A Study of Ethnic, Gender and Educational Differences in Attitudes toward COVID-19 Vaccines in Israel - Implications for Vaccination Implementation Policies

"...these findings are a warning signal to the authorities to focus information campaigns on sensitivity to the ethnic and gender differences in the attitudes towards the vaccine."

Evidence that a significant portion of the population in many countries may hesitate or refuse to get vaccinated against COVID-19 has highlighted the need for demand generation strategies, such as engaging trusted sources to advocate for vaccination. The aim of this study was to determine ethnic, gender, and education differences in Israel in the attitude towards the new COVID-19 vaccines, prior to their December 2020 introduction. This information could help guide development of policies for promoting uptake of the vaccine in different communities.

A sample of 957 adults aged 30 and over, of whom 606 were Jews (49% males) and 351 were Arabs (38% males), took part in an online national cross-sectional survey in October 2020.

The findings indicate marked differences between Arabs and Jews and males and females. Among the men, 27.3% of the Jewish and 23.1% of the Arab respondents wanted to be vaccinated immediately, compared with only 13.6% of Jewish women and 12.0% of Arab women. An affirmative answer to the question of whether they would refuse the vaccine at any stage was given by 7.7% of Jewish men and 29.9% of Arab men, and 17.2% of Jewish women and 41.0% of Arab women. In answer to the question of whether they would agree to participate in vaccine trials, among males, 18.9% of Jews and 16.4% of Arabs said they would agree to participate in trials at every stage (p=0.543). Among females, the figures were much lower, at 7.4% for Jews and 6.0% for Arabs (p=0.516). Higher education was associated with less vaccine hesitancy.

In multiple logistic regression analysis, the most outstanding ethnic difference was in the total refusal of the vaccine, where the Arab participants were much more likely to say they would refuse vaccine than the Jewish participants. This was similar in both males and females. Also, females in both ethnic groups were more likely to refuse vaccine than males. The ethnic and gender differences persisted after controlling for age and education. Other factors associated with vaccine hesitancy were the belief that the government restrictions were too lenient and the frequency of socialising prior to the pandemic.

The study revealed a relatively high percentage reported would be reluctant to get vaccinated, prior to the introduction of the vaccine. These findings are consistent with the actual uptake of the vaccine: The uptake in the Arab population has been much less than in the Jewish population (and somewhat less in young women). These findings are of interest to the researchers because for routine childhood vaccines in Israel, the compliance is significantly higher in the Arab population. They note that childhood vaccines differ from the COVID-19 vaccines in that have been well integrated into the health system, and childhood vaccines are by and large trusted by the public. However, the novelty of the COVID-19 vaccines and their rapid development has attracted misinformation in the media, especially the media from Arab-speaking countries. There is also an interaction with gender. While women in general showed less willingness to take the COVID-19 vaccine than men, this is particularly evident among Arab women, This could be related to the misinformation that is being spread in the media regarding the potential effect of the vaccine on fertility.

The finding in this study of greater vaccine hesitancy in minorities has been reported from other countries. There are many possible factors that differ between groups, including include fear about COVID-19, individual perceived risk, perception of the severity of the disease, fear of side effects, and concern about the efficacy and length of vaccine testing. Public belief in misinformation about COVID-19 and the COVID-19 vaccines is "likely to be one of the major causes of COVID-19 vaccine hesitancy in Israel, particularly in the Arab population, where there is much more exposure to foreign media where vaccine hesitancy is common." Thus, the researchers argue, "It is essential that the public be guided to sources providing accurate information."

The findings of this study have been presented in Israeli government committees to assist decision-makers in identifying sub-groups who are more resistant to vaccination and producing more targeted information campaigns. While this study did not address potential interventions that could be used, the researchers suggest:

• In-depth research into the ethnic, gender, and education related factors associated with COVID-19 vaccine hesitancy;
• Identification and assessment of the role of misinformation and how it spreads through the conventional and social media;
• Efforts to obtain valid data early in the planning process in order to tailor information campaigns to address the concerns of different sub-groups in the population;
• More community engagement to develop targeted messages to the suspected-vaccine hesitant groups;
• Collaboration between civil society organisations and government ministries, health service providers, and local authorities to promote sector-specific vaccine promotion campaigns.