key: cord-0902389-3xwrex4u
authors: Fadhel, Fahmi Hassan
title: Vaccine hesitancy and acceptance: an examination of predictive factors in COVID-19 vaccination in Saudi Arabia
date: 2021-12-30
journal: Health Promot Int
DOI: 10.1093/heapro/daab209
sha: e700f43ec172c2c2fce33070ed5d6192a6589441
doc_id: 902389
cord_uid: 3xwrex4u

Vaccine hesitancy is a global health issue and can be affected by several variables. We explored the predictive factors and causes of vaccine hesitancy among adults in Saudi Arabia. An online survey method with multiple regression analysis was used to identify factors predicting of vaccine hesitancy in 558 adults (46.24% women and 53.76% men). The prevalence of vaccine hesitancy is 20.6%, with higher rates among females, young people and single people. About 70% of the participants believe that vaccine hesitancy is due to concerns about the safety and efficacy of the vaccine, a lack of information about the disease and vaccine or social media. The vaccine acceptance rate is 71.3%; 17.2% are not willing to accept a COVID-19 vaccine and 11.5% are unsure. Males and married people are more accepting of the vaccine. The risk factors that predict vaccine hesitancy include age, gender, belief in conspiracy theories and psychosocial factors. Meanwhile, age, gender, belief in conspiracy theories, concerns about the safety and efficacy of the vaccine and psychosocial factors significantly predict vaccine acceptance. The high rate of vaccine hesitancy could undermine efforts to combat COVID-19. Factors predicting vaccine hesitancy can be used in interventions to address this issue during major epidemics.

Coronavirus vaccines were quickly produced and approved on an emergency basis to contain and control the epidemic; they appear to prevent the spread of COVID-19 (Hotez et al., 2021) . Some of these vaccinations use a new technology based on mRNA, which has raised the fears of many people due to concerns about the speed of development of the vaccine (Chou and Budenz, 2020; Mills et al., 2020) . Such concerns have increased vaccine hesitation around the world.

According to the World Health Organization, vaccine hesitancy is the 'delay in acceptance or refusal of vaccination despite [the] availability of vaccination services' (MacDonald and SAGE, 2015) . It is one of the 10 major threats to global health (WHO, 2020) and is considered one of the most disruptive factors affecting progress in vaccinating people against infectious diseases (Geoghegan et al., 2020) . In many countries, misinformation and vaccine hesitation are major obstacles to achieving community immunity (Larson et al., 2014) .

Vaccine hesitancy is a global problem associated with multiple and complex causes depending on when and where vaccination occurs, which vaccine is involved, the target audience for the vaccine (Palamenghi et al., 2020; Lazarus et al., 2021) and psychological, cognitive and demographic factors (Hornsey et al., 2018; Akande et al., 2021) . It also varies with culture, geography, the timing of vaccine delivery and confidence in the vaccine itself (Palamenghi et al., 2020; Robertson et al., 2021) . Earlier studies revealed regional variations in perceptions of the effectiveness and safety of vaccination; it has been noted that hesitancy is a major problem in high-income countries (Wagner et al., 2019; Kennedy, 2020; Lin et al., 2020; Sallam, 2021) . Lower-income regions had the highest certainty regarding vaccine safety and effectiveness (Wagner et al., 2019; Lin et al., 2020; Sallam, 2021) , while there is a relatively high trend toward acceptance of the COVID-19 vaccine in middle-income countries (Lazarus et al., 2021) .

In Saudi Arabia, especially at the beginning of the emergence of the COVID-19 vaccine, many incorrect ideas about the vaccine spread through social media. Most of them revolve around conspiracy theories and question the effectiveness of the vaccine, indicating that medical companies and institutions seek profit and do not care about people's health. These rumors and fabricated news affect the intention to receive the vaccination. Therefore, it is appropriate for future intervention programs to target these rumors and misinformation and to refute them.

In this context, the acceptance rate among Malaysians was high (Sallam, 2021; Syed Alwi et al., 2021) . A percentage of the population in the USA said they would not be vaccinated (Chou and Budenz, 2020) ; this percentage ranged between 18.8% and 27.3% (Akel et al., 2021) . In other communities, about one-quarter of parents were reluctant to take the vaccine, whether for themselves, their spouses or their children (Xu et al., 2021) . A recent review revealed that the highest vaccine acceptance rates were found in Ecuador, Malaysia, Indonesia and China. Meanwhile, the Arab countries topped the list of nations with a low acceptance rate for the COVID-19 vaccine; the lowest acceptance rates were in Kuwait, Jordan, Italy, Russia, Poland, USA and France. Low rates of vaccine acceptance were found in the Middle East, in addition to Russia, Africa and several European countries (Sallam, 2021) . Vaccine hesitancy was higher among urban residents, females, older adults and those without reported symptoms. The differences were not significant according to other social and economic characteristics, behaviors, health conditions and labor market variables (Oliveira et al., 2021) .

In a study that included a large sample of 19 countries, 71.5% of participants reported that they would take the COVID-19 vaccine. The participants who had high confidence in information obtained from government sources were more accepting of the vaccine (Lazarus et al., 2021) . In total, 67% confirmed that they would accept the COVID-19 vaccine (Malik et al., 2020) . Studies have also shown an association between demographic, social, economic and behavioral variables with acceptance of the COVID-19 vaccine, while 22% of respondents said that they were not willing to take the vaccine (Kadoya et al., 2021) .

The high rates of vaccine hesitation are a clear indication of the obstacles that stand in the way of vaccination (Xu et al., 2021) and are considered an international threat to progress in the fight against vaccine-preventable infectious diseases. This makes hesitancy a central issue in COVID-19 immunization plans (Oliveira et al., 2021) . However, most causes of vaccine hesitancy remain unclear and complex, as they include demographic, socioeconomic, cultural, behavioral and psychological factors (Palamenghi et al., 2020) , such as the effectiveness, safety, and people's trust of the vaccine, which will inevitably affect the vaccine's acceptance.

Despite the importance of exploring the factors associated with this problem, studies in Saudi Arabia and Arab countries are still rare. This issue requires further investigation due to the role that cultural differences might play in factors influencing vaccine hesitancy. Therefore, understanding vaccine hesitancy related to COVID-19 and its associated factors is critical to designing a successful immunization program. Also, it will help with the development of evidence-based interventions to address anti-vaccine attitudes (Malik et al., 2020) , which further increases the importance of research in this area.

This study aims to identify prevalence rates and the predictive factors of COVID-19 vaccine hesitancy and acceptance among adults in Saudi Arabia.

This study collected self-reported data through online scales from an adult sample in Saudi Arabia to assess vaccine hesitancy, the reasons for hesitancy and factors that correlate with vaccine hesitancy. Data were collected from 8 to 27 July 2021. The questionnaire was distributed online in the Arabic language with a link from Google Forms and was designed to avoid missing values. Before answering the questionnaire, participants provided online written informed consent. Ethics approval was obtained from the competent authorities.

Most of the participants were recruited online via emails, SMS massages and announcements about the questionnaire on Saudi psychological forums (mental health and psychotherapy forums or the websites of counseling and psychotherapy centers located in most Saudi cities). Individuals who gave their email addresses or phone numbers, the questionnaire was sent to them via email or SMS message. Only 412 (19.49%) of the 2113 who were contacted via email or phone message, agreed to participate in this study.

The other participants were recruited online through the SOADAA Center.

Eligible individuals were age 18 years and above, fluent in Arabic and resided in the Saudi Arabia.

Vaccine hesitancy and related variables were assessed as follows:

a. Vaccine Hesitancy Questionnaire (VHQ): A four-item questionnaire about hesitancy and acceptance of the COVID-19 vaccine (e.g. willingness and acceptance of taking the vaccine, whether they had gotten the COVID-19 vaccine or still hesitated, the number of shots received if one had taken the vaccine, and whether they had refused a vaccination-such as the influenza vaccine-in the past). The response options for this question were 'yes', 'no' and 'not sure'. b. Questionnaire of Vaccine Hesitancy Reasons (QVHR): A 38-item questionnaire with a five-point scale (1¼ strongly agree, 5 ¼ strongly disagree) was prepared for this study to assess the cases or conditions that might be among the reasons for hesitating to take the COVID-19 vaccine. The questionnaire was prepared after a review of the scales and literature in this area [e.g. (Jolley and Douglas, 2014; Larson et al., 2015; Shapiro et al., 2016 Shapiro et al., , 2018 Wallace et al., 2019; Majid and Ahmad, 2020; Cerda and Garc ıa, 2021; Truong et al., 2021) ]. In this questionnaire, we inquired about the reasons why people hesitate to receive the COVID-19 vaccine. We provided several possible reasons (38 items drawn from previous literature), and the respondent had to choose the appropriate answer for each item from five alternatives. The items were divided into eight subscales: lack of information about the disease and vaccine (six items), belief in conspiracy theory (five items), the role of social media (three items), concerns about the safety and efficacy of the vaccine (seven items), psychological and social factors (five items), distrust of health institutions (four items), vaccine risks (six items) and religious reasons (two items). c. Vaccine Conspiracy Beliefs Scale (VCBS): Developed by Jolley and Douglas (Jolley and Douglas, 2014) and validated by Shapiro et al. (Shapiro et al., 2016) . It consists of six items on a seven-point scale for assessing the belief in a conspiracy theory regarding the safety and efficacy of the vaccine. In this study, we used a five-point scale (1¼ strongly distrust, 5 ¼ strongly trust).

Demographic variables covered socio-demographic characteristics, such as gender, age, education, marital status and previous infection with corona or not.

Statistical analysis was performed using the IPM SPSS software (version 25). The dataset included 558 participants, which is a sufficient sample size to detect the effect of independent variables on vaccine hesitancy using multiple regression. The independent variables included age, gender, educational level, marital status and overall score on the VCBS, as well as the overall score on the eight subscales on the QVHR.

To examine the psychometric properties of the scales, the reliability coefficients of Cronbach's alpha and split-half were conducted and internal consistency was examined. The prevalence rates of vaccination hesitancy and acceptance in the total sample were estimated at the 95% confidence level. Pearson's chi-square test (a ¼ 0.05) was used to estimate the prevalence rates based on independent variables.

We relied on linear regression analysis (Inter method) to detect factors predicting vaccine hesitancy and acceptance. All independent variables were entered one by one. The final model was obtained by keeping variables in the analyses with p < 0.05.

The study's sample (n ¼ 558) included 46.24% women and 53.76% men. Age ranged between 18 and 65 years (mean 38.66 6 9.067). The majority of respondents were married (73.8%), while (21.3%) were single and (4.8%) were divorced or widowed. A total of 58.2% had tertiary education, 9% had attended secondary school, 22% had a master's degree and 10.6% had a doctorate. A total of 58.6% had received one shot of the COVID-19 vaccine, 21% had received two shots and 20.4% had not received the vaccine yet. The percentage of those who refused or hesitated to previously receive any vaccination (such as the influenza vaccine) was 37.8%. The descriptive statistics of the sample are shown in Table 1 .

The questionnaire of vaccine hesitancy was validated and had good psychometric properties. The reliability coefficient of Cronbach's alpha was (0.589), while it was (0.46) in the split-half reliability (the Spearman-Brown coefficient was 0.63). In the QVHR, the reliability coefficient of Cronbach's alpha was (0.908), while it was (0.896) in the split-half reliability (the Spearman-Brown coefficient was 0.945). The VCBS is a validated scale (Jolley and Douglas, 2014; Shapiro et al., 2016) . In this study, the reliability coefficient was (0.926) in Cronbach's alpha and (0.857) in the split-half reliability (the Spearman-Brown coefficient was 0.92).

The internal consistency of questionnaires was calculated; the correlation ranged between 0.267 and 0.827 on the VHQ. It ranged between 0.195 and 0.645 in the QVHR. Meanwhile, the correlation ranged between 0.70 and 0.91 on the VCBS. All correlations were significant at the 0.01 level (2-tailed).

Vaccine hesitancy among participants was 20.6%. Females reported higher hesitancy than males, and the gender differences were significant (v 2 ¼ 7.251, p ¼ 0.007). Married people were less hesitant (17.47%) than single (29.41%) and divorced/widowed people (29.63%). The differences were significant (v 2 ¼ 9.451, p ¼ 0.009). Vaccine hesitancy was higher among younger people (between 18 and 37 years old) than among participants aged between 38 and 47 or between 48 and 65 (v 2 ¼ 10.450, p ¼ 0.005), as shown in Table 2 .

Vaccine hesitancy was higher among secondary school than university degree holders and higher degree holders, but the differences were not significant (v 2 ¼ 6.606, p ¼ 0.086), as shown in Figure 1 .

Vaccine acceptance was 71.3% (n ¼ 398); 17.2% (n ¼ 96) were not willing to accept a COVID-19 vaccine, and 11.5% (n ¼ 64) were unsure. Males were more accepting of the vaccine (77.33%) than females (64.34%), and the differences were significant (v 2 ¼ 11.448, p ¼ 0.001).

Married people were more accepting of the vaccine (74.76%) than single people (65.55%) and divorced/ widowed people (44.4%). The differences were significant (v 2 ¼ 13.855, p ¼ 0.001). Older people (from 48 to 65 years old) were more accepting of the vaccine (76.3%) than other age groups, but without significant differences (v 2 ¼ 4.601, p ¼ 0.100). The differences in vaccine acceptance were not significant according to educational level (v 2 ¼ 0.501, p ¼ 919). Table 3 shows the response rate to the QVHR. As per Table 3 , 85.7% of respondents believed that 'concerns about the side effects of the vaccine, such as allergies, blood clots, etc.' are the cause of vaccine hesitancy, while 84% of the participants thought that the vaccine hesitancy was related to the belief that 'the disease is new and unknown previously'. Meanwhile, 'the lack of confidence in the efficacy of the vaccine' and 'the long-term effects of vaccines are not known' got 83% and 82%, respectively. Table 4 shows the response rate to the subscales in the QVHR.

As per Table 4 , most respondents (76.22%) attributed vaccine hesitancy to concerns about the safety and efficacy of the vaccine, 73.33% to a lack of information about the disease and vaccine, 70.8% to social media, 67.9% to conspiracy theories and 62% to psychological and social factors.

The results of this study revealed that few participants agreed with conspiracy theories regarding the COVID-19 vaccine, as shown in Table 5 .

We used multiple regression analysis employing the Inter method to detect the factors predicting vaccine hesitancy. The results are shown in Table 6 and Figure 2 below. Table 6 shows that age, gender, total score of the conspiracy belief scale and total score of the second and fifth subscales of the QVHR significantly predicted vaccine hesitancy.

The factors that predicted vaccine acceptance included age, gender, total score of the conspiracy belief scale and total score of the second, the fourth and the fifth subscales in the QVHR. Table 7 shows these results.

We conducted a study of COVID-19 vaccine hesitancy and acceptance among adult participants. Vaccine hesitancy in the current study was relatively high and comparable to that of previous studies (Cerda and Garc ıa, 2021; Robinson et al., 2021; Xu et al., 2021) . These results reflect the persistence of hesitation in a significant proportion of adults, which requires further treatment.

Compared to other studies (Fisher et al., 2020; Majid and Ahmad, 2020; Malik et al., 2020; Martin et al., 2021; Oliveira et al., 2021; Robinson et al., 2021; Truong et al., 2021) , females, single people and younger people were more hesitant than other groups. Potential impacts of demographic variables (such as gender, marital status, age and education) on public attitudes toward vaccines should be considered. We believe that the best way to deal with vaccine hesitancy and enhance vaccine acceptance among the population is to employ factors that affect vaccine acceptance, such as gender, age, education level, beliefs in conspiracy theories and psychosocial factors. For example, psychological counseling can be used to counter fake news in the context of these factors (Atehortua and Patino, 2021; Talabi et al., 2021) .

In this study, vaccine acceptance was fairly high. It became clear that about one-third of the participants either would not accept a COVID-19 vaccine or were not sure. These results point to the need to enhance vaccine acceptance among the population in Saudi Arabia through education campaigns and are consistent with the results of previous studies (Malik et al., 2020; Akel et al., 2021; Chigozie et al., 2021; Kadoya et al., 2021; Lazarus et al., 2021; Oliveira et al., 2021) .

In this regard, researchers realize that vaccines, even if they are highly effective, do not work for everyone (Madison et al., 2021) , with the potential for side effects. Other factors playing a prominent role in the increase in attitudes against the COVID-19 vaccine include misinformation and social media (Broadbent, 2019; Kennedy, 2020; Wilson and Wiysonge, 2020; Piedrahita-Vald es et al., 2021) , where skeptical voices emerged with evidence of low vaccine acceptance (Bendau et al., 2021) . It has been found that gender, age and the use of social media are highly predictive of a belief that vaccines are unsafe. In addition, the spread of misinformation is of great statistical importance in predicting a decline in response to vaccination (Fisher et al., 2020; Malik et al., 2020; Wilson and Wiysonge, 2020; Martin et al., 2021; Robinson et al., 2021) .

On the other hand, researchers have found several factors that can increase the likelihood of accepting a COVID-19 vaccination. These factors include being male, being married, being aware of a high risk of infection, having received the influenza vaccine, believing in the vaccine's efficacy and valuing doctors' recommendations regarding the COVID-19 vaccine (Wang et al., 2020) . The most significant factors associated with vaccine hesitancy included misinformation about the vaccine, refusal of a previous vaccine (such as influenza), concerns about the safety and efficacy of the vaccine and psychological factors (Broadbent, 2019; Fisher et al., 2020; Kennedy, 2020; Lin et al., 2020; Malik et al., 2020; Wilson and Wiysonge, 2020; Bendau et al., 2021; Martin et al., 2021; Piedrahita-Vald es et al., 2021; Robinson et al., 2021) .

As an extension of those previous studies (Broadbent, 2019; Fisher et al., 2020; Kennedy,2020; Malik et al., 2020; Wilson and Wiysonge, 2020) , we found that gender, age (between 38 and 47 years old), vaccine conspiracy beliefs and two subscales in the QVHR-the second subscale (belief in conspiracy theory) and the fifth subscale (psychological and social factors)-significantly predicted vaccine hesitancy.

With regard to the responses to the items on the QVHR, we found that the items relating to the side effects of the vaccine, such as Item No. 15 'concerns about the side effects of the vaccine, such as allergies, blood clots, etc.', Item No.1 'The disease is new and previously unknown' and Item No. 4 'The long-term effects of vaccines are not known', had the highest rate of agreement among the participants. The items that talked about the inconsistency between vaccination and the Islamic religion were less accepted among the respondents. On the other hand, 'concerns about the safety and efficacy of the vaccine', 'lack of information about the disease and vaccine' and 'the role of social media' were the most accepted reasons for vaccine hesitancy. The 'belief in conspiracy theory' obtained the agreement of two-thirds of participants. The percentage of psychological and social factors was not high. Reasons related to 'distrust of health institutions' and 'vaccine risks' were accepted by almost half of the respondents (Table 4) . Consistent with the results of this study, studies have found that fears over unknown future effects are the main reason for hesitancy (Robertson et al., 2021) . Reasons for vaccine hesitancy included fears of vaccination, a lack of trust, anti-vaccine beliefs or attitudes, a need for more information (Fisher et al., 2020) and concerns regarding side effects, safety, lack of information and vaccine effectiveness (Syed Alwi et al., 2021) . In addition, individuals with conspiratorial beliefs were less willing to vaccinate (Jennings et al., 2021) .

In this study, we hypothesized that conspiracy theory beliefs would be a significant predictor of vaccine hesitancy and vaccine acceptance. The results supported this hypothesis, as conspiracy theory beliefs (through the total score on the conspiracy beliefs scale) significantly predicted vaccine hesitancy and acceptance (see Tables 6  and 7) . These results may be attributed to the spread of information related to conspiracy theories surrounding the coronavirus and about vaccines since the beginning of the coronavirus pandemic, as well as since the start of vaccination. The relationship between belief in conspiracy theories about the COVID-19 vaccine and hesitation or acceptance with regard to the vaccine can be understood by looking at the differences between hesitating and unhesitating people. The average scores of the hesitating people on the conspiracy beliefs scale and the second subscale, 'belief in conspiracy theory' (on the QVHR), were greater than those of unhesitating participants. This also applies to vaccine acceptance. The appropriate interpretation of these results is that when a person believes that vaccines are unsafe, are ineffective, or may have negative effects in the future, such beliefs will be reflected in the person's attitudes toward the vaccine and will manifest as a hesitation or refusal of the COVID-19 vaccine.

It was noteworthy that the psychological and social factors mentioned in the QVHR included fear, anxiety and negative emotions toward the vaccine. In this regard, a significant relationship was found between anxiety or fears of COVID-19 and vaccine acceptance (Bendau et al., 2021) . There is also credible evidence that psychological factors correlate with the prevalence and severity of vaccine side effects, and that anxiety, stress, depression, unhealthy behaviors and loneliness can impair the immune system's response to the vaccine (Madison et al., 2021) .

Factors that contributed to the increased acceptance of the COVID-19 vaccine included being male, older age and married. Males, older people and married people were less hesitant than females, young people and single or divorced people. Also, this study revealed that the total score on the conspiracy belief scale and the second (belief in conspiracy theory), fourth (concerns about the safety and efficacy of the vaccine) and fifth (psychological and social factors) subscales in the QVHR and gender significantly predicted vaccine acceptance.

An Italian survey found that, compared to other countries, the proportion of participants intending to get the COVID-19 vaccine was very small (Palamenghi et al., 2020) . Approximately 42.4% of respondents in the USA either were unsure or did not intend to receive a COVID-19 vaccine (Fisher et al., 2020) . The percentage of those who said they would not take the COVID-19 vaccine was 5.2%, without significant differences between males and females in the average willingness to accept the vaccine. Also, age and educational level were found to have a significant and positive relationship with vaccination acceptance (Bendau et al., 2021) . Fisher et al. (Fisher et al., 2020) found that lower educational level, younger age and previous refusal to receive the influenza vaccine were the factors most associated with vaccine hesitancy. Mesele (Mesele, 2021) reported that over half of the participants confirmed that they would not accept the COVID-19 vaccine. The elderly were more accepting of the vaccine than the younger, males were more accepting than females and holders of university or postgraduate degrees were more accepting than those without a university degree. Unemployed participants were less accepting of the vaccine compared to the employed or retired (Malik et al., 2020) . In contrast to the results of our study, the novelty of the disease and concerns about the safety and efficacy of the vaccine have caused a significant proportion of vaccination refusals in the USA (Chou and Budenz, 2020) and Brazil (Oliveira et al., 2021) .

Finally, this study revealed important results that will have an impact on efforts to combat vaccine hesitancy among adults.

Our findings provide support for the importance of studying the factors associated with vaccine hesitancy and acceptance during major epidemics.

There is a high rate of vaccine hesitancy among adults. One-fifth of the respondents hesitated to receive the vaccine, and nearly one-third did not accept the COVID-19 vaccine. Most participants agreed that factors related to the safety and efficacy of the vaccine, and long-term side effects, were the most common reasons for vaccine hesitancy.

There is an urgent need to implement more awareness of the importance of the vaccine to eliminating the COVID-19 pandemic.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

There is no conflict of interest.

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