COVID-19 vaccine attitude, vaccine literacy, and religious attitudes: a cross-sectional study in Turkiye

Abstract

Background

The relationship between COVID-19 vaccine attitude and vaccine literacy and religious attitude has been shown in studies. The purpose of the present study was to determine the relationship between COVID-19 vaccine attitude, vaccine literacy and religious attitudes and the factors affecting vaccine attitudes.

Methods

This descriptive, cross-sectional study was conducted with 830 individuals over 18 years of age in Diyarbakır and Kahramanmaraş provinces of Turkiye. The “Personal Information Form”, “Attitudes Towards COVID-19 Vaccine Scale”, “COVID-19 Vaccine Literacy Scale” and “OK-Religious Attitude Scale” were used to collect the study data. Mean, standard deviation, minimum, maximum, number and percentage, Pearson Correlation and Stepwise Multiple Linear Regression Analysis were used in the analysis of the data.

Results

In the study, religious attitude was not associated with COVID-19 vaccine literacy and COVID-19 vaccine attitude. It was determined that having three and more doses of the vaccine and communicative/critical VLS increased the positive attitude towards the COVID-19 vaccine (p < 0.05). 17.3% of the positive attitude-dependent variable toward the COVID-19 vaccine was explained together with these predictors. The place of residence in Kahramanmaraş and using continuous drugs increased the negative attitude towards the COVID-19 vaccine and having 2 doses of vaccination and being married decreased it (p < 0.05). 19.9% of the negative attitude-dependent variable towards the COVID-19 vaccine was explained together with these predictors.

Conclusions

From the results obtained, it was concluded that the religious attitude of individuals was not related to COVID-19 vaccine literacy and vaccine attitudes, and that COVID-19 vaccine literacy predicted vaccine attitude.

Background

Coronavirus disease 2019 (COVID-19) has caused a pandemic whose effects are still ongoing and have not been brought under control because its rate of infection and spread is much higher than other viral infections [1]. Despite all individual and national measures taken to reduce the number of deaths it causes and to control its contagion, the virus continues to spread with new mutations [1, 2]. Vaccines are among the most important inventions of the 20th century in terms of public healthcare. The discovery of vaccines against infectious diseases causing epidemics resulted in the elimination of many diseases and the prevention of a significant number of deaths and permanent complications [3]. The most appropriate way to avoid the health challenges and harms of the COVID-19 pandemic was to develop effective vaccines and ensure comprehensive vaccine administration [4]. The purpose of vaccination was proposed as a key priority to stop the related transmission, reduce the number of patients to be cared for in intensive care units, and end the ongoing pandemic [5]. Many scientific studies have proved that immunization is an effective tool in protecting public health and preventing diseases. Immunization was highly effective in reducing the incidence of COVID-19 and limiting disease progression [4, 6]. The COVID-19 pandemic and the COVID-19 vaccine have been facing the threat of various true or false information outbreaks since the day they were introduced [7]. During the pandemic period, a lot of inconsistent information has been put forward regarding the advantages and disadvantages of vaccines for individuals. Misleading information about vaccines that does not reflect the truth causes vaccine hesitancy in individuals. This attitude constitutes a significant obstacle to achieving herd immunity [8]. Vaccine hesitancy has been rated among the top 10 global public health threats by the World Health Organization [9, 10].

It was reported that approximately one in three people was undecided about having the COVID-19 vaccine [11]. More than half of the population must be vaccinated to avoid the spread of a virus infected with COVID-19 virus [11, 12]. When studies were examined, it was found that different approaches stemming from different value systems and perspectives were effective in being vaccinated. These are public health stances against individual rights, various religious perspectives, and skeptical, insecure approaches [13]. After its emergence in 2019, the COVID-19 pandemic and the COVID-19 vaccine caused the threat of a variety of true or false information epidemics [14]. Biasio et al., [15] reported that vaccination literacy and access to reliable information may be affected because of the free circulation of information about the vaccine because of the uncontrolled use of media/social media, fake news, and false information.

Vaccine literacy is defined as having information about vaccines, developing an uncomplicated system for delivering and presenting vaccines to the public, and establishing the health system in a way to ensure the continuation of vaccine-related practices [16]. Studies conducted show that poor vaccine literacy is significantly associated with attitudes toward and reluctance to be vaccinated against COVID-19 [11, 17, 18]. Vaccine literacy was shown to be an important factor in influencing vaccination intention and reducing vaccination hesitancy [19, 20]. Anti-vaccine communities prevent its implementation by planning strategies against the COVID-19 vaccine campaign through different sources to spread fiction and rumors. Unverified and unscientific information plays important roles in the continuation of the pandemic by increasing vaccine hesitancy [21]. The reasons for vaccine hesitancy vary according to heterogeneous reasons such as religion, culture, gender, access to vaccines, and trust issues [17, 22]. It is reported that religious concerns about immunization date back to 1796, when the smallpox vaccine was discovered, and it has a long history dating back to the claim that it was against God’s will. In our present day, the basis of opposition to vaccines for religious reasons is the mistrust of the products in vaccine compositions. It was also reported that there are contradictions between the components of vaccines and the beliefs and practices of different religious groups [13, 17]. No study explaining the relationship between COVID-19 VL and religious attitudes was found in the literature. However, studies showing that religious attitudes can play a role in cognitive processes such as health literacy, access to information, and evaluation are important in explaining the indirect relationship between religious attitudes and vaccine literacy [23, 24].

Furthermore, considering the relationship between religious attitude and COVID-19 vaccine attitude, it may also be related to COVID-19 VL. The purpose of the present study was to determine the relationship between COVID-19 vaccine attitude, vaccine literacy, and religious attitudes, and the factors affecting vaccine attitudes. The findings of the study will inform healthcare staff in public health studies to develop strategies to increase public acceptance of the COVID-19 vaccine. Thus, public acceptance and awareness of vaccines to be developed against possible pandemics can be increased.

Study questions

• What are the attitudes of the participants towards the COVID-19 vaccine?

• What are the COVID-19 vaccine literacy rates of the participants?

• What is the relationship between participants’ COVID-19 vaccine attitudes, vaccine literacy, and religious attitudes?

• What are the factors that affect the COVID-19 vaccine attitude of the participants?

Methods

Study design

This descriptive, cross-sectional study was conducted between April 15 and June 15, 2022. The study was carried out with individuals who were aged 18 years and over registered in a Family Healthcare Center (FHC) in the city of Diyarbakır in the Southeastern Anatolia Region of Turkiye and Kahramanmaraş in the Mediterranean Region.

Participants and procedures

The population of the study consisted of 13,435 people who were aged 18 and over registered in an FHC in Diyarbakır and 11,140 people aged 18 and over registered in an FHC in Kahramanmaraş. The sample was calculated with the OpenEpi program. The sample of the study consisted of 746 people, with the known population sampling method at a 95% Confidence Interval, and a 5% margin of error, a minimum of 374 people in Diyarbakır, and a minimum of 372 people in Kahramanmaraş. The sample calculation was as follows.

• Sample size n = [DEFF*Np(1-p)]/[(d2/Z21-α/2*(N-1) + p*(1-p)]

• Population size (for finite population correction factor or fpc) (N): 11,140

• Hypothesized % frequency of outcome factor in the population (p): 50%+/−5

• Confidence limits as % of 100 (absolute +/- %)(d): 5%

• Design effect (for cluster surveys-DEFF): 1

FHCs with similar sociocultural levels were selected to avoid differences in the study results in Diyarbakır and Kahramanmaraş. These FHCs comprised the segment of individuals with a medium socioeconomic structure in these cities. Individuals who would participate in the study were determined with the random sampling method from FHC records. These individuals were interviewed at the FHC or in their homes. A total of 872 people were interviewed (440 in Diyarbakır and 432 in Kahramanmaraş), and 42 people who filled in the data forms incompletely or did not want to participate in the study were excluded from the study. As a result, the study was completed with a total of 830 people (416 people in Diyarbakır and 414 people in Kahramanmaraş). The data were collected with the face-to-face interview method. Data collection took about 20–25 min.

Inclusion criteria of the study

The individuals who were aged 18 and over, at least primary school graduates, who wanted to participate in the study, and who filled out the form completely.

Independent variables were determined as age, city of residence, gender, educational status, marital status, continuous medication use, relatives catching COVID-19, getting the COVID-19 vaccine, vaccine dose, COVID-19 VLS total, functional VLS, communicative/critical VLS, and religious attitude.

The dependent variables were determined as positive attitude towards the COVID-19 vaccine and negative attitude towards the COVID-19 vaccine.

Data collection tools

The “Personal Information Form”, “Attitudes Towards COVID-19 Vaccine Scale-(ATV-COVID-19)”, “COVID-19 Vaccine Literacy Scale-(COVID-19, VLS)”, and “OK-Religious Attitude Scale-(ORAS)” was used.

Personal information form

This form was created by the researchers by reviewing the literature and consisted of questions that included information about the demographic characteristics of individuals, such as age, gender, educational status, economic status, disease health status, information about COVID-19, having COVID-19, and having the COVID-19 vaccine.

Scale of attitudes towards COVID-19 Vaccine-(ATV-COVID-19)

The scale was developed by Geniş et al. in Turkiye in 2020 [25]. The scale has 9 items and two sub-dimensions (positive and negative attitude). The statements in the scale are evaluated with a 5-point Likert scale between “I strongly disagree (1)” and “I strongly agree (5)”. A value between 1 and 5 is obtained by dividing the total score obtained by summing the item scores in the scale sub-dimension by the number of items in the relevant sub-dimension. High scores obtained from the positive attitude sub-dimension indicate that the attitude towards the vaccine is positive. The items in the negative attitude sub-dimension are calculated after they are reversed, and the high scores in this sub-dimension indicate that the negative attitude towards the vaccine is less. The positive attitude dimension includes questions 1–4, and the negative attitude dimension includes questions 5–9. The Cronbach’s Alpha Coefficient of the scale was determined as 0.80. In the present study, Cronbach’s Alpha Coefficient of the scale was found to be 0.762.

COVID-19 vaccine literacy scale-(COVID-19 VLS)

The scale was developed by Biasio et al. in 2021, and its validity and reliability study was conducted by Durmuş et al. for Turkish [16, 26]. It consists of two sub-dimensions (Communicative/Critical Skills and Functional Skills) and 12 statements. A 4-point Likert scale was used in scale expressions. For Communicative/Critical Skills, the rating is as follows: (1) Never, (2) Rarely, (3) Sometimes, (4) Often. For Functional Skills: (1) Often, (2) Sometimes, (3) Rarely, (4) Never. The average of the results being close to 4 indicates that the vaccine literacy level is high. The Cronbach’s Alpha Coefficient of the scale was 0.868. In this study, Cronbach’s Alpha Coefficient of the scale was found to be 0.784.

OK-Religious Attitude Scale -(ORAS)

The Religious Attitude Scale, which was developed by Ok [27], is a 5-point Likert-style scale and consists of 8 items and 4 sub-dimensions (cognition, emotion, behavior, and relationship). Options in the scale are scored as 1: I totally disagree, 2: I slightly agree, 3: I half agree, 4: I mostly agree, and 5: I totally agree. The scale consists of 8 items (6 positive and 2 negative). The lowest score that can be obtained from the scale is (8 × 1 = 8) and the highest score is (8 × 5 = 40). In the sub-dimensions, the lowest possible score is “1 × 2 = 2” and the highest score is “5 × 2 = 10”. High scores on the scale indicate a high level of religious attitudes. The Cronbach’s Alpha Coefficient of the scale was found to be 0.90. In the present study, Cronbach’s Alpha Coefficient of the scale was found to be 0.907.

Ethical considerations

The study adhered to the principles of the Declaration of Helsinki. Written permission was obtained from the Republic of Türkiye Ministry of Health, General Directorate of Health Services (13.09.2021/2021-09-13T21_02_10). The study was approved by the Non-Invasive Ethics Committee of a University (13.10.2021/416). Necessary permissions were obtained from Diyarbakır and Kahramanmaraş Provincial Health Directorates (10/12/2021-191023, E-90410089-771; 28/03/2022-E-13511907-604.02.01). Necessary explanations were given to the participants about the research, and their informed consent was obtained before participation.

Data analysis

All the data were analyzed in the IBM SPSS Statistics 20.0 program. Mean, standard deviation, minimum, maximum, number, and percentage were used in the analysis of the descriptive data. Kurtosis, Skewness, and Shapiro-Wilk were used for normality tests. The Student t-test, the ANOVA test, and the Pearson Correlation were used to compare the independent variables with scale scores. The variables that were significant in the Student’s t-test, ANOVA, and the Pearson Correlation Analysis were included in the regression analysis. The Stepwise Multiple Linear Regression Analysis was performed to predict positive and negative attitudes toward the COVID-19 vaccine based on independent variables. The Stepwise Regression Model allows the establishment of a regression model consisting of only significant variables by adding the variables that have the greatest effect on the dependent variable from all independent variables taken into the model in order. This method creates a simpler, more meaningful, and interpretable model by determining the most effective independent variables from a large number of independent variables. It uses the few variables needed to explain the data. This makes the model understandable and generalizable. In the current study, because there were so many independent variables, a stepwise regression model was used to create a simpler model. Categorical variables were included in the model as dummy variables. It was found that all of the Variance Inflation Factor (VIF) values of the independent variables were less than 5. For this reason, no multicollinearity problem was detected between the independent variables. Cronbach’s Alpha Coefficient was calculated in the internal consistency analysis of the scales. All findings were evaluated at a p < 0.05 significance level.

Results

It was found that 59.0% were female, the mean age was 36.86 ± 13.87 years, and 49.6% had university or higher education. It was found that 44.9% of them has past COVID-19 history, 88.7% of them had COVID-19 vaccine, 62.5% of those who did not have the vaccine did not trust the vaccine, 62.2% had 2 doses of vaccine, 60.7% had a negative effect after vaccination and 44.2% received information about COVID-19 from Media-TV (Table 1).

Table 1.

The distribution of the participants according to descriptive characteristics (n = 830)

Features	N	%
City
Kahramanmaraş	414	49.9
Diyarbakır	416	50.1
Gender
Female	490	59.0
Male	340	41.0
Age
18–25	237	28.6
26–40	281	33.9
41–60	263	31.7
61 and above	49	5.9
Place lived for a long time
Town center	595	71.7
District	123	14.8
Village	112	13.5
Educational status
Primary school	170	20.5
Middle school	74	8.9
High school	174	21.0
University and above	412	49.6
Marital status
Married	509	61.3
Single	307	37.0
Widow	14	1.7
Economic situation
Income less than expenses	337	40.6
Income equals expense	378	45.5
Income more than expenses	115	13.9
Working status
Not working	400	48.2
Officer	251	30.2
Employee	86	10.4
Small business	31	3.7
Retired	34	4.1
Farmer	11th	1.3
Unspecified	17	2.0
Presence of chronic disease
Yes	158	19.0
No	672	81.0
Continuous medication use
Yes	181	21.8
No	649	78.2
Perception of health status
Good	343	41.3
Middle	457	55.1
Bad	30	3.6
Catching COVID-19
Yes	373	44.9
No	457	55.1
Relatives with COVID-19
Yes	679	81.8
No	151	18.2
Being vaccinated against COVID-19
Yes	736	88.7
No	76	9.2
I do not think I will	18	2.2
Reason for not being vaccinated (n = 32)
Insecurity	20	62.5
I do not think that I have the virus	10	31.3
I did not consider it necessary	2	6.3
Vaccine administered (n = 736)
Pfizer Biotech	565	76.8
Sinovac	99	13.5
Pfizer BioNTech + Sinovac	72	9.8
Vaccine dose administered (n = 736)
1 dose	49	6.7
2 doses	458	62.2
3 doses	178	24.2
4 doses or more	51	6.9
Adverse effects after vaccination (n = 736)
Yes	447	60.7
No	289	39.3
What kind of adverse effect was there (n = 987)*
Pain in the vaccinated arm	389	39.4
Pain in the whole body	151	15.3
Headache	120	12.2
Weakness, fatigue	186	18.8
Nausea vomiting	47	4.8
Problems with the heart	45	4.6
Shortness of breath	49	5.0
Source of information about COVID-19 (n = 1316)*
Book-Magazine-Official publication	141	10.7
Media-TV	587	44.6
Newspaper-Print media	113	8.6
Social media	310	23.6
Family-Friend	156	11.9
I did not receive any information	9	0.7

*More than one answer was given

The religious attitude scale total score of the participants was found to be 35.32 ± 6.22, the COVID-19 VLS scale mean score was 2.62 ± 0.49, and the ATV-COVID-19 mean score was 3.23 ± 0.72. Significant correlations were detected between the COVID-19 VLS and the ATV-COVID-19 total and subscales (p < 0.05). No correlation was detected between the religious attitude total and all subscale scores and other scale scores (p > 0.05) (Table 2).

Table 2.

The correlation analysis between the scale scores

	Mean ± SD	Min/Max	1	2	3	4	5	6	7	8	9	10	11th
1. Religious attitude total	35.32 ± 6.22	8–40	1.000
2. Cognition	9.44 ± 1.51	2–10	r = 0.602** p = 0.000	1.000
3. Emotion	8.42 ± 2.04	2–10	r = 0.883** p = 0.000	r = 0.373** p = 0.000	1,000
4. Behavior	8.40 ± 2.07	2–10	r = 0.891** p = 0.000	r = 0.346** p = 0.000	r = 0.748** p = 0.000	1,000
5. Relationship	9.04 ± 1.86	2–10	r = 0.887** p = 0.000	r = 0.403** p = 0.000	r = 0.716** p = 0.000	r = 0.760** p = 0.000	1,000
6. COVID-19 VLS total	2.62 ± 0.49	1–4	r = 0.007 p = 0.832	r=−0.019 p = 0.582	r=−0.002 p = 0.954	r=−0.012 p = 0.731	r = 0.056 p = 0.110	1,000
7. Functional VLS	2.36 ± 0.70	1–4	r=−0.048 p = 0.168	r=−0.033 p = 0.348	r=−0.064 p = 0.067	r=−0.061 p = 0.078	r = 0.005 p = 0.895	r = 0.642** p = 0.000	1,000
8. Communicative/critical VLS	2.76 ± 0.58	1–4	r = 0.038 p = 0.268	r=−0.005 p = 0.894	r = 0.036 p = 0.299	r = 0.022 p = 0.528	r = 0.068 p = 0.050	r = 0.885** p = 0.000	r = 0.212** p = 0.000	1,000
9.ATV-COVID-19 total	3.23 ± 0.72	1–5	r=−0.015 p = 0.668	r=−0.020 p = 0.563	r=−0.032 p = 0.357	r = 0.028 p = 0.417	r=−0.030 p = 0.394	r=−0.014 p = 0.679	r=−0.075* p = 0.030	r = 0.027 p = 0.433	1,000
10. Positive attitude	3.53 ± 1.09	1–5	r=−0.028 p = 0.429	r=−0.046 p = 0.181	r=−0.022 p = 0.524	r=−0.018 p = 0.597	r=−0.009 p = 0.788	r = 0.140** p = 0.000	r = 0.070* p = 0.044	r = 0.136** p = 0.000	r = 0.668** p = 0.000	1,000
11. Negative attitude	2.98 ± 0.97	1–5	r = 0.005 p = 0.895	r = 0.015 p = 0.674	r=−0.023 p = 0.505	r = 0.054 p = 0.117	r=−0.031 p = 0.366	r = 0.145** p = 0.000	r=−0.164** p = 0.000	r=−0.085* p = 0.014	r = 0.745** p = 0.000	r = 0.001 p = 0.976	1,000

r: Pearson Correlation Coefficient

*p < 0.05

**p < 0.01

The Stepwise Multiple Linear Regression Model established between positive attitude toward the COVID-19 vaccine and COVID-19 VLS total, functional VLS, communicative/critical VLS, getting the COVID-19 vaccination, and the dose of vaccine administered is given in Table 3. It was found that having the COVID-19 vaccine (ß=1.111), having three and four or more doses of the vaccine (ß=0.359; ß=0.591, respectively), communicative/critical VLS (ß=0.175) increased the positive attitude toward the COVID-19 vaccine. Receiving the COVID-19 vaccine increased positive attitude towards the COVID-19 vaccine by 1.111 points, receiving 3 or more doses of vaccine increased positive attitude towards the COVID-19 vaccine by 0.359 and 0.591 points, respectively, and a one-unit increase in communicative/critical VLS increased positive attitude towards the COVID-19 vaccine by 0.175 points. All the coefficients obtained were statistically significant and 17.3% of the positive attitude-dependent variable toward the COVID-19 vaccine was explained together with these predictors (F = 44.392, p = 0.000, Adj.R² = 0.173, SE = 0.986.).

Table 3.

The multiple linear regression analysis between the positive attitude towards the COVID-19 vaccine and independent variables (The Stepwise Model)

	B(95%CI)	SE	Beta		t	P	Zero-order	Partial	Part
(Constant)	1,954 (1,583–2,324)	0.189		10,351		0.000
Being vaccinated (Yes)	1.111 (0.894–1.329)	0.111	0.325	10,023		0.000	0.367	0.329	0.317
Communicative/critical VLS	0.175 (0.058–0.292)	0.060	0.094	2,933		0.003	0.136	0.102	0.093
Vaccine dose (3 doses)	0.359 (0.189–0.528)	0.086	0.136	4.153		0.000	0.187	0.143	0.131
Vaccine dose (4 or more doses)	0.591 (0.305–0.877)	0.146	0.131	4.053		0.000	0.151	0.140	0.128

B: Non-standardized coefficient, Beta: Standardized coefficient, F = 44.392, p = 0.000, Adj.R² = 0.173, SE = 0.986. Having the COVID-19 vaccine (Yes:1 No:0), the Vaccine dose administered (1 dose:1 2 doses:0 3 doses:0 4 and more doses:0) was taken as the dummy variable. Durbin Watson: 1.722

The established stepwise multiple linear regression model regarding the relationship between negative attitudes toward the COVID-19 vaccine and COVID-19 VLS total, functional VLS, communicative/critical VLS, age, city of residence, gender, education, marital status, continuous drug use, having COVID-19 by relatives, and dose of vaccine administered is given in Table 4. It was found that living in Kahramanmaraş (ß=−0.778) and continuous medication use (ß=−0.192) decreased the score of negative attitude toward the COVID-19 vaccine (i.e., increased negative attitude), and having 2 doses of vaccine (ß=0.221) and being married (ß=0.175) increased the score of negative attitude (i.e., decreased negative attitude). Living in Kahramanmaraş decreased the negative attitude towards the COVID-19 vaccine by 0.778 points, taking regular medication decreased the negative attitude towards the COVID-19 vaccine by 0.192 points, receiving 2 doses of vaccine increased the negative attitude towards the COVID-19 vaccine by 0.221 points, and being married increased the negative attitude towards the COVID-19 vaccine by 0.175 points. All the coefficients obtained were statistically significant and 19.9% of the negative attitude-dependent variable towards the COVID-19 vaccine was explained together with these predictors (F = 52.503, p = 0.000, Adj.R2 = 0.199, SE = 0.867).

Table 4.

The multiple linear regression analysis between the negative attitude towards the COVID-19 vaccine and independent variables (The Stepwise Model)

	B(95%CI)	SE	Beta	T	p	Zero-order	Partial	Part
(Constant)	3,182 (3,041 − 3,324)	0.072		44,130	0.000
City (Kahramanmaraş)	−0.778 (−0.897 - −0.658)	0.061	− 0.401	−12,763	0.000	− 0.423	− 0.406	− 0.397
Vaccine dose (2 doses)	0.221 (0.101–0.342)	0.061	0.114	3,606	0.000	0.168	0.125	0.112
Marital status (Married)	0.175 (0.051–0.298)	0.063	0.088	2,779	0.006	0.086	0.096	0.086
Constant medication use (Yes)	−0.192 (−0.337 - −0.047)	0.074	− 0.082	−2,594	0.010	− 0.082	− 0.090	− 0.081

B: Unstandardized coefficient, Beta: Standardized coefficient, F = 52.503, p = 0.000, Adj.R² = 0.199, SE = 0.867. City (Kahramanmaraş:1 Diyarbakır 0), Gender (Female:1 Male:0), Education (Primary School:1 Secondary School:0 High School:0 University:0), Marital Status (Married:1 Single + widowed:0) drug (Yes:1 No:0), Relatives caught COVID-19 (Yes:1 No:0), Vaccine dose administered (1 dose:1 2 doses:0 3 doses:0 4 and more doses:0) was taken as the dummy variable. Durbin Watson:1.749

Discussion

The data of the present study were collected after the vaccination program against the COVID-19 pandemic started in Turkiye. Academic studies were conducted in many areas regarding the COVID-19 pandemic and studies are still ongoing. It is already known that the knowledge, perception, and attitude of society during such pandemics have an important place in the process of controlling it and in protecting and planning the public for the following years [18, 28–30]. It is accepted that vaccination literacy and vaccination attitude are important components of vaccination acceptance and vaccination in controlling the pandemic [31]. The data obtained in the study were discussed in terms of vaccine attitude, vaccine literacy, religious attitude relationship, and factors that affected COVID-19 vaccine attitude.

It was determined in the study that the participants’ total and sub-dimensions of ATV-COVID-19 were high. This finding is consistent with the literature data [26, 32–35]. The fact that positive attitudes toward the vaccine were above the average can be considered as the fact that individuals experienced the negative effects of COVID-19 for a long time during the pandemic process, and they want to get rid of negativity and be protected as soon as possible.

In the present study, the participants’COVID-19 VLS and sub-dimensions were found to be moderate. In many studies conducted on the subject, the COVID-19 VLS levels of the participants were found to be above the average [15, 26, 35–37]. In Turkiye, Durmuş et al. [16] conducted a study and reported that the mean of COVID-19 VLS was at a lower level than in our study. It is considered that the differences in VL levels among the participants in previous studies were caused by sociodemographic characteristics and different approaches. Also, it can be reported that an important factor affecting VL was the presence of more than one type of COVID-19 vaccine in Turkiye and each one being administered at certain rates.

Consistent with other studies [38], the participants’ level of religious attitudes was determined to be high in our study. However, it was also found that religious attitude was not associated with COVID-19 VL and COVID-19 vaccine attitude. Similar to our findings, in the literature, in addition to studies supporting that religious attitudes are not associated with COVID-19 vaccine attitudes [38, 39], there are also studies reporting that they are related [21, 40–42]. The impact of religious attitudes on health behaviors is complex. In some cases, they may increase the tendency to engage in health-protective behaviors, while in other cases, they may increase the tendency to reject medical interventions. For example, attitudes toward vaccines or modern medicine may vary among different religious groups [43, 44]. In this context, the high religious attitude positively affected the desire to eliminate this disease, which negatively affected society, as soon as possible. No studies were found in the literature dealing with the relationship between religious attitudes and COVID-19 VL. There is a need for comprehensive studies addressing the relationship between religious attitudes and vaccine literacy in society.

Health literacy is an important factor in improving health-related behaviors and positive choices. Studies conducted show that vaccine literacy is significantly associated with attitudes toward COVID-19 vaccination and reluctance to vaccinate against COVID-19 [7, 45, 46]. In the present study, it was found that participants with high communicative/critical VL had increased positive scores in ATV-COVID-19. In the study of Korkut et al. [35], it was reported that there was a positive relationship between communicative/critical VL and ATV-COVID-19. In the study that was conducted by Biasio et al. [15] in Italy, a significant relationship was reported between interactive-critical VL and positive attitudes/perceptions about future COVID-19 vaccines. These findings support our study findings. Attitudes toward vaccines are influenced not only by knowledge, but also by critically questioning and evaluating that knowledge and making informed decisions. Therefore, analyzing and interpreting information plays a more decisive role in shaping attitudes than simply possessing information [47].

In the present study, it was found that the dose of vaccine administered affected the vaccination attitude. It was also found that having three doses or more of the vaccine increased the positive attitude toward the COVID-19 vaccine, but having two doses of the vaccine decreased the negative attitude. It was stated that those who believed that COVID-19 is a serious disease and those who learned about the second booster dose from scientific journals were more likely to have a positive attitude [48]. In the study of Elmaoğlu et al. [49], being willing to be vaccinated for COVID-19 increased the positive attitude toward the COVID-19 vaccine and decreased the negative attitude. In the study of Korkut et al. [35], having a COVID-19 vaccine increased the positive attitude toward the COVID-19 vaccine and decreased the negative attitude. These results can also be interpreted as having a positive attitude toward vaccination increases the level of vaccination. Contrary to our study findings, it was found that being vaccinated against COVID-19 during pregnancy did not affect the COVID-19 vaccination attitude [50].

Attitudes and beliefs toward vaccines may differ according to the city or region of a country [2, 51, 52]. In the present study, a difference was detected in terms of negative attitudes towardthe COVID-19 vaccine according to the place of residence. It was found that the negative attitudes of the participants living in Kahramanmaraş were higher. Contrary to the findings of the present study, in a study conducted in China, it was reported that the region of residence did not affect COVID-19 vaccine acceptance [53]. Although the current study was conducted in FHCs where individuals with similar characteristics (education, socioeconomic status, etc.) lived, there may be differences between the two cities in terms of characteristics such as culture, social status, belief, and lifestyle. These characteristics may also have affected individuals’ vaccination attitudes.

The study showed that being married reduced negative attitudes toward the COVID-19 vaccine. This finding can be considered as the fear of infection and the protection of family members were effective in the attitude toward receiving the COVID-19 vaccine. The findings are consistent with similar study findings in the literature [41, 53–55]. It was also stated that marital status did not affect vaccination attitudes [56].

Although it was reported previously that continuous drug use did not affect the negative attitude toward the COVID-19 vaccine [35], it was determined in this study that continuous drug use increased the negative attitude toward the COVID-19 vaccine. Continuous drug use can often be an indicator of the presence of chronic disease. For this reason, the incorrect negative information on COVID-19 vaccines spread in society and the media may have caused individuals who use drugs to have a negative attitude toward the vaccine.

Limitations and strengths

The study was conducted with adults who lived in two different cities in Turkiye. For this reason, the results of the study cannot be generalized to the wider population. Since the study was cross-sectional, causal inferences cannot be made. Since the questions were retrospective, there may have been a recall bias in the participants. Also, asking sensitive questions about the vaccination and religious attitudes of individuals may not reflect true opinions because of the potential to increase the bias of answers. The main strengths of this study were that it is one of the rare studies examining the relationship between COVID-19 vaccine attitudes, vaccine literacy, and religious attitudes, and it had a relatively large sample size.

Conclusion and recommendations

According to the results of the study, it was determined that the COVID-19 VL level was at a moderate level, and the vaccine attitude and religious attitude levels were high in two different cities in Turkiye. It was also found that the positive attitudes toward the COVID-19 vaccine increased as the communicative/critical vaccination literacy level of the participants and the dose of vaccine administered increased.

Although the score of negative attitude toward the COVID-19 vaccine decreased (i.e., negative attitude increases) in those living in Kahramanmaraş and those who used medication continuously, the score of negative attitude toward the COVID-19 vaccine increased (i.e., negative attitude decreases) in those who had 2 doses of the vaccine and those who were married. In the present study, it was determined that religious attitude was not associated with COVID-19 VL and COVID-19 vaccine attitude. The results of the present study are valuable in terms of originality. It is important to increase the attitudes of individuals toward immunization in case of any pandemic, both at the national and international levels. In this context, communication strategies that take into account socio-cultural sensitivities should be developed according to regional differences (in collaboration with community leaders, civil society organizations, etc.). Healthcare professionals should focus on enhancing communicative/critical vaccine literacy to improve public vaccine attitudes.

Vaccine literacy education programs that focus on developing individuals’ critical thinking skills in public health policies should be integrated into school curricula and family health centers. One-on-one counseling, risk communication, and information programs should be developed for groups at risk in terms of vaccine attitudes. In addition, it would be useful to replicate the study outside the local or cultural context in which it was conducted, particularly among different religious traditions or demographic groups. In the future, the validity of the findings could be tested more robustly through longitudinal and mixed-method studies.

Abbreviations

ATV COVID-19

Attitudes towards COVID-19 vaccine scale

VLS

Vaccine literacy scale

FHC

Family healthcare center

ORAS

Ok-

religious attitude scale

SPSS

Statistical package for the social sciences

Authors’ contributions

GY and FT: Conceived and designed the study. FT: Created the first draft of the manuscript. GY and FT: Assisted with data collection and edited the manuscript. GY: Performed data analysis and edited the manuscript. GY and FT approved the final version of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study adhered to the principles of the Declaration of Helsinki. Written permission was obtained from the Republic of Türkiye Ministry of Health, General Directorate of Health Services (13.09.2021/2021-09-13T21_02_10). The study was approved by the Non-Invasive Ethics Committee of a University (13.10.2021/416 ). Necessary permissions were obtained from Diyarbakır and Kahramanmaraş Provincial Health Directorates (10/12/2021-191023, E-90410089-771; 28/03/2022-E-13511907-604.02.01). Necessary explanations were given to the participants about the research, and their informed consent was obtained before participation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.