key: cord-0840281-aosppnfu authors: Abdulah, Deldar Morad title: Prevalence and correlates of COVID‐19 vaccine hesitancy in the general public in Iraqi Kurdistan: A cross‐sectional study date: 2021-08-10 journal: J Med Virol DOI: 10.1002/jmv.27255 sha: e46b9459a6e06d62a2ceef7e0ce3f11d33f519fd doc_id: 840281 cord_uid: aosppnfu Low vaccine acceptance is a major barrier to vaccination coverage in every health system. This study aimed to explore the prevalence and associated factors of the COVID‐19 vaccine hesitancy in a sample of the general population in Iraqi Kurdistan. The general population with both genders with different educational levels and sociodemographic characteristics from the Duhok governorate was eligible to participate in this cross‐sectional study in 2021. Therefore, an online Google form was sent to main pages and social groups through two main social media platforms. To obtain a representative sample of individuals with different educational levels, the author visited the main shopping center in Duhok city to collect the information from illiterate and low‐level education individuals. The study found that 83.5% (n = 773) of the participants have not received and 51.4% (n = 476) did not intend to receive the COVID‐19 vaccine. A small percentage has not decided to receive a COVID‐19 vaccine yet (n = 17, 1.8%). The intention to receive a COVID‐19 vaccine was increased with increasing level of education; 25.9%, 26.7%, 39.8%, and 53.6% in illiterate, under high school, high school, and college and higher, respectively (p < 0.0001). Healthcare workers were more likely to intend to receive a COVID‐19, 57.5% vs 40.1%, p < 0.0001. Individuals who had concerns about the side effects of a COVID‐19 vaccine were more likely to not receive and not intend to receive the COVID‐19 vaccine. Prevalence of COVID‐19 vaccine hesitancy was high in this region and was correlated with lower education and concerns about side effects. and February 2021 a total of 7669 persons were infected by the COVID-19 and 510 of them died (1.09%) in the Duhok governorate. 9 By 25 July 2021, 1,552,648 and 123, 332 had confirmed and active COVID-19 disease across Iraq. 10 The current condition in Iraqi Kurdistan calls for the urgency in vaccinating and examining the contributing factors to vaccine hesitancy. In 2012, the Strategic Advisory Group of Experts (SAGE) of the World Health Organization created the definition of vaccine hesitancy as delay in acceptance or refusal of vaccination despite the availability of vaccination services. Vaccine hesitancy is considered to be a complex and context-specific issue and it differs based on the time, place, and types of vaccines. Certain factors affect the rate of vaccine acceptance such as convenience, complacency, and confidence". 11 Immunization is considered to be one of the most important actions that protect children from serious illnesses. The vaccine saves the lives of millions every year worldwide. The low acceptance of specific vaccines or vaccination programs in the general public has become a major issue to the vaccination coverage in highincome, 12, 13 and low and middle-income countries. 14 Several factors are associated with low vaccine acceptance, such as cultural and environmental factors. The definite reasons for low vaccine acceptance are often not completely known to health policymakers. Vaccine hesitancy is a complex issue and is different according to time, location, and types of vaccines. In addition, it is affected by issues like complacency, convenience, confidence, and sociodemographic contexts. 15 The vaccination for COVID-19 in Iraq started on May 10, 2021. By July 5, 2021, 0.97% and 1.74% of Iraqi populations have received all doses and the first dose of the vaccination against the COVID-19, respectively. We need to find out the complex factors that influence vaccination decisions in general populations. In addition, the determinants of vaccine hesitancy must be examined in a specific population to improve vaccine coverage. There is no official study on the prevalence of COVID-19 vaccine hesitancy in Iraqi Kurdistan. In this regard, the author aimed to explore the prevalence and its as- To obtain the representative sample of the target population, an online form was sent to the main pages and social groups. The social media groups consisted of employees, nurses, policymakers, and entertainment, news, media groups, job opportunity, university, industry, and music professionals. Most of the individuals who use social media are those with some degree of literacy. The individuals with low levels of education and illiterate individuals were sought in a face-to-face technique. In this regard, the author visited the main shopping areas of Duhok city for four days to include the illiterate and low education level individual. Therefore, the main shopping areas were divided into four parts. The individuals who visited the shopping centers and the vendors were invited personally to answer the questions. In a face-to-face technique, the author used the researcher-administered technique to collect information. The officially recognized governorates inside Iraqi Kurdistan are Erbil, Sulaymaniyah, Halabja, and Duhok 16 (see Figure 1 ). The target populations of this study live in the Duhok governorate. It has the following seven districts: Zakho, Semel, Amedi, Shekhan, Duhok, Akre, and Bardarash. The members of the above-mentioned groups were from different districts of the Duhok governorate. The KRG has provided the following vaccination settings for the COVID-19 vaccine in different districts of the Duhok governorate. The Cochran formula is: where, e is the desired level of precision (i.e., the margin of error), p is the (estimated) proportion of the population that has the attribute in question, and q is 1 − p. The education of the participants was categorized as illiterate, under high school, high school, and college and higher. The persons who complete two years at university receive the institute degree and those who complete four years or more at a university receive the college degree in this region. The author categorized both institutes and colleges in one category of education because the author did not expect a significant difference in the awareness of these persons toward the COVID-19 vaccination. The general information of the individuals was presented in numbers The permission to conduct this study was obtained from the College of Nursing, University of Duhok. Verbal consent was acquired from all individuals before participation in this study either through an online technique or personal invitation. The study did no harm to the individuals because no intervention was applied to the subjects. The individuals were free to reject participation. The mean age of the participants was 33. and believed new vaccines carry more risks than older vaccines (52.7%). The participants reported that the information they receive about the COVID-19 vaccine is reliable and trustworthy (60.0%). In addition, they believed that getting the COVID-19 vaccine is considered a good way to protect them from COVID-19 disease (71.0%). They reported that they follow the advice of their doctors and healthcare providers to receive the COVID-19 vaccine (60.3%). However, they were concerned about the serious adverse effects of the COVID-19 vaccine (56.4%) and did not believe that they did not need the COVID-19 vaccine because the disease is not common anymore (78.5%), see Table 2 . The study reported that the intention of the participants to receive the COVID-19 vaccine was increased with increasing the level of education. The intention of the participants to receive the COVID-19 vaccine was 25.9%, 26.7%, 39.8%, and 53.6% in illiterate, under high school, high school, and college, and higher, respectively (p < 0.0001). The participants with lower levels of education were more likely to be hesitant to receive the COVID-19 vaccine. The percentage of hesitancy was decreased with increasing level of education. In addition, the persons who work in a healthcare setting were more likely to intend to receive the COVID-19 compared to those persons who work in a non-health setting or unemployed, 57.4% versus 40.1%, p < 0.0001. A similar pattern was found for the individuals who received the COVID-19 vaccine. The individuals who had concerns about the side effects of the COVID-19 vaccines were more likely to not receive and not intend to receive a COVID-19 vaccine ( Table 3) . The individuals who intended or did not intend to receive the COVID-19 vaccine had a similar mean age ( Figure 2 ). The study showed that the individuals who reported that the Several factors could be associated with vaccine hesitancy; such as misinformation and conspiracy theories. 21, 22 Also, health inequalities, socioeconomic disadvantages, racism, and obstacles to access are considered to be the drivers of low confidence and poor uptake. 5 24 This study showed that the persons who had the concerns of side-effects of a COVID-19 vaccine were more likely to be hesitant to receive a COVID-19 vaccine, that is, 54.2%. In addition, they had a significantly higher prevalence rate of not receiving a COVID-19 vaccine, 85.8% versus 80.5%, respectively. Previous studies have reported that the rejection rate is higher for the vaccines with unknown side effects compared to the less effective vaccine with lesser side effects. 25 vaccine. Fake news about the COVID-19 vaccine is circulating among the populations since the advent of the vaccine. 27 Montagni et al. 28 T A B L E 4 Association of vaccine hesitancy items to receive the COVID-19 vaccine The main limitation of this study is that a percentage of the responses were collected through an online technique. The online technique may not make for complete homogeneity of the responses in terms of education, age, gender, and other sociodemographic aspects. In addition, the online technique did not allow the author to include more required contributing factors in the study. 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