key: cord-0939335-r5iqxgrg
authors: Khan, Zaid; Khursheed, Syed Quibtiya; Dar, Shabir Ahmad; Shah, Naveed Nazir; Reagu, Shuja; Alabdulla, Majid; Haq, Inaamul; Ud Din Azad, Aaliya Mohi; Dar, Khurshid Ahmad; Farooq, Syed Suraiya; Wani, Zaid Ahmad
title: Vaccine hesitancy and coronavirus disease-19: Where do we stand?
date: 2022-02-26
journal: J Educ Health Promot
DOI: 10.4103/jehp.jehp_642_21
sha: 7f636e70b7ab068f555efe6dbf6fb1d4008a6b35
doc_id: 939335
cord_uid: r5iqxgrg

BACKGROUND: Vaccine hesitancy is seen, globally, as a major factor that will determine future coronavirus disease-19 (COVID-19) spread and its effective management. This study aimed to identify COVID-19 vaccine perception, acceptance, confidence, hesitancy, and barriers among the general population. MATERIALS AND METHODS: This was an online survey which was developed and shared through social media platforms among the general population of Kashmir. The survey captured demographic data and used a validated hesitancy measurement tool. We analyzed the data using descriptive statistics and multivariable logistic regression using Stata 15 (Stata Corp. 2017. Stata Statistical Software: Release 15. College Station, TX, USA: Stata Corp LLC). RESULTS: A total of 835 responses were received. Most participants were males, with females compromising of 19.5% participants. 65.1% of participants were in the age group of 30–50, whereas 19.2% were below 30 years of age. 52.70% of respondents were willing to take the vaccine when available, while 32.5% of respondents were unsure about their decision of inoculation. The most cited reason for willingness to get vaccinated was an understanding of the disease and vaccination. 41.70% felt that the vaccines developed against COVID-19 have not been fully tested; therefore, concerns around the safety and its longer-term side effects were the reasons cited. Public health messaging should be tailored to address these concerns. CONCLUSIONS: Vaccine hesitancy is a global threat undermining the control of preventable infections. The government should take proactive steps to address the factors that may potentially impact the benefits expected from the introduction of a COVID-19 vaccine in the union territory.

T he coronavirus disease-19 (COVID- 19) emerged from China and rapidly spread to many other countries worldwide. [1] Since the time COVID-19 was declared a pandemic by the World Health Organization (WHO), [2] pharmaceutical companies and governments worldwide have been trying to develop effective vaccinations against it to bring back normalcy. With the emergence of reliable vaccines from pharmaceutical companies vaccine, even when available. [4] Vaccine hesitancy as an observable attitude within groups is complex and varies on a multitude of factors such as complacency, convenience, and confidence. [4] Vaccine hesitancy -the reluctance or, refusal to take the vaccine, is an old phenomenon that threatens global health. The WHO has declared vaccine hesitancy as one of the planet's biggest health threats in 2019. [5] Vaccine hesitancy toward a newer vaccination program can be high even in communities with traditionally high acceptance for other vaccines. Indian states of Tamil Nadu and Karnataka, which had high acceptance toward other vaccination programs showed high hesitance toward the measles-rubella vaccine at the time of its introduction. The factors such as misinformation about the vaccine regarding its adverse effects played a central part in this observes hesitancy. [6] Even today, the message of the discredited study in 1998 by Andrew Wakefield, who linked the measles, mumps, and rubella vaccine with autism, is used in spreading vaccine doubts and conspiracy theories. [7] By making use of the Vaccination Attitudes Examination (VAX), [8] this study aims to identify the major factors of vaccine hesitance within the general population of the Jammu and Kashmir region of India, to implement countermeasures to ensure that the majority of the population develops acceptance toward COVID-19 vaccination programs.

After approval from the Institutional Ethics Committee, a cross-sectional study using the Survey Monkey platform was conducted among the general population of Kashmir.

The survey was shared through social media platforms and was designed in such a manner that a single response can be filled using in one device. The survey was shared using exponential nondiscriminative snowball sampling technique in which the respondents were requested to complete the survey and forward the link as much as possible among close contacts. On clicking the link, the respondents would get auto-directed to the survey. The first page of the survey consisted of information regarding the purpose and how the data collected will be utilized. Respondents were asked to give consent and confirm which was followed by a set of questions used in the survey.

Respondents more than 18 years old, having sufficient knowledge of the English language and internet access took part in the survey. The data collection was done for 10 days from February 10, 2021, to February 20, 2021.

Information regarding demography, health, various beliefs toward vaccines, in general, and COVID-19 vaccine, in specific, among various other questions regarding immunity and other beliefs and fears, was asked. This was done using a validated vaccine hesitancy measurement tool − The Vaccine Attitudes Examination Scale (VAX) [8] after due permission was sought.

The selection of VAX and the design of the composite questionnaire were guided by the SAGE group recommendations in assessing vaccine hesitancy.

The main outcome variable was vaccine hesitancy. Participants responded to the question "Will you take the COVID-19 vaccine when it becomes available" in one of five ways -"definitely," "probably," "not sure," "probably not," or "definitely not." We classified any of the latter three responses as "vaccine hesitancy. " We recorded beliefs about the COVID-19 vaccine and immunity on a six-point Likert scale ranging from "strongly disagree" to "strongly agree."

The research protocols were approved under CDSCO U/P No: ECR/1422/Inst/JK/2020 by the institutional ethics committee of Govt. Medical College, Srinagar.

We summarized the categorical variables as percentages. Logistic regression was used to identify variables significantly associated with vaccine hesitancy. Variables that were associated with vaccine hesitancy at 10% level in univariable analysis were used to build the multivariable logistic regression model. Responses to questions in the VAX questionnaire were dichotomized as "disagree" or "agree" prior to analysis. We used Stata version 15 (StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX, USA: StataCorp LLC) for data analysis. Statistical significance was set at a 5% level.

A total of 1114 responses were received, of which 835 respondents were from Jammu and Kashmir and hence were evaluated.

Most of the participants were males, with females compromising of 19.5% subjects. 65.1% of participants were in the age group of 30-50, while 19.2% were below 30 years of age. 53.1% of participants were postgraduates and 78.3% of participants were married. Basic demographic data and other descriptive statistics are listed in Table 1 .

A majority of participants (91.9%) had received childhood vaccinations but only 50.3% of participants had received any influenza vaccination in the past 3 years [ Table 1 ].

34.6% of participants had at least one person in the family already been tested positive for COVID-19. Self-reported history of chronic medical illness was present in 19.2% of participants of which 38.2% had hypertension, 24.8% were diabetic and 15.9% had asthma [ Table 1 ]. 6.1% of participants reported that they were suffering from at least one mental illness, among whom 3.6% reported anxiety while 1.9% of participants said they had depression [ Table 1 ].

52.7% of participants were willing to take the vaccine when available, while 6.1% said that they would not take the vaccine when available. 32.5% of participants were unsure about their decision [ Table 2 ].

The most cited reason for willingness to get vaccinated was an understanding of the disease and vaccination, reported 62.9% of those willing to take the vaccine [ Table 2 ].

People who had previously been inoculated, at least once, for influenza in the past 3 years were twice more unlikely of getting vaccinated for COVID-19 [ Table 1 ]. Interestingly, willingness to take the medicine notwithstanding, 54.4% of people didn't feel safe even after getting vaccinated [ Table 3 ]. 41.70% of participants felt that the vaccines developed against COVID-19 have not been fully tested yet, and hence, not safe [ Table 4 ]. 43.80% of participants did not rely on vaccines to stop infectious diseases [ Table 3 ].

Being vaccinated (P = 0.026), natural immunity lasts longer than a vaccination (P = 0.001), natural exposure to viruses and germs gave the safest protection (P = 0.026), and being exposed to disease naturally (P = 0.030) was safer for immune system than being exposed through vaccination was significantly reported by those living in India but outside J and K and those living outside India [ Table 5 ].

This is one of the first studies, that we are aware of, that utilizes a validated vaccine hesitancy tool to measure the degree of hesitancy to COVID-19 vaccination and its main attitudinal determinants among the nonhealthcare workers in India. This study shows a moderate degree of hesitancy at 14.8% to COVID-19 vaccination among the respondents. However, when combined with those that are unsure of the vaccination, hesitancy is present in around 47.3% of the respondents. Research on similar 

lines across the world found a vaccine hesitancy of 25% in Canada, [9] 20% in the U. S, [10] 20% in Qatar, [11] while it was determined to be around 9% in Britain. [12] When we compare the COVID-19 vaccine hesitancy in healthcare workers, the lowest acceptance rates were reported from DRC (27.7%). [13] These figures appear to be in keeping with the variance in the hesitancy rates across different countries and population groups. Emerging evidence suggests that vaccine hesitancy is lower in lower-income countries with higher trust in the state governments as compared to higher-income countries. Similar trends were seen in South Asia and Eastern Africa. [14] It is important to understand that the healthcare workers remain the key figures in vaccination programs and they are generally the most trusted by general public in recommending vaccination. [15] In East and Southeast Asia, the overall acceptance rates among the general public were relatively high. This includes more than 90% acceptance rates in Indonesia, Malaysia, and China, Thus contradicting our study results. [16] [17] [18] Therefore, low rates of vaccine acceptability can be explained by the widespread embrace of conspiratorial beliefs in the region. Therefore, any hesitancy or lack of trust among this population group can have a far-reaching impact on success of any vaccination programs. Contd...

The most significant determinants of vaccine hesitancy were: (1) Worry about unknown effects of the vaccine and (2) belief that natural immunity lasts longer than an immunity attained through vaccination. Interestingly, even though the degree of hesitancy has some variance across the globe, the themes that determine the attitudes to refusing COVID-19 vaccination are somewhat similar. There appears to be a consistent theme of distrust in the safety of the COVID-19 vaccines with concerns that it was rushed through and not fully tested for longer-term side effects. The presence of such mistrust among health-care workers who traditionally have more access to reliable healthcare information underlining the deficit of trust and informs the task ahead for health care policy-makers. In the published studies described above, a more or less consistent theme of concerns around the safety of the vaccine itself is emerging as the most prominent. This concern cuts across demographic variables and countries. The possible safety concerns reported by the published data included unexplored side effects of the vaccine, beliefs about the COVID-19 disease, public perception of vaccine trials being rushed through, pharmaceutical companies profiteering from the vaccine, and preferred reliance on natural immunity-thus matching our study results. [19] [20] [21] [22] Participants who believed that vaccines have not been fully tested yet were more than three times more likely to reject being vaccinated when available. This points out the immediate need for awareness drives and transparency regarding vaccination development from the side of governments as well as the pharmaceutical companies that are in process of rolling out vaccines for the public. People who had not been administered with influenza vaccination were also more apprehensive about the COVID-19 vaccination and were twice more likely to reject the vaccination when available, than those participants who had been vaccinated against influenza at least once in the last 3 years.

Nearly half of the participants were, at least, not sure about getting elderly members vaccinated, while almost half of participants were, at least, not sure about getting their children vaccinated. These figures seem to be in line with the vaccine hesitancy rate of 47%, and people who did not show willingness toward having themselves vaccinated also show hesitance towards getting the elderly and children vaccinated. [11] Almost one-third of participants were not willing to get vaccinated due to risk of major bleeding [23] even before traveling abroad and instead, accepted being quarantined for 2 weeks. This is again an indication of mistrust toward vaccination programs, in general, and COVID-19 vaccination, in specific. Misinformation through social media regarding COVID-19, its management, and vaccination programs is common and accessible. On the other hand, there seems to be a lack of awareness programs and transparency about the disease and its vaccination development. Innovative and active management of this situation by using all available tools can go a long way in achieving a higher trust and acceptance towards COVID-19 vaccination programs, which is central to global pandemic management.

COVID-19 vaccine hesitancy can be the limiting step in the global efforts to control the current pandemic with its negative health and socioeconomic effects. [24, 25] Findings of similar studies across the world are consistent with conclusions drawn from this survey, where mistrust and misinformation appear to be the biggest contributors to vaccine hesitancy. [26] Among the general population, this study also found that the number of people who were willing to take the vaccine citing their understanding of the disease and the vaccine itself, as the primary reason were three folds more than those who trusted the advice of their doctor or, hospital.

Thus, estimates of vaccine acceptance rates can be helpful to plan actions and intervention measures necessary to increase the awareness and assure people about the safety and benefits of vaccines, which in turn would help to control virus spread and alleviate the negative effects of this unprecedented pandemic. [27, 28] Mistrust toward vaccines represent a significant challenge in achieving the vaccination coverage required for population immunity. Vaccine safety communication to increase public trust by the time a COVID-19 vaccine is available should begin now. Evaluation of attitudes and acceptance rates toward COVID-19 vaccines can help to initiate communication campaigns that are much needed to strengthen trust in health authorities. [29] 

This survey was conducted before the actual vaccination programs were rolled out when there were a lot of myths associated with the efficacy and safety of the vaccines available and the hesitancy rates and attitudes are likely to vary as the situation evolves. Lack of knowledge about the nonresponders may bias the results.

Offer tailored communication from trusted sources such as community representatives, health-care providers, and local authorities that is culturally relevant and accessible in multiple languages. Religious or traditional community leaders can engage key audiences through open discussions, advocacy, and integrated community activities. The need of hour is to engage masses in dialog about vaccine safety, efficacy and importance and discuss the risks and benefits of vaccination.

Vaccine hesitancy is a global threat undermining the control of preventable infections. It can be a decisive factor that would hinder the successful control of the current COVID-19 pandemic. It is recommended to build COVID-19 vaccination trust among the General Public, via the spread of timely and clear messages through trusted channels advocating the safety and efficacy of currently available COVID-19 vaccines. Further, the government should take pro-active steps to address the factors that may potentially impact the benefits expected from the introduction of a COVID-19 vaccine in the union territory.

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The authors would like to thank all the participants who participated in the survey. Special thanks to Prof. Leslie Martin for her kind permission to use the Vaccination Attitudes Examination (VAX) Scale.

Nil.

There are no conflicts of interest.