key: cord-0784763-hxrrvqtr
authors: Abou-Arraj, N. E.; Maddah, D.; Buhamdan, V.; Abbas, R.; Jawad, N. K.; Karaki, F.; Alami, N. H.; Geldsetzer, P.
title: Perceptions of and obstacles to SARS-CoV-2 vaccination among adults in Lebanon: a cross-sectional online survey
date: 2021-05-24
journal: nan
DOI: 10.1101/2021.05.21.21257613
sha: fb0c774ae2bb134d734eec23602d81a9c9aa5d8b
doc_id: 784763
cord_uid: hxrrvqtr

The COVID-19 pandemic is an additional burden on Lebanon's stressed population, fragmented healthcare system, and political, economic, and refugee crises. Understanding the population's intentions to vaccinate, and perceptions of and obstacles to SARS-CoV-2 vaccination, can inform Lebanon's vaccination efforts. We performed a cross-sectional study from 29 Jan 2021 to 11 Mar 2021 using an online questionnaire in Arabic via convenience "snowball" sampling to assess the perceptions of adults residing in Lebanon. 1,185 adults participated in the survey. 46.1% [95% CI: 43.2%-49.0%] of survey participants intended to take the SARS-CoV-2 vaccine when available to them, 19.0% [16.8%-21.4%] indicated that they would not, and 34.0% [31.3%-36.8%] were unsure. The most common reasons for hesitancy were concerns about safety, limited testing, side effects, and efficacy. Vaccine hesitancy appears to be high in Lebanon. Disseminating clear, consistent, evidence-based safety and efficacy information on vaccines may help reduce vaccine hesitancy, especially among the large proportion of adults who appear to be unsure about (rather than opposed to) vaccination.

As of 18 May 2021, Lebanon's cumulative positive COVID-19 case count was 536,554 40 people (78,611 cases per million), and at least 7,641 people have died [1] . Already a devastating 41 toll, this number is likely significantly underreported due to lack of testing and fragmented health 42 infrastructure in the country [2] . In addition to the pandemic, Lebanon has been struggling with 43 multiple challenges: a political crisis and economic collapse driven by corruption that began in 44 2019 and worsened throughout 2020, leading to widespread mistrust of the government, 45 inflation, unemployment, poverty, and increased food insecurity, on top of the strain of being the 46 country with the highest number of refugees per capita in the world due to the protracted Syrian 47 refugee crisis [2] [3] [4] [5] [6] . Given Lebanon's compounding crises and limited resources, mass 48 vaccination is a challenging but vital mission. Understanding the population's perceptions of 49 SARS-CoV-2 vaccines is critical for implementing a successful vaccination campaign in the 50 elderly age, higher educational attainment, and higher physical activity [12, 13] . In a study of 74

Lebanese physicians' perspective on the pneumococcal and influenza vaccines, physicians cited 75 availability and cost concerns, patients' declining to be vaccinated, and physicians' doubts over 76 efficacy as barriers to vaccination [14] . For the refugee population specifically, several studies 77 have assessed vaccination in displaced Syrians living in Lebanon, finding inadequate rates of 78 childhood vaccination, high variability by location within Lebanon, and challenges in 79 maintaining vaccination records [15] [16] [17] . 

To assess perceptions of SARS-CoV-2 vaccination in Lebanon, we designed a cross-100 sectional descriptive study employing a remote online Arabic survey. We originally intended to 101 distribute it to randomly selected Lebanese phone numbers to obtain an unbiased nationally 102 representative sample, but during piloting, this method needed to be aborted because of 103 exceedingly low response rates (less than 1%), thought to be due to mistrust of messages and 104 links received from an unknown phone number. Given these constraints, we changed our 105 distribution methods to convenience "snowball" sampling, a method further described below that 106 had successfully been used elsewhere in the Middle East to quickly recruit a large sample size 107 [23] . 108

After making these adjustments, an anonymous, online, self-administered survey was 109 created and distributed using convenience "snowball" sampling. The recruitment and survey 110 period was six weeks: 29 January 2021 -11 March 2021. This time period spanned before and 111 after initiation of SARS-CoV-2 vaccination in Lebanon, which began on 14 February 2021 [7] . 112 113

The target population was all adults living in Lebanon, including the significant refugee 115 population. While all adults living in Lebanon were eligible to participate, they needed to be able 116 to access the self-administered online survey tool, either on a mobile phone or computer. The 117 survey was in Arabic, so participants were required to be literate in Arabic or to be assisted by 118 someone who was. 119

The survey consisted of 31 multiple-choice and free-response questions (depending on 142 branch points, participants were not asked each question), divided into an introduction with the 143 informed consent document, followed by questions about screening, demographics, questions 144 experience with COVID-19, and perceptions of SARS-CoV-2 vaccination. No identifying data 145 was collected. The first questions asked participants to provide informed consent, to affirm that 146 they were 18 years or older and living in Lebanon, and to verify that they had heard of 147 "coronavirus" (as SARS-CoV-2 and COVID-19 are referred to in Lebanese Arabic). If they 148 declined, the survey automatically ended. If they passed these questions, they were able to 149 proceed with the survey. 150

The survey consisted of three sections. The "coronavirus vaccine" section assessed 151 intentions to receive or not to receive vaccination and motivations behind these decisions. It also 152 asked about participants' preferred location to receive the coronavirus vaccine, how much money 153 they would be willing to pay for the vaccine if it were to cost money, and if monetary incentives 154 could influence their decision on taking the vaccine. 155

The "experience with coronavirus" section surveyed participants' most frequently used 156 news sources about coronavirus, their most trusted news sources, how often they wore a face 157 mask as a preventative measure when leaving their homes, and whether they or anyone they 158 knew had been infected with coronavirus. 159

The "demographics" section included questions on gender, age, religion, household 160 income for the year 2019, education level, geographic location, nationality, and refugee status. 161

Once participants started the survey, they had 48 hours to complete it before the survey 162 automatically recorded their responses. Participants were prevented from taking the survey 163 multiple times on the same device using a Qualtrics feature based on browser cookies. 164 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) software and focused on description rather than identifying causal links [28] . 169

Several quality measures were implemented. To ensure that participants had at least a 170 baseline familiarity with the survey topics, one of the screening questions asked whether 171 participants had heard of "coronavirus." If they had not, they were not able to proceed with the 172 survey; only 5 participants (0.42%) were excluded because of not being aware of "coronavirus." 173

To identify participants who randomly clicked through the survey, a filter was applied to detect 174 participants who completed the survey in less than 120 seconds; no participants did so. 175

For some multiple-choice questions, similar categorical responses were consolidated into 177 binary or fewer categories to facilitate interpretation. For binary and categorical variables, the 178 absolute number and relative proportions of participants who selected each response was 179 calculated. Wilson score 95% confidence intervals were calculated for proportions. 180

Given that the survey period spanned the initiation of SARS-CoV-2 vaccination in 181

Lebanon, a sub-analysis was performed in which participants were divided by whether they 182 completed the survey before or after vaccine initiation. For each of these sub-groups, sample 183 demographics were recalculated and are displayed in Table 1 . We did not use sampling weights 184 in our analysis given that this was a non-probabilistic sample of the Lebanese population that 185 was unlikely to be representative of the general population even after weighting. 186

If participants indicated that they intend to vaccinate, they were then asked, "Why do you 188 plan to get the coronavirus vaccine if and when it becomes available to you?" If they intended 189 not to vaccinate, they were asked, "Why do you plan on not getting the coronavirus vaccine if 190 and when it becomes available to you?" If they were uncertain about vaccinating, they were 191 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Figure  228 2). 229

There were less strong but still apparent trends toward higher proportions of participants' 230 intending to vaccinate if they identified as older in age; lived in Beirut or Akkar governorates 231 (Mount Lebanon as reference); had attained higher educational status; or were employed. There 232 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) When compared to participants who reported "sometimes," "rarely," or "never" wearing 244 a mask when outside the home (n = 97 [8.8%]), participants who reported wearing a mask 245 "always" or "most of the time" (n = 1011 [91.2%]) were much more likely to intend to vaccinate 246 (50.0% [46.8%-53.1%] vs 18.6% [11.7%-28.0%]). 247

We also asked participants to identify their top three most commonly used sources of 248 news for coronavirus. Participants who reported commonly obtaining news from newspapers and 249 magazines or the radio were more likely to intend to vaccinate than those who reported 250 television, social media, other internet websites, and family and friends as common sources of 251 news. Very few participants (n = 6 [0.5%]) reported that religious leaders are a commonly used 252 source of news. 253 254

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. (Table 2) . Importantly, these groups were 258 contacted differently and differed in several key demographic characteristics: the group of 259 participants who responded after initiation of vaccination was younger and had a higher 260

proportion of participants that lived outside of the Mount Lebanon region, identified as Shi'a or 261 Sunni rather than Druze or Christian, had European or North American or multiple citizenships, 262 and identified as refugees (Table 1) . 

Most frequently, participants cited the following motivations for their decisions to 276 vaccinate: to protect themselves, their families, and the public, and to end the pandemic and 277 return to normal life (Table 4 ). Somewhat frequently given reasons for intending to vaccinate 278 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. ; https://doi.org/10.1101/2021.05.21.21257613 doi: medRxiv preprint included that participants felt like they "had no other choice" given the state of the pandemic, 279

and that participants trusted science and research. 280 281

Among participants who responded that they did not intend to be vaccinated, several 283 themes emerged (Table 4) (Table 4) . Somewhat 292 frequently mentioned concerns included mistrust of the Lebanese government and healthcare 293 system, potential fraud in storage or marketing of the vaccines, wanting more information about 294 the vaccines, and needing more time to decide which vaccine to take. 295

One of our study's primary objectives was to determine the proportion of Lebanese adult 298 residents who intended to take (vaccine acceptance), who did not intend to take (vaccine 299 hesitancy), and who were unsure about taking the SARS-CoV-2 vaccine (vaccine uncertainty) 300 when available to them (while deciding to use these terms, we acknowledge that they imperfectly 301 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. ; https://doi.org/10.1101/2021.05.21.21257613 doi: medRxiv preprint capture the complexity of individuals' decisions about vaccines) [29] . Our findings of rates of 302 vaccine acceptance and vaccine hesitancy were similar to studies of other countries in the Middle 303

East and across the world. Vaccine acceptance of 46.1% in our sample was similar to rates in 304

Kuwait (53.1%) and Qatar (45%-60%); higher than rates in Jordan (28.4%); and somewhat lower 305 than in Saudi Arabia (64.7%) [23, [30] [31] [32] . Rates of vaccine acceptance in our study were also 306 similar to a large survey of 15 developed countries across the globe, in which 54% of they would be willing to take a vaccine; it is important to note that at this time, no vaccines were 316 developed or approved, and this survey's population was 73.7% male and 89.0% aged younger 317 than 45 years old, compared to our population which was 62.1% female and 79.1% aged younger 318 than 45 years old [11] . 319

One of our important secondary objectives was to assess which demographic 320 characteristics were associated with vaccine hesitancy. Our findings of trends toward increased 321 vaccine hesitancy in women, younger age groups, unemployed individuals, and individuals with 322 lower education attainment are generally consistent with findings in the Middle East and 323 globally, with the notable exception that in Kuwait and Qatar, hesitancy was increased in older 324 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) about religion and income, respectively, demonstrating the topics' sensitive natures. Therefore, 328

we do not recommend making inferences from our study about differences in vaccine acceptance 329 or hesitancy by religion or income. Similarly, refugees (n = 56, 5.1%) were underrepresented in 330 our sample. While no significant difference in vaccine acceptance by refugee status emerged, 331 further focus on vaccination in refugees in Lebanon is merited given their multiple 332

Another important secondary objective of our study was to evaluate how individuals' 334 experiences with COVID-19 affected vaccine acceptance. Unsurprisingly, frequent mask 335 wearing was associated with increased vaccine acceptance, likely because these individuals see 336 COVID-19 as a more serious threat than those who do not wear masks frequently. The non-337 significant trend toward increased vaccine acceptance among participants with a close 338 acquaintance who contracted COVID-19 could imply that personal experience with someone 339 affected by the virus increases willingness to vaccinate. Interestingly, however, neither personal 340 history of infection nor history of infection in a close contact was consistently associated with 341 vaccine acceptance in a meta-analysis of SARS-CoV-2 perception studies [37] . 342

The timing of our survey period spanned the initiation of vaccination in Lebanon. While 343 our data suggested increased vaccine acceptance among participants who completed the survey 344 after initiation of vaccination, this must be interpreted cautiously. The demographics of the 345 respondents after initiation of vaccination were significantly different from those who completed 346 the survey before initiation of vaccination. We believe that the differences in vaccine acceptance 347 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. ; https://doi.org/10.1101/2021.05.21.21257613 doi: medRxiv preprint before and after initiation of vaccination more likely reflect differences in populations surveyed 348 during these periods, given the selection bias inherent in the convenience "snowball" sampling 349 method. 350

Our study was conceived with the goal of providing information that would be useful for 351 implementation of vaccination efforts in Lebanon. The logistical considerations about which we 352 asked can provide some guidance. The most commonly selected sources of news about COVID-353 19 were television, social media, and internet websites; among these, television and internet 354 websites were the most trusted. Though religion is influential in Lebanon, only 6 (0.5%) 355 participants cited religious leaders as an important source of COVD-19 news. Given that 356 respondents who selected newspapers, magazines, and radio were more likely to intend to 357 vaccinate, focusing dissemination of vaccine promotion efforts on television, social media, and 358 internet websites would appear to be most efficient to reach those who are hesitant to vaccinate. 359

Survey respondents also reported preferring to receive the vaccine at familiar, established 360 health care sites: hospitals, doctors' offices, primary health centers, and pharmacies. While 361 temporary dedicated vaccination centers were not popular, a small but significant number of 362 participants (106, 11.8%) stated they would prefer vaccination by a visiting medical professional 363 to their homes. This could be an important means of reaching vulnerable patients willing to be 364 vaccinated but unable to go to vaccination sites. A final logistical consideration about which our 365 survey asked was whether a financial incentive would change participants' minds so that they 366 decide to vaccinate; overwhelmingly, they indicated that it would not (98.3%). Based on this 367

study, it appears that offering a financial incentive would not be an efficient means of increasing 368 vaccination rates in Lebanon. 369 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. study cited conspiracy theories as reasons for not vaccinating, these were relatively uncommon, 382 especially compared to a study in other Arabic speaking countries, which found rates of belief in 383 conspiracy theories of over 50% [32] . 384

Interestingly, logistical factors were not frequently of concern among adults living in 385

Lebanon. Despite financial hardships in Lebanon, barriers to vaccine access (cost, transportation, 386 proximity to medical care) were not cited frequently as concerns about vaccination in our study. 387

This might be explained by the fact that it has become common for governments, including in 388 developing countries, to distribute the vaccine free of charge as a part of public health mandates. 389

While a few participants did express preference for "the vaccine from China or Russia," most 390 perceptions applied generally to all SARS-CoV-2 vaccines, and there were relatively few 391 concerns about vaccine properties like number of required doses, country of origin, or specific 392 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This cross-sectional study assessed intentions to vaccinate against SARS-CoV-2 among 431 adults residing in Lebanon, analyzed characteristics that were associated with vaccine acceptance 432 and hesitancy, and described motivations for and concerns about vaccination. We recommend 433 disseminating clear, consistent, evidence-based safety and efficacy information on vaccines on 434 the most commonly reported news sources by participants: television, social media, and news 435 websites. As vaccination efforts continue, repeated assessments of intentions to vaccinate, 436 concerns or obstacles regarding vaccination, and changes in motivations should be performed, 437 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. 

The authors declare no known financial or personal competing interests that could have 453 influenced the study's work or paper's findings. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 24, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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In these graphs, the sample population is stratified by age group and gender. For each stratum, the proportion (as a 517 percentage) that indicated that they intend to receive the vaccine, do not intend to receive the vaccine, and are unsure 518 about receiving the vaccine is displayed in the corresponding cell in the top, middle, and bottom graphs, 519 respectively. This analysis only includes participants who provided age, gender, and their intentions about 520 vaccination. As only 7 participants identified as "other" gender, only participants identifying as "male" or "female" 521 were included .   522   523  524  525  526  527  528  529  530  531  532  533  534  535 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 24, 2021. ; https://doi.org/10.1101/2021.05.21.21257613 doi: medRxiv preprint 577  578   579  580  581  582  583  584  585  586  587  588  589  590  591  592  593  594  595  596  597  598  599 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 24, 2021. ; . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

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