Introduction
The advent of the COVID-19 pandemic has engendered an unprecedented global health crisis, mandating a pressing imperative for efficacious vaccination initiatives to curtail the relentless propagation of the virus. In response, several nations, notably China, Denmark, Thailand, Hong Kong, and Singapore, have undertaken proactive vaccination endeavors to augment vaccine acceptance and instill vaccine confidence among their heterogeneous populace. As the world grapples with expeditious vaccination dissemination, a nuanced comprehension of the multifaceted determinants influencing vaccination uptake, adversities arising from immunization, and the establishment of unwavering vaccine trust within diverse social contexts becomes paramount in steering public health policies and strategic interventions (Sallam et al., 2022). This seminal literature review seeks to undertake a meticulous analysis and rigorous assessment of three scholarly journal articles to gain insights into the uptake and adverse reactions of COVID-19 vaccination among people living with HIV in China, sociodemographic differences in vaccine uptake in Denmark, and the effectiveness of chatbots on COVID vaccine confidence and acceptance in Thailand, Hong Kong, and Singapore (Roy et al., 2022). Through the judicious evaluation of the methodological robustness and pertinence of these seminal studies, we endeavor to distill a comprehensive elucidation of the current state of knowledge in this domain, thereby informing the development of local and national vaccination guidelines and strategies to enhance vaccine acceptance and equity.
To facilitate a coherent understanding, defining and explaining some key terms and concepts is pertinent. Vaccination uptake refers to the proportion of the population that accepts and receives the COVID-19 vaccine, while adverse reactions encompass the undesirable and unintended health outcomes that may occur following immunization. Vaccine confidence pertains to the trust and willingness of individuals and communities to adhere to vaccination recommendations and overcome vaccine hesitancy (Lee et al., 2023). “Herd Immunity,” or community immunity, is also essential in vaccination tactics. It occurs when a large section of a community becomes immune to an infectious disease by vaccination or exposure, protecting those who remain vulnerable. The pathogen’s contagiousness determines herd immunity’s threshold, which helps prevent infectious disorders like COVID-19.
Vaccination programs must address “Vaccine Hesitancy.” Even when vaccines are available, many refuse to be vaccinated. Complacency, convenience, and vaccine confidence affect vaccine hesitation, hindering immunization efforts and reducing vaccination efficacy; thus, it must be addressed and understood (Roy et al., 2022). “Epidemiological Studies” are essential to public health research. These studies investigate population health occurrences, diseases, and conditions, shaping evidence-based public health policies by assessing illness trends, risk factors, and health outcomes. Also, “Randomized Controlled Trials (RCTs)” dominate vaccine assessment clinical research. RCTs randomly assign people to either a vaccination group or a placebo or other treatment group, revealing vaccination causality, safety, and efficacy by comparing outcomes between groups (Khan et al., 2021). Finally, “Cross-Cultural Differences” must be acknowledged in varied vaccination programs. Behaviors, beliefs, attitudes, and customs vary throughout cultures and societies. Since vaccination views vary widely, considering these variations is crucial for culturally relevant communication and interventions. By familiarizing themselves with these additional terms and concepts, readers will be better prepared to engage with the literature review and gain a deep understanding of COVID-19 vaccination uptake, adverse reactions, and vaccine confidence among the diverse populations of China, Denmark, Thailand, Hong Kong, and Singapore.
The confluence of this literature review lies in its manifestation of a definitive discourse delineating the imperativeness of a holistic appraisal of COVID-19 vaccination uptake, the array of untoward effects arising from immunization, and the intricate paradigm of vaccine confidence among disparate populations in China, Denmark, Thailand, Hong Kong, and Singapore. Such enlightened scrutiny is indubitably instrumental in shaping efficacious and culturally congruent vaccination strategies, engendering an unwavering trust in vaccines, and ultimately thwarting the relentless propagation of the pandemic (Biden, 2021). Consequently, the implications of this review resonate not only at a regional level but also globally, contributing to the formulation of precisely targeted public health interventions and policies that fortify vaccination efforts and fortuitously enhance pandemic preparedness.
Discussion of the Literature
In their work, “Uptake and Adverse Reactions of COVID-19 Vaccination Among People Living with HIV in China: A Case-Control Study,” the researchers sought to learn more about the variables that might affect PLHIV in China’s uptake of COVID-19 vaccine and their adverse reactions to it. This study is critical since PLHIV are a vulnerable population, and it is essential to know how they respond to vaccination to develop efficient public health plans for the pandemic (Zhao et al., 2021). It is laudable that the study concentrated on PLHIV since this population may have particular concerns and difficulties with vaccination. According to Zhao et al. (2021), “People living with HIV (PLHIV) are one of the most vulnerable groups,” which emphasizes the significance of researching their experiences with immunization. The study included 527 PLHIV who had received vaccinations and 1091 who had yet to give analysts access to a sizable dataset. The statistical power and generalizability of the results to the more significant population of PLHIV in China are improved by a bigger sample size. The researchers used multivariable logistic regression analysis to find variables related to vaccination uptake. This strategy improves the study’s conclusions and aids in the control of potential confounding variables. Zhao et al. (2021) state, “Chi-squared test and multivariable logistic regression were used to assess factors associated with vaccine uptake.”
Unfortunately, because this was case-control research, the information on vaccination uptake and adverse reactions was gathered retroactively via an online survey. As people might not accurately recall prior events or experiences related to vaccination, this raises the likelihood of recall bias. The need for more randomization in the study design is one of its limitations. Participants in a case-control study are chosen according to their outcome status, and this non-random selection may induce bias (Zhao et al., 2021). The study’s description states that “PLHIV in China were recruited by convenience sampling.” This restriction is explicit.
The results of this study have significant ramifications for developing focused public health initiatives to increase PLHIV COVID-19 immunization coverage. Healthcare practitioners can, for instance, use the study’s findings to create teaching programs that notably address the issues and obstacles the study found, like adverse reactions and ART outcomes (Shakeel et al., 2022). Healthcare practitioners can create specialized communication strategies that promote the advantages of vaccination while addressing concerns by identifying factors linked to vaccine reluctance among PLHIV. For instance, healthcare professionals could point out that the study found that “people who received media information regarding COVID-19 vaccine were more likely to be vaccinated.” The study pinpoints PLHIV’s worries about vaccination, namely the worry of unpleasant reactions and the potential influence on ART effectiveness or HIV disclosure (Khan et al.,2021). Healthcare practitioners can use this information to address these worries and boost vaccine confidence by offering tailored counseling and support. However, the case-control design and non-randomized methodology make it difficult to draw firm conclusions on causality. The results show how crucial it is to address vaccine skepticism, knowledge gaps, and safety worries among disadvantaged communities to raise immunization rates.
Furthermore, the COVID-19 pandemic has created substantial difficulties for global public health, prompting the development and implementation of vaccine measures to control transmission and minimize mortality and morbidity (Shakeel et al., 2022). One such vaccination program was begun in Denmark on December 27, 2020, to vaccinate all individuals aged 12 years and above. In the publication, “Sociodemographic differences in Covid-19 vaccine uptake in Denmark: a nationwide register-based cohort study,” Mie Agermose Gram et al. analyze sociodemographic differences in COVID-19 vaccine uptake across all persons invited for vaccination in Denmark.
Gram et al.’s work present evidence from a statewide register-based cohort study, offering a solid dataset to assess sociodemographic characteristics and COVID-19 vaccine uptake. The chosen nationwide register-based cohort research design is a form of observational study. Observational studies are valuable in pharmacoepidemiology, as they allow researchers to analyze the effects of pharmaceuticals (in this case, vaccines) in real-world contexts. Such studies give knowledge on vaccination uptake and its drivers in varied populations, which is vital for understanding vaccine acceptance and creating tailored interventions (Shakeel et al., 2022). Gram et al.’s study demonstrates the necessity of literature search tactics to uncover relevant studies. The researchers relied on comprehensive statewide registries, including the Danish Civil Registration System, Danish Vaccination Register, and others, to acquire individual-based data. By conducting a large-scale, register-based analysis, the scientists acquired a representative sample and evaluated the vaccination coverage accurately (Gram et al., 2023). The study design and methodology illustrate the critical appraisal and analysis of research papers to ensure their validity and relevance to pharmacy practice and public health actions.
According to Gram et al. (2023), all Danes above the age of 12 were included in the study’s massive dataset, which contained 5,164,558 individuals. This study’s sizable sample results in increased generalizability and sufficient statistical power to find relationships between sociodemographic characteristics and vaccination rates. The objective measurement of the study’s outcome variable was through the Danish Vaccination Registry, and it was defined as the number of participants who received at least one dose of a Covid-19 vaccine. Moreover, socioeconomic data was properly acquired from all Danish registries, including age, sex, immigrant status, degree of education, disposable income, and history of SARS-CoV-2 infection, to eliminate any measurement bias.
In addition, logistic regression models were used to analyze the correlations between demographic characteristics and vaccination rates in this study. Age, sex, immigrant status, education, income, and prior SARS-CoV-2 infection were other potential complicating factors. Valid findings and meaningful correlations can only be uncovered with the help of appropriate statistical approaches. Therefore, changes in vaccination rates over the study’s follow-up period (December 27, 2020–October 20, 2021) could be adequately tracked. According to the author, “the overall vaccination coverage was 87.1% by October 20, 2021” (Gram et al., 2023, p. 391). In the study, researchers discovered that vaccination rates varied significantly by age group, with the youngest age group (12–24 years) having the lowest vaccination coverage. This emphasizes the importance of making concerted efforts to raise youth vaccination rates. Also, children of non-Western immigrants were less likely to get vaccinated than children of Western immigrants (Gram et al., 2023). This implies that cultural and linguistic factors may affect vaccine acceptability in specific immigrant populations. People who had never had a PCR test were also less likely to get vaccinated, according to Gram et al. This may reflect reluctance or ignorance about the importance of getting tested for and vaccinated against COVID-19. People with lower education and income levels were less likely to be vaccinated than those with higher education and income levels. Equalizing access to and uptake of vaccines requires addressing inequalities in socioeconomic status.
However, the nature of comparison groups in a cohort research design precludes the inclusion of a dedicated control group. A control group would have allowed for a more direct comparison of vaccinated and unvaccinated people, which could have led to stronger causal implications. Furthermore, the study focused on vaccination rates across different socioeconomic classes without delving deeply into the reasons underlying vaccine resistance or hesitancy among those groups (Khan et al., 2021). Finding out why some people are reluctant to get vaccinated could lead to more targeted efforts to overcome resistance and increase confidence in the vaccine. Prior research in this area has examined people’s thoughts on the topic of Covid-19 vaccination, finding that those with higher incomes and education levels are more likely to be open to the idea of getting vaccinated.
Disparities in age, income, education, ethnicity, and immigrant status, among others, have been documented across several countries. Younger age groups, for example, have been demonstrated in international research to have lower vaccine acceptance rates due to a combination of a reduced perceived risk of severe disease and safety concerns. According to a Scottish study, “white ethnicity was positively connected with vaccine acceptability compared to black, Asian, and minority ethnic groups.” In contrast to Black and African American racial groups, Asian and American Indian/Alaska Native groups were favorably related to Covid-19 vaccine acceptability (Fiolet et al., 2022). In addition, those of lower socioeconomic positions may need help getting to vaccination sites. They may be more hesitant due to misconceptions and a lack of faith in the medical establishment.
Therefore, increasing immunization coverage among at-risk communities is a public health priority in light of sociodemographic differences in COVID-19 vaccine uptake. Efforts to increase vaccine confidence should counter myths and misinformation, debunk fears, and build faith in the medical system (Biden, 2021). To reduce vaccine reluctance among newcomers and certain ethnic groups, community involvement, and culturally adapted communication tactics can play an important role. Targeted outreach and mobile vaccination clinics can also help increase accessibility for those with fewer resources.
Achieving high vaccination coverage has been challenging due to various factors, including vaccine hesitancy. Vaccine hesitancy, defined as being conflicted about or opposed to getting vaccinated, has been identified as a significant obstacle to increasing vaccine uptake, particularly among specific populations like seniors and parents of children (Leung et al., 2022). Vaccine hesitancy is influenced by multiple factors, including perceptions of vaccine importance, efficacy, and safety, concerns about side effects, accessibility to vaccines, and personal or religious beliefs. In the countries under study, namely Thailand, Hong Kong, and Singapore, vaccine hesitancy was observed among seniors and parents of children, with concerns ranging from adverse events in seniors to uncertainty about vaccine effectiveness and safety for children. The article “. Effectiveness of Chatbots on COVID vaccine confidence and Acceptance in Thailand, Hong Kong, and Singapore,” by Lee et al., focuses on the effectiveness of chatbots in improving vaccine confidence and acceptance in different populations in China, Denmark, and Thailand, Hong Kong, and Singapore (Lee et al., 2023). The study aims to address the impact of chatbots in enhancing vaccine attitudes and behaviors, particularly among unvaccinated individuals and those with delayed vaccinations.
The review highlights for example, in Thailand, low vaccine uptake among seniors was associated with concerns about serious adverse events following immunization, while parents expressed uncertainty and safety concerns about vaccinating their children. Similar patterns of vaccine hesitancy were observed in Hong Kong and Singapore, underscoring the need to address these issues to increase vaccine acceptance (Lee et al., 2023). The study emphasizes the significance of using innovative digital tools like chatbots in health communication during a pandemic. With an overwhelming amount of online information, including misinformation, chatbots offer a promising solution to provide accurate and timely information to the public. Chatbots can be accessible and scalable tools to address vaccine-related concerns and enhance vaccine confidence. However, rigorous evaluations of their impact in the context of vaccine communication are still limited.
According to Lee et al. (2023), the research conducted randomized controlled trials (RCTs) on 2,045 adult guardians of children and seniors who were unvaccinated or had delayed vaccinations in Thailand, Hong Kong, and Singapore. Participants were exposed to COVID-19 vaccine chatbots for a week, and changes in vaccine confidence and acceptance were assessed between the intervention and control groups. The findings demonstrated mixed success in improving vaccine confidence and acceptance across different populations. Chatbot users in the Thailand child group exhibited increased confidence in vaccine effectiveness. However, in the Hong Kong child group and Singapore child group, more chatbot users reported decreased vaccine acceptance and confidence in safety, respectively. Notably, the Hong Kong senior group did not show significant vaccine confidence or acceptance changes. In the Thailand kid group, participants using the COVID-19 vaccination chatbots were less likely to lose faith in vaccine efficacy than the control group. In particular, chatbot users were more confident in statements like “vaccines are effective” [Intervention: 4.3% vs. Control: 17%, P = 0.023], “vaccines are effective regardless of manufacturers” [14% vs. 55%, P < 0.001], and “vaccines are effective against all variants” [8.7% vs. 48%, P < 0.001] (Lee et al., 2023, Table). The study found no vaccine confidence differences in Hong Kong children. The intervention group employing chatbots was more likely than the control group to report a drop in vaccine acceptance (“Has your child received/do you intend for your child to receive a COVID-19 vaccine?”) (26% vs. 12%, P = 0.028) (Lee et al., 2023, Table).
Chatbots demonstrated beneficial impacts in some subpopulations but highlighted difficulties in increasing vaccine uptake in other subpopulations. The restricted generalizability of the results is one potential flaw in the study’s design. The study concentrated on specific demographics in three places (Thailand, Hong Kong, and Singapore), which might not accurately reflect the diversity of the global population (Leung et al., 2022). Because of the sample size and demographics, it may not be easy to generalize the results to other groups or locations. In the Hong Kong and Singapore groups, for example, the study admits an overrepresentation of minority subpopulations (such as Filipinos and Indonesians), which may restrict the generalizability of the findings to other populations in those areas or elsewhere.
The one-week chatbot intervention period in the study may not be long enough to fully capture the intervention’s long-term effects on vaccine acceptance and confidence. Since attitudes and actions relating to vaccination can be complicated, it may take longer to see significant changes. To comprehend how long-lasting the impacts of the intervention will be, long-term follow-up evaluations are crucial (Lee et al., 2023). Future research should consider extended intervention times and follow-up assessments to evaluate the intervention’s long-term effects. Additionally, neither participants nor researchers were made blind to the intervention as part of the study design. Blinding can reduce bias in outcome evaluations, mainly when using self-reported metrics. The study urges more investigation into the relationship between chatbot usage and actual vaccine uptake in order to strengthen the body of evidence supporting the efficient use of vaccine chatbots. Furthermore, vaccine reluctance must be addressed to increase vaccination rates and restore normalcy in the examined locations and elsewhere, and vaccine communication must be improved.
Conclusion and Recommendations
The literature review emphasizes assessing COVID-19 vaccination uptake, side effects, and vaccine trust in China, Denmark, Thailand, Hong Kong, and Singapore. COVID-19 Adoption and Side Effects Vaccination China’s PLHIV are fragile. Therefore, public health programs must consider their immunization response. Media coverage boosts PLHIV immunization (Zhao et al., 2021). Thus, personalized counseling and assistance for adverse reaction fears can enhance PLHIV vaccine trust. These findings should be used to customize vaccine hesitancy and concerns initiatives for vulnerable populations like PLHIV.
Targeted interventions require sociodemographic knowledge about vaccine uptake. Younger people, non-Western immigrants, and low-income people have lower immunization rates. At-risk groups need targeted outreach, culturally customized communication, and vaccine hesitancy interventions to increase vaccination rates (Gram et al., 2023). This study’s sociodemographic differences should inform policymakers and healthcare practitioners about vaccine access and confidence initiatives for at-risk communities.
Pandemic chatbots can answer vaccine concerns and boost vaccine confidence. Chatbot treatments enhanced vaccine trust in specific populations but failed in others (Lee et al., 2023). Chatbots’ long-term effects on vaccine acceptability require extended intervention periods and follow-up analyses. Increasing vaccination rates requires addressing vaccine hesitancy and increasing vaccine communication. Public health officials could also use chatbots to dispel COVID-19 immunization myths and resolve concerns—combat vaccine hesitancy to boost vaccination rates. Evidence-based information, dispelling misconceptions, and strengthening medical system confidence can achieve this. Community involvement and culturally-adapted communication can help varied communities accept vaccines. Finally, authorities should ensure vaccine access for all, especially vulnerable groups with little means.
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doi https://doi.org/10.1080/21645515.2021.1991183.
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