 is an Associate Professor in the Department of Epidemiology, Biostatistics and Occupational Health at McGill University. She's an infectious disease epidemiologist, and she's interested in the prevention and control of infectious diseases, including evaluating the uptake of vaccines and the impact of vaccination programs and identifying factors that increase disease risk and the risk of severe outcomes. I do want to mention that Dr. Busta has had a very unusual entry into the CLSA team. She came, moved to Montreal from the University of Minnesota in January 2020, and has essentially been working from home since that time. So we're very pleased that we have been able to engage her in her work and that today's webinar will be a presentation of some very important work that she's done using the CLSA data. So now I'm going to pass the microphone on to Nicole, so thank you for giving the webinar to Nicole, and we look forward to hearing you. Thank you so much, Tina. It's really a pleasure to be here today, and thank you so much for the invitation to share this work, which I think is really timely and hopefully something that you will all find very interesting. Okay, let me just advance the slides here. Okay, I wanted to start off today's presentation by acknowledging all the many team members of the CLSA who have contributed to this study. Often when I present, you see my work because I am the one that's giving the presentation, but there are so many individuals, study coordinators, team members, analysts, staff members behind the scenes at the CLSA making these studies possible, and I really want to acknowledge their contributions because it's been a really difficult and challenging year, and it's really remarkable that they've been able to collect these data. In addition, I want to acknowledge the CLSA participants themselves who have been just remarkable in terms of their participation in many ongoing studies throughout the COVID-19 pandemic, and I've also noted our co-authors on this particular study who have made really substantial contributions to making this work as interesting and robust as possible. So for today's talk, I've divided the slides into three sections. I'm going to first introduce you to the CLSA COVID-19 questionnaire study for those who might not be familiar with the design of the study. Then I'm going to speak specifically about the analysis of the survey data that we did regarding vaccine willingness among participants, and finally, I want to put these results in the current context of COVID-19 vaccine uptake in Canada and highlight some of the progress and some of the challenges that remain. So let's go ahead and get started with a description of the COVID-19 questionnaire study. So for those who may be joining us for the first time today, this slide shows the core CLSA data collection schedule prior to the COVID-19 pandemic. So the CLSA is a longitudinal study that's been following about 50,000 participants in Canada who were aged 45 to 85 at baseline, and the plan is to follow them for 20 years. And you can see here the timing of the baseline data collection, the follow-up one and the follow-up two data collection prior to the start of the pandemic. The CLSA COVID-19 questionnaire study was launched in April 2020 and embedded within the CLSA cohort study itself. The design of the study was created to try and address some of the concerns about the impact of the COVID-19 pandemic on older adults in Canada. This questionnaire study consists of weekly, bi-weekly, monthly data collection, and it was conducted from April 2020 until the end of 2020 last year. The aims of the CLSA COVID-19 questionnaire study itself were to collect a whole host of data at routine intervals on a number of different factors and a number of different ways that the COVID-19 pandemic could be affecting individuals. So study questions investigated the factors related to COVID-19 health, including reported symptoms, testing experience and outcomes, a number of different risk factors, the experience that individuals had with healthcare usage and access, a number of different health behaviors, including public health measures and prevention and control measures that were implemented and how well individuals adhered to those. There were additional data collection elements related to social factors, depression and anxiety, economic consequences and hardships, and functional ability and mobility. The CLSA COVID-19 survey recruitment followed the plan shown here. So we began with the CLSA baseline sample, which is shown at the top in the blue box here, and all 51,338 participants that participated in the baseline sample were initially eligible. Of course, we then excluded the about 8,638 participants who had died since the initial data collection or withdrawn from the study or were not available for other reasons. That left 42,700 participants who were eligible to be invited, and those with a known email address were invited for the web-based version of the COVID-19 questionnaire study, and the rest were invited via telephone. Through that invitation process, an additional 189 participants were excluded for the reasons shown here in this gray box, leaving an eligible participant base of 42,511 individuals. Following the invitation to participate in the COVID-19 questionnaire study, 28,559 CLSA participants agreed to participate, and that was 67.2% of the eligible individuals who were invited. The CLSA COVID-19 questionnaire study that participants consented to followed this schematic. So as I mentioned, the baseline survey was launched in April 2020, and individuals participated either via a web-based survey that they completed on their own or over the telephone. And they completed multiple weekly surveys and bi-weekly surveys if they were participating over their phone. And then following that, there were a number of different monthly surveys that were launched, followed by an exit survey at the end of 2020. And we have previously published a COVID-19 results dashboard on the CLSA website. The link is here at the bottom of the screen. And this dashboard presents the baseline survey results that came from that first round of data collection from April 2020. Today, I'm going to be talking about results from the survey that was conducted between September 29th to December 29th 2020, what we termed the exit survey at the end of 2020. The aims of the COVID-19 exit survey were really to try to capture the history of experiences that individuals had over the course of the 2020 pandemic. So we asked questions about COVID-19 health and outcomes, COVID-19 attitudes and behaviors, perceptions about the pandemic, perceptions about transmission and risk, and vaccines, and again, the impact of COVID-19 control policies on individuals' lives and different aspects of their lives. In addition to a number of questions in this exit survey about general physical health, work and lifestyle, healthcare access and mental health. And I'm going to be primarily focusing on those factors that are listed here in the first column because they're related to the COVID-19 vaccine uptake. And I do want to note that all questionnaires for each of the studies, each of the rounds of surveys that I mentioned in this questionnaire study are available online on the CLSA website. And so the link is right here at the bottom of the screen. And I really encourage you to take a look at those surveys. They're really rich and they capture a lot of different elements of these factors and others throughout the course of 2020. Okay, so that is the brief overview that I wanted to give of the COVID-19 questionnaire study. So hopefully you have a really good sense now of what we were aiming to accomplish and how extensive the data collection process was in order to capture the different elements and aspects of the COVID-19 pandemic and how it impacted older adults in Canada. Now we'll move on to describing the analysis of the COVID-19 survey data on vaccine willingness. So the COVID-19 exit survey participant demographics are shown here on this slide. Ultimately, of those about 25,000 individuals that completed the baseline survey, 23,822 completed the exit survey nine months later. Those individuals were about 60% were over the age of 65, 53% were female, about 93, 94% identified as white. In terms of education, the majority had a post-secondary degree about 78%. And you can see the income distribution of participants here as well. And the majority of participants also came from an urban area about 82% indicated that they were living in an urban area. So this just gives you a kind of overview of the participants who completed the exit survey, which are relatively similar to those who participated in the CLSA in general. Our first question that we wanted to ask was how willing individuals were to receive a COVID-19 vaccine? So the question that was asked in the exit survey in September to December 2020 is if a safe and effective COVID-19 vaccine were available to you, how likely would you be to choose to get the vaccine? Now remember at this time no COVID-19 vaccines were approved for use anywhere in Canada. So this question was asked prior to the initial approval or authorization of COVID-19 vaccines. And what we found was that a high proportion of individuals indicated that they were very likely to receive a COVID-19 vaccine about 72.7%. In addition, about 11.5% indicated that they were somewhat likely. And these two categories together are combined in all of the analyses that I'll be speaking about from this point on. In addition, almost 10% of individuals indicated at that point that they were uncertain. And there were about 6% of individuals that indicated that they were somewhat or very unlikely to receive the COVID-19 vaccine. We then went and looked at the distribution of COVID-19 vaccine willingness by age and by sex at birth. And you can see in the first graph here at the top the age distribution of the willingness to receive COVID-19 vaccine. And what we see is a slightly higher degree of willingness for individuals who marked that they were very likely to receive the vaccine among the two older age groups. But overall, very consistent, strong likelihood of willingness to receive the vaccine with a very small proportion of individuals marking that they were unlikely or very unlikely to receive the vaccine. And what we also saw in this survey is that a slightly higher proportion of males indicated that they were very likely to receive the vaccine, which is not typically what we see for vaccine studies. Typically females are more likely to obtain a vaccine once offered. In addition, we looked at the distribution by education and by income. The top graph shows the education distribution across the difference willingness categories. And we see a consistent trend with a greater likelihood of being willing to receive a COVID-19 vaccine with increased education. So you can see this dark blue plot is increasing over time, not over time, I'm sorry, over the categories with those who have received a post-secondary graduation degree having the highest likelihood of being willing to receive a COVID-19 vaccine. When we looked at income, which is here in the bottom graph, you can see that the proportion of individuals that marked that they were very likely to receive a COVID-19 vaccine increased as the income categories increased from the lowest income category to the highest income category. And there was some difference in terms of the other categories, not just the very likely category across these income bands. In addition, we looked at the distribution by province and a number of other factors. I've just highlighted a couple of factors here in these plots to kind of give you an overview of how likely individuals were according to the Likert scale. And this distribution by province I think is really interesting and there's likely a number of different factors that are contributing to this distribution that we see. And I'm just providing this here so we can, for your information and for some discussion points, and you can see some of the different trends. For instance, those who indicated they were very likely to receive a vaccine was lowest in Quebec and New Bruns and there was some variation across the other provinces as well. So these bar graphs that I've just shown just give you a descriptive overview of the responses that we received among those more than 23,000 participants. In the next part of the analysis, we wanted to look at what the association was between these demographic factors and the likelihood of choosing to receive a COVID-19 vaccine. So we implemented a logistic regression model and report here the odds ratios and 95% confidence intervals for each of those factors for all of the demographic factors that I've described in a couple of other ones as well. And what we find from this logistic regression analysis is an increased willingness, a significantly increased willingness for those who are aged 65 and older compared to younger adults, those who are male compared to female, those who had higher education compared to lower levels of education and you can see this trend here. Those who had higher income compared to lower income and you can see that trend here as well with the adjusted odds ratios shown on the side and those who identified their race as white compared to those who selected any other category of race and those who indicated that they lived in an urban area compared to a rural area. You can also see the odds ratios associated with different provinces and which ones are associated with increased willingness versus a decreased willingness to receive a COVID-19 vaccine. After we looked at the demographic factors associated with willingness to receive a COVID-19 vaccine, we were really interested in investigating whether there are other factors associated with COVID-19 vaccine willingness. A number of different studies really look and focus exclusively on demographic factors, but we had the hypothesis that there were likely a number of other factors that may even have a greater, stronger association with COVID-19 vaccine willingness. And we selected three from the COVID-19 exit survey. First, we were interested in the role of receiving an influenza vaccine in the fall of 2020 and its association with COVID-19 vaccine willingness. And we conducted a logistic regression model that was controlled for all the demographic factors that I showed in the previous slide. And what we found was a very significant and a very large increased willingness among those who had been vaccinated for influenza in fall 2020 in their willingness to get a COVID-19 vaccine. And we found that those who had not yet gotten the vaccine because the survey was launched at a time early in the flu season, but were planning to also had a really significant increased willingness to get a COVID-19 vaccine on the order of 10, an odds ratio of 10 and 14 for those two categories. In addition, we looked at whether an individual's belief that they were previously infected with SARS-CoV-2. So we didn't just look at testing status because testing was quite limited in early 2020. We asked individuals whether they believed that they had been infected with SARS-CoV-2, whether they had experienced a COVID-19 case and looked at how associated that was with COVID-19 vaccine willingness. And again, we found that those who indicated that it was unlikely that they had been infected with SARS-CoV-2 were more likely to receive, to want to receive a COVID-19 vaccine. This potentially suggests that they were more, were taking additional measures to try and prevent infection or were looking forward to trying to continue to prevent infection given that they did not believe that they had been infected previously. And then finally, we looked at whether there was an association between how an individual felt about the consequences of the COVID-19 pandemic on themselves and their households and their willingness to get a COVID-19 vaccine. So that result is shown here in the bottom. And you can see that individuals that indicated that the impact of the COVID-19 pandemic on themselves and their households was negative, were significantly more likely to be willing to get a COVID-19 vaccine compared to if they felt the impact was overall positive. So to summarize that, having received a flu vaccine, believing that you had not previously been infected with SARS-CoV-2 and having experienced negative consequences of the pandemic were all significantly and independently associated with increased willingness to get a COVID-19 vaccine even after controlling for all the demographic factors that I mentioned in the previous slide. Another question that was really critical in this survey was trying to understand the primary reasons that individuals were willing or not willing to receive a COVID-19 vaccine. So in this graph, you can see the distribution of the primary reasons for vaccine willingness among those who indicated that they were very or somewhat willing to receive a COVID-19 vaccine. And the primary reasons that were indicated were a desire to protect oneself, a desire to protect one's family, and a desire to contribute to ending outbreaks. And those three responses are shown here in the first three bars. In addition, there was some indication that about 10% of participants were interested in getting vaccinated due to general concern about COVID-19 and general concern about the pandemic and that some were persuaded based on the recommendation of others. In addition to looking at the reasons that individuals were willing to get a COVID-19 vaccine, we looked at the reasons that those who indicated that they were uncertain about getting a vaccine or that they were somewhat or very unlikely to get a COVID-19 vaccine, what were the reasons that were driving their decision. And we found that the majority of those who were unwilling to receive a COVID-19 vaccine were primarily concerned about the safety of the vaccine. So you can see here in the blue bar more than 60% of individuals who had indicated they were uncertain, very or somewhat unlikely to get a COVID-19 vaccine, indicated that it was due to concerns about the safety of the vaccine. Nearly 20% indicated it was due to concerns about whether the vaccine would be effective. And then a smaller proportion of individuals indicated some of the other responses such as they weren't concerned about the COVID-19 pandemic in general. They weren't concerned about their own health. They didn't like needles or they weren't concerned for their family getting ill as well. So that kind of summarizes the key findings that we made based on the analysis of the COVID-19 exit survey. And I hope that gives you a sense of the key points that we've taken away from this analysis and trying to understand what degree of willingness there was for COVID-19 vaccine uptake and what factors were motivating individuals to get a vaccine. We think these results are really useful because they can help us design and target approaches and interventions that can try and increase confidence in COVID-19 vaccines and improve uptake. So some of the strengths of our study was that this was the largest survey among Canadian adults to date that has looked at vaccine willingness for COVID-19 vaccines. We were able to draw from the established national cohort of the CLSA, which gave us a really great platform for investigating these questions and allowed us to link back to some other data that had been collected previously in the cohort. However, our study does have some limitations. So first of all, our study was based on self-reported willingness to receive a COVID-19 vaccine only. At the time that we did this analysis, we didn't have any data on individuals' uptake of the vaccine. So it's important to consider whether self-reported willingness into September to December 2020 is similar to an individual's actual decision about getting a vaccine once they were offered the COVID-19 vaccines this past half year since the vaccines became available in Canada. And that's what we're going to take a look at next so we can compare some of these study findings to the current situation across Canada in terms of COVID-19 vaccine uptake. So with that, I'll move on to the third section to describe just a bit of brief details about the current COVID-19 vaccine uptake landscape across Canada and how that compares to some of our findings in this study. So you may be aware about the current progress on COVID-19 vaccine uptake. If we look at this map, it shows the percent of the eligible population ages 12 and older who have been vaccinated with at least one dose of a COVID-19 vaccine. As of, I believe this was June 19th when I pulled this map. And you can see that there's really been quite high uptake of this first dose across all the provinces. And overall, 75.3 percent of individuals age 12 and older in Canada have gotten at least one dose of vaccine. And of course, if we looked at the uptake of both doses, that percentage is much lower across Canada right now, given that the two doses were separated by a couple of months. But that rate is increasing quite rapidly as vaccine availability continues to ramp up. If we look at COVID-19 vaccine uptake specifically by age group, because as you'll recall, the CLSA data only gives us information about individuals 50 years and older. So I've subsetted the data available nationally here in the green, which comes from this link down here on the bottom by age group. So you can see the vaccine uptake over time from December when the vaccines first became available in Canada to June 19th, the last reported date. And these percents down here in the green box show the proportion of individuals in each 10-year age band that have received at least one dose of COVID-19 vaccine. And you can see the dark green is the individuals 80 years and older. The slightly lighter green is individuals 70 to 79, then individuals 60 to 69, and individuals 50 to 59 are shown here in the lightest green bar. And the total proportion that have gotten at least one dose are shown below. So these data come from the national statistics about COVID-19 vaccine uptake and rollout. So these reflect actual COVID-19 doses given. And if we compare those uptake percents to the proportion of individuals in the CLSA COVID-19 exit survey who indicated that they were very or somewhat likely to get COVID-19 vaccine, which is shown in this column here, the first column of percents, or if we look at the total percentage of individuals who indicated they were very or somewhat likely or uncertain about getting the vaccine in that time period from September to December 2020, those percentages are shown here. What you can note is that they're remarkably similar to the uptake percentages that we have seen already in the first six months of the vaccine rollout here in Canada. So this is a really good sign. It suggests that our survey data and what individuals reported as their willingness reflects their likely activity or their likely decision once they were offered a COVID-19 vaccine. And what we can see is that these percentages here are all greater than the percentage of individuals who indicated that they were very or somewhat likely, suggesting that some of the individuals who indicated that they were uncertain in the latter half of 2020 were able to make the decision to go ahead and get the COVID-19 vaccine. However, the percentages of individuals that were very somewhat unlikely or uncertain together is higher here than the uptake across all the age groups. So that suggests that there are still individuals who are uncertain and who may be kind of an easier target to provide education and resources and outreach to try and encourage vaccine uptake. In addition, we still have a proportion of individuals who have not gotten COVID-19 vaccine. As you saw in the results that I showed from the CLSA exit survey, there is a proportion of individuals who indicated that they were very unlikely from the outset to get a COVID-19 vaccine. And more significant efforts will be needed to try and encourage those individuals, address the concerns that they have, overcome the barriers and increase trust in their trust in vaccines, specifically COVID-19 vaccines. So I also wanted to note that there are a number of different approaches for engaging in effective communication about COVID-19 vaccines. And when I look at the current uptake levels across Canada, I'm really encouraged by the high uptake that we've seen, at least for the first dose so far. And I think that creates a lot of opportunities to build upon that early success and ensure that all individuals who are eligible get vaccinated. You've probably heard quite a lot about herd immunity and the benefits of herd immunity in protecting the whole population, but always it's better for an individual to be directly protected by getting vaccinated themselves. It provides much stronger reduction in the risk of getting the disease than relying on herd immunity or community immunity. So I just wanted to provide here a number of suggestions and approaches for engaging in effective communication about COVID-19 vaccines. So these are pulled for a number of different resources that I've provided at the bottom of the slide. But the idea here is if you're engaging in discussions with individuals who are hesitant about COVID-19 vaccination, that you really want to approach them empathetically and try and establish trust. Likely this is someone that you care about if you're just, if you're engaging in these conversations. And so trying to encourage their questions as in the second point and trying to listen and understand the reasons for concern in the third point is really important. You know, this experience with COVID-19 pandemic has been a really difficult one for so many reasons. And I think there's a lot of uncertainty that a lot of people are continuing to experience and a lot of questions about COVID-19 vaccines. As a vaccine researcher myself, we often see a number of questions when a new vaccine comes to the market. And I think with COVID-19 and COVID-19 vaccines, we've just seen the range of questions expand exponentially. So I think it's really important to try to understand where the individuals coming from and what concerns really are most critical in their mind that's present, preventing them from getting a COVID-19 vaccine. In addition, a lot of approaches have been demonstrated to be very effective when individuals share personal stories and when individuals work together to seek out evidence from trusted sources. So depending upon what concerns the individuals you're speaking with have about COVID-19 vaccines, you might share your experience in getting vaccinated if you've been vaccinated or you might seek together to contact healthcare professionals to look for resources online from sources like Health Canada or Science Up First or COVID-19 Resources Canada. Some of the individuals and groups that have been working together to create really nice infographics and provide a lot of frequently asked questions, responses to frequently asked questions to help people sort through the myriad of information that's out there about COVID-19 vaccines. Then it's really important to provide a strong personal recommendation to get vaccinated, which is really sincerely motivated by your concern and care for the individuals that you're speaking with. And then finally, it's important to recognize that many individuals are still facing barriers to getting COVID-19 vaccine. It's not just all about hesitancy or trust in vaccines. There are very real structural barriers that prevent individuals from getting vaccinated. So think about ways that you could perhaps help an individual schedule an appointment or arrange transportation to get to a vaccination site to help make it just that much easier for them to make the decision to actually get vaccinated. So I just wanted to share those tips because these questions tend to tend to be raised whenever I give presentations about vaccines. So I hope you find them useful. Okay. So with that, I would like to summarize the results that we found in this COVID-19 vaccine willingness study and leave plenty of time for your questions so we could have a bit more of a discussion. So in summary, the CLSA COVID-19 Questionnaire Study really presented an excellent opportunity for us to investigate COVID-19 vaccine willingness in a large and robust sample of more than 23,000 adults across Canada. And I've provided just a few of the distributions and descriptive and analytical results that we've had, but we're working on an even wider array of questions related to COVID-19 vaccine uptake. What we found through this analysis is that COVID-19 vaccine willingness among adults age 50 and older was five even prior to vaccine introduction. We estimated that it was about 84 percent for those who were very or somewhat likely to get a COVID-19 vaccine. From our analysis of demographic factors, we found that females those age 50 to 64 years old, those who identify with a race other than white, those with lower educational attainment and lower reported income and those living in rural areas indicated that they were less likely to get COVID-19 vaccine. However, in addition to these demographic factors, we found even larger associations with not having received a flu vaccine, having had COVID-19 vaccine previously and not having experienced the negative impacts of the pandemic. Those three factors were all independently associated with a decreased willingness to receive COVID-19 vaccine, even after controlling for the demographic factors. So I think these results in combination indicate that opportunities exist to address primary concerns that individuals have about COVID-19 vaccines, including safety concerns, which were the most common concerns raised. And I think that these results can help inform targeted outreach programs to improve COVID-19 vaccine uptake. For instance, the observation that having received that not having received a flu vaccine in the 2020-2021 season or not planning to receive a vaccine this past year for flu was associated with a decreased willingness to get a COVID-19 vaccines indicates that there is a group of individuals that do not plan to typically get a flu vaccine and also don't plan to get a COVID-19 vaccine. So there may be additional information and education and outreach that could be done to try and reach those individuals that don't typically receive a flu vaccine in a typical year. All right. So with that summary, I would really like to thank again all of the CLSA network of collaborating institutions who have participated in collecting the data for the core CLSA and also for the COVID-19 surveys, acknowledge the funding sources that made this COVID-19 questionnaire study possible, and provide the contact information for the CLSA and the website. Please do take a look at the website. As I mentioned, you'll find all of the questionnaires posted there, our baseline dashboard that you can take a look at and see some of the different responses from the baseline survey. We're also working on an exit survey dashboard, which hopefully will launch by the end of the summer. And finally, I wanted to note that there is the opportunity to request the COVID-19 CLSA questionnaire data. The next data access application deadline is coming up on September 8th. So if you're interested in perhaps requesting some of the data and conducting some analyses yourselves, please be sure to take a look at those questionnaires and try to formulate the study that will be most interesting to you to really take advantage of these data and really help us learn more about the impact of COVID-19 on the older population in Canada. So with that, thank you all so much for your attention and for attending today, and I would really be happy to take any questions that you have. Well, thank you very much, Nicole. The questions are popping into the chat box, and I'll get to those in a second. And perhaps you addressed it in an earlier slide, but I just want to ensure that we acknowledge the funding for the COVID-19 study, which came through the, oh, you have it there. There we go. Okay. Thank you. Okay. Yes. Thank you for the reminder. I thought you had that slide there. So thank you very much for that. And obviously, great appreciation to the funders that allowed us to implement this study within the CLSA in really, really short order. So thank you very much. There are quite a few questions. I'm manipulating the chat here. So there was an early question, which I think you've already answered in terms of looking at urban versus rural relationship to willingness to be vaccinated. I think you addressed that in your presentation. So just want to acknowledge the question was asked, but you did address it. Yeah. Okay. So urban, more likely, right? Okay. So there's another question I want to read out. So Alberta has bribed, I'm having trouble with it. Okay. So now I'm getting the survey and I can't get back to the chat. I think just pass the X, Tina. There we go. Okay. So Alberta has bribed people to get vaccinated via lottery. Has this proven to be an effective strategy? Do you know? This is a great question. So we like to use the term incentivized rather than bribed. And there have been studies in the past that have shown that incentives can be a really effective way for encouraging vaccination. But it really depends on a lot of context specific factors. So in the context of a number of different vaccines, either individuals, you know, there are a number of different policies that can be implemented to try to encourage vaccination on a broad scale. Things like vaccine mandates are sometimes used, sometimes incentives and sometimes penalties for not getting vaccinated. These COVID-19 vaccine incentives span a huge range of different types of incentives. There are universities in the U.S., for instance, that are offering lotteries for a free year's tuition. There are statewide lotteries. And as was just mentioned, this lottery here, I don't think there's been any analyses so far that have indicated there was a significant increase in uptake for the Alberta lottery just yet. Although if others know about that analysis, I'd really be interested to hear about it. There was an analysis just recently, I believe, of the Ohio lottery that's been offered in the U.S., so this was a statewide lottery. What individuals did is they looked at the increase in COVID-19 uptake in the weeks after the lottery was announced for those who were eligible for the lottery living on the border between Ohio and another state, compared to those who were living on the other side of the border and were not eligible for the lottery. They did see a significant increase for those who were eligible for the lottery, but it was very short lived. So it wasn't sustained over time. There was an increase and encouraged a small proportion of individuals to get vaccinated when this lottery was announced, but it wasn't sustained. And I think that's likely what we would expect from these types of incentive programs. They're going to appeal to a certain proportion of individuals, and they may not have broad appeal. It's another reason why jurisdictions need to investigate very, very carefully the reasons that individuals in their jurisdiction are not getting vaccinated, because those reasons are going to be very heterogeneous and really vary not only by geographic location, but over time. People's thinking about COVID-19 vaccines do change as time goes on, and we learn more and we gather more evidence about these vaccines. Yes, another question which is not unrelated to what you just said, but is it possible that some hesitancy in the fall of 2020 was due to political pressure in the U.S. to quickly approve the vaccine before the election? I mean, we live right next door, so there's a potential impact. Yeah, definitely. I think that there's, I think the conversation about COVID-19 vaccines has, I would say, evolved quite a lot over the last six to eight months, just because of the speed at which everything has been changing. We have so much more evidence about the safety and efficacy of COVID-19 vaccines now than we did in September to December 2020. The political situation has changed. The epidemic has also changed in different ways and different jurisdictions. Risk has changed, so I think all of those factors together have contributed to changes in people's willingness. That being said, one thing that I thought was very striking when putting this presentation together was how similar the rates of individuals, the proportion of individuals who indicated that they were very or somewhat likely or uncertain about getting the vaccine, how similar those are to the actual uptake right now in June 2020 here in Canada. I found that really striking. Usually we do see some movement one way or the other, but these percentages suggest that there's a pretty strong concordance between how people felt in September 2020 to December 2020 about COVID-19 vaccines and whether they actually did get vaccinated when given the opportunity this past spring. That suggests that many people's minds were perhaps already made up and perhaps that they were already driven. The factors that were driving them to express willingness to get a COVID-19 vaccine early persisted and they were able to maintain that willingness. What that also suggests though is that we haven't made enough headway among those who indicated they were significantly unlikely to get the vaccine and that's where we really need to figure out strategies to try and address those individuals and many studies have shown that there are some associations with political leanings at least in the U.S. and willingness to get COVID-19 vaccines. So I want to ask a question. I think I get to ask a question. So one of the issues and I don't work in the area of vaccine willingness but for the COVID-19 vaccine the questions were asked about a vaccine that wasn't yet rolled out. So perhaps there's a difference in asking people for their willingness to have something that they've never seen any experience with versus something that is much more commonplace like the influenza vaccine and I'm just wondering you know are in your experience are there differences in the willingness to be vaccinated when you know more about the vaccine than versus when you you know hasn't rolled out yet? Yeah it really depends. So this is a great question and this is something we always worry about in studies of self-reported vaccine willingness and so that's why I listed that as our main limitation because in studies of self-reported vaccine willingness you have to do a lot more work to try and figure out whether that correlates with an individual's actual decision at the moment that they are offered the opportunity to get the vaccine. So the data that was collected in the CLSA exit survey prior to the introduction of COVID-19 vaccines is really valuable for planning purposes but we do need ongoing evaluation to try to understand what how people's thinking has changed and how that willingness has you know varied over time as more information comes to the bear. One of the things that we did in the design of the question for this survey is we asked people if a safe and effective vaccine were available would you take that vaccine? So we did that to try to guard against people's concerns about whether the vaccines that were being developed would turn out to be safe because that can be a huge barrier. If you ask me if I'm willing to take a vaccine that I don't have the data for yet why would I how would I be convinced that it is safe and effective? So we tried to ask this question in a way where if you are already convinced that the vaccine was safe and effective or if the evidence showed the vaccine was safe and effective would you take it? And we still see that even in that context individuals raise safety as a main concern that there is a real great demand for additional safety data and additional efficacy data. So there's a question here and I think it's a very interesting question as all of the others but question is how big a role did social media play in the hesitancy in for example middle-aged women particularly in rural areas? Is there something you I mean I don't think we collected that information in the CLSA but based on your experience and the role of social media? Yeah that's a great question. Social media has played a very interesting role throughout the pandemic not just for vaccines but in in terms of a lot of misinformation that's being spread and a lot of disinformation campaigns as well. I can't speak specifically to its impact on hesitancy in middle-aged women or particularly in rural areas. Many surveys have looked at what the primary sources individuals use to get their information about vaccines and social media is often listed as one of the primary sources of information. I know the WHO has started this social media listening campaign where they're trying to monitor social media postings around the world in a lot of different contexts to try to get ahead of some of the misinformation that's spreading really rapidly and some of the disinformation campaigns that are that are being implemented. So I'm not entirely sure how it has affected the views of individuals in the CLSA survey. We do see differential social media usage by age group for sure and differential usage of different platforms by age group. Not from CLSA data but just in general among adults and we also do see a number of efforts. I think COVID-19 resources Canada is one group of hundreds of researchers throughout Canada who are trying to create infographics and media social media campaigns that can be spread more widely so that the the social media platforms are flooded with positive information and correct information about the great degree of evidence that we have for these vaccines and answer questions as well as they pop up. Okay so this speaks to the latter part of your presentation. The question or comment is that Canada seems to be a leading nation in vaccine uptake and so the question is are there any factors that you could think of that have led to this? Yeah this is a great question. So in general Canada has pretty high vaccine confidence overall so there are global studies that look at how confident individuals are across different countries and so in non-pandemic times flu vaccine uptake among adults vaccination of children is generally quite high in Canada compared to a number of other countries. There are a number of studies and I don't know if they have specifically included Canada but they are from political scientists who have looked at things like social cohesion in the population and how that relates to willingness to contribute to vaccination campaigns and those studies have shown that countries that have a much greater sense in their population of solidarity or social cohesion are much more likely to have higher vaccine uptake or much more likely to have individuals that would want to get vaccinated whereas countries which have a much more individualistic bent are less likely to see high vaccine uptake rates. So yeah Canada is certainly a leading nation in terms of COVID-19 vaccine uptake. I had taken out one of the slides so I didn't want to go over time but if you look from a site like our world and data if you compare Canada's first dose vaccine uptake for COVID-19 to all other countries in the world I believe that we're leading all countries in the world in terms of uptake in these first six months we're very fortunate to have the access to a great number of COVID-19 vaccines and an abundance of supply and people have really you know stepped up to go and get vaccinated once they became eligible. So there yeah so there are a number of different factors it's a very interesting area of study and I think it's one that a lot of political scientists have taken up quite recently. So there's a comment here which is a follow-up about the Alberta and we'll call it the incentive program in Alberta. So it's been reported in Alberta that there was an initial uptake following the Lotto announcement among the 18 to 34 age group which apparently helped push the first first vaccine level to 70% triggering the provincial open for the summer plan. So that's a little bit of context from someone who obviously has that information. Thank you. So there's another another question here which is long so just bear with me so it's a great and insightful presentation thanks. I wonder whether we could assess the ability of the model to predict the willingness to receive COVID-19 vaccine. If the ability of the model is good in terms of discrimination and calibration it may be a good tool to better allocate public health resources to convince people predicted to be less willing to get the vaccine. So can this model potentially used be used as decision-making tool to better define which people should be better convinced to get the vaccine? Yeah that's a great question and a great idea and certainly something to consider. I think I would from a statistical perspective I would really hope that we could develop like a validation data set and I know the CLSA has collected vaccine uptake through some of its other studies more recently. So one thing that I'm hoping that we can do in the near future is take the individuals that participated in this COVID-19 exit survey where we have their willingness to get COVID-19 vaccine and validate their willingness with their actual uptake from a different CLSA study that took place more recently the zero prevalence survey which collected actual uptake of COVID-19 vaccines. I think in doing that I would be a lot more confident about the ability of the model to basically identify who should be targeted or where I guess the best use of resources would be where intervening would likely be the most effective or likely be the most beneficial if we could really encourage individuals in those areas but certainly a really important question. It's always a challenge when using some of these descriptive results to indicate which groups should be focused upon because we don't have that kind of causal pattern to try to look at who really would benefit most from COVID-19 vaccine uptake interventions. Okay that's great. I just want to finish up because there are no more questions in the chat and I apologize if I missed anybody but I think I got all of them. So I just want to ask you sort of two questions. The first one is you've worked in the area vaccine willingness for many many years in many different countries and I'm just wondering if any of the results you saw here surprised you. That's a great question. I think I was a little bit surprised by the by the the three hypotheses that we investigated and let me just go to the slide so I can speak about them here. Yeah so these three hypotheses that we investigated about other factors that could be associated with COVID-19 vaccine willingness it's been it has been shown in other studies that flu vaccine willingness is correlated to COVID-19 vaccine willingness but I was surprised at the strength of that association. So this association shown here indicates that those who had been vaccinated for influenza in early fall 2020 were the odds was 14.6 the odds ratio was 14.6 compared to those who had not planned or were not getting vaccinated for flu in their willingness to get COVID-19 vaccines after accounting for all those demographic factors that we just talked about. So what that suggests to me is that the focus on demographic groups is likely misplaced or there's likely less of a benefit of focusing on on demographic groups. If you can find those individuals who haven't gotten the flu vaccine in the last year those are likely the individuals that are least likely to get vaccinated with COVID-19 vaccines and those are likely the individuals that are going to be the most challenging to reach because they haven't been getting flu vaccine even though they've been eligible they may have stronger beliefs about may have stronger beliefs that that questions about safety of vaccines or lack of value of vaccines or something like that and so if other messaging has not been effective in convincing them to get flu vaccines even though they're eligible even though they may be in high-risk groups as older adults that's going to present another challenge to try and get them vaccinated for COVID-19 vaccines. So just the the degree of that association was quite striking to me. I think that one thing that was also surprising to me was honestly that anyone indicated that the consequences of the COVID-19 pandemic was positive maybe that's just based on my own experience and experience of others I know but I think that that's surprising that some some people had a really positive experience over this past year but I don't think it's surprising that those who had a negative experience would want would be more likely to get vaccinated. Okay so we only have just three minutes left so very quickly so next steps for you in terms of this whole domain of research in Canada? Yeah so in terms of next steps I definitely want to see if we can try to validate some of this some of these willingness data to understand who actually went and got vaccinated and then I think it's going to be really important to try in my opinion to move the conversation past demographic groups and try to figure out those who are in some way ideologically opposed to COVID-19 vaccine or all vaccines in general and test methods for improving their trust in vaccines and developing relationships that can improve trust in vaccine I think that's going to be the biggest challenge for Canada and many other countries with access to vaccines over the next six months. In addition personally I'm very concerned about the growing disparity in COVID-19 vaccine access throughout the world and I I'm really hoping to start working on that area and to see Canada as a leader in trying to increase access because this pandemic is certainly not going to end unless there is greater access and and less disparity in terms of access to vaccines everywhere. I think Canada has a great opportunity here in this in this regard. Thank you. Thank you very much for agreeing to give the presentation Nicole and there were lots of interesting questions. I want to just remind everyone and I know Nicole has already put it in the slide that the next application deadline for access to the CLSA data including the COVID-19 questionnaire is on September 8th 2021. Please visit the website the CLSA website under the data access tab to get more information and I'd also like to ask you those people who are still on to please remember to complete the evaluation poll. So I think that's it. This is our last webinar for the summer season and I look forward to welcoming you all back on behalf of the CLSA to our webinar series in the fall. So thank you again for attending the presentation and have a great summer.