Citizens’ perception of and willingness to receive COVID-19 vaccination in Medan, Indonesia

Highlights

• •A particular challenge for COVID-19 vaccines is the manufacturing process.
• •Once the vaccine is available, people must receive the vaccine.
• •Skepticism about the projected COVID-19 vaccine may be partly due to a large amount of misinformation about the vaccine circulating on social media.

Summary

One of the efforts to control the COVID-19 pandemic is through vaccination, which is targeted to build immunity and prevent severe disease and finally to control transmission. This study aimed to analyze the perception of and the willingness to receive the COVID-19 vaccine among citizens of Medan. This research is an analytic study with a cross-sectional research design. Data collection was carried out from 16 April 2021 to 18 April 2021 by having participants fill out a Google Forms questionnaire. The population in this study was adults and elderly citizens in Medan who had not yet been vaccinated against COVID-19, and the sample was taken by consecutive sampling technique, which was the group of people who met the inclusion and exclusion criteria. The measurements of perceptions of and willingness to receive the COVID-19 vaccine used a previously validated questionnaire. The data was processed using SPSS. Data analysis used the Chi-square test (p<0.05). This study indicates that 31.8% of respondents positively perceive the COVID-19 vaccine. In comparison, 68.2% of respondents have a negative perception. On willingness to receive the vaccine, 80.2% accepted being vaccinated, 5.2% did not, and 4.6% had not decided whether to be vaccinated. There is a relationship between perception and willingness to undergo COVID-19 vaccination.

1. Introduction

COVID-19, or Coronavirus Disease 2019, is caused by SARS-CoV-2, a new coronavirus not previously identified in humans. The World Health Organization (WHO) declared COVID-19 as a Public Health Emergency on 30 January 2020, after discovering a case of pneumonia with no apparent cause in Wuhan, China, at the end of December 2019. The disease then spread rapidly and widely in various countries; the WHO announced the disease as a pandemic on 12 March, 2020 [1,2].

One of the efforts in preventing COVID-19 infection is the manufacture of vaccines to create immunity and prevent transmission [3]. Vaccines are antigens in forms of microorganisms, either dead or alive but attenuated; intact or in parts, which have been processed. Processed into toxoids, recombinant proteins will cause active specific immunity against certain infectious diseases when given to a person [4].

Indonesia is the 4th most populous country in the world, where the first case of the first COVID-19 case was reported in March 2020. In April 12, 2021, the number of confirmed cases was 1.577.526 cases with a mortality rate of 2.7% [4]. Moreover, to control the spread of the pandemic to all regions, restrictions on community activities, the 3Ts (testing, tracing, treatment), and vaccination programs have been implemented.

Currently, WHO has identified 42 potential COVID-19 vaccines being clinically tested. Of the 42 COVID-19 vaccine candidates, ten have entered the 3rd stage of clinical trials. Meanwhile, in Indonesia, according to information being reported by the mass media, the Indonesian government has now identified 3 COVID-19 vaccines that are still in development and are planned to be used in Indonesia, namely those from Biofarma and Sinovac (China), Kalbe Farma Genexine Inc. (Korea), and the Eijkman Institute for Molecular Biology (Indonesia) [5].

In the COVID-19 vaccine acceptance survey conducted by the Indonesian Ministry of Health in November 2020, more than 115,000 respondents from 34 provinces participated. Around 74% of the respondents relayed their knowledge about the government's plan in carrying out COVID-19 vaccination nationally. However, the survey did not reveal any confounding factors, thus further research is needed to determine these factors [6].

In research conducted by Tasnim and Herianto in Southeast Sulawesi in 2020 on public perceptions of the COVID-19 vaccine, around 59% of respondents had a good perception of the COVID-19 vaccine, and only 14.3% did not have a good perception. Most of the respondents (66.2%) expressed their willingness to be vaccinated with the COVID-19 vaccine. There are still around 33.8% of respondents who are not willing to be vaccinated for various reasons, including doubts about the safety and effectiveness of vaccines and also about vaccine availability [5].

Once the vaccine is available, many people must receive the vaccine. This skepticism about the projected COVID-19 vaccine may be partly due to a large amount of misinformation about the COVID-19 vaccine circulating on social media platforms, which is further reinforced by the already high rate of vaccine misinformation in general. Overall vaccine skepticism has increased so substantially that the WHO now considers it as a significant threat to global health. A particular challenge for COVID-19 vaccines is that their accelerated manufacturing process could contribute to the general impression that the vaccine will not be sufficiently tested for safety and efficacy [7]. The current study aimed to analyze the perception and acceptance of the COVID-19 vaccine among the citizens of Medan. Medan is the capital of the province of North Sumatra and is the 4th largest city in Indonesia and is the center of business and government as well as education, so policies in this city will become a reference for policies in other areas in the province of North Sumatra.

2. Methods

2.1. Design

This research was an analytic study with a cross-sectional research design. The population in this study was citizens aged 18 years and older who had not been vaccinated against COVID-19.

2.2. Population and Sample

The study used a consecutive sampling technique in which those who met the inclusion and exclusion criteria were taken, resulting in a total of 192 respondents (using the Slovin formula). Inclusion criteria consisted of citizens aged 18 years and older who had not been vaccinated against COVID-19, had social media (WhatsApp, Facebook, or Instagram), could access the questionnaire link, and were willing to fill out the questionnaire completely. Exclusion criteria were people who did not meet the requirements to be vaccinated based on the recommendation of the Indonesian Internal Medicine Association on March 18, 2021.

2.3. Data Collection

Data collection was carried out using a questionnaire consisting of three parts. The first section was sociodemographic characteristics, including respondents' information such as age, gender, occupation, education, and ethnicity. The second section was perceptions about the COVID-19 vaccine, eliciting information on community members' perceptions regarding the prospective COVID-19 vaccine. Eight questions were asked on the perception about the COVID-19 vaccine using a five-point Likert scale ranging from strongly agree to strongly disagree. Strongly disagree was given a score of 1, disagree = 2, undecided = 3, agree = 4, and strongly agree = 5. Perception assessment was categorized based on the total score of 8 questions, as positive perception if total score ≥ 32 and as negative perception if total score < 32. The third part of the questionnaire was the acceptance of COVID-19 vaccines. At this stage, respondents were asked whether they were willing to be vaccinated if the vaccine was available, and three options were offered: willing, not willing, and unsure. Data collection was carried out using the Google form because the pandemic made it challenging to meet face-to-face for direct interviews due to the social distancing policy for prevention of COVID-19 spreading. The recruited individuals were invited to a WhatsApp group created for this study. The participants in this study did not receive incentives in any form and were truly voluntary. Data analysis was carried out utilizing SPSS to determine the relationship between perception and willingness to be vaccinated, using a Chi-square test (p< 0.05).

3. Results

The following table displays respondents' demographic data, including age, gender, occupation, education level, and ethnicity.

3.1. Characteristics of respondents

The respondents' demographic data, including age, gender, occupation, education level, and ethnicity are displayed in tables. Table 1 shows that 127 (66.1%) respondents were female and only 65 (33.9%) were male. The majority were aged 20-30 years, as many as 87 (45.5%) people. Most of the respondents who participated worked outside of the health sector, as many as 167 (87%) people, while only 13 (13%) respondents worked in the health sector. A total of 124 (64.6%) respondents were undergraduates, 64 (33.3%) were high school graduates, and only four (2.1%) were junior high school graduates. There were eight ethnic groups that participated in this study. Most respondents were Bataknese, 80 (41.7%) people, while there was only one (0.5%) respondent of Bugis ethnicity.

Table 1.

Frequency distribution of demographic characteristics

Demographic Characteristics	Frequency (n=192)	Percentage (%)
Gender
Male	65	33.9
Female	127	66.1
Age (years)
<20	14	7.3
20-30	87	45.5
30-40	14	7.3
40-50	49	25.4
>50	28	14.5
Occupational Sector
Medical Sector (Hospital, Clinic, Pharmacy)	25	13
Non-medical Sector	167	87
Education
Middle School Graduate	4	2.1
High School Graduate	64	33.3
Bachelor	124	64.6
Ethnicity
Aceh	9	4.7
Batak	80	41.7
Bugis	1	0.5
Jawa	43	22.4
Lampung	1	0.5
Melayu	13	6.8
Minang	14	7.3
Chinese	31	16.1

3.2. Perceptions of the COVID-19 vaccine and willingness to be vaccinated

Based on Table 2, most respondents had a negative perception of the vaccine, as many as 131 (68.2%) people. Despite this, there were more respondents who were willing to be vaccinated, as many as 154 (80.2%) people.

Table 2.

Frequency distribution based on perception and acceptance of COVID-19 vaccines

	Frequency (n=192)	Percentage (%)	P-value
Vaccine Perception			0.0001
Positive	61	31.8
Negative	131	68.2
Vaccine Acceptance
Willing	154	80.2
Not willing	10	5.2
Unsure	28	14.6

3.3. The relationship among the characteristics with perception and acceptance of the COVID-19 vaccines

The results in Table 3 show that more women had a negative perception of the vaccine (85, 67%); however, women were also the majority who accepted the vaccination (111, 87.4%), Based on the chi-square results, there is no relationship between gender with perception (p=0.59). At the same time, there is a relationship between gender and vaccine acceptance (p=0.001). Based on age, the 20-30-year-old group had more negative perceptions (58, 66.7%); however, there were more who were willing to be vaccinated 69 (79.3%). Based on the Chi-square results, there was no relationship among age, perception, and vaccine acceptance (p<0.05). Based on the levels of education, most of the undergraduates had a negative perception (86, 69.4%); however, most of them were also willing to be vaccinated (102, 82.3%). The Chi-square results yielded p-values of 0.23 and 0.0001 respectively, showing no relationship between education level and perception, while it was significantly related to vaccine acceptance. There were more participants with occupations outside of the health-care services. Similarly, more had a negative perception (117 people, 70.1%), but were willing to be vaccinated (133, 79.6%). Based on the chi-square results, there was no relationship among occupation with perception and acceptance of the vaccines (p=0.16 and p=0.87 respectively).

Table 3.

The relationship among characteristics with perception and acceptance of Covid-19 vaccines

Characteristics	Vaccine Perception		p	Vaccine Perception			p
	Positive	Negative		Willing	Not willing	Unsure
Gender			0.59				0.001
Male	19	46		43	7	15
Female	42	85		111	3	13
Age			0.35				0.25
<20	8	6		13	1	0
20-30	29	58		69	2	16
30-40	3	11		12	0	2
40-50	14	35		44	2	3
>50	7	21		16	5	7
Education			0.23				0.0001
Middle School Graduated	0	4		0	2	2
High School Graduated	23	41		52	5	7
Bachelor	38	86		102	3	19
Occupation			0.16				0.87
Medical Sector	11	14		21	1	3
Non-medical Sector	50	117		133	9	25

*positive perception if total score ≥ 32 and negative perception if total score < 32

4. Discussion

The results show that even though most of the respondents were willing to be vaccinated, most of them had a negative perception of the COVID-19 vaccine. There was a significant relationship between the perception of the vaccine with the willingness to be vaccinated. In other words, respondents with positive perceptions of vaccines were significantly more willing to be vaccinated than respondents with negative perceptions of vaccines. This result is not in accordance with the research conducted by Tasnim (2020), which showed that 59% and 14.3% of respondents had excellent and suitable perceptions, and 66.2% of respondents were willing to be vaccinated [3]. The high number of negative perceptions of this vaccine is because of the source of information about the COVID-19 vaccine itself. In research conducted by Abdelhafiz et al. (2020) in Egypt, the internet and various social media platforms are the most common sources of information used by Egyptians in seeking information about COVID-19, beating traditional platforms such as television and newspapers [8]. Although the internet and social media provide an easy way to get information, they are also vulnerable to the spread of misinformation and hoax news, so internet and social media users are required to be more critical in filtering various information, including information about the COVID-19 vaccine [8]. Similarly in Indonesia, social media currently plays a vital role in exchanging information.

Most respondents negatively perceive vaccines, with males being almost the same as females. This study is not in line with the research conducted by Tasnim (2020), which showed that women have a better perception of the COVID-19 vaccine than men because women have more access to sufficient information about COVID-19 than men [5]. In the research conducted in Southeast Sulawesi Province, there are many women's organizations in each region or village, such as the Family Welfare Empowerment organization, the Islamic Women's Organization, and the Ten Household Group Organization. A women's organization is an organization that plays a role in improving women's general knowledge and skills, including about health [5]. Meanwhile, all of the respondents of the current study lived in Medan, the capital of North Sumatra province, thus there was no difference in access to information between men and women.

The results also showed that more female respondents were willing to be vaccinated than men. These results are not in line with those of the Zintel study, where 36 studies reported significant gender differences, with men being more likely to receive COVID-19 vaccines in 35 studies [9]. Only one study, conducted by Lazarus, reported that women were more likely to receive COVID-19 vaccines, but no strong association was discovered [10]. In the current study, more female respondents were willing to be vaccinated, perhaps because the gender proportion was imbalanced and the number was relatively small [9]. A study by Galasso also reported that women who were more concerned with the health consequences of COVID-19 were more likely to believe they were infected and could become seriously ill, leading to increased willingness to prevent COVID-19 infection, including vaccination. In addition, they were more averse to taking risks than men [11].

The results showed that most citizens who had negative vaccine perceptions were in the 20-30-year age group, as many as 58 people. This study was in accordance with research conducted by De Bruin (2020) regarding negative perceptions at a young age due to negative emotions such as anxiety and depression, which are more dominant than in old age. Persons of old age have a greater risk of dying if infected with COVID-19. Older people do not have to undergo quarantine or run out of money for treatment, which causes older people to experience depression or anxiety less often when infected with COVID-19 [12].

This study found the highest prevalence of feeling unsure about vaccination in the 20-30-year age group. Table 3 shows that in the 20-30-year age group there are 16 respondents who had not yet decided whether or not to vaccinate; this number is much higher than in other age groups. In this age range, subjects were still having doubts about the effectiveness or safety of the vaccine.

Almost all the citizens of Medan City who participated in this survey still have a negative perception of the COVID-19 vaccine, most of whom work in the non-health sector. However, statistically, there was no relationship between occupation and perception or willingness to be vaccinated. This result is in accordance with previous research, which states that the individual's employment status does not show a significant relationship with a person's perception of the COVID-19 vaccine, as well as that the individual's willingness to be vaccinated is not related to employment status [5].

According to a research study by Hope et al. in 2020 regarding the willingness to receive the COVID-19 vaccine in Indonesia, health workers appear to be more supportive of the COVID-19 vaccination program when compared to non-health workers. The desire to protect themselves, their family, friends, and patients has driven health workers' decisions to get vaccinated. More comprehensive knowledge about COVID-19 and relatively high awareness has led them to protect themselves so they do not transmit the virus to family members and others close to them. That makes health sector workers more willing to receive vaccines than those who work in the non-health sector [12]. Meanwhile, the people of Medan whose background is not in the health sector appear to be more familiar with information about the COVID-19 vaccine; therefore, there are still many who have a negative perception of the vaccine. However, this study found that the willingness to be vaccinated with the COVID-19 vaccine was good in both groups (Health Sector and Non-Health Sector).

There are still many negative perceptions by individuals based on their occupations. The study showed that education and counseling about COVID-19 vaccination still has to be improved so that the perceptions or views of the community, especially in Medan City, can be positive and have a good effect on willingness to get vaccinated against COVID-19. The public must have a good understanding of the COVID-19 vaccine and consciously and voluntarily get vaccinated. The primary purpose of this vaccination program is to establish herd immunity or community immunity. Thus, willingness to be vaccinated is not only due to orders from superiors, co-workers, or other reasons, but because people are aware of the importance of vaccination and the benefits obtained if they are vaccinated with the COVID-19 vaccine. Do not forget to provide post-vaccination education to the public in case there is an AEFI reaction (Adverse Event Following Immunization). The community does not need to be in panic and fear.

Respondents with a bachelor's degree education had the best perception and willingness compared to others. The results regarding perception in this study were not in accordance with the results of research conducted by Tasnim in the Southeast Sulawesi Region in 2020, with the number of respondents graduating from junior high school as many as ten people, education graduating from high school as many as 92 people, and completing undergraduate education as many as 83 people. The study divided perceptions into three levels: good, sufficient, and poor. In respondents who graduated from Bachelor's education, about 11 people had good perceptions, 52 people had sufficient perceptions, and 20 people had poor perceptions. The results of the willingness to be vaccinated in this study were in accordance with research conducted by Tasnim that found that 57 people were willing to be vaccinated, and 26 other people were not willing to be vaccinated [5], [13].

According to Rzymski et al., the transient problems associated with specific vaccines have the potential to affect confidence more significantly in individuals with lower education than higher education, highlighting the continuing need for experts to actively inform and explain about safety-related idiosyncrasies to the general public, as well as about the efficacy of the vaccine. The results of the study clearly show that education is not only related to awareness of the existence of a particular vaccine technology but also the level of trust held by respondents [14].

Based on the results of this study, even though the community's education level was good, it did not rule out that the community still had doubts about the COVID-19 vaccine. This doubt may arise because people with a higher education level are relatively able to access more information about the COVID-19 vaccine in comparison to those with lower education level. However, the information obtained may not be explored and filtered further, leading to misinformation and hoaxes. Despite this, since the vaccination is free and public awareness of the vaccine is generally good, the number of people willing to be vaccinated is greater than the number of those who are not. Therefore, from the results of this study, the public's willingness to be vaccinated based on education level is good even though more people hold a negative perception toward vaccination [14].

This study had limitations. First, it was an online questionnaire-based study, thus participants were only those with online access, so other people who cannot use the media or did not have media access could not participate in the study and the researcher could not ensure whether the questions had been answered alone or with the help of others. Second, the number of the participants was not large enough to generalize to the Medan population.

5. Conclusion

The study found a significant relationship between perception and acceptance of COVID- 19 vaccines. In spite of a majority of negative perceptions, the community was generally willing to receive vaccination. The public requires better education from experts to further comprehend COVID-19 and its vaccines in order to raise their awareness and willingness to get vaccinated, thus contributing to COVID-19 transmission prevention in Medan.

Conflict of interest

None.