Using the precaution adoption process model to understand decision-making about the COVID-19 booster vaccine in England

Background: COVID-19 continues to pose a threat to public health. Booster vaccine programmes are crit-ical to maintain population-level immunity. Stage theory models of health behaviour can help our under-standing of vaccine decision-making in the context of perceived threats of COVID-19. Purpose: To use the Precaution Adoption Process Model (PAPM) to understand decision-making about the COVID-19 booster vaccine (CBV) in England. Methods: An online, cross-sectional survey informed by the PAPM, the extended Theory of Planned Behaviour and Health Belief Model administered to people over the age of 50 residing in England, UK in October 2021. A multivariate, multinomial logistic regression model was used to examine associations with the different stages of CBV decision-making. Results: Of the total 2,004 participants: 135 (6.7%) were unengaged with the CBV programme; 262 (13.1%) were undecided as to whether to have a CBV; 31 (1.5%) had decided not to have a CBV; 1,415 (70.6%) had decided to have a CBV; and 161 (8.0%) had already had their CBV. Being unengaged was pos-itively associated with beliefs in their immune system to protect against COVID-19, being employed, and low household income; and negatively associated with CBV knowledge, a positive COVID-19 vaccine experience, subjective norms, anticipated regret of not having a CBV, and higher academic qualifications. Being undecided was positively associated with beliefs in their immune system and having previously received the Oxford/AstraZeneca (as opposed to Pfizer/BioNTech) vaccine; and negatively associated with CBV knowledge, positive attitudes regarding CBV, a positive COVID-19 vaccine experience, anticipated regret of not having a CBV, white British ethnicity, and living in East Midlands (vs London). Conclusions: Public health interventions promoting CBV may improve uptake through tailored messaging directed towards the specific decision stage relating to having a COVID-19 booster. (c) 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).