With emergency use authorization now granted to two COVID-19 vaccines, addressing vaccine hesitancy or resistance is of critical importance. Vaccine hesitancy is as a "delay in acceptance or refusal of vaccines despite availability of vaccination services." The current emphasis of the discourse on vaccine hesitancy tends to be on in the level of COVID-19 vaccine confidence and acceptance, but more needs to be addressed in order to meaningfully gauge readiness or predisposition toward COVID-19 vaccination. There is a large body of scientific research focused on knowledge, sociodemographic, and psychosocial factors as barriers to and facilitators of health behaviors, including .
Indeed, disease-related do not automatically translate into the adoption of behaviors conducive to health. A widely used empirical model, in this regard, is the , which posits that the knowledge-behavior relationship is mediated or explained by personal beliefs, which should be ascertained and targeted in patient counseling and health education in order to facilitate positive behavioral change. Furthermore, sociodemographic factors including ethnicity, gender, age, and level of education are considered moderators or effect modifiers, that is, these variables can alter or change the strength and/or direction of the belief-behavior relationship. Other relevant psychological models and theories include and the .
According to the HBM, personal beliefs or cognitions about susceptibility or risk of developing a disease together with beliefs about the severity of the disease determine the level of , a salient predictor of engagement in protective behaviors such as getting vaccinated. Additionally, beliefs about the benefits or effectiveness of the recommended behavior can augment the HBM's predictive value. Nonetheless, the by focusing exclusively on beliefs, which are necessary but not sufficient to understand psychological predisposition or readiness to act. regarding engagement in protective health behaviors is complex, and involves a "rational" risk-benefit analysis. Consequently, a broader construct, attitude, specifically the , is considered a more valid measure of psychological tendency or predisposition to act, compared to instruments that focus on beliefs only.
According to the tripartite model, attitude is composed of three dimensions; the cognitive (beliefs), the affective (feelings or emotions), and intentionality, and can vary by strength, and valence (positive/favorable or negative/unfavorable). Attitudinal instruments with items encompassing these three components generally possess acceptable (reliability and validity) in relation to a specific target behavior and context. The COVID-19 pandemic context is undoubtedly unique, and in order to facilitate vaccine acceptance, it is important to understand individual dispositions or attitudes toward COVID-19 vaccination, but developing psychometrically sound instruments is time-consuming - time we do not have.
The following set of items is being proposed as a guide for exploring and understanding the attitude toward COVID-19 vaccination. These twelve items are intended to operationalize tripartite attitude theory and the HBM by reflecting beliefs, feelings, and intentionality in relation to COVID-19 vaccination.
A composite score can be calculated with a possible maximum of 60, and a minimum of 12. Higher scores would suggest a more favorable disposition toward COVID-19 vaccination. Items number 4, 6, 7, and 10, are negatively worded, and must therefore be reverse-coded (5-1) when computing a composite score. The response to each item can serve as the basis for a conversation to elucidate and address perceptions and concerns about COVID-19 vaccination.
Rossi A. Hassad, PhD, MPH, is an epidemiologist and professor at Mercy College in Dobbs Ferry, New York. He is a member of the American College of Epidemiology and a fellow and chartered statistician of Britain's Royal Statistical Society.