Vaccine hesitancy, defined as a delay in acceptance or refusal of vaccination despite the availability of vaccination services [1], has been a factor inhibiting the uptake of COVID-19 vaccines and a challenge to public health in Canada [2]. As of August 28, 2021, Saskatchewan had the lowest COVID-19 vaccine uptake [58.3% of the total population fully vaccinated] among all provinces in Canada [66.8% nationally] [3]. Although vaccine hesitancy is not a new phenomenon, we still lack sufficient evidence to inform the effectiveness of strategies to address this issue, particularly in the context of COVID-19 vaccines [4]. With respect to COVID-19 vaccine hesitancy specifically, research by Muhajarine et al. provides insights into factors related to vaccine acceptance in Saskatchewan; for example, people who more often wear masks are more likely to accept a vaccination [5]. Researchers have also indicated that perception of COVID-19 as a threatening disease and negative attitudes or general mistrust towards vaccines are factors that may affect vaccine uptake [5-7]. From a broader population approach, Crawshaw et al. [8] recently initiated a living behavioural science evidence synthesis on COVID-19 vaccination uptake among the general public, outlining a number of barriers and facilitators to vaccination compiled from international studies. In all of these instances, while the authors are able to provide information about the types of interventions that may increase vaccine uptake, there is limited information about how effective these strategies are in practice, particularly in different local contexts where a number of factors may differ from published research.

One benefit to the approach of Crawshaw et al. [8] is their use of a behavioural framework to contextualize their results in terms of behaviour change efforts and provide direction for policymakers when implementing changes. Their review uses the COM-B model of behaviour [Capability + Opportunity + Motivation = Behaviour] [9] and the Theoretical Domains Framework (TDF) [10] to categorize their findings into various barriers and enablers of vaccine uptake based on behavioural science. The COM-B model describes any behaviour as a function of an individual’s capability, opportunity, and motivation to perform that behaviour [9]. The TDF expands upon these three categories to include 14 theoretical domains that can inform implementation interventions based on multiple behavioural theories [10]. For example, in their review, Crawshaw et al. [8] identified gaps in knowledge about COVID-19 vaccines as a common barrier to vaccine uptake. This barrier was mapped to the knowledge domain within the TDF and represents a barrier to an individual’s capability (COM-B) to perform the behaviour (i.e., seek a vaccination).

Given the paucity of evidence regarding which interventions are most effective at promoting vaccine uptake among hesitant individuals, as part of a larger developmental evaluation of Saskatchewan’s vaccine rollout program, we set out to determine what was motivating individuals to seek a COVID-19 vaccine in Saskatchewan. We also asked both immunizers and individuals receiving a vaccine what they thought would motivate vaccine hesitant individuals to seek a COVID-19 vaccine. We used the framework developed by Crawshaw et al. [8] to present local data in a similar context, in an effort to provide policymakers with locally-relevant, evidence-based information on which behaviour change efforts may be most effective in promoting vaccine uptake. The information from our surveys may also be relevant to other jurisdictions throughout Canada and globally.

In the context of this survey and concurrent local policy changes around third dose eligibility for travel purposes, it is not surprising that the most common reason for seeking a COVID-19 vaccination was to meet travel restrictions. As a behaviour change strategy, however, travel restrictions are underpinned by foreign governments i.e., other countries, states, or provinces imposing vaccine-related travel restrictions upon citizens foreign to those governments. For example, if the US government requires foreign visitors to provide proof of vaccination for entry into the USA [19], it may motivate Canadian citizens to seek a vaccination if they intend to travel to US destinations. However, if the Canadian government were to impose similar restrictions on US travellers, it is unlikely to have the same effect on Canadian citizens seeking a vaccination. Another way to view this may be governments recommending their citizens be vaccinated before travelling to certain destinations [20], as a way of preventing travellers from becoming infected with COVID-19 while abroad and/or returning home while still infective. This approach is similar to that which already exists for a number of communicable infectious diseases [21, 22]. Regardless of the approach, while there is a paucity of data in the literature to indicate the efficacy of instituting travel restrictions in promoting vaccine uptake among hesitant individuals, our results show that 33/194 (17.0%) respondents receiving their first dose indicated travel purposes as a reason for seeking a vaccine. Thus, employing travel restrictions in cooperation with neighbouring states, provinces, or countries may be an effective strategy to increase COVID-19 vaccine uptake.

Apart from travel purposes, the most common reason individuals reported seeking a vaccine was having a positive attitude toward or high perceived benefit of COVID-19 vaccines. Paul et al. [23] found that general mistrust in vaccines and concerns about future side effects would be barriers to achieving population immunity to COVID-19 through vaccination in the UK. Together, these data underscore the importance of public health messaging to target the mistrust barrier and promote positive attitudes towards COVID-19 vaccines. It is interesting that 64/139 (46.0%) of these responses in our survey were from individuals in the <20 and 30-39 year old age categories; these two categories combined also make up nearly half (121/262, 46.2%) of the individuals receiving their first dose (Table 1). However, these individuals have been eligible to receive a vaccine in Saskatchewan since at least May 20, 2021, 14 weeks prior to the survey, and even earlier for 30-39-year-olds and for individuals living in the Far North regions [13]. This indicates that a perceived benefit or positive attitude toward vaccines among these individuals is not enough to motivate them to seek a vaccine in a timely manner, and there are likely other factors to consider. For example, 3/149 (2.0%) respondents in the 30-39-year-old age category who indicated they had a positive attitude toward or high perceived benefit of COVID-19 vaccines also indicated that they were receiving their vaccine due to the next most common response: mandates or restrictions [which were becoming more prevalent among schools, businesses, and workplaces toward the end of the summer]. This information may be of use to policy makers who shouldn’t rely solely on promotion of the benefits of vaccination to motivate younger individuals to get vaccinated sooner rather than later during a pandemic.

Indeed, mandates and restrictions, the next most common response, appear to be more effective at motivating younger individuals and those seeking a first dose to get vaccinated given that 85/91 (93.4%) of those who provided this reason were <50 years old and 59/194 (30.4%) were receiving their first dose. Cascini et al. [24] showed that younger individuals were associated with increased vaccine hesitancy in their review of vaccine uptake among the global general population. A survey of 18 cities and counties across the US also showed that COVID-19 vaccination being required for activities was an important factor in the decision to get vaccinated for 68% of the general population [25]. In Saskatchewan, as of August 28, 2021, only 50.6% of individuals aged 12-49 were fully vaccinated compared to 82.8% of those >50 years old [3], indicating that vaccine mandates and restrictions may be an effective way to increase the number of fully vaccinated individuals among younger age categories.

Both immunizers and those seeking a COVID-19 vaccine had similar responses when asked how vaccine uptake could be promoted among hesitant individuals. The most common responses were mandates and restrictions and having access to, and trust in, reputable information sources. Similar to what many immunizers reported in our study, a survey of healthcare workers at a tertiary care hospital in the Czech Republic identified concerns about vaccine safety and efficacy and distrust in vaccine efficacy as top reasons for vaccine hesitancy among that population [26]. After those two responses, immunizers more often emphasized ease of access in terms of time, convenience, and cost as an enabler for vaccine hesitant individuals (this was also a top response in the Zencity et al. survey) [25], while those seeking a vaccination identified a barrier of beliefs about personal choice/freedom/feeling forced. Both respondent groups also identified incentives (e.g., money, prizes, etc). as a top five enabler, but immunizers more often identified media issues (e.g., coercion, negative influence, oversaturation, scare tactics, conflicting information, misinformation). Media issues was the sixth most popular comment among individuals seeking a COVID-19 vaccine, as well.

Both the media issues and access to, and trust in, reputable information sources categories contained abundant variation in the specifics of responses. For example, the availability and spread of misinformation via social media were often noted, as were continuously changing recommendations based on new information about COVID-19, vaccines, and public health measures, with respondents, indicating they believed that both of these led to confusion and low uptake among vaccine hesitant individuals. Many respondents wrote about a need for more plain language information [free of scientific jargon], while others said more data and epidemiologic information about viral spread and vaccine efficacy among population subgroups (e.g., percentage of fully vaccinated individuals who are infected or hospitalized with COVID-19) would be useful in persuading hesitant individuals to get vaccinated. In fact, the latter point has recently been implemented in the Government of Saskatchewan’s public updates [27]. Additionally, as seen in Table 5, immunizers most often indicated reasons that relate to concerns about COVID-19 vaccines i.e., vaccine development, safety, and necessity as potential reasons for hesitant individuals not seeking a vaccine (again, similar to the findings of [26]). All of the above can be addressed, in part, by ensuring individuals have access to, and trust in, reputable information sources.

Lastly, many individuals seeking a vaccine responded with, “I don’t know,” to the question of what would promote vaccine uptake among hesitant individuals. This indicates that many people are at a loss for how best to convince the remaining unvaccinated individuals across populations to take part in this most important public health measure.

Our survey of both immunizers and individuals seeking a COVID-19 vaccination in Saskatchewan indicates that mandates and restrictions, promoting positive attitudes towards vaccines, and ensuring people have access to, and trust in, reputable information sources are key enablers for promoting vaccine uptake among vaccine hesitant individuals. While mandates and restrictions may more effectively promote vaccine uptake among younger individuals, promoting reputable information and counteracting misinformation may be more effective at reaching a broader contingent of the population.