Factors Impacting Vaccine Hesitancy Among the Elderly During the COVID-19 Pandemic in China: A Review

Abstract

This review examines three key factors that impacted vaccine hesitancy among the elderly during China’s COVID-19 pandemic in 2020-2022. The elderly are a high-risk group for a poor outcome from COVID-19 due to preexisting factors such as comorbidities. Even once a vaccine was available for them in China, there was great reluctance for the elderly to get fully immunized. This reluctance to vaccination provides an essential and helpful example for future generations so we can learn from the past to implement safety measures and prevent deaths. This review offers the additional benefit of making this example better known to a broader audience on a global scale.

The three factors contributing to vaccine hesitancy among the elderly that are examined in this paper are the role of vaccination policy, health literacy, and coping skills. China’s initial exclusion of the elderly from the vaccination guidance, coupled with strict eligibility requirements, led many to perceive the vaccines as dangerous. Low health literacy causes the elderly to rely on unverified social media sources, spreading misinformation. Lastly, factors such as stress and isolation drove vaccination avoidance behaviors, hindering access to medical care and information. This review offers valuable insights into the complex drivers of vaccine hesitancy in China’s elderly population, informing future public health strategies.

Introduction

As a novel airborne viral infection, SARS-Cov-2 (commonly known as COVID-19) spread globally soon after its discovery in Wuhan, China, in 2019. The pandemic eventually resulted in 7 million deaths and three-quarters of a billion cases of infection through 2022(World Health Organization, 2024). Globally, the elderly and immune-compromised comprised the majority of deaths during the first two years of the pandemic. China, in particular, was hit hard because it has 200 million elderly, defined as individuals aged 65 and above. While China had ranked among the top countries for life expectancy pre-pandemic, it was estimated that the elderly comprised 76.51% of deaths during the first year of the pandemic (China CDC Weekly, 2023).

Despite being the most vulnerable demographic, the elderly demonstrated the most vaccine hesitancy in China. Vaccination hesitancy refers to the delay in acceptance or refusal of safe vaccines despite the availability of vaccination services (World Health Organization, 2015). According to the World Health Organization, vaccine hesitancy is influenced by confidence, misinformation, complacency, and convenience. Now that nearly two years have passed since the COVID-19 health crisis, more evaluation can be done on the factors contributing to vaccine hesitancy. This paper thus seeks to examine the three most prominent factors of the government’s initial vaccine policy, health literacy, and the efficacy of the elderly’s coping strategies that contributed to high vaccine hesitancy to determine the most culpable factor.

Vaccination Policy

In China, vaccination hesitancy in the elderly population appears to have been influenced by the delay in their eligibility for the vaccine, as determined by China’s policies at the beginning of 2021. China was able to develop a vaccination against COVID-19 at record speed, which became available by January 2021, and was cautious in its implementation (Wang et al., 2023). According to an article by Wang et al. in the magazine Nature Medicine, the Chinese “government excluded older populations (those aged 60 or older) from its early vaccination guidance” for COVID-19, fearing the comorbidities and potential for harmful side effects that the elderly populations may be susceptible to (Wang et al., 2023). In setting this policy, China considered its rapidly aging population, with the population shrinking in the magnitude of hundreds of millions, and recognized the need to prevent as many deaths as possible, even from deaths resulting from vaccination side effects. This same reasoning underlined its Zero-COVID Policy that strove to reduce COVID-19 infections in China. The dynamic zero-COVID policy sought to identify the early onset of cases through frequent screening and isolate the infected individual to pre-empt any chance of widespread cases (Ba et al., 2023). Even before the onset of the COVID-19 pandemic, the Chinese policy of non-pharmaceutical interventions, or NPI policy, already reflected the government’s concern about deaths caused by the side effects of medicine (Mohamadi et al., 2021). In the same spirit, the Chinese government introduced a policy that excluded the use of vaccination to protect the elderly in the first two months of vaccination use. During those two months, the greater general population could observe the efficacy and any potential unknown harmful side effects from vaccination. The necessary delay and initial exclusion of the elderly from COVID-19 vaccination may help to explain the death toll in the first half of 2021.

Understanding that the 200 million elderly in the country were more vulnerable since many had existing and chronic conditions, the government also deferred to the elderly to be vaccinated at their own pace instead of encouraging them to be vaccinated earlier like some of the younger groups (Peng, 2023). Unfortunately, vaccine hesitancy among the elderly became a persistent problem after the vaccinations were deemed safe for use. Part of this may have been due to continuing restrictions. As of April 2021, requirements for the elderly population to be eligible to receive vaccination shots remained higher than other demographic groups. All elderly were required to have blood pressure within a specific range, and many were disqualified because their pressure was too high (Wang et al., 2023). In addition, anyone with a preexisting chronic condition, such as diabetes or kidney disease, was disqualified on the grounds of “contraindication.” Regrettably, many elderly who were otherwise eligible interpreted the strict requirements for vaccination as indicative of the vaccine’s potential danger to their age population.

In late 2021, a new strain of the virus known as Omicron – not as lethal as previous strains but spreading much more quickly – also led many to believe that the existing vaccinations were mistakenly ineffective. Between those who were not eligible and those who were fearful, millions of elderly were not vaccinated (Zhao et al., 2022). This fear would persist until 29 November 2022, when the government policy emphasized that all elderly should be vaccinated. Thus, it can be seen that in the intervening time – almost two years – a large proportion of the elderly population in China, for one reason or another, were not vaccinated. The extensive infarction rate and high mortality figures amongst the elderly can be attributed to this vaccination hesitancy.

Health Literacy

Despite the elderly Chinese people over the age of 65 having a literacy rate of 85%, which is a high number compared to the world average, health literacy among them is much lower (Trading Economics, 2024). Health literacy is defined as “the degree to which individuals have the ability to find, understand, and use information and services to find health-related decisions and actions for themselves and others” (CDC, 2023). One of the factors contributing to relatively low health literacy rates is how information is disseminated in China, especially in rural areas. Instead of looking for trustworthy articles published by reliable universities and studies online and even reliable news channels, many tended to rely on word-of-mouth and information that originated from unverified sources on the internet. As a result, hearsay and social platforms like WeChat proved much more potent than state media, especially without internet research-based culture (Zhu et al., 2022). Therefore, a closer examination of how the Chinese elderly population engages with information on vaccinations sheds light on why so many were misinformed and held negative views of the vaccinations.

One aspect of the misinformation was the sheer amount of contradicting information floating around either on WeChat or among rumors circulating in rural areas through word-of-mouth. According to a study by Xudong Gao, Feng Ding, et al., “72.3% of elderly participants reported COVID-19 information avoidance”, citing “information overload.” The high number indicated that many elderly found too much contradictory information on COVID-19, and it was difficult to ascertain the truth from fear-mongering articles (Gao et al., 2022). As such, many chose to avoid reading COVID-related articles altogether, instead remaining ignorant. This study concluded that the Chinese health authorities could have done a better job communicating the importance of vaccination and proper ways to protect themselves. Another article written by Pan Li, Zhong Jiaming, et al. corroborates the findings by Gao and Ding, which state that health information literacy in China is relatively low. Almost 85% of all participants scored less than 60 points on a 100-point system, indicating that the elders’ understanding of other vaccines and how COVID might impact them was very low (Li et al., 2022). This low health information literacy could be attributed to the education level and the absence of information tailored toward the elderly, who might not have been as well-educated as their young counterparts.

The difficulty controlling the spread of misinformation regarding the harmful side effects of vaccination on social messaging platforms like WeChat further exacerbated the collective reluctance of the elderly in China to want to be vaccinated (Zhu et al., 2022). Since there is no vetting process on WeChat, conspiracy theories and misinformation regarding COVID are spread quickly. Anyone can post videos regarding COVID-19, irrespective of background. Furthermore, the ease of sharing the links in family groups aided in the spread of misinformation regarding COVID-19, in particular, fear-mongering regarding the danger of vaccinations (Gao et al., 2022). Furthermore, the researchers found that because respect for the elderly is so entrenched in Chinese culture when the elderly generation shared a conspiracy theory or misinformation regarding COVID-19 on WeChat, the younger generation was reluctant to challenge or debunk them. This reluctance helps to explain why the conspiracy rate amongst the elderly was high and their health literacy was low (Zhu et al., 2022).

In a study conducted on COVID-19, information on WeChat was found to influence health behavior based on criteria considered by the Health Belief Model (HBM). HBM predicts health behavior based on one’s perception of disease. Therefore, This model is the most prevalent model used to study behavior-related changes related to vaccinations. (Wu et al., 2023). The study found that 89% of all the papers published on WeChat were not associated with any academic institution (Wu et al., 2023). Thus, the truthfulness of its findings could not be verified or further evaluated for credibility. The most popular articles viewed by users during this period were vaccination effectiveness and disease protection. The paper suggested that the WeChat platform significantly altered the public perception of vaccination efficacy and its side effects, contributing significantly to vaccination hesitancy (Wu et al., 2023). Hence, by analyzing the health literacy rate in the elderly Chinese population and the widespread use of media platforms such as WeChat, it is clear that health literacy was a major factor in creating hesitancy against vaccination, likely contributing to the higher infection and mortality rate amongst the elderly. Coping Strategies and Other Health-Related Behaviors

Another essential factor to consider in relation to vaccine hesitancy during the COVID-19 pandemic among China’s elderly is coping skills or coping strategies, which are based on existing medical knowledge and the ability to access necessary medical care. Coping is defined more broadly as “the thoughts and behaviors mobilized to manage internal and external stressful situations… aim(ed) to reduce or tolerate stress” (Algorani et al., 2023). During the COVID-19 pandemic, coping was needed by the elderly population in China to alleviate stress, fear, and depression. Coping skills or strategies also include health-related behaviors such as frequent use of hand sanitizer, scheduled hospital visits, and tests to prevent the infection of COVID-19. Despite the recognized benefits of staying in touch with social groups, many elderly people in China displayed avoidance behaviors during the pandemic that went beyond physical contact, resulting in a reduction of information-communication technology such as face calls (Tang et al., 2023)—cumulatively, two and half years of isolation caused much psychological distress to many due to loneliness. Another independent study done by a Japanese team also confirms the direct link between psychological distress and the perceived feelings of loneliness engendered by isolation (Konno et al., 2021). There were also some spatial differences in coping skills displayed during the pandemic, as identified in a survey conducted by Wu, Zhang, and others(2022). In this survey, participants in Northeast China, which is less economically developed, tended to score higher on fear as a factor compared to the generally better-educated Southwest provinces, which had access to better news. This suggests that coping skills also depend on correctly interpreting news, staying informed, and managing one’s fear of COVID-19.

A specific factor that hinders coping skills and other health-related behaviors is stress. Research has shown that stress during the pandemic was induced by worries over being infected, excessive protective behavior, and frequency of access to COVID-19 news, and contributed to an increased proportion of elderly with anxiety disorders (Wu et al., 2022). The study also found that patients’ resilience directly correlates with how much an individual fears COVID-19 and how often they engage in physical exercise to keep their minds and bodies healthy (Wu et al., 2022). Those who were more afraid scored higher on the stress scale and, on the whole, struggled to find effective coping mechanisms such as exercise and maintaining key social contact. In other words, the elderly who were more afraid tended to self-isolate more (not go out, socialize through phone or social media) or exercise. This fear would drastically impact their stress level compared to those who engage in some form of socializing. Only 34% of the 800 elderly studied during the pandemic said they used social media actively to engage with their families and friends, which explains why the level of education played a role. The subjects with additional years of schooling tended to adopt better-coping mechanisms such as exercising, educating themselves, and maintaining social contact through modern technology. The less educated elderly subjects were less proficient with technology. Granted, under strict lockdown, many could not physically see their friends and family, and the parks were also shut down. In such circumstances, those with access to technology had greater coping skills. Economically, those who owned a garden or more private space also tended to do better for their mental and physical health (Kastner et al., 2023). Another study also supports that offering and receiving social interactions helped the elderly with their mental well-being and, by extension, their coping strategies, such as seeking help and advice from friends and loved ones (Tang et al., 2023). Furthermore, the elderly, like individuals of other ages who trusted the government’s policies and were confident in their community and medical professionals, also became less stressed, wore masks, and got vaccinated (Tang et al., 2023). They were also better able to adopt better health-related behaviors such as going for a walk, eating more protein, and proactively getting tested routinely. The study concluded that those who could maintain a positive mindset of trust and settle into a routine could better manage their fear and health situation. The proper mindset and support system proved the critical difference to more resilient and healthier individuals within the elderly group.

Discussion

The government policy regarding vaccinations, where the elderly were asked not to be vaccinated for the first two months after the inception of the vaccination and had further restrictions once eligible, unfortunately, contributed to vaccine hesitancy among this population. Social media platforms in China, most notably WeChat, picked on this information and amplified it. Consequently, the elderly population who were vulnerable to misformation became more afraid of the vaccination due to conspiracy theories and distortion of facts they saw on WeChat. In hindsight, additional efforts to educate the elderly on health literacy might have increased the vaccine uptake among the elderly and improved their ability to cope during the pandemic. The studies covered in this research paper all point to the fact that vaccination hesitancy as a result of misinformation and low health literacy adversely impacted the elderly’s capacity to cope with the pandemic.

The lack of health literacy played a unique and vital role in fueling vaccination hesitancy and reduced coping skills among the elderly during the COVID-19 pandemic. Although the initial vaccine policy precluded the elderly from receiving vaccinations in China, the government soon made it abundantly clear that vaccination would effectively mitigate the spread of COVID-19 and reduce the severity of the symptoms in this age group. The misinformation regarding vaccination had already spread, however, especially among the elderly, who tended to access information regarding the disease through social media sites and conversations with their peer instead of official medical sources. This played a greater role in the educated and more rural regions of the Northeast instead of the country’s more urban, better-educated Southeast region. Differences in health literacy also affected coping mechanisms and physical/mental health regulation. The less someone receives updated and official data, the more likely the person is to be vaccinated due to unfounded fear.

Conclusion

The large and growing number of elderly in China posed a unique challenge during the COVID-19 pandemic. This was partly due to the difficulty of protecting them from a virus they were especially vulnerable to, given their comorbidities and weakened immune systems. Vaccine hesitancy exacerbated the situation in China due to the elderly population’s comparatively low health literacy and the vaccine rollout for this age group. This paper highlights a valuable lesson on the interplay of factors impacting vaccine hesitancy. Improving health literacy among the elderly may improve how this population responds to future challenges.

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