key: cord-0722728-k46n5jlt authors: Marzo, Roy Rillera; Ahmad, Absar; Abid, Khadijah; Khatiwada, Asmita Priyadashini; Ahmed, Ali; Kyaw, Thin Mon; Abidin, Insyirah Bt Zainal; Srithar, Metahra; Sinnathamby, Sathiajothi; Sarvasundram, Arivalagan Palani; Shrestha, Sunil title: Factors influencing the acceptability of COVID-19 vaccination: A cross-sectional study from Malaysia date: 2021-09-01 journal: Vacunas DOI: 10.1016/j.vacun.2021.07.007 sha: c49a5e36c465b253bfa4b92fc7cab9a38ecc2976 doc_id: 722728 cord_uid: k46n5jlt Background: With the surge of COVID-19 cases worldwide, vaccines against COVID-19 are also developing across the countries. However, the acceptability of COVID-19 vaccination among general people is questionable. The availability of several vaccines' options against COVID-19 has perplexed people regarding individual vaccines' efficacy and safety. Therefore, we aim to determine the acceptance, preferences, impact factors of future COVID-19 vaccines in Malaysia and the factors influencing the COVID-19 vaccination acceptance among vaccine demand and vaccine delay groups. Material and Methods: An online-based cross-sectional survey was conducted among Malaysian residents 18 years and above of either gender using the snowball sampling technique. A self-administered questionnaire was made available to participants through various social media networks, email, and telegram. The data obtained from the survey were analyzed using SPSS version 25.0. Association between background characteristics and respondents were analyzed using the Chi-square test in the vaccine delay group and vaccine acceptance group. Results: Total of 1282 responses were considered for the study, mainly from male respondents (71%). Among the respondents, 95.9% thought that vaccination would be an effective way to prevent and control COVID-19, and 96% would accept vaccination if the COVID-19 vaccine were successfully developed and approved for listing in the future. Essential factors influencing vaccination decisions were vaccine convenience (95.7%) and doctor’s recommendation (97.3%). Bivariate analysis revealed that age less than 24 years, Malay race, living in urban areas, tertiary education, students, single marital status, family income (Malaysian ringgits) RM 4850 to RM 10959 and >RM 10960 were significantly associated with vaccine acceptance of COVID19 vaccination. Conclusion: All the factors influencing COVID-19 vaccine acceptance rates throughout the country should be studied on a larger scale, and appropriate steps to ensure vaccine acceptance among the public should be meticulously devised by the government and related authorities. The coronavirus disease pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has wreaked havoc worldwide, especially in Southeast Asia 1-3 . Food and Drug Administration (FDA) has approved some drugs to treat severe COVID-19 cases, there is no specific and effective therapy. Therefore, all countries are attempting to halt the disease from spreading by enforcing lockdowns and quarantines, community-wide use of facemasks at all hours, social distancing measures, and travel ban 4, 5 . Unfortunately, these initiatives have resulted in substantial physical and psychosocial deterioration of individuals 6 , as well as a global economic recession. 4, 7 Therefore, designing and deploying a COVID-19 vaccine is one of the most cost-effective and successful approaches to fighting the pandemic 1,8,9 . Various research institutes funded by governments, philanthropists, and pharmaceutical firms actively create and test the most effective COVID-19 vaccine 1 . The first COVID-19 vaccine based on mRNA was developed and evaluated by Moderna Inc in the United States, and then CanSino Biologics in China tested a non-replicating vector-based vaccine 10 . Other vaccine candidates are being developed, including inactivated 11 , sub-unit 12 , live attenuated 13 , replicating viral vector-based vaccines 13 , and DNA-based vaccines 10 . Nevertheless, it is not clear how efficacious will these vaccines will be. People can assume that the pandemic vaccine is dangerous due to its novelty or alleged lack of research 14 . As a result, public understanding of COVID-19 vaccine safety may play a role in vaccine acceptance 15, 16 . Indonesian study reported, 52% of individuals are willing to get vaccinated against COVID-19;while 48% of the individuals would delay the vaccination until the vaccine's safety was verified 1 . J o u r n a l P r e -p r o o f 6 COVID-19 is one of the greatest human health crises globally, so community engagement and vaccine coverage are critical factors in overcoming this pandemic 17, 18 . However, the acceptability level of the Covid-19 vaccine is less well known, and there could be major differences in the rates of acceptance vaccine against COVID-19 concerning different populations 14 . According to a global survey, it ranges from 55% (in Russia) to 89% (in China) 19 . Whereas study conducted in Malaysia showed 93% acceptance 20 . Further, the most frequent reasons identified for vaccine refusal were vaccine safety 21 , vaccine efficacy 22 and vaccine side effects 20, 23 . With this background, the main aim of this research was to determine the acceptability level of the COVID-19 vaccine in Malaysia. The specific objectives were to determine the acceptance, preferences, impact factors of the future COVID-19 vaccine and determine the influencing factors of COVID-19 vaccination acceptance among the vaccine demand and vaccine delay groups. This research will help formulate the best approaches to implement potential vaccination policies in Malaysia and reduce factors affecting vaccine acceptance and immunization programs. An internet-based cross-sectional survey was conducted from October 2020 to January 2021, when the movement restriction due to COVID-19 was active in Malaysia. Snowball sampling, a convenience sampling method, was used for the data collection using research networks of universities, hospitals, friends, and their relatives. 7 The study received ethical approval from Asia Metropolitan University's Medical Research and Ethics Committee (Reference no. AMU/MREC/FOM/NF/2020/38). Malaysian residents of 18 years old and above and of either gender were selected and enrolled in the study. All the enrolled participants consented to the online survey. The self-administered questionnaire was designed based on previous studies and frameworks to assess vaccine acceptance for newly emerging infectious diseases such as H1N1 or Ebola 7, 8 . The contents of the questionnaire included (1) socio-demographic characteristics such as age, gender, place of residence, race, educational level, occupation, number of family members, marital status and family income; (2) acceptance, attitude, vaccination preferences for future COVID-19 vaccination and the importance of identified impact factors on the respondents' vaccination decision-making, such as vaccine price, convenience and doctor's recommendations. All questions were close-ended, with tick boxes provided for responses. The Cronbach's alpha of 0.812 indicated that the questionnaire has an excellent internal consistency. The structured online questionnaires were conveniently distributed through emails, Facebook, WhatsApp, Telegram, Instagram, and other social media throughout this network in Malaysia. The online link for collecting data was available for about four months. Our study was an entirely voluntary online survey. The survey form was provided with a setting such that the consented participants could respond to questions only once using a single account to prevent more than one response from the same history. Spreadsheets of responses were exported into IBM SPSS version 25 for further analysis. Page 8 of 21 J o u r n a l P r e -p r o o f 8 The data captured in the online google form were examined for errors then cleaned and exported into SPSS version 25.0 for further analysis. Descriptive statistics were used to summarize the respondent's socio-demographic. Chi-square test was used to analyze the significance of the association between background characteristics and respondents in the two groups (vaccine delay group vs vaccine acceptance group. A logistic regression model was employed on those variables that appeared to have a p-value of < 0.05 in the bivariate analysis to identify determinants of participants' acceptance of a COVID-19 vaccine. The significance of adjusted Odds Ratio (AOR) in multivariate analyses were assessed at α = 0.05. We received 1,310 responses (Response rate 97.8%) during the survey period; 28 were excluded because of failure in fulfilling the inclusion criteria and incomplete data. Table 1 presents the basic characteristics of respondents. Nearly 70% of the respondents were less than 24 years old, and 71% were male. Most (89%) were residents of the urban area, and around 60% of respondents were from the Indian ethnicity. Almost 73% were tertiary , and two-third of the respondents were students. About 73% of respondents were single, and most of the respondent's monthly incomes were between RM 4, 850 to RM 10, 959. Table 2 shows the acceptance, preferences, and impact factors of the future COVID-19 vaccine.. Chi-square test with p-value less than 0.05 is considered significant. All significant values are highlighted in bold. of people would be willing to take a vaccine with a 95% efficacy, but this acceptance level decrease sharply as the vaccine's safety declines (67%). We also observed that only 38.2% of respondents in the vaccine accept group wanted to take vaccinated as quickly as possible when it became available, whilst 61.8% wanted to wait before the vaccine's safety was confirmed. Another research conducted by Woon et al. in Malaysia also reported vaccination safety as one of the leading reasons for vaccine refusal 38 . Hence, these findings highlight that the majority of Malaysians are in favour of the COVID-19 vaccine. However, these acceptance levels will be affected if vaccines need to be purchased and have a high cost, the government does not adequately subsidize them, and there is a lack of accessibility 1 and aware about the COVID-19 vaccine than rural dwellers, so they are more worried about side effects and are more likely to avoid vaccination before effectiveness is confirmed 41, 42 .Another reason for the vaccination delay is that people in urban areas are less afraid of COVID-19 than people in rural areas. Again, this may be attributed to urban areas having more access to information and daily alerts about COVID-19 43 . In the present study, it has been found that high-income groups have less acceptance of the vaccine than the low-income population. Cerda et al. lower-income and higher-risk populations can obtain vaccines at no cost, but high-income individuals must pay, so the willingness to pay for vaccines could contribute to vaccine refusal 44 . Therefore, the price of vaccination should be affordable for all with promising results 45 . People's education level plays a significant role in several measures related to vaccination experiences and behaviours, including evaluating both efficacy and the likelihood of severe side effects [46] [47] [48] [49] .In this study, people with a higher level of education (tertiary education) were more likely to consider vaccination than those with a lower level of education (post-secondary education and secondary education or less) (AOR: 1.988, 95 percent CI: 0.99-3.99).The global survey results also indicated that people with higher education were more willing to get vaccinated than people having lower education 50 . Another study conducted in Indonesia also revealed that acceptance of vaccine was higher in individuals having postgraduate education 1 . This highlights that health departments should design education programmes for increasing awareness regarding COVID-19 vaccination among people with lower education, leading to an overall improvement in acceptance and compliance of the general public 45 . Another interesting result of our research was that married individuals were less likely to get vaccinated than unmarried individuals (AOR: 0.851, 95% CI: 0.407-1.781). However, a study conducted in Saudi Arabia revealed that married people were more likely to accept vaccination than unmarried ones (AOR: 1.79; 95% CI: 1.28-2.50) 51 . Hence, our result highlights that married people perceived themselves to be at lower risk of COVID-19 infection. This finding may be attributed to the fact that the proportion of single people in our survey was much higher than married. Hence, future vaccine awareness strategies should consider subpopulations' health, science, and general literacy levels, recognize locally trusted knowledge providers, and go beyond merely stating that vaccines are safe and effective. Vaccine awareness and adoption strategies should specifically resolve community-specific concerns or myths, spot-on historical problems that contribute to skepticism, and be sensitive to religious or political views 14, 52 . Researchers have found successful strategies for increasing vaccine trust and decreasing vaccine apprehension in various settings but converting this research into large-scale vaccination programs would necessitate a keen understanding of and commitment to current consumer attitudes and needs. It would be crucial to include both formal and informal opinion leaders in these groups 1, [35] [36] [37] [38] 53 . This study advances the understanding of how health-related attitudes evolve. Focus on vaccinerelated attitudes and intentions is essential because experts and stakeholders agree that having enough people vaccinate against COVID-19 is key to stemming the pandemic. While the focus of this paper is vaccine attitudes, broad dataset offers a unique opportunity to understand attitudes and behaviors over time. Due to the richness of data in this study, its unique nature, and its timeliness, we believe it is essential to make it available to other researchers interested in exploring it and publishing additional findings. Also, this research study has important practical implications for public health policy. The main strength of this study was a large number of respondents. However, a significant limitation is the representativeness of the sample population; data collection occurred online, which means we may not have reached vulnerable groups, including those with lower socioeconomic backgrounds and those who are illiterate. Since the recruitment of these respondents was done through convenience sampling, the presence of bias may limit its findings. However, the efficiency of data collection, lower cost, and acceptability of online survey recruitment could provide a valuable alternative for the formal regional or national survey. The government and other relevant authorities should carefully consider all of the factors influencing COVID-19 vaccine acceptance rates across the country and devise measures to make the public aware of vaccine hesitancy's potential benefits and risks. Acceptance of a COVID-19 Vaccine in Southeast Asia: A Cross-Sectional Study in Indonesia Impact of the COVID-19 pandemic on psychosocial health and well-being in South-Asian (World Psychiatric Association zone 16) countries: A systematic and advocacy review from the Indian Psychiatric Society COVID-19 vaccination campaign in Nepal, emerging UK variant and futuristic vaccination strategies to combat the ongoing pandemic Understanding COVID-19 vaccine demand and hesitancy: A nationwide online survey in China Is Pakistan prepared to tackle the coronavirus epidemic? Public Knowledge and Practices regarding Coronavirus disease 2019: A cross-sectional survey from Pakistan Concerns of HIV-positive migrant workers in COVID-19 pandemic: A call for action Fighting COVID-19: A quick review of diagnoses, therapies, and vaccines COVID-19 vaccine hesitancy worldwide: A concise systematic review of vaccine acceptance rates Developing Covid-19 Vaccines at Pandemic Speed Looking beyond COVID-19 vaccine phase 3 trials A strategic approach to COVID-19 vaccine R&D Immunological considerations for COVID-19 vaccine strategies Myths and conspiracy theories on vaccines and COVID-19: Potential effect on global vaccine refusals A conjoint analysis of stated vaccine preferences in Shanghai, China Perceptions of measles, pneumonia, and meningitis vaccines among caregivers in Shanghai, China, and the health belief model: a cross-sectional study Public knowledge, attitudes and practices towards COVID-19: A cross-sectional study in Malaysia Public Knowledge and Practices regarding COVID-19: A cross-sectional survey from Pakistan A global survey of potential acceptance of a COVID-19 vaccine Factors influencing acceptance of COVID-19 vaccination among Malaysian adults COVID-19 vaccine roll-out in South Africa and Zimbabwe: urgent need to address community preparedness, fears and hesitancy Italian Adults' Likelihood of Getting COVID-19 Vaccine: A Second Online Survey COVID-19 vaccine hesitancy in a representative working-age population in France: a survey experiment based on vaccine characteristics Acceptance of COVID-19 Vaccination during the COVID-19 Pandemic in China The demand for a COVID-19 vaccine in Ecuador Parents' and guardians' views on the acceptability of a future COVID-19 vaccine: A multi-methods study in England Intention to participate in a COVID-19 vaccine clinical trial and to get vaccinated against COVID-19 in France during the pandemic Vaccine hesitancy: the next challenge in the fight against COVID-19 Once we have it, will we use it? A European survey on willingness to be vaccinated against COVID-19 COVID-19 vaccine hesitancy is associated with beliefs on the origin of the novel coronavirus in the UK and Turkey Attitudes toward a potential SARS-CoV-2 vaccine: a survey of US adults Vaccine hesitancy in Maltese family physicians and their trainees vis-a-vis influenza and novel COVID-19 vaccination High Rates of COVID-19 Vaccine Hesitancy and Its Association with Conspiracy Beliefs: A Study in Jordan and Kuwait among Other Arab Countries A global survey of potential acceptance of a COVID-19 vaccine Vaccine hesitancy around the globe: Analysis of three years of WHO/UNICEF Joint Reporting Form data-2015-2017 COVID-19 Vaccine Hesitancy Worldwide: A Concise Systematic Review of Vaccine Acceptance Rates Fearing the disease or the vaccine: The case of COVID-19 Factors influencing acceptance of COVID-19 vaccination among Malaysian adults Determinants of COVID-19 vaccine acceptance in the US Factors associated with decision making on COVID-19 vaccine acceptance among college students in South Carolina Knowledge, attitudes and perceptions towards COVID-19 vaccinations: a cross-sectional community survey in Bangladesh Relationship Between Fear of COVID-19, Psychopathology and Sociodemographic Variables in Malaysian Population Willingness to Pay for a COVID-19 Vaccine. Applied Health Economics and Health Policy Acceptance of COVID-19 Vaccination during the COVID-19 Pandemic in China Perceptions and Factors of Influenza Vaccination among Nurses A LITERATURE REVIEW OF PARENTAL BARRIERS TO CHILD IMMUNIZATIONS Impact on routine immunization services during the lockdown period in India: Implications and future recommendations Bridging the gap for clinical pharmacist in developing countries like Pakistan Education is now a bigger factor than race in desire for COVID-19 vaccine Determinants of COVID-19 vaccine acceptance in Saudi Arabia: a web-based national survey Knowledge, perception and attitude about Crimean Congo Hemorrhagic Fever (CCHF) among medical and pharmacy students of Pakistan Unequal distribution of COVID-19 vaccine: A looming crisis All authors declare no conflict of interest.