ABSTRACT
This study examined the factors associated with acceptance of the COVID-19 vaccine compared to hesitance in the Pakistani population and specifically focusing on the perceived beliefs, knowledge, concerns, risk, and safety perception relating to the COVID-19 vaccine. A total of 423 subjects were recruited from the Pakistan Institute of Medical Sciences, Islamabad, Pakistan. A 27-item valid and reliable questionnaire was used to assess socio-demographic characteristics, acceptance, and hesitance toward COVID-19 vaccine, perceived beliefs, knowledge, perceived concerns, risk, and safety of COVID-19 vaccines and its source of information. Chi-square tests and logistic regression were used for analysis. About 53% of the participants were planning to get vaccinated and a significantly greater proportion of better educated, higher income, and healthier participants in the vaccine acceptance group (p < .05). The odds of knowing the vaccine they should get, having the confidence in the vaccine to stop the pandemic, and understanding the way vaccines work, were greater in the vaccine acceptance group than the vaccine-hesitant group (OR: 5.4; 3.5, 2.1, 3.1, respectively). Most participants (52.3%) obtained the information regarding the COVID-19 vaccine from the print and live news media (52.3%) followed by social media (23.7%). The lack of knowledge, understanding, and perception of the risk, safety partly explains the low rate of vaccine acceptance in the Pakistani population. Strategies to raise awareness of the benefits of vaccination should target individuals in the lower socioeconomic group and those with chronic disease.
KEYWORDS: COVID-19 vaccine, vaccine acceptance, vaccine hesitancy, vaccination misinformation
Introduction
Preventive measures such as social distancing, quarantine of suspected and confirmed cases, travel restrictions, strict and smart lockdowns, mandatory use of face masks, and hygiene practices have been recommended and enforced to control the spread of COVID-19.1 These measures had influenced and changed the way of life and consequently affected individual’s physical, psychosocial and economic well-being.2–4 Mass vaccination is recognized as the most efficient approach to control the spread and severity of the COVID-19 pandemic in a long run. The success of the COVID-19 vaccination is dependent on long-term vaccine development and its planning and delivery initiatives. By late November 2020, several international pharmaceutical companies have reported the efficacy and effectiveness of vaccines from large clinical trials.5 Due to the urgency of the pandemic situation, these vaccines received early regulatory approvals by national drug and pharmaceutical agencies in December 2020 and vaccination programs have been rolled out in many countries soon after.6,7
At the same time, many unfounded theories, myths, and misconceptions relating to the adverse effects, unusual rapid development, and early regulatory approvals are revolving in the social and print media. Consequently, these are creating distrust in the vaccine and doubt about participation in the vaccination program.8,9 The term vaccine hesitancy is defined by the World Health Organization (WHO) as ‘delay in acceptance or refusal of vaccination despite the availability of vaccination services’;10 conversely, vaccine acceptance refers to the likeliness to get vaccinated.11 Vaccine hesitancy is not a novel phenomenon and has been one of the top global health threats well before the COVID-19 outbreak.12,13 The levels of hesitancy vary across time and place, depending on several factors such as complacence, convenience, and confidence.12 In the USA, it was reported that 20% of American people are not willing to receive the COVID-19 vaccine and another 31% are not sure of it.14 In China, numerous vaccine-related scandals, reports of side effects, and distrust in the country’s immunization program have hampered the confidence in Chinese vaccines.15 In Pakistan, vaccine hesitancy remains a challenge; the Global Polio Eradication Initiative (GPEI) that runs the polio vaccination program since the year 1988, still faces accusations that the vaccine is of poor quality, contains an active virus, and religiously prohibited.16 A similar perception against the COVID-19 vaccines is circulating in the media; some community leaders and political commentators are involved in spreading unfounded claims that the pandemic is a part of a greater plan targeting the middle- and south-east nations, and that the vaccines are religiously prohibited, contain nano-chips that can be controlled via 5 G frequency spectrum, and will be implanted in human bodies through a mandatory vaccination program.17,18 How much of these claims have influenced vaccine hesitancy in the Pakistani population is not known. Equivalently, the factors that influence vaccine acceptance, in the population is also not clear and an understanding of these can help promote and accelerate the vaccination program. The objective of this study was to examine the factors associated with acceptance of the COVID-19 vaccine compared to hesitance in the Pakistani population and specifically focusing on the perceived beliefs, knowledge, concerns, risk, and safety perception relating to the COVID-19 vaccine.
Methods
This cross-sectional study was carried out between January and March 2021 at the hospital of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. It was approved by the Ethical review board of Shaheed Zulfiqar Ali Bhutto Medical University (Reference no. F.103/21/SOD/ERB). A convenient sample of patients and their attendants aged 18 years old and above who were visiting the hospital were invited to participate in the study. The sample size calculation, based on the assumptions that 50% of the Islamabad population (n ≈ 1.65 million) are hesitant to receive vaccination with 95% confidence levels, and a 5% margin of error, showed that a total of 385 subjects were needed. A total of 423 subjects were recruited for this study after accounting for 10% refusal and incomplete response. Participation was voluntary and the participants were informed about the purpose of the study before data collection.
The participants were asked to complete a questionnaire with 27 items in four sections. The first section collected the socio-demographic information including age (categorized as 18–30, 31–40, 41–50, 51–60, > 60), sex, marital status (single, married, divorced), level of education (0–5, 6–12, and ≥13 years), employment status (full-time, part-time, unemployed, retired), residential state (Federal, Punjab, Sindh, Baluchistan, KPK, Gilgit Baltistan, AJK), locality (Urban and Rural), personal income (5000–20000, 21000–35000, 36000–50000, and ≥ 50000 PKR), cohabitation (alone, with parents, with wife/children, and with friends/others) and presenting any medical condition(s) (Yes, No, Don’t Know).
The second section assessed the acceptance and hesitance toward the COVID-19 vaccination program by asking, ‘Do you plan on getting the COVID-19 vaccine when it becomes available?’ and the participants were categorized into the ‘vaccine acceptance’ and ‘vaccine hesitance’ groups based on the responses ‘Yes’ and ‘No’/‘Unsure/Maybe,’ respectively.19 The second, third, and fourth sections were adopted from Volkman et al., (2020). The second section assessed the perceived beliefs and knowledge related to the COVID-19 vaccine. The third section assessed the perceived concerns, risk, and safety of COVID-19 vaccines. Lastly, the fourth section asked about the sources by which the participants obtain the information on COVID-19 vaccines and assessed the trust level of these sources. The response for each item was recorded on a 6-point Likert scale, from 1 (strongly agree, agree, and probably agree) to 6 (strongly disagree, disagree, and probably disagree). The former three responses were recoded as agree and the latter three as disagree for the analysis. The subject’s source of COVID-19 vaccine information was assessed by asking them to indicate how likely they would use the mention sources (healthcare workers, print and live news media, government, social media, friends, parents, others and never heard about it) to obtain information on vaccines: and their preferred vaccine (Chinese, American/German, UK, Russian) were also assessed in the fourth section.20
Statistical analysis
The summary statistics were obtained for all variables. A chi-square test was used to examine the association of socio-demographic characteristics with attitude toward COVID-19 vaccination. The analysis to examine the factors associated with vaccine acceptance was carried out using logistic regression. All analysis was performed at a 5% significance level and carried out in IBM SPSS software version 25.0 (SPSS Institute, Chicago, IL, USA).
Results
From a total of 423 respondents who were invited to participate, 410 participants had consented and completed the self-administrated questionnaires with a response rate of 96.9%. The sample consists of a high percentage of females (57%), under 30-years-old (62.4%), college-educated (50%), married (52.2%), income earners of less than 50000 PKR (47.3%) individuals. Most of the subjects were from the Federal capital Islamabad (44.1%), living with their parents (48.5%), residing in the urban areas (71.1%), and without any history of chronic disease or illness (84.1%).
About 53% (95% CI: 47.7%, 57.6%) of the participants were planning to get vaccinated when the vaccine becomes available. There were a significantly greater proportion of better educated, higher income, and healthier participants in the vaccine acceptance group (p < .05) (Table 1).
Table 1.
Distribution of the sample by the socio-demographic characteristics and attitude toward the COVID-19 vaccine
| Number = (%) |
P-Value | |||
|---|---|---|---|---|
| Characteristics | Number (%) | Vaccine Acceptance N = 216 (52.7) |
Vaccine Hesitant N = 194 (47.3) |
|
|
Age 18–30 31-40 41–50 >51 |
256 (62.4) 81 (19.8) 51 (12.4) 22 (5.4) |
145 (67.1) 36 (16.7) 21 (9.7) 14 (6.5) |
111 (57.2) 45 (23.2) 30 (15.5) 8 (4.1) |
.05 |
|
Gender Male Female |
176 (42.9) 234 (57.1) |
86 (39.8) 130 (60.2) |
90 (46.4) 104 (53.6) |
.2 |
|
Marital status Single + Divorced Married |
196 (47.8) 214 (52.2) |
108 (50.0) 108 (50.0) |
88 (45.4) 106 (54.6) |
.3 |
|
Education level 0–5 years of schooling 6–12 years of schooling 13+ years of schooling |
54 (13.2) 151 (36.8) 205 (50.0) |
19 (8.8) 85 (39.4) 112 (51.9) |
35 (18.0) 66 (34.0) 93 (47.9) |
.02 |
|
Employment status Full time job Part time job Unemployed + Retired |
180 (43.9) 38 (9.3) 192 (46.8) |
98 (45.4) 16 (7.4) 102 (47.2) |
82 (42.3) 22 (11.3) 90 (46.4) |
.4 |
|
Region Federal capital Punjab Sindh Baluchistan KPK Gilgit AJK |
181 (44.1) 121 (29.5) 21 (5.1) 10 (2.4) 45 (11.0) 14 (3.4) 18 (4.4) |
93 (43.1) 64 (29.6) 9 (4.2) 7 (3.2) 23 (10.6) 9 (4.2) 11 (5.1) |
88 (45.4) 57 (29.4) 12 (6.2) 3 (1.5) 22 (11.3) 5 (2.6) 7 (3.6) |
.8 |
|
Location Urban Rural |
291 (71.0) 119 (29.0) |
158 (73.1) 58 (26.9) |
133 (68.6) 61 (31.4) |
.3 |
|
Personal income PKR 0–20000 21000-35000 36000–50000 >50000 Never estimate/ not sure |
82 (20.0) 71 (17.3) 41 (10.0) 96 (23.4) 121 (29.5) |
36 (16.7) 34 (15.7) 18 (8.3) 67 (30.6) 62 (28.7) |
46 (23.7) 37 (19.1) 23 (11.9) 29 (14.9) 59 (30.4) |
.004 |
|
Living with Alone With parents With wife & children With friends & others |
46 (11.2) 199 (48.5) 126 (30.7) 39 (9.5) |
25 (11.6) 99 (45.8) 70 (32.4) 22 (10.2) |
21 (10.8) 100 (51.5) 56 (28.9) 17 (8.8) |
.7 |
|
Illness/Disease Yes No Don’t know |
54 (13.2) 345 (84.1) 11 (2.7) |
26 (12.0) 188 (87.0) 2 (0.9) |
28 (14.4) 157 (80.9) 9 (4.6) |
.046 |
In general, participants in the vaccine acceptance group had better knowledge, confidence, and understanding of the COVID-19 vaccine. The odds of knowing the vaccine they should get, having the confidence in the vaccine to stop the pandemic, understanding the way vaccines work, and believing that vaccines strengthen the immune system, were greater in the vaccine acceptance group than vaccine-hesitant group (OR: 5.4; 3.5, 2.1, 3.1, respectively,). The vaccine acceptance group was less likely to consider other life activities to be more important than the vaccine-hesitant group (OR = 0.4); but more likely to agree with the effectiveness, efficacy, safety, and comfort in the vaccine administration (OR ranges from 1.7 to 4.5) (Table 2).
Table 2.
COVID-19 vaccine-related perceived beliefs, knowledge, concerns, risk, and safety perceptions
| Accepting Vaccine N = % |
Vaccine Hesitant N = % |
Total N = % |
Unadjusted OR |
P-value | Adjusted OR* |
P-value | |
|---|---|---|---|---|---|---|---|
| Perceived beliefs and knowledge (Agree) | |||||||
| 1. I know which COVID-19 vaccines I should get for myself. | 113 (77.4) |
33 (17.0) |
146 (35.6) |
5.93 (3.49–10.0) |
0.001 | 5.35 (3.37–8.47) |
.001 |
| 2. I have heard about the COVID-19 vaccine. | 207 (95.8) |
154 (79.4) |
361 (88.0) |
7.19 (2.82–18.3) |
0.001 | 5.97 (2.81–12.6) |
.001 |
| 3. I think the COVID-19 vaccine is needed and COVID-19 vaccine is the most likely way to stop this pandemic. | 152 (70.4) |
79 (40.7) |
231 (56.3) |
4.59 (2.72–7.75) |
0.001 | 3.45 (2.29–5.20) |
.001 |
| 4. I understand how vaccines work,’and ‘I understand the basic primary mechanism for how vaccines work to boost the immune system. | 116 (53.7) |
68 (35.1) |
184 (44.9) |
2.17 (1.27–3.71) |
0.005 | 2.14 (1.44–3.20) |
.001 |
| 5. I believe there are better ways to prevent vaccine preventable disease than with a vaccine. | 110 (50.9) |
109 (56.2) |
219 (53.4) |
0.82 (0.54–1.24) |
0.36 | 0.80 (0.54–1.19) |
.28 |
| 6. I think vaccines strengthen the immune system. | 137 (63.4) |
70 (36.1) |
207 (50.5) |
3.30 (2.09–5.20) |
0.001 | 3.07 (2.05–4.59) |
.001 |
| Concerns, Risk and safety perceptions (Agree) | |||||||
| 7. I consider other activities more important than getting a vaccine. | 93 (43.1) |
122 (62.9) |
215 (52.4) |
0.45 (0.30–0.69) |
0.001 | 0.44 (0.30–0.66) |
.001 |
| 8. Getting vaccinated against COVID-19 is risky | 78 (47.0) |
88 (53.0) |
166 (40.5) |
0.92 (0.61–1.40) |
0.72 | 1.02 (0.68–1.51) |
.91 |
| 9. I think COVID-19 vaccine are effective | 158 (73.1) |
73 (37.6) |
231 (56.3) |
4.43 (2.84–6.90) |
0.001 | 4.51 (2.97–6.86) |
.001 |
| 10. I think there is adequate safety information given about COVID-19 vaccine. | 128 (65.6) |
67 (34.4) |
195 (47.6) |
2.81 (1.85–4.25) |
0.001 | 2.75 (1.84–4.12) |
.001 |
| 11. I trust that adverse COVID-19 vaccine reactions will be reported to general public. | 130 (60.2) |
105 (54.1) |
235 (57.3) |
1.40 (0.92–2.13) |
0.107 | 1.28 (0.86–1.89) |
.21 |
| 11. I believe COVID-19 vaccine are safe for me. And I believe vaccine are safe for my community. | 126 (58.3) |
58 (29.9) |
184 (44.9) |
3.65 (2.37–5.64) |
0.001 | 3.28 (2.18–4.94) |
.001 |
| 12. Vaccine administration is painful or inconvenient. | 46 (23.7) |
75 (34.7) |
121 (29.5) |
1.78 (1.13–2.81) |
0.013 | 1.71 (1.10–2.64) |
.015 |
| 13. Are you concerned about the safety of COVID-19 vaccine. | 91 (46.9) |
135 (62.5) |
226 (55.1) |
1.80 (1.18–2.76) |
0.006 | 1.88 (1.27–2.79) |
.002 |
*Adjusted for age, education level, personal income, and illness/ disease.
Most participants obtained the information regarding the COVID-19 vaccine from the print and live news media (52.3%) followed by social media (23.7%). More participants in the vaccine acceptance group relied on information from healthcare agencies (p < .001) and more likely to trust the source of information from these sources (p < .001). Chinese and American/German COVID-19 vaccines were the two most preferred vaccines (23% and 23%) and these were also the preferred choice of the vaccine acceptance group (29% and 34%) compared to none in the vaccine-hesitant group (54%) (Table 3).
Table 3.
Information about COVID-19 vaccine and preference of origin of a vaccine
| N (%) | COVID-19 Vaccine related Attitude |
P-Value | ||
|---|---|---|---|---|
| Vaccine Acceptance N (%) |
Vaccine Hesitant N (%) |
|||
Participants were asked to indicate how likely they would use the following sources to obtain information on COVID-19 vaccines:
|
38 (9.3) 217 (52.9) 10 (2.4) 97 (23.7) 25 (6.1) 12 (2.9) 7 (1.7) 4 (1.0) |
27 (12.5) 116 (53.7) 6 (2.8) 49 (22.7) 16 (7.4) 2 (0.9) 0 0 |
11 (5.7) 101 (52.1) 4 (2.1) 48 (24.7) 9 (4.6) 10 (5.2) 7 (3.6) 4 (2.1) |
.001 |
How much do you trust the information from these sources?’
|
18 (4.4) 174 (42.4) 175 (42.7) 43 (10.5) |
2 (0.9) 90 (41.7) 94 (43.5) 30 (13.9) |
16 (8.2) 84 (43.3) 81 (41.8) 13 (6.7) |
.001 |
Which vaccine would you prefer?
|
96 (23.4) 94 (22.9) 54 (13.2) 13 (3.2) 153 (37.3) |
62 (28.7) 74 (34.3) 23 (10.6) 8 (3.7) 49 (22.7) |
34 (16.0) 20 (10.3) 31 (17.5) 5 (2.6) 104 (53.6) |
.001 |
Discussion
The effectiveness of the COVID-19 vaccine depends on its coverage because herd immunity will only develop if the vaccination rate is high in the population. Therefore, to protect the most vulnerable population, it is important to understand the public intention and behaviors toward getting a vaccination. It will allow the concerned authorities and health officials to design and implement specific and targeted interventions to raise awareness in the population and persuade them toward accepting the COVID-19 vaccination. In this prospect, this study examined the factors associated with the acceptance of the COVID-19 vaccine in the Pakistani population. To the best of our knowledge, this is the first study in Pakistan examining these factors and the findings are expected to guide and help the public health officials in making decisions relating to the COVID-19 vaccine program.
This study revealed that about half of the sample were either unsure or unwilling to get vaccination; the percentage who are confident and willing to get the COVID-19 vaccination is comparably lower than the UK (76.9%), Ireland (65%), USA (57.6% – 68.6%), Greece (57.7%), China, Indonesia, Malaysia (> 90%) and European countries (62–80%).19,21–26 However, the acceptance rate is lower in some middle-east countries such as Saudi Arabia (31.8%), Jordan (28.4%), and Kuwait (23.6%), the overall acceptance rate in the region is only at 29.4%.27 India, a neighboring country with similar socio-economic conditions and cultural backgrounds, has a more than 80% acceptance rate.23 The Pakistani population is seemingly reluctant to get the COVID-19 vaccine, a similar trend observed in the Polio and other vaccination programs have been linked to unfounded religious beliefs and perception in the local communities and attributed to lack the basic knowledge.16,28 The low acceptance rate will dampen the aim to acquire herd immunity in the population and this will impact heavily on the country’s economy and population’s health. Therefore, there is an urgent need to design and start a COVID-19 vaccine awareness campaign aiming at increasing the acceptance rate in the Pakistani population.
The COVID-19 vaccine acceptance in the sample is associated with a better level of education and income, likely because the tendency to believe in myths and conspiracies is lower. A similar is reported in the UK, Australia, and some middle-east populations, only one study in Greece demonstrated contrasting finding whereby those with less education are more likely to get vaccination.21,27,29 The higher rate of acceptance among healthy participants is in contrast with a few reports from the middle-east.27,30 The awareness campaigns focusing on educating the population about the efficacy, safety, and importance of vaccination should target those in the lower socioeconomic background.
The data showed that the predictors of vaccine acceptance are a better understanding of, and knowledge about the COVID-19 vaccine, and a positive perception about its risk, safety, and comfort in administration. New vaccines are likely to be rejected than the familiar ones.31 Negative perceptions against the COVID-19 vaccine that highlights the adverse effects and safety concerns, and conspiracy threats are reasons for hesitating vaccination.26 Distrust in governments and pharmaceutical companies further endorse conspiracy beliefs. In Jordan, there was an 11% increase in the belief that the pandemic is a conspiracy caused by a man-made virus. With similar campaigns and propaganda roaming in Pakistan, there is a challenge to increase the vaccination rate in the population. To improve vaccine acceptance, it is essential to highlight adequate information to the general population with a focus on the risk and safety information that is supported by strong evidence about the vaccine efficacy. Early engagement to increase vaccine awareness through campaigns and advertisements can lower the mistrust.16 Collaborative approaches by health authorities involving multiple societal stakeholders should identify effective public communication campaign strategies to raise awareness and understanding about the pandemic and the importance of vaccination and increase vaccine acceptance. In the previous polio vaccination campaign, the immunization teams saw encouraging results through community engagement whereby religious leaders were engaged to work with the community as vaccine advocators to counter the religious prohibition claims and as mythbusters to dilute the religious conspiracy beliefs.16,32
The large majority of participants relied on mainstream print, live news, and social media for information about the COVID-19 vaccine. There is less control over the information on social media platforms; hence, unauthentic, inaccurate, and doubtful can spread easily. Emerging evidence suggests that correcting misinformation on social media may be effective in changing health beliefs.20 The vaccine acceptance group relied on information about the vaccine from the health authority, which is a more trusted source,33 compared to the vaccine-hesitant group who received them from the social network. Therefore, healthcare professionals should play a leading advocacy role in promoting the COVID-19 vaccination. However, there was little trust in the information, the similar has been reported in earlier studies.27
The strength of this study resides in the sizable sample recruited from the biggest hospital of Islamabad and included participants from different regions of Pakistan (Punjab, Sindh, KPK, Baluchistan, Gilgit, AJK, and Federal territories) representing the ethnic and cultural diversity of the country. The findings should be interpreted with caution as the sample was recruited from a single institution using convenient sampling technique, creating inherent bias, thus limits the generalizability of the findings. Further studies including participants from remote areas and using random sampling representing the whole population are recommended. The inference is also limited to findings relating to the COVID-19 vaccine only and does not apply to vaccines for more dormant and less virulent viruses. Despite these limitations, this study contributes to understanding the Pakistani population’s attitude and behavior regarding the COVID-19 vaccine.
Conclusion
The lack of knowledge and understanding, and perception of the risk, safety, and comfort in administration partly explains the low rate of vaccine acceptance in the Pakistani population. This potentially harms the efforts to control the spread of COVID-19 in Pakistan through herd immunity. Strategies to raise awareness of the benefits of vaccination should target individuals in the lower socioeconomic group and those with chronic disease. Health professionals should work together with community leaders to provide accurate information and knowledge regarding vaccination to clarify the misconceptions relating to the risk and safety concerns. This study provides useful insights to government agencies, healthcare workers, and other authorities to mitigate the impact of vaccine hesitancy in the Pakistan population.
Funding Statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosure of potential conflicts of interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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