Community Insights Regarding COVID-19 Vaccine Uptake Intention versus Hesitancy

Background: It is widely believed that vaccine hesitancy is prevalent. Achievement of COVID-19 vaccination depends upon public willingness towards immunization against this disease. This study aimed at revealing the underlying situation regarding community hesitancy for COVID-19 vaccine. This study was conducted to determine the level of acceptance of COVID-19 vaccine uptake among community and to seek association between socio-demographic factors and various perceptions about COVID-19 vaccine. Methods and Materials: A cross-sectional study was carried out on 390 health-care providers and general Pakistani people of age 20 years and above through non probability snowball sampling. An online questionnaire was used to gather data. The socio-demographic variables along with various Original Research Article Memon et al.; JPRI, 33(58B): 108-117, 2021; Article no.JPRI.77382 109 concepts regarding intentions to take vaccine as well as hesitancy for the same were tried to bring on the surface. The p-value ≤ 0.05 was considered statistically significant. Results: This study reveals that 61.28% of participants desired to get vaccinated. There was significant association between the desire to get vaccination with participant’s age & occupation (pvalue < 0.01). The significant association between the positive views of the health-care providers and the other study subjects (p<0.00) is highly encouraging. The other socio-demographic variables have varied effect on vaccine uptake intentions and hesitancy and require further research on this subject. Conclusion: The study conducted on three hundred & ninety respondents consistently reveals the significant association between the positive views of the health care providers and the other study subjects with the p-values lesser than 0.001. The study concludes that other socio-demographic fabric of the community showed varied effect on COVID 19 vaccine uptake intentions and hesitancy. Recommendation: 1. The broad based qualitative research is strongly recommended in order to better seek the community insights & perceptions regarding this public health issue. 2. The large number of Community people although want to get vaccinated against covid-19, still there is a widespread prevalent doubts about this vaccine as being not so safe for them. Such type of doubts among community necessitate that some counselling sessions be conducted in order to remove uncertainties among common people. Motivations of people need to be raised so as to increase the coverage of covid-19 vaccination.


INTRODUCTION
The corona virus disease 2019 (COVID- 19) pandemic has imposed a serious disease burden throughout the world in an unfortunate background of unavailability of any specific antiviral treatment for this disease [1][2]. Immunization is the most successful and costeffective health intervention for controlling the infectious diseases. Similar is the case with vaccines against COVID-19 which remain of great importance to prevent and control COVID-19 [3,4,5]. However, the achievement and coverage of COVID-19 vaccination program depends on consumers' willingness and acceptance for the vaccination [6]. Therefore, it is very important to know the consumers' perceptions regarding vaccination against a newly emerged disease. However, public perception towards COVID-19 vaccine uptake is not available. Generally, consumers have queries regarding the safety and efficacy of the vaccine, adverse health outcomes etc. Besides this, there are prevailing myths and misconceptions about the need for vaccination and lack of trust in the health system [7][8].
Compliance for immunization against a novel strain of influenza altogether changes due lack of knowledge among the community regarding vaccine-preventable diseases [9]. Misinformation leading towards vaccine hesitancy could put public health at risk in responding to the current crisis [10]. Vaccine hesitancy is characterized by unwillingness or delay in acceptance and even refusal of vaccination although the service of vaccination is available. This could be due to failure of effective public health messaging because people who are hesitant can be convinced towards the vaccines' safety, efficacy, and necessity [11].
With the surge of post marketing phase of COVID-19 vaccines in different countries, community reservations regarding uptake of this vaccine is highly expected. This situation is more serious in the scenario of using imported vaccines in Pakistan. This situation necessitates that researcher should come forward to have an insight into perceptions of common people regarding this vaccine.
This study helps in finding out false perceptions regarding COVID-19 vaccine; this will in turn help in designing simple health education messages to motivate common peoples about COVID-19 vaccine and ultimately it will increase the vaccine uptake rate in developing countries.

METHODOLOGY
This Cross-sectional study was carried out among 390 health care providers and general Pakistani people above age 20 years via non probability snowball sampling. An online predesigned close ended Google form questionnaire was used to gather data about the community perceptions regarding COVID 19 vaccination. The study was completed in 4 months after the approval of ERC. Respondents of either gender, above 20 years of age were included in the study. The data was analyzed by using SPSS 23.00 and the associations between variables were sought by applying chi-square test, with p< 0.05 set as cut-off for level of significance.

RESULTS
The demographic characteristics of three hundred & ninety respondents are summarized in Table 1. There was slight males' preponderance in comparison to females i.e.52.31% males against 47.69% females. The age distribution of respondents was40.89 ± 3.54 years. The gender wise segregated age distribution was observed as 39.40 ± 4.34 years in males as compared to 42.39 ± 4.85 years in females. Majority of the respondents (95.90%) belonged to Sindh province and the participation from other provinces was only 4.10%. The 43.08% participants were health care providers while 56.92% were related to other occupations as shown in Table 1.  Table 3 shows the significant associations between the desire to get vaccination with participants age & their occupation (p-value < 0.01). Gender of participants revealed consistent in significant association with desire to get vaccination (p= 0.35), vaccine providing complete protection against COVID-19 (p = 0.52), vaccine safety for all ages (p= 0.13) and participants opinion about prior adequate testing of vaccine (p= 0.23). Contrasting to this, segregation of study participants into health care providers & other occupations consistently depicted significant associations with all the variables related to their opinion regarding uptake of vaccine i.e. p= < 0.01. Table 4 shows that associations between nature of occupation & perceived health hazards of COVID -19 vaccine ere all statistically significant (p <0.001) except the perception that COVID-19 vaccines contain the microchip for population tracking (p=0.38). the gender of the respondents showed no significant association with any of the perceived health hazards; while age of the respondents revealed significant results with perceptions of the respondents that the vaccine may lead to death (p< 0.001).

DISCUSSION
Vaccines are the most optimal public health strategy to prevent infectious diseases [12]. The study aimed to link vaccine hesitancy with related conspiracy thinking of consumers. Despite the fact that vaccination is considered as successful contributor to improvement of health and prevention of diseases, vaccine hesitancy contributes towards reduced uptake [13].
Nonetheless, the current study showed that 61.28% of total population wants to get COVID-19 vaccination. Increased vaccine acceptance in relation to vaccine effectiveness was found in other studies [14]. Among them 70% (p<0.001) of young population wanted to get vaccination; Salam et al in their study conducted in eleven counties also endorsed the same findings reporting age of study subjects as being significant factor contributing towards desire to get vaccinated [15]. In this study female (63.97%) participants were found willing to get vaccination than male while males were the most common recipients of COVID-19 vaccine in another study [15].
This study shows that majority of the health care providers i.e. 80.95% wanted to get COVID 19 vaccination that revealed statistically significant difference in distribution of health care providers and particpants related to other occupation (p<0.001) as they are at higher risk of get infected with COVID 19. Study of indonesia (Harapan) also support this study [16]. Another systematic review involving eight studies regarding acceptancce of COVID 19 vaccine conducted on healthcare workers and three surveys reported vaccine acceptance rates below 60%, with the highest rate being among doctors in Israel (78.1%) and the lowest vaccine acceptance rate (27.7%) reported among healthcare workers in the Democratic Republic of the Congo (DRC). Among the three studies conducted on parents/guardians, the vaccine acceptance rates were more than 70%. Similarly, two studies conducted in Malta on the university students revealed the vaccine acceptance rate as 57.3%; in this study the university staff was excluded. The study conducted by Salam et al however showed the vaccine acceptance rate as 86.1% in Italy [15]. The wide spread continuum of any vaccine uptake largely depends upon the level of acceatability of latter by the community [17].
Widespread online misinformation has been observed during current pandemic period and could seriously intimidate vaccine acceptance in countries where accurate evidence-based information is not readily accessible [18]. To combat this situation, it is necessary to have a complete knowledge about the demographics of those who pose refusal towards a newly introduced vaccine [19].
However, the prevalence of belief towards the COVID 19 vaccine providing full protection was 31.28%; overall concern towards vaccine causing side effects was 42.56%. Among study respectively. This is a very important piece of information arising from current study because it has been observed that understanding who will take up a vaccine, who plans not to or are uncertain, and why, is critical to designing a successful vaccination programme [21].
The current study showed 42.60% prevalence of the perception thatCOVID-19 vaccine can cause or enhance the disease in which 35.08% participants were younger than thirty years (p= 0.10), 40.19% were males against 45.16% females (p=0.32), 27.38% health care providers (p<0.001).
Another study with similar objectives showed 82.7% respondent thought about possibility of being re-infected after recovering from a previous COVID-19 infection and 1.1% respondent said they already had COVID-19, so they think they are immune to the disease [14]. Vaccineassociated enhanced disease has been rarely encountered with existing vaccines [22].
Taken as a whole, the main reasons given for vaccine hesitancy among community are fears about side effects (infertility) and future adverse effects (i.e. death, microchip installation for tracking population) of a COVID-19 vaccine. Study on international survey among low and middle countries The main reasons of vaccine refusal were fear of side effects (41.2%) and participants from Asian countries (Malaysia, Thailand, and Bangladesh) recorded a high percentage for fear of COVID-19 vaccine side effects [14]. Study of Lucia VC et all also showed the similar contributing factors to vaccine hesitancy that were concerns about serious vaccine side effects and lack of the information [23]. The results relating to uncertainty and misconceptions about COVID-19 point to areas that could be usefully targeted by public information campaigns [24].

STRENGTH
This is the first large representative study conducted in Pakistan about vaccine uptake or hesitancy and the reasons about why a COVID-19 vaccine has been accepted or refused. The results inferred from this study may be utilized in formulation of behavior change strategies in community so as to enhance the COVID-19 uptake.

CONCLUSION
The study conducted on three hundred & ninety respondents consistently reveals the significant association between the positive views of the health care providers and the other study subjects with the p-values lesser than 0.001. The study concludes that other socio-demographic fabric of the community showed varied effect on COVID 19 vaccine uptake intentions and hesitancy.

RECOMMENDATIONS
1. The broad based qualitative research is strongly recommended in order to better seek the community insights & perceptions regarding this public health issue.
2. The large number of Community people although want to get vaccinated against covid-19, still there is a widespread prevalent doubts about this vaccine as being not so safe for them. Such type of doubts among community necessitate that some counselling sessions be conducted in order to remove uncertainties among common people. Motivations of people need to be raised so as to increase the coverage of covid-19 vaccination.

CONSENT
Informed consent was obtained from all subjects involved in the study.

ETHICAL APPROVAL
Ethics approval was obtained from Liaquat university Of Medical and Health Sciences RESEARCH ETHICS COMMITTEE. (NO. LUMHS/REC/-63 DATED: 29-3-2021)

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author, RAFAINA SHAH., upon reasonable request.