The perception of people regarding Covid-19 vaccines worldwide- A systematic review

Search strategy

The databases like PubMed and Google Scholar were used for searching papers. All papers published on people’s perception regarding the COVID-19 vaccine, acceptance to take the covid-19 vaccine, hesitancy to take the vaccine, and the reasons for acceptance or hesitancy were included in the review.

A set of keywords were listed, which reflected the papers of relevance. The words like Covid-19 vaccine AND perception, Covid-19 Vaccine and people, Covid-19 Vaccination AND acceptance were used to look at people’s perception regarding theCovid-19 vaccination and the reasons behind their acceptance or hesitance to take the vaccine.

The search was done between 25 March - 30 April 2021, and all papers published between 1^st January 2020 and 30^th April 2021 were included.

Study selection

The studies were included if they met the following characteristics: 1) Script was written in English. 2) They included primary research. 3) Quantitative study design 4) the papers included research on acceptance, hesitancy, trust, concerns, perception, and attitudes about the COVID-19 vaccine. 5) Published in peer-reviewed journals.

Studies excluded if 1) They talked about the vaccine trial, 2) They were not talking about the perception of people, 3) If the paper was about vaccine development and research 4) non-peer-reviewed and non-research papers.

Two authors screened the abstract and full text of the papers and it was analyzed. The data were cross-checked for consistency.

Data extraction

We found a total of 111 Papers. Out of the total 19 were rejected after reading the abstract and 29 were rejected after reading the whole paper. Finally, a total of 63 Papers were included in the study. The data about the perception of people about vaccines, hesitancy, acceptance, intent to take vaccines, and factors associated were extrapolated. The data was then summarized based on the place of study and the factors associated with perception regarding the covid-19 vaccine.

Characteristics of papers included in the review

A total of 64 papers have been included in the review where there is a mention of vaccine acceptance, vaccine hesitancy, and perceptions regarding the Covid-19 vaccine. Most of the studies are surveys done on an online medium during the months of March 2020 until April 2021. Some studies were conducted in hospitals or provinces of a country whereas there are studies that were conducted in more than one country. There 7 studies that were conducted in more than one country.

Factors associated with vaccine acceptance/hesitancy

Educational level

The acceptance is increasing with an increase in the level of education in countries like the US, UK, China, Egypt, France, Saudi Arabia, Australia, Japan, and other countries.^[3], ^[9], ^[15], ^[18], ^[22], ^[38], ^[42], ^[43], ^[44], ^[45], ^[46], ^[47], ^[48], ^[54], ^[55], ^[56], ^[57], ^[58], ^[59], ^[60], ^[61], ^[62] A study conducted in Jordan shows that Higher percentages of those who work/study in the medical field responded: “Yes' ' rather than “Not sure” (39.7 vs. 23.9%).^[11] In a cross-sectional study conducted in Indonesia, in School graduates there is 94.2% acceptance, 93.3% acceptance among university graduates;^[30] in another study conducted in Children’s Hospital of Ankara City Hospital, Turkey on parents, shows that parents who are highly educated, are less likely to accept the vaccine^[32] and also in the study conducted in China reported that, the participants with a master’s degree or above had a higher rate (42.8%) of vaccine hesitancy compared to those with a bachelor’s degree.^[61]

Employment

Working in the private sector more likely to accept vaccines, was reported in studies conducted in Hong Kong^[8] and a study conducted in Indonesia showed that Private sector employees had 93.6% acceptance, 91.9% acceptance among civil servants.^[30] A study conducted among Italian patients who recovered from COVID-19 Infection shows that employees working in contact with the public seemed to be more prone to undertake the SARS-CoV-2 vaccination.^[59] A national cross-sectional study conducted in China shows that those working in port affairs or customs reported the highest rate of vaccine willingness 84.0%, followed by medical employees 80.8%, and transportation 9.8%.^[61] There was a 96% of acceptance among people who lost their job during the pandemic, 75% among those who are at home but were confident to return to work, and 72% of acceptance among people with essential occupations like education and security was noted in a study conducted in Israel.^[4] 48.1% acceptance was based on employer recommendation in the survey conducted in the 18 countries.^[2]

Among the health care professionals, 72.4% of hourly employees and 88.6% of salaried employees are willing to accept vaccines in a cross-sectional study conducted in Ann & Robert H. Lurie Children’s Hospital of Chicago.^[56] The intention to receive a COVID-19 vaccine was 61.6% at hospital A and 67.3% at hospital B, in a survey of employees in two large hospitals in Philadelphia among clinical and non-clinical staff.^[34] Rates of intention were 92.1% in physicians, 88.8% in pharmacists, 64.7% in nurses, 60.1% in assistant nurses, 70.3% in midwives, 95.8% in physiotherapists, and 67.1% in other HCWs, was reported in a cross-sectional study conducted among French healthcare professionals during the first pandemic wave. ^[33] Vaccine acceptance among Maltese health workers shows that doctors- 86%; nurses- 64%; allied health professionals- 67%; others- 63% willing to take.^[36] Intention to take the vaccine was about 60% among nurses in Hong Kong.^[41]

Studies conducted in the UK, Northern Italy, and Japan reported that individuals and families with low monthly income are more hesitant to vaccinate;^[53], ^[54], ^[63] a study conducted in the USA to determine the factors associated with vaccine hesitancy shows that people who being unemployed were more unwilling^[3] and A higher odds of delay and refusal was also found for individuals who lost income during the pandemic compared to those who did not was reported in a study conducted in Portugal.^[49] More hesitancy was reported among self-employed individuals in a study conducted in Northern Italy from January 19th to 26th, 2021.^[53] Nurses and assistant nurses were less inclined to get vaccinated against COVID-19 than physicians in the study conducted among French healthcare professionals.^[33]

Co-morbid conditions

In Hong-Kong China people with chronic diseases were more likely to accept the Covid-19 vaccines.^[8] In Jordan 37.1% would take the vaccine if they have other health complications.^[12] In Congo, 33.3% of students who believed to have bad health were more accepting of the vaccine. ^[13] In Kuwait, the people who are underweight, overweight, and obese were more willing to get vaccinated.^[19] In Italy, 70% of people with disabilities, 74% who were immune-compromised or in treatment with immune- suppressors had greater acceptance of vaccines compared to others.^[20] In Australia, 25% of people with chronic health conditions were ready to take vaccines.^[28] There was a higher acceptance seen in people with a history of chronic diseases among the Arab-speaking population. ^[31] In Japan, 78.4 % of people with chronic diseases were willing to take vaccines as compared to 61.3% of people without chronic diseases.^[35] In the USA, 73% with underlying conditions and 66% without any underlying conditions were willing to get vaccinated^[43] In Portugal, people with co-morbid conditions had lower refusal than people without comorbid conditions.^[49]

Political inclination

38.8% of participants of the survey done in 16 countries around the world believed that vaccine development and distribution was rushed due to political reasons ^[17] In France, it was seen that the people who didn’t prefer the party in power were hesitant to take the vaccine ^[22] The hesitancy was higher among people in Portugal who found the measures implemented by the government inadequate. ^[49] In another study conducted in the USA during July 2020, the democratic supporters had a higher acceptance of the vaccine.^[57] Here, people also mentioned that they would trust the vaccine more if the president recommends it. In France, lower hesitancy among people with lower party preference.^[22]

Family and marital status

In China, Greece, married people or people who were co-habiting or with children were more likely to accept vaccines (5,24). In a survey done across 16 countries around the world, it was seen that non- married were reluctant to take the vaccine.^[17] In Wuhan, China 30% of married showed higher intent of getting vaccines.^[29] 72.6% of parents were willing to get their children vaccinated in Shenzhen, China.^[21] On the contrary in Indonesia, 94.6% unmarried and 91.7% married accepted the vaccine.^[30] In Japan, 43.5% unmarried and 33.8% married were unlikely to get themselves vaccinated^[54] In China, 51.7% are willing to get their children vaccinated whereas 10.9% are not willing to vaccinate their children.^[15] The survey from 16 countries showed that 73.4% of non-pregnant women had the intention to receive the vaccine whereas 52% of pregnant women had the intention to get the vaccine. 69.2% of women had the intention to vaccinate their children.^[17]

COVID-19 vaccine acceptance level was above 80% for pregnant women in Mexico and India; and below 45% for the US, Australia, and Russia. 73.4% of non-pregnant women intended to receive the vaccine.

COVID-19 vaccine acceptance level was above 90% for non-pregnant mothers in India, Brazil, and Mexico. COVID-19 vaccine acceptance levels among mothers for their children was above 85% in India, Mexico, Brazil, and Colombia whereas it was 56% for Australia, the US, and Russia and below 52% for Australia, the US, and Russia.^[17] In Portugal, individuals with children of school age were hesitant to get their children vaccinated.^[49] In New Zealand, individuals without children were intended to get vaccinated compared to those with children.^[51]

Covid vaccine development and safety

11% of participants in Denmark, France, Germany, Italy, Portugal, the Netherlands, and the UK thought vaccines were not dangerous to health and 15% of participants did not wish to get themselves vaccinated as they had doubts regarding the safety of the vaccine.^[5] In Japan, 31.7% felt that the newer vaccines are riskier than older vaccines. ^[35] 46.1% of participants of a study in Arab countries and people from Germany and Canada felt that the vaccine production was rushed and there were doubts on the credibility of the vaccine production.^[22], ^[48] In Bangladesh, people who believed that COVID-19 vaccines made in America and Europe are safer than those made in other countries, and the COVID-19 vaccines made in India are safer than those made in other countries had more hesitancy.^[60] In a study in Congo, it was found that 14.4% believed that vaccines would kill people from Africa, and 5.9% believed that it would sterilize people.^[13] 20.8% of people in a study from Italy believed that they won’t need vaccines either because of previous conditions or age.^[59] In Poland, women believed that vaccines may cause infertility among women.^[64] In the study among the health care professionals in Thessaly, Greece 93% who refused the vaccine were in fear of side effects.^[14] 83% of people thought that vaccines are not safe in Italy.^[23]

Place of development of the vaccine

Vaccine development also had an impact on vaccine acceptance. In a study from china, it was seen that 32.5% preferred the domestic vaccine or vaccine produced in their country and this preference increased to 48.2% by October 2020.^[6] Only 3.4% of people preferred imported vaccines over domestic vaccines in China.^[16] In another study from china in May 2021, 64.2% preferred domestic vaccines whereas only 11.9% preferred foreign vaccines.^[29] In a study from the USA, it was found that the participants were least likely to choose vaccines developed outside the US, mainly in China.^[57] 53% of participants from the USA thought that the government and the pharmaceutical companies were conducting a vaccine trial on common people.^[45]

Sars-CoV2 virus

People who believed that the virus was developed by humans were less likely to be vaccinated. In Jordan, 29.7% believed Covid-19 was a man-made disease.^[37] 6.8% believed that they could contact COVID-19 from the vaccine in Turkey.^[32] whereas in Philadelphia 25.4% believed that they could contact the virus from a vaccine.^[34] 2% of participants of the study in Florida believed that they could get infected by the vaccine.^[39] In Bangladesh, people believed that Corona virus is a myth to force vaccinations on people and they were more hesitant to take the vaccine. ^[60] In Hong-Kong, China 27.9% of people believed that the Covid-19 vaccine was unnecessary.^[8] In UK and Turkey, higher acceptance could be seen among participants who believed in the natural origin of the virus.^[40]