SummaryOBJECTIVE: This study aimed to assess the public perception of COVID-19 vaccination certificates as well as potential differences between individuals.
METHODS: Between 17 March and 1 April 2021, a self-administered online questionnaire was proposed to all persons aged 18 years and older participating in the longitudinal follow-up of SARS-CoV-2 seroprevalence studies in Geneva, Switzerland. The questionnaire covered aspects of individual and collective benefits, and allowed participants to select contexts in which vaccination certificates should be presented. Results were presented as the proportion of persons agreeing or disagreeing with the implementation of vaccination certificates, selecting specific contexts where certificates should be presented, and agreeing or disagreeing with the potential risks related to certificates. Logistic regression was used to calculate odds ratios for factors associated with certificate non-acceptance.
RESULTS: Overall, 4067 individuals completed the questionnaire (response rate 77.4%; mean age 53.3 ± standard deviation 14.4 years; 56.1% were women). About 61.0% of participants agreed or strongly agreed that a vaccination certificate was necessary in certain contexts and 21.6% believed there was no context where vaccination certificates should be presented. Contexts where a majority of participants perceived a vaccination certificate should be presented included jobs where others would be at risk of COVID-related complications (60.7%), jobs where employees would be at risk of getting infected (58.7%), or to be exempt from quarantine when travelling abroad (56.0%). Contexts where fewer individuals perceived the need for vaccination certificates to be presented were participation in large gatherings (36.9%), access to social venues (35.5%), or sharing the same workspace (21.5%). Younger age, no intent for vaccination, and not believing vaccination to be an important step in surmounting the pandemic were factors associated with certificate non-acceptance.
CONCLUSION: This large population-based study showed that the general adult population in Geneva, Switzerland, agreed with the implementation of vaccination certificates in work-related and travel-related contexts. However, this solution was perceived as unnecessary for access to large gatherings or social venues, or to share the same workspace. Differences were seen with age, sex, education, socioeconomic status, and vaccination willingness and perception, highlighting the importance of taking personal and sociodemographic variation into consideration when predicting acceptance of such certificates.
IntroductionThe COVID-19 pandemic will continue to have an impact on several dimensions of physical and mental health, as well as on social and economic parameters for years to come [1–3]. With the advent of effective vaccines, mass vaccination is recognised as a way out of the pandemic, especially when it is taken into account that any public health restrictive measures should be an adequate response to specific and demonstrable risk [4, 5]. Countries with extensive vaccination programmes have already implemented “green passes”, and the European Union deployed COVID certificates , in an effort to resume and once again allow free movement. Switzerland’s COVID certificates have been available since June 2021. COVID certificates can attest to an individual’s vaccination status, a past SARS-CoV-2 infection or the absence of current infection . As of September 2021, COVID certificates in Switzerland are used for indoor events, discos and dance events, indoor areas of bars and restaurants, cultural sporting and recreational facilities, international travel, and large gatherings of at least 1,000 individuals .
Implementation is underway, but little is known about the public perception of COVID certificates. There has been conflicting evidence about the role of COVID certificates in vaccination programme uptake and as a strategy in a phased reduction of lockdown measures [8, 9]. Vaccination certificates could allow safer access to several activities, and may increase the uptake of immunisation when an incentive-based approach is considered [10, 11]. However, they could also be viewed as coercive measures creating a backlash and further increasing any pre-existing resistance to vaccination [10, 12, 13]. A recent review of the public perception of COVID certificates, their potential impact on behaviour, and the uptake of testing and vaccination reported different acceptance rates depending on context (travel, social or professional) . There was little information on sociodemographic differences in most of the studies included in this review . A survey addressed to 12,000 scientists revealed their overall favourable attitudes towards COVID certificates . Scientists perceived immunity certificates favourably for their positive impact on public health and the economy, despite highlighting risks related to equity and equality of the implementation process. Differences were perceived among participants as US-based scholars, men and scientists with more conservative political views were overall more favourable to immunity certificates .
To date, there is little information about the general population-based acceptance and perception of COVID certificates. In November 2020 , we published results on the perception of immunity certificates, mostly in relation to natural immunity. This study aimed to evaluate the public perception of vaccination certificates as a primary outcome while assessing differences between sociodemographic groups as secondary outcome measures.
Study setting and data collectionIn the spring of 2021, a self-administered online questionnaire was proposed to all persons 18 years and older participating in the longitudinal follow-up of SARS-CoV-2 seroprevalence studies in Geneva, Switzerland [17, 18]. This longitudinal follow-up is conducted via the Specchio-COVID19 platform, which allows participants to answer regular online questionnaires . The Specchio-COVID19 platform launched in December 2020 follows up individuals who have participated in seroprevalence studies in the canton of Geneva. Participants were randomly selected from the general population at two time-points, first between April and June 2020, with individuals participating in a previous general health study (Bus Santé, an annual health examination survey of a sample representative of the Geneva population [17, 20]); and second between November and December 2020 with individuals randomly selected from population registries of the canton of Geneva .
All individuals gave consent, and the study was approved by the Cantonal Research Ethics Commission of Geneva, Switzerland (protocol numbers CER 2020–01540 and CER 2020–00881). Questions about vaccination certificates were part of a larger vaccination questionnaire (analysis submitted to Swiss Medical Weekly). Specific questions about vaccination certificates were elaborated based on the results of the initial questionnaire on the perception of immunity certificates , as well as the results of a qualitative study conducted between July and November 2020, aimed at identifying arguments for or against immunity certificates . An initial invitation to complete the questionnaire was sent by e-mail on 17 March 17 with a reminder 2 weeks later. We included participants who answered between 17 March and 1 April 2021.
The questionnaire (table S1 in the appendix) was collaboratively constructed by physicians (IG, MN), epidemiologists (IG, SS, HB), sociologists (CBJ, VF), and an ethicist (SH). Two main questions were asked: (1) Select the context(s) in which a vaccination certificate should be presented (with a list of contexts); (2) What is your opinion about the following statements on the implementation of a COVID-19 vaccination certificate (with a list of statements)? The answers to the latter question were based on a five-point Likert scale with the following categories: 1 “strongly disagree”; 2 “disagree”; 3 “neither agree nor disagree”; 4 ”agree”; 5 ”strongly agree” (table S1 in the appendix for details).
Education was categorised as follows: “primary” included compulsory education and no formal education; “apprenticeship” included apprenticeships; “secondary” included secondary school and specialised schools; “tertiary” included universities, higher professional education and doctorates. Occupational position was categorised as follows: unskilled workers were qualified employees practising manual labour, craftsmen, traders, farmers and employees without specific training; skilled workers were qualified employees (non-manual labour); highly skilled workers were employees with a profession requiring intermediate training; professional-managers were company managers with more than 10 employees or individuals with a profession requiring university training; independent workers were individuals who worked as consultants, were independent or were company managers with fewer than 10 employees. Household income was calculated taking into consideration household revenue and the number of individuals in a household. Household income was then compared with the cantonal database available online  with the categories defined as “low” (below first quartile); “mid” (between quartiles 1 and 3); “High” (higher than the third quartile). Individuals were considered to have a prior SARS-CoV-2 infection if self-reported or if their serological test was positive for anti-SARS-CoV-2 antibodies as part of the seroprevalence studies. COVID-19 vaccination willingness was defined as the combined answer to the following two questions used in the larger vaccination questionnaire: “Did you get vaccinated against SARS-CoV-2? (yes, no, scheduled appointment)” and “Do you intend to get vaccinated once you will be eligible for vaccination against SARS-CoV-2? (yes, rather yes, rather no, no, does not know, not available)”. Answers “yes” and “scheduled appointment” to the first question and answers “yes” and “rather yes” to the second question were later combined as willingness to get vaccinated. Answer “no” to the first question, and answers "no” and “rather no” to the second question were later combined as not willing to get vaccinated. Vaccination perception was defined as the answer to the question used in the larger vaccination questionnaire: “Do you think that vaccination is an important step to surmount the pandemic?” (yes, rather yes, rather no, no).
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