Trajectory of COVID-19 vaccine hesitancy post-vaccination and public’s intention to take booster vaccines: A cross-sectional analysis

ABSTRACT

Vaccine hesitancy (VH) is not a new phenomenon in Pakistan and is regarded as one of the primary causes of unsatisfactory vaccination campaigns. This study determined post-vaccination COVID−19 VH, factors influencing COVID−19 vaccine uptake, and public’s intent to receive booster vaccinations. A cross-sectional study was conducted among adult population of Lahore, Pakistan. Participants were recruited via convenience sampling between March and May 2022. SPSS version 22 was used for the data analysis. A total of 650 participants were included in the study (age = 28.1 ± 9.7 years; male-to-female ratio nearly 1: 1). The majority of participants received Sinopharm followed by Sinovac vaccine. The top three reasons of vaccine uptake were “only vaccinated individuals are allowed at the workplace, and educational institutes” (Relative importance index (RII) = 0.749), “only vaccinated people are allowed to go to markets, malls and other public places” (RII = 0.746), and “protect myself from the infection” (RII = 0.742). The mean COVID−19 VH score was 24.5 ± 6.2 (95% CI 23.9–24.9), with not being pro-vaccines and poor economic status were the significant predictors of COVID−19 vaccine hesitancy among immunized individuals (p < .05). Acceptance of booster vaccines was negatively associated with younger age and a lower level of education. Furthermore, being pro-vaccine was associated with a greater likelihood of accepting booster vaccines (p = .001). The Pakistani public continues to express VH toward COVID−19 vaccines. Therefore, aggressive measures must be taken to combat the community factors that contribute to it.

Introduction

Coronavirus disease, also known as COVID−19, is arguably the worst public health emergency since the 1918 influenza pandemic.¹ Initial attempts to control the spread of COVID−19 included social isolation, the use of face masks, and complete or partial lockdowns. Due to the rapid development of multiple COVID−19 vaccines as a result of intensive scientific research and innovation, the management of the pandemic has been shifted to vaccines. The COVID−19 vaccination campaign is one of the world’s largest vaccination programs against an infectious disease that has immunized a substantial portion of the global population.² However, COVID−19 vaccine hesitancy (CVH) and various conspiracy theories surrounding the disease and its vaccines continue to undermine the efforts of public health authorities to vaccinate the population en masse.^3–5

Pakistan is a low-middle-income country with a population of nearly 230 million and healthcare system that is under-developed. In Pakistan, vaccination campaign against COVID−19 was initiated in the early February 2021. Initially, the vaccines were distributed to frontline medical forces,⁶ and then the elders were given priority before the middle-aged and young populations.^7,8 In September 2022, the COVID−19 vaccines were rolled out for children aged 5 to 18 at all national vaccine centers.⁹ In addition, the booster vaccine is available to health professionals, immunocompromised patients, travelers, and all adults over the age of 18. As of May 29, 2023, more than half of the country's population has been fully vaccinated.¹⁰ The continued presence of polio cases in Pakistan is evidence of the pervasiveness of vaccine hesitancy in the country.^11,12 Existing literature uncovered substantial CVH associated with diverse conspiracy theories, mistrust of the government, and efficacy and safety concerns regarding corona vaccines.^13–15 Such obstacles can significantly impede COVID−19 vaccination efforts in Pakistan. Moreover, due to a recent outbreak of COVID−19 in neighboring China and the threat of newer corona variants and/or sub-variants,^16,17 it is crucial to keep the infection under control in Pakistan by vaccinating the general population and administering booster shots to those who have already been immunized with primary doses. In this context, this study highlights post-vaccination COVID−19 vaccine hesitancy, factors influencing COVID−19 vaccine uptake, and the public’s intent to receive booster vaccines.

Methods

Study design, location, and participants

A descriptive, cross-sectional study was conducted among the adult population of Pakistan’s second largest metropolis (Lahore). The inclusion criteria for the present study were (1) adults (≥18 years old), (2) the ability to speak Urdu, and (3) willingness to participate.

Ethical considerations

Prior to the administer the survey, the Research Ethics Committee of the Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, reviewed and approved the protocol for this study (REC/DPP/FOP/57). Each participant verbally consented to participate in the study. In addition, no personal information was collected in order to protect the respondents’ anonymity. On request, the questionnaire was distributed to study participants and collected once it was completed.

Sampling

Our objective was to recruit as many individuals as possible during the survey period in order to increase the sample’s potential representativeness. Hence, a minimum sample size was not calculated a priori. This method has been utilized in numerous previous studies.^18–20 We recruited participants using a convenience sampling technique between March and May of 2022.

Data collection procedure

Two research teams composed of five pharmacy students in their final year conducted interviews with potential study participants and recorded their responses. In the last week of February 2022, these teams participated in data collection training and a practice/mock session. In addition, a pilot survey was conducted to identify any issues with the data collection. In March 2022, data collection (using paper forms) commenced.

Data collection form

An anonymized questionnaire was developed to determine public’s attitudes toward COVID−19 vaccination post immunization, factors influencing COVID−19 vaccine uptake, opinions pre- and post-immunization, and their willingness to recommend COVID−19 vaccine and its booster shot to others. The initial draft of the questionnaire was reviewed by a panel of five health sciences specialists. The draft was revised based on the panel’s recommendations. After receiving expert panel approval, this draft was used for data collection. The final data collection form had the following six sections;

• Section 1: It collected demographic information of the study participants e.g., age, gender, education, income, marital status, smoking status, health professional in the family/relative, presence of long-standing disease, drug allergy, corona infection in self, family and/or friends.

• Section 2: It contained four items to assess COVID−19 vaccination status (first dose, second dose and two questions related to booster shots) of the study participants.

• Section 3: It comprised of 10-item COVID−19 vaccine hesitancy scale (C19V-HS). Responses were recorded on a five-point Likert scale ranging from ‘1-strongly disagree’ to ‘5-strongly agree.’ Vaccine hesitancy score was computed by reversing the score of first seven questions of the scale so that higher scores would reflect higher degree of vaccine hesitancy.¹⁴

• Section 4: It contained 10-items to determine factors associated with COVID−19 vaccine uptake in the study population. Responses to all the items were recorded on a five-point Likert scale ranging from ‘1-strongly disagree’ to ‘5-strongly agree.’

• Section 5: It consisted of three items (yes/no/unsure) to determine (1) participants willingness to recommend vaccine to others, (2) views on the need of booster vaccine and (3) willingness for booster vaccine uptake.

• Section 6: It had four items (yes/no) to determine participants’ opinion about COVID−19 vaccine before and after immunization.

Statistical analysis

All collected data were entered into Microsoft Excel, cleaned, and exported to SPSS version 22 for data analysis. Continuous data were presented as mean and standard deviation whereas categorical data were presented as proportion and percentages. C19V-HS scores were compared between demographic variables using independent t-test and one-way ANOVA, where applicable.

In addition, the relative importance index (RII) was computed for each item in sections 3 and 4 of the study tools. The highest value of RII (0 ≥ RII ≤ 1) associated with highest rank for items in sections 3 and 4. The estimation was based on the following equation:

$$\mathrm{R}\mathrm{e}\mathrm{l}\mathrm{a}\mathrm{t}\mathrm{i}\mathrm{v}\mathrm{e}\mathrm{i}\mathrm{m}\mathrm{p}\mathrm{o}\mathrm{r}\mathrm{t}\mathrm{a}\mathrm{n}\mathrm{c}\mathrm{e}\mathrm{i}\mathrm{n}\mathrm{d}\mathrm{e}\mathrm{x}\left(\mathrm{R}\mathrm{I}\mathrm{I}\right)=\frac{{\sum }^{\mathrm{W}}}{\left(\mathrm{A}\ast \mathrm{N}\right)}=\frac{5n5+4n4+3n3+2n2+1n1}{5N}$$ (1)

Note: W is the weight assigned to each item by the study participant (range 1 –5). A being the highest weight and N is the total sample (650 people).

Multiple linear regression with Stepwise approach was employed to identify factors associated with post-vaccination COVID−19 vaccine hesitation (dependent variable: C19V-HS score). Item 3 of Section 5 of the study instrument was used to ascertain the participants’ intent to receive booster doses (response coding: 1 = Rejecter, 2 = unsure (fence-sitter) and 3 = acceptor). The proportional odds regression model was used to evaluate factors associated with booster vaccine acceptance. Odds ratio (OR) and confidence intervals were derived by exponentiation of estimates. We considered a p-value of less than 0.05 for all the statistical procedures in this study.

Results

Participants’ characteristics

The research team approached 928 individuals, of them, 672 agreed to participate in the survey. Reasons for refusal in 256 encounters are presented in Figure 1. Of 672 consented individuals, 650 returned adequately completed study instruments and were included in the final analysis. The participants’ characteristics are shown in Table 1. The mean age of the study participants was 28.1 ± 9.7 years (range 18–65), with the majority (54%) being <25 years old followed by age group of 25–35 years (25.8%). The male-to-female ratio was close to 1:1 (male 52.2%, female 47.8%). Regarding education, 24.9% of our sample had no formal education, 9.4% had primary education, 11.8% had secondary education, and 53.4% had tertiary education. Approximately, one-third of the study participants (36%) reported having a healthcare worker in their family or among relatives. As indicated in Figure 2, approximately 31% of participants reported having COVID−19 infection, while 49.7% reported having family members and relatives or friends who had contracted the infection during the pandemic.

Figure 1.

Study flowchart.

Table 1.

Demographic data of the sample population.

Variables	N (%)
Age (28.1 ± 9.7 years; range 18–65)
<25 years	351 (54.0)
25–35 years	168 (25.8)
35–45 years	87 (13.4)
>45 years	44 (6.8)
Gender
Male	339 (52.2)
Female	311 (47.8)
Education
No formal education	162 (24.9)
Primary	61 (9.4)
Secondary or higher secondary	77 (11.8)
Tertiary	350 (53.8)
Income (PKR)
<50,000	353 (54.3)
50,000–100,000	120 (18.5)
100,000–150,000	94 (14.5)
>150,000	83 (12.8)
Marital status
Single	408 (62.8)
Married	214 (32.9)
Divorced/widow	28 (4.3)
Smoking status
Never smoker	484 (74.5)
Currents smoker	142 (21.8)
Former Smoker	24 (3.7)
Healthcare professional in the family/relative
Yes	234 (36.0)
No	416 (64.0)
Any long-standing diseases?
Yes	73 (11.2)
No	577 (88.8)
Allergy to any medicine?
Yes	78 (12.0)
No	572 (88.0)

NB: PKR-Pakistani Rupee.

Figure 2.

Self-reported COVID−19 infection in study participants.

COVID−19 vaccine status of the sample

Table 2 details the vaccinations received by participants in the study. Majority received Sinopharm (1^st shot: 43.2%, 2^nd shot: 42.3%) followed by Sinovac (1^st shot: 29.2%, 2^nd shot: 29.5%). Single-dose vaccine (CanSino) was administered to 12.3% of the study sample. Of 570 participants, 569 (99.8%) received second dose. Only 7.5% (n = 49) of individuals reported receiving a COVID−19 booster shot; the majority of these individuals received the Pfizer-BioNTech vaccine (n = 20), followed by the Moderna vaccine (n = 13).

Table 2.

COVID −19 vaccination status.

	N (%)
First dose (N = 650)
Pfizer-BioNTech	55 (8.5)
Oxford-AstraZaneca	9 (1.4)
Moderna	35 (5.4)
SinoPharm	281 (43.2)
SinoVac	190 (29.2)
CanSino	80 (12.3)
Second dose (N = 569)
Pfizer-BioNTech	55 (8.5)
Oxford-AstraZaneca	9 (1.4)
Moderna	38 (5.8)
SinoPharm	275 (42.3)
SinoVac	192 (29.5)
Booster dose
Yes	49 (7.5)
No	601 (92.5)
Booster vaccine (N = 49)
Pfizer-BioNTech	20 (3.1)
Oxford-AstraZaneca	2 (0.3)
Moderna	13 (2)
SinoPharm	6 (0.9)
SinoVac	6 (0.9)
CanSino	2 (0.3)

Participants’ attitudes toward COVID−19 vaccine

The attitudes of participants toward the COVID−19 vaccine were evaluated using a 10-item scale (Figure 3). Of these, Item−4 (having myself vaccinated for COVID−19 is important for the health of others in my community) was ranked highest as it elicited maximum positive response, with a RII of 0.778. The second and third highest ranked items were “COVID−19 vaccine is important for all of us during the pandemic” and “Getting corona vaccine is the best way to protect myself and my loved-ones from the infection,” respectively. It was concerning to see that the RII for the statement “COVID-vaccines are not really needed because the disease will eradicate soon” was 0.701.

Figure 3.

COVID−19 vaccine hesitancy among study participants.

The average score on the C19V-HS score was 24.48 ± 6.23 (95% CI 23.98–24.99). Except for one variable, no significant differences in C19V-HS scores were observed across demographic variables. Those who had a family member or relative who contracted COVID−19 during the pandemic scored significantly lower on the vaccine hesitancy scale than those who did not (23.64 ± 6.15 vs 25.09 ± 6.78; p = .003).

Factors influencing COVID−19 vaccine uptake in the sample

Figure 4 illustrates all the factors influencing COVID−19 vaccine uptake among the study participants. The items such as “only vaccinated individuals are allowed at workplace, university and/or college” (RII = 0.749), “only vaccinated people are allowed to go to markets, malls and other public gathering places” (RII = 0.746), and “protect myself from the infection” (RII = 0.742) were the top three reasons for vaccination.

Figure 4.

Factors that encouraged respondents to take COVID−19 vaccine.

Trajectory of COVID−19 vaccine hesitancy pre- and post-immunization

Prior to receiving their first COVID−19 vaccination, 55% of respondents reported hesitancy (Figure 5), with safety concerns (20.5%), efficacy concerns (16%), and mistrust of the government (13.4%) constituting the most prevalent reasons. Although we observed a slight improvement in participants’ opinion following vaccination (45.7% vs 51.1%), a sizable proportion still had concerns regarding the safety and efficacy of vaccine (Figure 6). Furthermore, around 7% on respondents believed that COVID−19 vaccines were unnecessary.

Figure 5.

Participant’s opinion about COVID−19 vaccines before taking the first dose.

Figure 6.

Views of study participants pre- and post-vaccination.

As anticipated, individuals who reported being hesitant prior to receiving their first dose had higher C19V-HS scores (25.54 ± 6.48 vs 23.22 ± 6.45, p < .001). People who were in favor of the vaccines had better attitudes toward COVID−19 vaccination (22.92 ± 6.30 vs 26.89 ± 6.24, p < .001). Most importantly, those with negative opinions toward COVID−19 vaccines post-vaccination had higher C19V-HS scores (26.27 ± 6.84 vs 22.78 ± 5.80, p < .001).

Predictor of COVID−19 vaccine hesitancy post-immunization

A multiple-linear regression analysis was performed to determine the variables associated with COVID−19 vaccine hesitancy (dependent variable: C19V-HS score; Method: Stepwise). Covariates used for the analysis included age, gender, education, income status, marital status, smoking status, health professional in family/relative, chronic disease, drug/medicine allergy, COVID−19 infection in self, family or relative, self-reported reluctance to COVID−19 vaccine before vaccination, and being pro-vaccines. As shown in Table 3, not being in favor of the vaccines and having a low socioeconomic status were the significant predictors of COVID−19 vaccine hesitancy after vaccination (p < .05).

Table 3.

Factors associated with COVID − 19 vaccine hesitancy.

Coefficientsa
Model	Unstandardized Coefficients		Standardized Coefficients	t	p-value	95% Confidence interval		Collinearity statistics
	B	SE	Beta			Lower bound	Upper bound	Tolerance	VIF
(Constant)	20.165	.845		23.857	.000	18.505	21.824
Being in favor of the vaccines	3.987	.500	0.297	7.967	<.001	3.004	4.969	1.000	1.000
Income	−0.667	.225	−0.110	−2.958	.003	−1.109	−0.224	1.000	1.000

^aDependent variable: C19V-HS score; VIF-variance inflation factor; SE-standard error.

Participants’ views on the need of booster vaccine and their intention to take booster doses

Approximately 71% of respondents indicated they would recommend COVID−19 vaccine to family and friends who have not yet received the vaccine (Table 4). Concerningly, only 35.8% believed that booster doses are necessary (not sure 36.9%; not needed 27.2%), while 36.6% are willing to receive them. As shown in Table 4, those who refused to recommend the corona vaccine to others had a significantly higher vaccine hesitancy score. Those who supported booster doses had significantly lower hesitancy scores than those who opposed them. Additionally, as anticipated, those who were willing to receive a booster dose of vaccine had a significantly lower vaccine hesitancy score than those who refused to do so. However, there was no significant difference of hesitancy score between booster vaccine acceptors and fence-sitters (those who selected option “unsure”) (Table 4).

Table 4.

Participants’ views on the need booster vaccine and booster vaccine-uptake.

Statement	Response options	N (%)	Vaccine hesitancy score	p-value*	Multiple comparisons**
Would you recommend COVID−19 vaccines to your family, friends or relatives who have not received vaccine yet?	Yes Unsure No	460 (70.8) 112 (17.2) 78 (12.0)	23.4 ± 5.9 2.1 ± 6.4 30.1 ± 7.1	<.001	a > b (p = .035), a > c (p < .001), b > c (p < .001)
Do you think that booster doses are needed to have a continuous protection against COVID−19?	Yes Unsure No	233 (35.8) 240 (36.9) 177 (27.2)	22.6 ± 5.9 23.8 ± 5.2 27.9 ± 7.6	<.001	a > c (p < .001), b > c (p < .001)
Will you take booster doses of COVID−19, if it is recommended by the authorities?	Yes Unsure No	236 (36.6) 143 (22.0) 271 (41.7)	23.1 ± 5.9 23.5 ± 5.5 26.3 ± 7.2	<.001	a > c (p < .001), b > c (p < .001)

Note: *Welch ANOVA; **Games–Howell test.

As shown in Table 5, an ordinal logistic regression was conducted using 14 variables that were regressed onto a three-point “intention to take booster vaccine” outcome. Our findings indicated young age and lower levels of education were negatively associated with acceptance of booster vaccines. Additionally, being in favor of vaccines was associated with increased odds of accepting booster vaccines (p = .001).

Table 5.

Factors associated with intention to take booster vaccine.

Variables	Proportional odds regression
	AOR (95% CI)	p-value
Age (years)
<25	0.609 (0.304–2.672)	.168
25–35	0.509 (0.261–0.991)	.047
35–45	0.589 (0.297–1.239)	.167
> 45	1.00 (Reference)	–
Gender
Male	0.731 (0.518–1.030)	.074
Female	1.00 (Reference)	–
Education
No formal education	0.236 (0.120–0.465)	<.001
Primary	0.330 (0.159–0.682)	.003
Secondary or higher secondary	0.312 (0.149–0.658)	.002
Tertiary	1.00 (Reference)	–
Income (PKR)
<50,000	1.123 (0.608–2.096)	.700
50,000–100,000	1.266 (0.740–2.166)	.389
100,000–150,000	1.338 (0.754–2.373)	.320
>150,000	1.00 (Reference)	–
Marital status
Married	1.002 (0.651–1.545)	.991
Not married	1.00 (Reference)	–
Smoking status
Ever smoker	0.746 (0.495–1.125)	.163
Never Smoker	1.00 (Reference)	–
Healthcare professional in the family
Yes	0.936 (0.654–1.340)	.791
No	1.00 (Reference)	–
Chronic diseases
Yes	1.178 (0.705–1.968)	.531
No	1.00 (Reference)	–
Any allergy to medicines
Yes	0.923 (0.566–1.505)	.749
No	1.00 (Reference)	–
COVID−19 infection in self
Yes	1.092 (0.760–1.568)	.754
No	1.00 (Reference)
COVID−19 infection in family members/relatives
Yes	0.945 (0.742–1.508)	.053
No	1.00 (Reference)	–
Before getting COVID−19 vaccine, I was reluctant to take it
No	1.203 (0.867–1.670)	.270
Yes	1.00 (Reference)	–
Before getting COVID−19 vaccine, I was in favor of vaccines
Yes	1.818 (1.293–2.555)	.001
No	1.00 (Reference)	–

NB: AOR-adjusted odds ratio; CI-confidence interval; PKR-Pakistani Rupee.

Discussion

This is the first study of its kind to examine the COVID−19 vaccine hesitancy (CVH) among immunized individuals in Pakistan, its underlying factors, and its transitioning before and after vaccination. Despite receiving primary doses, a substantial proportion of study participants had noticeable CVH scores, and only one-third agreed to receive booster doses. More than half of respondents initially expressed reluctance to receive COVID−19 vaccines. Vaccine requirements in the workplace or in public places, as well as the perceived protective benefits of the vaccines, were the leading motivators for study participants to receive vaccinations. CVH was associated with those who opposed vaccination prior to the COVID−19 vaccination campaign and with those of lower socioeconomic status. Participants who were pro-vaccine prior to receiving COVID−19 vaccines were more likely to accept booster doses, whereas younger participants and those with lower levels of education predict a negative association with booster vaccine acceptance. Taken together, these findings have significant ramifications for Pakistan’s health authorities. In order to design and implement targeted, it is essential to quantify determinants and contextual factors of VH.

As estimated by the 10-item C19V-HS, the average VH score (i.e., 24.48) was less than half the total score of 50. The majority of study participants believed that COVID−19 vaccines were essential for protection. However, nearly 23% of respondents indicated that vaccines are unnecessary because the disease will soon be eradicated. These findings corroborate with recent multinational studies from Asian and African regions.^14,21 Alarmingly, more than one-third of the study were concerned about the safety of COVID−19 vaccines. A recent study evaluating vaccine hesitancy in 23 countries indicated that negative perceptions on vaccine safety have been strongly associated with vaccine hesitancy.²² The safety of COVID−19 vaccines is evident through phase−3 clinical trials,^23,24 as well as real-world pharmacovigilance data.^25–27 Moreover, a number of studies evaluating the side effects of COVID−19 vaccines in Pakistan have revealed a satisfactory safety profile among vaccine recipients.^28–30

The deluge of vaccine hesitancy (VH) against COVID−19 during the pandemic posed substantial obstacles to optimizing the vaccination coverage.^31,32 Prior to the pandemic, the phenomenon of VH already existed and is ranked among the top ten global health threats.³³ The infodemic crisis during the COVID−19 pandemic resulted in a global increase in VH prevalence.³⁴ Nevertheless, it is essential to recognize that VH is a dynamic and complex process, and that VH trajectories within the same population may vary over time.³⁵ Existing literature indicated the change in VH following the administration of vaccines.³⁶ Kumar et al. outlined the six phases of VH during the COVID−19 pandemic: vaccine-related eagerness or desperation, ignorance, resistance, confidence, complacency, and apathy. These phases occur sequentially but may coexist simultaneously.³⁵ However, there are numerous approaches to addressing the VH, and it can be addressed more persuasively if its complexity and origin are comprehended. Existing evidence suggests that concerns about the safety of COVID−19 vaccines are one of the leading causes of VH.^37,38 Despite the fact that the study participants have received COVID−19 vaccinations, a sizable proportion of VH in our study may be associated with widespread safety concerns in the general population. In this context, the health authorities should prioritize assuaging concerns and doubts of the general population.

Restoring public confidence in vaccines is crucial to the success of national and international vaccination campaigns. Interestingly, 63% of study participants reported following the vaccination recommendations of their healthcare providers. According to another finding of our study, approximately half of respondents have received the COVID−19 vaccines on the advice of medical professionals. A nationally representative survey of 340,543 adults in the United States concluded that the advice of healthcare professionals can increase COVID−19 vaccination rates.³⁹ Another study conducted in a developing country (Papua New Guinea) revealed that 48% of respondents intended to vaccinate based on the advice of medical professionals.⁴⁰ These results necessitate measures involving healthcare professionals to promote vaccination among the general population. During the COVID-19 pandemic, VH among healthcare professionals must also be considered a major concern. Before encouraging healthcare professionals to recommend COVID−19 vaccination, health authorities should address their concerns.

Participants were asked about the factors that influenced them to get vaccinated, and workplace and public vaccination requirements ranked highest. Previous research indicates that government-mandated vaccination requirements or certificates are associated with higher vaccination rates.⁴¹ A large survey of 19 countries, representing approximately 55% of the world's population, uncovered a rise in COVID−19 vaccine uptake among hesitant populations in response to government mandates.⁴² Vaccine mandates remained a contentious issue throughout the pandemic. It is essential to note that VH can influence people’s compliance with government mandates and their opposition to such policies. In this context, effective vaccination policies, including mandates, necessitate transparent and sophisticated communication of safety and efficacy to the public. In conjunction with other studies, our findings demonstrate that direct or indirect government mandates increase vaccination rates.

The belief that vaccination can protect against COVID−19, severe illness, and death is positively correlated with vaccination rates.⁴³ More than two-thirds of the study participants stated that they have taken the vaccines to prevent infection. Similar results have been observed on CVH scale, where 74.3% of respondents agreed that vaccines are most effective way to protect oneself and one's family. Nonetheless, a sizable proportion of participants disagreed that they received the vaccine for protection. Other studies conducted in Nepal⁴⁴ and Bangladesh⁴⁵ have also indicated negative perception regarding protective benefits of vaccines. This issue can be effectively addressed through the use of behavior-informed messages. A simple message such as “Get vaccinated to protect yourself and your family from coronavirus” distributed through the media and cellular services, for example, may prove to be an effective measure.

More than half of respondents were hesitant to receive the COVID−19 vaccine prior to their first injection. Concerns about the safety and efficacy of the vaccine, as well as a lack of trust in the government, were frequently cited as reasons for participants’ reluctance to receive the vaccine. These findings align with the findings of a Japanese study that assessed VH at two distinct time points.⁴⁶ In addition, other studies have demonstrated that mistrust in government agencies, medical organizations, and the pharmaceutical industry is a significant factor in the spread of VH during the COVID−19 pandemic.^47–50 A recent multinational study also revealed that the general public questioned the authenticity and trustworthiness of COVID−19 vaccine-related information disseminated by health authorities.¹⁴ The mistrust of general population on the health authorities is quite common in developing countries,^44,45,51 that might be associated with various challenges and strains in healthcare system. Surprisingly, we discovered that participants’ perceptions of COVID−19 vaccines’ safety gradually improved over time. In contrast, participants’ belief in the effectiveness of COVID−19 vaccines decreased by 1.5% in our study. Compared to their opinions prior to vaccination, a greater proportion of participants denied the necessity of vaccines after receiving their doses. These results suggest that the administration of the vaccine had little or no effect on COVID−19 vaccination opinions and attitudes. We attribute this minor shift in the perceptions and attitudes of the study participants primarily to a lack of trust in government. In this context, it is strongly advised to restore the public’s trust in healthcare authorities, as this could translate into confidence in vaccines. Assuring the transparency and integrity of advisory bodies for the COVID−19 pandemic, as well as encouraging community participation in these bodies, would help to boost public trust in authorities and vaccines. Dispelling concerns about safety and efficacy of COVID−19 vaccines, and mistrust for the government and authority through context specific, culturally appropriate, and evidence-based communications and interventions will entrench the existing anti-authority beliefs among the general population.

A multiple linear regression analysis revealed a significant relationship between VH and participants’ reluctance to receive vaccines prior to the COVID−19 vaccination rollout or a lower socioeconomic status. These findings indicate that the administration of COVID−19 vaccines had no effect on the extent of hesitancy among study participants. On the other hand, Suzuki et al. found a significant relationship between lower annual household income and VH.⁵² The correlation between annual income and vaccination hesitancy has also been established by a number of other studies.^53,54 It is important to note that household income or socioeconomic status is affected by other factors, such as family structure; therefore, future studies should take these factors into account when determining the relationship between income status, vaccine hesitancy, and vaccine intention.

The WHO advises individuals aged 18 or older to receive a booster dose of COVID−19 vaccines four to six months after the completion of the primary vaccination series.⁵⁵ There is also discussion about COVID−19 annual booster vaccinations and the possibility of implementing this policy in some countries around the globe.⁵⁶ Determining booster dose intention and its underlying factors will help health authorities and policymakers in developing and implementing effective strategies to maximize booster-dose coverage. Our analysis revealed that only 37% of study participants were willing to take booster doses, if advised by the health authorities. Only 7.5% of the sample received booster vaccine, which may be attributable to the predominance of younger population (18–35 years) and the time of data collection. Similar to the primary COVID−19 vaccination, the elderly and other vulnerable populations received the booster vaccine first. Booster shot campaign was expanded to young population (age >18; one booster dose after 6-month gap from complete vaccination) in late January 2022, primarily due to the rapid increase of COVID−19 caused by the omicron variant of SARS-CoV−2. Regarding booster-dose acceptance, the existing literature provides variable rates of intended booster vaccination. In a recent meta-analysis of 48 studies, the pooled proportion of COVID−19 vaccine booster-dose acceptance ranged from 41% to 98%, with an average of 81%.⁵⁷ This meta-analysis also revealed that Southeast Asia had the lowest booster-dose acceptance rate (52%) compared to other WHO regions. Variations in booster vaccination rates across published studies are attributable to study population, regional vaccine mandates, timing of data collection, study questionnaire, cultural or regional differences, and vaccine accessibility. In our study, those who refused booster doses had significantly higher VH scores, suggesting that VH is a major contributor to the low acceptance rate for booster doses. Intriguingly, participants who refused to recommend vaccines to their friends/family and those with negative attitudes, such as the belief that COVID−19 booster doses are not required for continuous protection, had significantly higher VH scores. Our results showed that young age and lower education levels were negatively associated with booster vaccines` acceptance. Yoshida et al. presented comparable findings and reported that young people are less likely to accept COVID−19 booster doses.⁵⁸ These results are also consistent with the findings of a number of other studies examining the effect of age on vaccine acceptance.^59,60 Lower education level was another determinant of booster vaccine intention in our study. Feng Hao examined the multilevel determinants of COVID−19 booster intention among Americans and found that those with less education are more reluctant to take booster doses.⁶¹ Taken together, these findings underscore the need to promote booster intention among hesitant populations, such as the less educated and younger individuals.

We believe that effective communication and adequate mass education are the key to overcoming vaccine hesitancy. The planning and implementation of the communication strategies must be meticulous. We can learn from Israel’s effective COVID vaccination program, which addressed vaccine hesitancy and achieved a very high coverage rate within the first three months.⁶² Many countries have combated vaccine hesitancy and instituted vaccination programs through effective communication. Each country could develop more effective communication plans for individuals, families, communities, and the nation as a whole by studying how other regions have dealt with the various phases of vaccine hesitancy. Successful strategies for combating VH that are developed and implemented during the COVID−19 pandemic may help shape the future course of global vaccination campaigns.

Several limitations should be considered when interpreting this study’s results. We surveyed opinions on vaccination at two time points (before and after COVID−19 vaccination) and participants were asked to recall past and respond to the questions. A number of cognitive biases, such as memory and hindsight biases, may be induced by this method. A prospective longitudinal survey in this context may produce variable results. It is essential to note that the results may vary over time for the same participants. The timing of data collection should also be considered a significant factor influencing the participants’ perceptions. In Pakistan, for instance, all COVID−19-related restrictions have been lifted at the time of data collection, which may affect the perceived need for vaccination. In addition, the country was undergoing a political and economic crisis at the time of data collection. The majority of participants had tertiary education, so the results may not be applicable to individuals with lower education levels. Likewise, the majority of respondents were young and urban residents; consequently, our findings may not apply to the country’s elderly and rural populations. Nonetheless, this study adds to our understanding of vaccine hesitancy and willingness to receive booster doses in the country’s second largest city. The findings of our study provide important recommendations for future research and public health interventions. The health authorities must consider these directives. Moreover, our findings can serve as a guide for the design and implementation of future studies and campaigns to increase vaccination rates. Future research should address the limitations of the current study. In this study, the validity of the inferential analysis is assured by the large sample size.

Conclusions

This study indicates that VH against COVID−19 is prevalent despite receiving the primary doses. Most of the participants immunized against COVID−19 either to comply with workplace/school vaccination requirements or to prevent infection. Before vaccination, approximately half of the participants were hesitant to receive the COVID−19 vaccine, and after vaccination, there was a slight improvement in participants’ opinions. The safety and efficacy of vaccines were the major concerns among study participants. Post-vaccination VH was significantly related to a history of vaccine reluctance and low socioeconomic status. One-third of study participants reported an intention to take booster doses, which was negatively correlated with young age and education level. Since VH is a complex behavior involving multiple factors and is subject to change over time, it is important to regularly assess the psychological and behavioral factors associated with vaccine acceptance. Structured public education programs, positive peer influence, the restoration of public trust in health authorities, and the measurement of public attitudes toward COVID−19 vaccination campaigns are necessary. Given the dynamic nature of the pandemic and the interaction of ever-changing factors that influence vaccine acceptance, our findings should be replicated in future research to determine the trajectory of vaccine hesitancy over time.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).