Attitude, Awareness, and Knowledge of Saudi Citizens towards COVID-19 Vaccination in Qassim Region – Saudi Arabia

Cross sectional study was conducted to evaluate the Attitudes and awareness level of Citizens towards COVID-19 vaccination in Qassim region. The present study’s results showed that awareness of COVID-19 Vaccination in Qassim regionSaudi Arabia shows that the mean score of awareness was 3.49 (SD 0.864) out of 5. Regarding vaccination decision among Saudi citizens in Qassim region, (22.7%) of the participants were undecided, (14.7%) refused, and (62.6%) agreed to get a vaccine against COVID-19. Reason for vaccine refusal mainly was they don't believe the vaccine. 96 Participants (32.0%) were working in the healthcare sector, (44.8%) of them had received the COVID-19 Vaccine, and (38.5%) refused. The level of awareness among healthcare participants was (80.2%). The average knowledge score was 3.49 (SD =.864) out of a possible 5. Original Research Article Puteh et al.; JPRI, 33(43B): 53-67, 2021; Article no.JPRI.72497 54 Participants who reported having a graduate level of education had a considerably higher mean knowledge score. The mean score of attitudes was 1.95 (SD=1.176) out of 5, with majority of positive attitude score 62.7%. ((65.7% They received the first dose, and 6.0% they received the first dose and second dose)). Participants with age group 55 years and above years, are more aware towards COVID-19 Vaccination than other age groups. Married persons are more aware towards COVID-19 Vaccination than other categories. Participants with graduate educational level are more aware towards COVID-19 Vaccination than other educational levels. Employed persons are more aware towards COVID-19 Vaccination than other categories. Whereas, there is no relation between age and awareness among Saudi citizens towards COVID-19 (P-value= 0.140). As well, there is no relation between employed citizens and awareness among Saudi citizens towards COVID-19 (Pvalue =0.136), and there is relation between marital status and awareness among Saudi citizens (P-value = 0.013).


BACKGROUND
Coronavirus disease (COVID-19) is a lethal virus that still affects many places throughout the world. The coronavirus disease 2019 (COVID-19) virus is quickly spreading in China, and scientists are working to find effective treatments. (Gao, et al 2020). The second epidemiological report for coronavirus illness (COVID-19), formerly known as novel coronavirus (2019-nCoV), was released in Australia on February 8, 2020, at 19:00 AEDT. It contains information on Australian cases reported for the week ending 8 February 2020 at 19:00 AEDT, as well as information on the international situation and current information on the severity, transmission, and spread of the COVID-19 virus. (NIRST 2020).
Vaccine uptake, particularly universal vaccine adoption, is a social enterprise that necessitates the study of human variables. The 23-person Working Group on Readying Populations for COVID-19 Vaccines was organised to give a starting point for this crucial component of a future COVID-19 immunisation campaign in the United States. A synthesis of the primary difficulties and possibilities connected with a potential COVID-19 immunisation campaign, as well as empirically-informed recommendations to improve public understanding of, access to, and acceptance of vaccinations that protect against SARS-CoV-2, is one of the group's outcomes. While this list isn't exhaustive, it does cover the majority of the steps that should or should be taken [1].
A recent contagious respiratory infectious disease produced by a novel coronavirus (SARS-CoV-2) that has the same veiled RNA structure as SARS-CoV-1 that triggered the severe acute respiratory syndrome (SARS) outbreak has caused a large global human calamity. The World Health Organization (WHO) has classified it as a pandemic. The date is March 12, 2020. COVID-19 instances were first discovered in Wuhan, China, at the end of December 2019. The virus has now infected almost every country on the planet, and the number of deaths is rapidly rising. Globally, about 3.5 million cases and 245,258 deaths had been documented as of May 3rd, 2020. The African continent was the least affected at the time of the study, with 43,909 cases and 1764 fatalities, but the numbers were rising. Since March 8, 2020, cases have been reported in the Democratic Republic of the Congo (DRC), which is located in Central Africa. The DRC reported 7379 cases and 182 deaths as of July 3, 2020. While social isolation and quarantine may help to limit the transmission of the virus and flatten the epidemic curve, they may not be enough to totally stop it [2]. COVID-19 is a lethal virus that still affects many places throughout the world. A COVID-19 vaccine is being developed to counteract the disease's spread and terrible effects is still ongoing, and other, As the epidemic progresses, more effective vaccines are likely to be developed. The study's objective is to was to evaluate the Attitudes and level of awareness of Citizens towards COVID-19 vaccination in Qassim region.

Problem Statement
One of the most important challenges faced by the Ministry of Health is awareness of Citizens about the COVID-19 vaccination.

Research Questions
-What are the Attitudes, level of awareness, and knowledge of Citizens towards COVID-19 vaccination in Qassim region?

Research Objective
-To evaluate the Attitudes, level of awareness, and knowledge of Citizens towards COVID-19 vaccination in Qassim region.

Introduction
The WHO Technical Advisory Group on Behavioral Insights and Sciences for Health met with the WHO Department of Immunization, Vaccines, and Biologicals on October 15, 2020, to address behavioural factors in relation to COVID-19 vaccine acceptance and uptake. The conversation centred on a series of fundamental concerns about using evidence-based and behaviorally informed techniques to achieve high and equitable vaccine uptake. This meeting report is the result of the WHO TAG members' discussion at the meeting. It solely includes the subjects that were discussed during the meeting. Following the meeting, the members' thoughts and recommendations were recorded [3].
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-caused Coronavirus Disease 2019 (COVID-19) has recently become a pandemic. Because SARSsudden CoV-2's debut and quick expansion endangers world health and the economy, efforts to restrict the virus's transmission are urgently needed. Various diagnostic kits to test for SARS-CoV-2 are already available for use in order to expedite appropriate treatment and minimise the virus's transmission. Several medicines have shown in vitro efficacy or possible clinical effects against SARS-CoV-2. Furthermore, universities and organisations all around the world are working feverishly to discover therapies and vaccinations to combat the disease [4].
There is widespread agreement that developing a COVID-19 vaccine is the most effective way to contain the COVID-19 pandemic in the long run. The quick creation of vaccine candidates and beginning of trials is the consequence of an extraordinary research effort and global collaboration. We look at the different types of vaccines and the progress of ten vaccine candidates against SARS-CoV-2, the virus that causes COVID-19, that are now in early phase human studies. We also evaluate the numerous hurdles of producing and distributing a novel vaccine on a global scale, and advise caution in our estimates for the timeline ahead [5].
Could COVID-19 immunizations make people more susceptible to ADE (antibody-dependent enhanced) breakthrough infections? This is improbable because coronavirus infections in humans lack the clinical, epidemiological, molecular, and pathological characteristics of dengue viruses' ADE sickness (DENV). SARS and MERS CoVs, unlike DENV, primarily infect respiratory epithelium rather than macrophages. The focus of severe disease is on elderly people with preexisting problems, rather than newborns or people who have had previous coronavirus infections. Animals given SARS or MERS immunizations developed vaccine hypersensitivity responses (VAH), which were comparable to those seen in humans given inactivated measles or respite vaccines [6].

Awareness
Awareness is the knowledge of your condition or work, or effects of your condition [7]. Awareness is the state or capacity to experience events, objects, or sensory patterns, to sense, or to be aware of them. Sense data may be verified by an observer at this stage of consciousness without inherently suggesting comprehension. More generally, it is the condition or quality of being conscious of something. Awareness is characterized in biological psychology as the perception and cognitive reaction of a person or animal to a situation or event. There is a contrast between two different current definitions of awareness. In recent masked-prime study, an ability to make forced-choice decisions above the production level of success is considered a significant factor. The second definition, suggested by Henley [8], is subjective and specifically equates an observer's experience of stimuli with self-reports that measure conscious awareness. "It is found that a better objective measurement of awareness is required, in order to distinguish between the two different subjective states of seeing and not seeing [9].

Vaccine Refusal
Some have pondered, in the early months of the COVID-19 outbreak, if the power of this worldwide experience will solve the problem of vaccine rejection, which has plagued the global public health community for decades. The job that vaccination programmes accomplish for the community-social, political, and moral as well as biological-determines public trust in them [10]). Most of the participants were hesitant about COVID-19 vaccines. The most common reasons for refusal were anxiety about vaccine side effects, lack of knowledge about the effectiveness of vaccines, and distrust of vaccines originating from abroad [11].

Introduction
The understanding of the basic aspects of methodology is essential for any researcher. (Garg, 2016). Research is a systematic process, which uses scientific methods to generate new knowledge that can be used to solve a query or improve on the existing system. (Bhaskar and Manjuladevi, 2016). This chapter aims to provide an understanding of the research methodology and design used to achieve the research objectives discussed in chapter one. This study will be conducted by quantitative method, to arrive at a better understanding of attitudes and awareness of Citizens towards COVID-19 vaccination in Qassim region.

Research Design
A cross-sectional study design will be conducted from March to May, 2021, using questionnaire. Sample size is n=300 randomly sampling. The collected quantitative data will be descriptive statistics; t-test will be done to examine if there is a significant difference in means (SD) for the participants. Chi-square to determine if there is significant association between social demography and the awareness toward COVID-19 vaccination. The collected data will be analyzed using SPSS, version 20.

Sample Size
Calculating the sample size is essential to reduce the cost of a study and to prove the hypothesis effectively [12]. Calculating the sample size is a most important determinant of statistical power of a study. A study with inadequate power, unless being conducted as a safety and feasibility study, is unethical [13]. The participant sample size will be determined using Electronic Sample Size Calculator. Based on the online calculator and the appropriate sample size for this study is (n) = 300 individuals.

Study Location
The study will be conducted in Qassim region. Qassim region is located at the center of the country, Qassim is an agricultural region. Buraidah, the capital of the Qassim province, plays a major role in the production of dates in the KSA. It is known as the "alimental basket" of the country, because of its agricultural assets. Qassim has an area of 73,000 km² and a population of 1,387,996. Of this population, 991,032 are Saudi (71.40%), and 396,964 are non-Saudi (28.60%). The population of Qassim represents 4.37 % of the total population of the KSA.

Target Population
All Saudi Citizens living in Qassim region. The target population for this research is (300) Saudi citizens who are living in Qassim region. Buraydah, Unizah, Al Rass, Badaea, Al Methnab, and other cities located in Qassim region.

a. Inclusion Criteria:
-Age 18 and above -Saudi Nationality.
-Living in Qassim region b. Exclusion Criteria: -Below age 18 years -Non-Saudi Nationality.
-Living out of Qassim region

Research Variables
There are many independent variables and dependent variable in this research. The variables are listed below.

Dependent variable
There is dependent variable in this research. The dependent variable is "Attitudes and awareness of Citizens towards COVID-19 Vaccination"

Independent variables
There are six independent variables in this research. The variables are listed below.
i. Age ii. Gender iii. Marital Status iv. Education level v. Occupation vi. Household Size

Research Instrument
In this study, paper questionnaire will be applied. A questionnaire is a research instrument consisting of a series of questions and other prompts for the purpose of gathering information from respondents [14]. The English instrument that will be used in this study "The Public Citizen Survey of COVID-19 Vaccine" from The University of Nevada, Reno School of Medicine, University of Nevada, Reno School of Community Health Sciences, to collect information on participant knowledge and attitudes about COVID-19 vaccines. The translated into Arabic language and validated questionnaire Arabic version will be used for this study.

Introduction
For any researcher, understanding the basic aspects of methods is important (Garg 2016). Study is a systematic process that uses scientific techniques to produce new information that can be used to address a query or develop the current framework" (Bhaskar & Manjuladevi 2016). The purpose of this chapter is to provide an interpretation of the study methodology and design used to achieve the research objectives that were discussed in the chapter I.

Research Design
For this study, a cross-sectional design was used with the quantitative method (questionnaire), to evaluate the Attitudes and level of awareness of Citizens towards COVID-19 vaccination in Qassim region. The data collection occurred between the 10th March to 31st May, 2021 . The sample consisted of simple randomly sampled Saudi citizens living in Qassim region. The sample size of this study is (n=300).

Study Location
Study location appears to play a vital role in research between two different cities. This research was done in Saudi Arabia-KSA, with the target population is citizens of Qassim region. The KSA comprises 13 administrative regions, and each region is divided into governorates. Qassim region is located at the center of the country, Qassim is an agricultural region. Buraidah, the capital of the Qassim province, plays a major role in the production of dates in the KSA. It is known as the country's "food basket", because of its agricultural assets.

Sample Size
The sample size for this study was calculated using The Statistic Calculation Software, with a total of n=300, with the power of this study is 0.8 (80%) that was calculated by G* Power software. The collected data will be analyzed using (SPSS) version 20.

Target Population
The target population for this study is all Saudi citizens of Qassim region below 18 years.

Research Instrument
A questionnaire is a study method consisting of a set of questions and other instructions to obtain data from participants [14]. The instrument that adopted and used in the study was the University of Nevada, Reno School of Medicine, Reno School of Community Health Sciences to evaluate the Attitudes and level of awareness of Citizens towards COVID-19 vaccination in Qassim region. This instrument is written originally in English and was prepared for using in society of an English-speaking. Using it in some other language demands that the instrument be translated into the language of the target community. Prior to its use for data collection, the instrument was translated by the researcher from original language (English) to Arabic and for validated it to ensure the functional equivalence in the two languages of its questions.

Measurement
COVID-19 vaccine awareness was assessed using a survey method and guidelines. The questionnaire about awareness had 3 items as presented in Table 3 with a category ("Yes", "No", "Don't know"). The awareness level was assessed by the answer and the knowledge level indicated by four categories: Poor, Average, good and very good. Q1: Are you aware of the novel coronavirus COVID-19 pandemic? Q2: 16. How would you rate your knowledge level on novel coronavirus/ COVID-19? Q3: Please select the answer depending on how much you agree with the statement below; -If a vaccine for COVID-19 becomes available and is recommended for me, I would get it; (1) Strongly Disagree, (2) Disagree, (3) Neither agree nor disagree, (4) Agree, (5) Strongly agree, and (6) Don't know.

Characteristics of the sample
Of the 300 participants from Qassim region invited to participate in the study, 300 (100%) returned the questionnaires. The sample consisted of (77.0 %) males and (23.0%) females. Approximately, more than half of the participants (56.3%) were from Buraydah City whereas (43.7.0%) were from the other cities in Qassim region. Furthermore, the most common age group was 35-44 years (37.7%), followed by 25-34 years (35.7%). The majority of the participants (83.0%) were married. With regards to the educational level of participants, (39.7%)had a bachelor's degree. Regarding employment status, the majority of the participants (89.3%) were employed, whereas (6.7%) were unemploed, and (4.0%) were Retired. The majority of the household size members (44.0%) were 4-6 Persons, followed by (38.7%) were 7-9 Persons in the family.

Awareness level among Saudi Citizens towards COVID-19 vaccination
The present study's results showed that awareness of COVID-19 Vaccination in Qassim region-Saudi Arabia shows that The mean score of awareness was 3.49 (SD 0.864) out of 5 as shown in Table 2  In this study, most of the respondents (67.0%) were aware towards COVID-19 vaccination, and oppositely, (33.0%) not aware. Female participants are more aware towards COVID-19 Vaccination than male participants (p<0.001), as shown in Table 3. & Fig.1.
Participants with married status are more aware towards COVID-19 Vaccination than other age groups. Employed persons are more aware towards COVID-19 Vaccination than other categories. Whereas, there is no relation between employed and awareness among Saudi citizens towards COVID-19, and there is relation between marital status and awareness among Saudi citizens. As shown in Table 4 and Table 5.   Participants with age group 55 years and above years, are more aware towards COVID-19 Vaccination than other age groups. Married persons are more aware towards COVID-19 Vaccination than other categories. Participants with graduate educational level are more aware towards COVID-19 Vaccination than other educational levels. Whereas, there is no relation between age and awareness among Saudi citizens towards COVID-19, "Are you aware of the novel COVID-19 Pandemic? As shown in Table 6.

Knowledge towards the COVID-19 vaccine
The distribution of each knowledge item about the COVID-19 vaccine are presented in Table 7. The mean score of knowledge was 3.49 (SD = .864) out of 5.
The mean score of knowledge was significantly higher among participants who reported having graduate level of education, Table 9.

Attitude towards COVID-19 vaccine
The distribution of each of the awareness items towards the COVID-19 vaccine is presented in Fig. 4.1. When participants were asked about their attitudes towards COVID-19 vaccination, 44 participants (22.7%) They do not believe the COVID-19 vaccination. The mean score of attitudes was 1.95 (SD=1.176) out of 4, with majority of positive attitude score was 62.7%. (65.7% They received the first dose, and 6.0% they received the first dose and second dose).

CONCLUSION
The study drew 300 individuals from the Qassim district, and 300 (100%) of them returned the questionnaires. refused. The level of awareness among healthcare participants was (80.2%). The mean score of knowledge was 3.49 (SD = .864) out of 5. Participants who reported having a graduate level of education had a considerably higher mean knowledge score. The mean score of attitudes was 1.95 (SD=1.176) out of 4, with majority of positive attitude score 62.7%. (65.7% They received the first dose, and 6.0% they received the first dose and second dose). Participants with age group 55 years and above years, are more aware towards COVID-19 Vaccination than other age groups. Married persons are more aware towards COVID-19 Vaccination than other categories. Participants with graduate educational level are more aware towards COVID-19 Vaccination than other educational levels. Employed persons are more aware towards COVID-19 Vaccination than other categories. Whereas, there is no relation between age and awareness among Saudi citizens towards COVID-19 (P-value= 0.140). There is no relation between employed and awareness among Saudi citizens towards COVID-19 (P-value =0.136), and there is relation between marital status and awareness among Saudi citizens (P-value = 0.013).

THE RECOMMENDATION
This study recommends for urgent need to implement a comprehensive training courses and workshop of infection control for COVID-19 across all healthcare professionals (Especially, the administrative employees), and also for citizens through different ways to achieve a sustainable healthcare service with knowledge and awareness in infection control management and new communicable infections.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
The approval letter was issued by decision No.(H-04-Q-001) on the 08th of March, 2021 from Central IRB-MOH (Department of research, Qassim health affairs, Saudi Arabia).

Questionnaire-English version
Dear participant; In the importance of your opinions and participation, could you please give us part of valuable time to fill this questionnaire? This questionnaire is to evaluate Attitude and Awareness of Citizens Towards COVID-19 Vaccination in Qassim Region I am informing you that your answer would be treated as confidential and you will take about ten minutes of your time to complete this questionnaire. Grateful