated than non-hesitant individuals (Yang et al., Reference Yang, Shi, Liu, Zhang, Miao and Jin2024).

Approximately 8 out of every 10 participants reported using the internet, and 6 out of 10 indicated they used it to access information about vaccines. The most frequently consulted sources of vaccine information were health professionals and the internet. Vaccination intent was higher among those who did not use the internet to find vaccine information, those who did not actively use social media, and those who primarily relied on health professionals for vaccine-related information.

In a study by Alzahrani et al., similar to this study, the most common sources of vaccine information were reported to be doctors, the internet, and social media. The study found a significant difference in vaccine hesitancy rates depending on the information sources (Alzahrani and Alghamdi, Reference Alzahrani and Alghamdi2023). Skafle et al. synthesized the results of 19 studies measuring the impact of misinformation on social media and concluded that social media content negatively influenced vaccine hesitancy and uptake (Skafle et al., Reference Skafle, Nordahl-Hansen, Quintana, Wynn and Gabarron2022). Other studies have also found that individuals who rely on social media for vaccine information are more likely to be hesitant (Dambadarjaa et al., Reference Dambadarjaa, Altankhuyag, Chandaga, Khuyag, Batkhorol, Khaidav, Dulamsuren, Gombodorj, Dorjsuren, Singh, Nyam, Otganbayar and Tserennadmid2021; Horiuchi et al., Reference Horiuchi, Sakamoto, Abe, Shinohara, Kushima, Otawa, Yui, Akiyama, Ooka, Kojima, Yokomichi, Miyake, Mizutani and Yamagata2021; Al-Amer et al., Reference Al-Amer, Maneze, Everett, Montayre, Villarosa, Dwekat and Salamonson2022; Brackstone et al., Reference Brackstone, Marzo, Bahari, Head, Patalinghug and Su2022; Alzahrani and Alghamdi, Reference Alzahrani and Alghamdi2023; Aleksandric et al., Reference Aleksandric, Dangal, Nilizadeh and Mustata Wilson2024).

In a study by Huang et al., vaccine hesitancy was lower among those who received clinical recommendations, consistent with this study’s findings (Huang et al., Reference Huang, Su, Xiao, Wang, Si, Wang, Gu, Ma, Li, Zhang, Yang, Yu and Qiao2022).

In a study by Nikoloski et al., individuals who were hesitant about vaccination had less trust in healthcare workers and relied more on social media for COVID-19-related information. Those who received information from healthcare providers were more likely to get vaccinated; however, hesitant individuals relied more on private healthcare providers, social media, and the internet for information (Nikoloski et al., Reference Nikoloski, Aliyev, Bain, Menchini, Hegazi, Zalkha, Mouawad, Kapil and Gillespie2023).

Unlike traditional media, social media allows individuals to rapidly create and share content globally without editorial oversight, which can lead to the rapid spread of misinformation (Puri et al., Reference Puri, Coomes, Haghbayan and Gunaratne2020). The spread of misinformation undermines trust in science and contributes to increasing vaccine hesitancy (Huang et al., Reference Huang, Su, Xiao, Wang, Si, Wang, Gu, Ma, Li, Zhang, Yang, Yu and Qiao2022; Kosiyaporn et al., Reference Kosiyaporn, Netrpukdee, Pangkariya, Chandrasiri and Tangcharoensathien2023; Ugarte and Young, Reference Ugarte and Young2023). Many people lack adequate health and digital literacy when searching for reliable health information, and social and economic inequalities exacerbate this (Kbaier et al., Reference Kbaier, Kane, McJury and Kenny2024). To reduce the impact of social media and the internet on vaccine intent, improving individuals’ ability to find, understand, evaluate, and apply vaccine-related information online – known as digital vaccine literacy – is crucial.

When evaluating the psychological factors affecting vaccine attitudes and behaviors, it was found that those who would not hesitate to get vaccinated, those who had received the COVID-19 vaccine, and those who had been vaccinated for the flu had higher confidence and collective responsibility scores, while their complacency scores were lower. Interestingly, general vaccination intent was associated with lower calculation scores, while COVID-19 vaccine recipients had lower constraint scores.

Van de Berg et al.’s assessment of the 5C psychological factors related to COVID-19 vaccination suggested that interventions to increase COVID-19 vaccination coverage should address confidence and complacency (van de Berg et al., Reference van de Berg, Coyer, von Both, Scheuerer, Kolberg, Hoch and Böhmer2024). In studies conducted in other countries, collective responsibility (Alenezi et al., Reference Alenezi, Alarabi, Al-Eyadhy, Aljamaan, Elbarazi, Saddik, Alhasan, Assiri, Bassrawi, Alshahrani, Alharbi, Fayed, Minhaj Ahmed, Halwani, Saad, Alsubaie, Barry, Memish, Al-Tawfiq and Temsah2022) and calculation (Wagner et al., Reference Wagner, Liberatore, Schmelzer and Dratva2022) were found to influence vaccination and intent, respectively. This highlights the importance of evaluating vaccination determinants specific to each region, as different psychological factors may have varying impacts across societies. While confidence and complacency commonly influence vaccine attitudes and behaviors, the effects of collective responsibility and calculation may differ across communities.

In a study by Sanftenberg et al., no significant relationship was found between the psychological factors of vaccination and seasonal flu or pneumococcal vaccination. However, confidence, complacency, and constraints were influential factors for COVID-19 vaccination (Sanftenberg et al., Reference Sanftenberg, Bader, Rottenkolber, Sebastiao, Kühlein, Eidenschink, Gágyor, Wildgruber, Hausen, Janke, Hoelscher, Teupser, Dreischulte and Gensichen2024). Studies suggest that different psychological factors may play a role in each vaccine. Unlike Sanftenberg et al., this study found that the psychological factors influencing general vaccination intent were similar to those influencing flu vaccination, except that COVID-19 vaccination was significantly affected by the constraints factor. These constraints could be related to the impact of the pandemic on healthcare services and the initial lack of an available vaccine.

In the multivariate analysis evaluating factors influencing vaccination intent, psychological factors – rather than demographic variables – were significant predictors of vaccine intent. Increases in confidence and collective responsibility were associated with higher vaccination intent, while higher calculation scores were linked to lower intent. Although complacency was statistically significant in the binary comparison, it did not retain significance in the multivariate model and was therefore not included in the final reported results. Receiving the COVID-19 vaccine, having a high socioeconomic status, and not actively using social media were other significant predictors of non-hesitant vaccination.

The existing literature, like this study, shows that individuals’ trust in vaccines and their sense of responsibility to prevent the spread of disease meaningfully increase vaccination intent. The 5C model supports that psychological factors such as ‘Confidence’ and ‘Collective Responsibility’ are key to reducing vaccine hesitancy. In these studies, participants had confidence in the safety and efficacy of vaccines and were motivated by a sense of social responsibility and collective action to reduce infection within their communities (Paterson et al., Reference Paterson, Meurice, Stanberry, Glismann, Rosenthal and Larson2016; Chaturvedi et al., Reference Chaturvedi, Gellner and Pandey2019; Dhalaria et al., Reference Dhalaria, Arora, Singh, Mathur and S2022; Limbu and Gautam, Reference Limbu and Gautam2023; Aggarwal et al., Reference Aggarwal, Singh, Alam, Sharma, Saroj, Zaman, Usman, Kant and Chaturvedi2024).

Confidence is a prominent psychological factor influencing vaccine attitudes and behaviors, appearing in nearly every related study. Interventions designed to enhance trust can foster positive perceptions of vaccines by boosting confidence in their safety and effectiveness (Betsch et al., Reference Betsch, Schmid, Korn, Steinmeyer, Heinemeier, Eitze, Küpke and Böhm2019; van de Berg et al., Reference van de Berg, Coyer, von Both, Scheuerer, Kolberg, Hoch and Böhmer2024).

A study conducted in Switzerland by Wagner and colleagues found that increased deliberation reduced vaccination intention (Wagner et al., Reference Wagner, Liberatore, Schmelzer and Dratva2022). Both studies found that when adults carefully weighed the benefits and risks of vaccines, their intention to vaccinate decreased. How individuals assess these benefits and risks and which information sources they rely on is critical. Commonly used information sources, like the internet and social media, tend to emphasize risks and side effects. Furthermore, it is known that the quality of information on these platforms is inconsistent, with inaccurate or harmful content often being more prominent (Dubé et al., Reference Dubé, Laberge, Guay, Bramadat, Roy and Bettinger2013). This may lead to increased deliberation, which could decrease vaccination intention.

This study has some limitations. Since participation was voluntary, the sample’s representativeness is considered limited. Moreover, as adults in the middle-age group are known to use Family Health Centers less frequently than younger or older adults, the findings may not fully reflect the vaccination attitudes of the general adult population. Additionally, conducting research among individuals who visited a primary healthcare facility where vaccinations are available may indicate that these individuals have greater trust in basic health services, potentially leading to higher vaccination intention than the general population.