Background
The Covid 19 pandemic has created havoc in the life of people around the globe. In December 2019, the outbreak of novel coronavirus- severe acute respiratory syndrome coronavirus2 (SARS-CoV-2)- rapidly increased the threat worldwide. In the spring of 2020, despite implementing all the preventive measures to contain the spread of the disease, the number of deaths and persons infected with the virus increased daily in all the countries. It brought life to a standstill as countries went on lockdowns to curtail the spread of the infection. The limited knowledge of the infection and the accelerated increase in the infection was a matter of concern. More than 158 Billion cases have been reported worldwide, and more than 3 billion deaths by the virus.1
The high number of cases and deaths due to this virus became a cause of panic. Despite effective treatment, protective measures like wearing masks, avoiding physical contact, maintaining hand hygiene, and social distancing were adopted worldwide.
The only measure the world could resort to in times of crisis was the development of vaccines. Vaccination has always been a means of prevention of disease. A vaccine is a biochemical component that activates our body’s immune system and provides us safety against the disease. The whole world waited for a preventive vaccine that curtails the further spread of the disease but also restores social and economic activities. Simultaneously, many institutes like Oxford, Gamaleya research institute, and pharmaceutical companies like Pfizer, Moderna, and others began the race towards the production of vaccination against the SARS-Cov-2 virus, as a long-term solution to control the pandemic and to ensure the protection of the vaccinated population thereby generating herd immunity within the community. More than 140 vaccine candidates were registered with the world health organization for starting trials.
The perception regarding any vaccine, acceptance of vaccines, and willingness to take vaccines among people would determine the success of the planned mass vaccination program. Similarly, the most important element to start the vaccination program and to make it a success is ‘vaccine acceptance’ among the population.
The belief of people differs according to their social and cultural differences. Various other factors like the normative beliefs trust in the government trust in the vaccine and its development, and past experience also have a significant role in vaccine acceptance or hesitance. Studies examining people’s perception of the polio vaccine showed the changing acceptance of the oral polio vaccine to gender, religion, exposure to negative information, and educational status.
The review of the papers on the perception, acceptance, reasons of acceptance, hesitance, reasons of hesitancy, and willingness to take the covid-19 vaccine from different countries would give an idea about the change in the perception in people of different countries and the factors affecting the people’s perception.
The summary of the findings will be helpful to the policymakers in designing policies suitable to create awareness, communicate positive information, and increase the willingness to vaccinate themselves among the common public of countries of similar socioeconomic status.
Materials and Methods
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 1st January 2020 and 30th 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.
Results
The studies looking at the perception of the covid-19 vaccine, and factors associated with its acceptance or hesitancy in a particular population have been studied in various parts of the world. The studies give us an insight into the main factors associated with vaccine acceptance or hesitancy.
The intention of receiving the vaccination is varied across many countries, some showed high acceptance while others at lower levels. The factors which influence the level of acceptance and perception of people towards the Covid-19 vaccine are discussed.
A total of 111 papers were identified. After a thorough screening, a total of 64 papers were included in the study.
Table 1
Summary of papers included in the study
|
Sl. no |
Author(s) |
Country |
Timeline |
Target Population |
Vaccine acceptance or vaccine hesitancy (%) |
|
1 |
Lazarus.J.V.et.al 2 |
19 Countries |
June 16- June 20 |
13,426 |
71.5% responded that they would take a vaccine if it were proven safe and effective |
|
2 |
Malik.A.A.et.al 3 |
US |
May-20 |
600 |
67% Acceptance |
|
3 |
Dror.A.A.et.al 4 |
Israel |
19-March 2020 onwards for 15 days. |
1941 |
75% acceptance of the whole population. |
|
4 |
Neumann-Böhme S. et.al 5 |
Denmark, France, Germany, Italy, Portugal, the Netherlands, and the UK |
2-15 Aril 2020 |
1451 |
73.9% of the total would take the vaccine if available. |
|
5 |
Wang.J.et.al 6 |
China |
Mar-20 |
2058 |
91.3% total accept vaccine when it would be available. |
|
6 |
García.L.Y.et.al 7 |
Chile |
April 18- May 5 2020 |
566 |
vaccine acceptance rate 90.6% |
|
7 |
Wanga.K.et.al 8 |
Hong Kong, China |
26 February to 31st march |
806 |
40% intent to accept vaccines. |
|
8 |
Fisher.K.A.et.al 9 |
US |
April 16-April 20 |
1000 |
10.8% do not intend to take the vaccine |
|
9 |
chungzhang.K.et.al 10 |
Shenzhen, China |
September 1- 7 2020 |
2653 |
53.5% have the behavioral intension |
|
10 |
Mohammed Al- Mohaithef. et.al 11 |
Saudi Arabia |
|
1000 |
64.7%- vaccine acceptance |
|
11 |
Walid A.et.al 12 |
Jordan |
|
1144 |
52.3% won't take the vaccine |
|
12 |
Ditekemena.J.D.et. al 13 |
Congo |
24 August to 8 September 2020 |
4131 |
55.9% were going to take the vaccine. |
|
13 |
Papagiannis.D.et.al 14 |
Thessaly, Greece |
15-22 December 2020 |
1500 |
80% vaccine acceptance among those who reported vaccines are safe. |
|
14 |
Gan.L.et.al 15 |
China |
23 October- 10 November 2020 |
1009 |
7.1 are not willing to take vaccines. |
|
15 |
Wang.J.et.al 16 |
China mainland |
March 2020& nov- Dec 15, 2020 |
March (n = 2058 November- December (n = 2013) |
23.1% rejected the vaccine |
|
16 |
Skjefte.M.et.al 17 |
16 countries |
October 28- November 18, 2020 |
17,871 |
73.4% of non-pregnant women had the intention to receive vaccines. 52% of pregnant women had the intention to get a vaccine. |
|
17 |
Saied.S.M.et.al 18 |
Tanta and KAfrelsheik University, Egypt |
Jan-21 |
2133 |
46% had vaccine hesitancy |
|
18 |
Alqudeimat.Y.et.al 19 |
Kuwait |
August 26- September 1, 2020 |
2368 |
53.1% -vaccine acceptance |
|
19 |
Gennaro.F.D.et.al 20 |
Italy |
October1- November1, 2020 |
1841 |
Average acceptance of 67% acceptance in Italy |
|
20 |
Zhang.K.C.et.al 21 |
Shenzhen, China |
September 1- 7, 2020 |
2,281 |
72.6% of parents accepted to get their children vaccinated. |
|
21 |
Ward.J.K.et.al 22 |
France |
7th April to 4th May 2020 |
5018 |
a quarter of respondents would not use it. |
Table 0
|
Table 1 Con.... |
|||||
|---|---|---|---|---|---|
|
22 |
Biasio.L.R.et.al 23 |
Northern, central, and southern Italy |
5th June 2020- 25 June 2020 |
885 |
66% had the intention to take the vaccine. |
|
23 |
Caserotti.M.et.al 24 |
Italy |
February to June end 2020 |
3691 |
40.1% vaccine hesitancy |
|
24 |
Kourlaba.G.et.al 25 |
Greece |
28 April - 3 May, 2020 |
1000 |
26% unwilling to take the vaccine |
|
25 |
Verger.P.et.al 26 |
France, Belgium, and Canada |
October- November 2020 |
2,678 |
46% of vaccine acceptance |
|
26 |
Alley.S.J.et.al 27 |
Seattle, Washington, Provo |
9-19 April 2020, 30th July- 16 August 2020 |
2343 |
Approximately 86% are willing to get vaccinated. |
|
27 |
Seale.H.et.al 28 |
Australia |
18-24 March 2020 |
1420 |
4.1% disagreed |
|
28 |
Lin.Y.et.al 29 |
Wuhan, China |
1-19 May |
3,541 |
28.7% definite intent to take the vaccine. |
|
29 |
Winardi.W.et.al 30) |
Indonesia |
March 25- April 6, 2020 |
1,359 |
93.3% and 67.0% of participants would like to be vaccinated if the vaccine had 95% and 50% effectiveness |
|
30 |
Sallam.M.et.al 31 |
Arab speaking population |
14-18 December 2020 |
3414 |
29.4% vaccine acceptance. |
|
31 |
Yigit. M.et.al 32 |
Children’s Hospital of Ankara City Hospital, Turkey |
|
428 |
66.1% of parents were reluctant to receive foreign COVID-19 vaccines |
|
32 |
Gagneux- Brunon.A.et.al 33 |
University Hospital of Saint-Etienne (France) |
26th march- 2nd July 2020 |
1421 online and 626 on site |
25.9% - vaccine hesitancy |
Table 0
|
Table 1 Cont.... |
|||||
|---|---|---|---|---|---|
|
33 |
Kutera.B.J.et.al 34 |
Philadelphia |
November 13, 2020 and December 6, 2020 |
12,034 |
63.7% of these employees said they planned to receive a COVID-19 vaccine |
|
34 |
Yoda. T.et.al 35 |
Japan |
Sep-20 |
1067 |
65.7%-vaccine acceptance |
|
35 |
Grech.V, et.al 36 |
Malta-Europe |
sep 11- 16,2020 |
1002 |
57.6% intended to be vaccinated, 31.6% were uncertain and 10.8% did not intend to be vaccinated |
|
36 |
Sallam.M.et.al 37 |
Jordan |
Jan 19-23, 2020 |
1106 |
Yes, -34.9%, no -39.6%, and maybe 25.5% |
|
37 |
EdwardsI.B.et.al 38 |
Australia |
august |
3000 |
36 per cent of Australians are hesitant and 6 percent resistant |
|
38 |
Kelkar.A.H.et.al 39 |
Florida |
31 Dec2020- 16 Jan2021 |
600 |
vaccine acceptance- 67% |
|
39 |
Malik.A.A.et.al 40 |
UK and Turkey |
May-20 |
5025 |
vaccine hesitancy Turkey: 31% UK: 14%; 3% rejection of the vaccine |
|
40 |
Kuok.K.O.et.al 41 |
Hong Kong |
mid-March and late April 2020 |
1,660 |
Intention to take 63% |
|
42 |
Qiao.S.et.al 42 |
South Carolina |
September and October 2020. |
1370 |
more intent to take the vaccine |
|
43 |
Reiter.P.L.et.al 43 |
USA |
May 2020 |
2,006 |
69%- vaccine acceptance |
|
44 |
Robertson.E.et.al 44 |
UK |
monthly from April to July, then every two months |
42,330 |
18% being vaccine-hesitant |
|
45 |
Salmon.D.A.et.al 45 |
USA |
November 25 and December 7, 2020 |
2525 |
Intenders (50%), Wait and Learn (40%), and Unlikely (10%) |
|
46 |
Eguia.H.et.al 46 |
Spain |
mid-March 2020 |
731 |
22.43%-vaccine-hesitant |
|
47 |
Gadoth.A.et.al 47 |
Los Angeles |
24 September 2020 and completed online through 16 October 2020. |
1069 |
1.30% never intend to get vaccinated |
|
48 |
Qunaibi.E.A.et.al 48 |
Arab countries |
14-Jan 2021 to 29-Jan, 2021 |
1069 |
12.6%-answered “Yes”; 4.5%-“Depends on the type of vaccine”; 20.9%- answered “I will wait and see its effects on others”; 21.7%-answered “I am not sure”;40.4% chose “No” |
|
49 |
Soares.P.et.al 49 |
Portugal |
29 September 2020- 8 January 2021 |
1943 |
35.3%- take the vaccine as soon as possible; 55.5% would wait before taking the vaccine ; 44.7% would wait some time; 10.8% would wait a long time; 9.2% would not take the vaccine. |
|
50 |
Vallée.A.et.al 50 |
Foch Hospital, Suresnes, France |
Jan-21 |
690 |
vaccine hesitency-28.7% |
|
51 |
Jagadish Thaker 51 |
New Zealand |
June 26 to July 13, 2020 |
1040 |
vaccine hesitency-26% |
|
52 |
Dickerson.J.et.al. 52 |
Bradford |
April–June 2020 |
1727 |
29%would want a COVID- 19 vaccine |
|
53 |
Reno.C.et.al 53 |
Northern Italy |
January 19 to January 26, 2021 |
1011 |
68.9% confident about the vaccine while 31.1% reported hesitancy |
|
54 |
Machida.M.et.al 54 |
Japan |
14 January 2021 and 18 January 2021 |
2956 |
62.1%-were vaccine acceptance |
Table 0
|
Table 1 Cont.... |
|||||
|---|---|---|---|---|---|
|
55 |
Luciano.B.et.al 55 |
Maranhão, Brazil |
October 19 to 30, 2020 |
3000 |
17.5%-vaccine hesitancy |
|
56 |
Kociolek.L.K.et.al 56 |
Ann & Robert H. Lurie Children’s Hospital of Chicago |
21 dec- 13 January, 2021 |
7,012 |
59.8% will receive vaccine |
|
57 |
Kreps.S.et.al 57 |
US |
9-Jul-20 |
2000 |
Higher vaccine accthe eptance |
|
58 |
Doherty.R.A.et.al 58 |
North Carolina |
August 27, 20Decand Decemer 15, 2020 |
1004 |
69% of respondents reported Vaccine hesitanthe |
|
58 |
Gerussi.V.et.al 59 |
Italy |
1 March 2020 to 30 May 2020. |
1067 |
acceptanceed 34.2% or reluctant to receive 24.9% hesitant |
|
60 |
Hossain.M.B.et.al 60 |
Bangladesh |
1-7 February 2021 |
1497 |
41.1% of the respondents acceptance.respondents’ |
|
61 |
Wang.C.et.al 61 |
China |
January 10 to January 22, 2021. |
9508 |
67.1% participants reported willingness to accept |
|
62 |
Raja.A.S.et.al 62 |
Amazon mechanical trunk, US |
17018 November 2020 |
1756 |
37.8% hesitant to take the vaccine. 21.3% non- accepting |
|
63 |
Paul.E.et.al 63 |
U.K |
21 March 2020 |
32,361 |
64% intent to take vaccine |
|
64 |
Rzymski.P.et.al 64 |
Poland |
17 February and 11 March 2020 |
1020 |
Less vaccine acceptance among women |
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
Age
The majority of studies conducted in the US, UK, China, Japan, and Australia (2, 5, 27, 34, 37, 43, 53, 60 ) reported that vaccine acceptance is high among the elderly when compared to middle and young age groups. In a study conducted in Spain, there is a slight difference in acceptance levels among middle and older age groups.46 The middle-aged group is more inclined to take vaccines in a study conducted in China between 23rd October to 10th November 2020.15 Participants aged 21-24 years accepted vaccines the most, least acceptance to the vaccine is reported among people between 55- 64 years of age in a study conducted in Kuwait and in France and Canada).22, 19 In another study conducted in Brazil, individuals more than 60yrs of age group are more hesitant to take vaccines as compared to middle and younger age groups.55 In Seattle willingness to get vaccinated decreased in all age groups with time.27
In a dual survey conducted in Australia, during the months of April and August, Willingness to get themselves vaccinated decreased from April to August in all age groups.38. In Indonesia, a cross- sectional study on the acceptance of vaccines reported that the highest acceptance is 95.5% among people of age 21-30 years and the lowest acceptance of 88.8% was among people of age 31-40 years.30 In the majority of surveys, the less than 30years age group were more hesitant to take vaccines and has lower confidence levels followed by the people belonging to the 30-50 years of the middle age group.
Gender
Based on the studies from China, Denmark, France, Germany, Italy, Portugal Netherlands, and the UK done between the months of March 2020 to April 2021, Males are more likely to get vaccinated for covid-193, 4, 5, 6, 7, 8, 22, 26, 40, 61 as compared to women but in a study from China between the month of October, and November and in Indonesia women are more intended to get themselves vaccinated.15, 30 72% of men are likely to get vaccinated in the US,1 . Women are more likely to take vaccines only if they have high efficacy in Shenzhen, China.10
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 vaccine32 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 Kong8 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 unwilling3 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
Region
A study conducted in China during the first round of vaccination shows that urban participants received more vaccinations when compared to rural participants.61 A dual survey conducted in Australia during the months of April and between July and August in 2020, reported that non-Victorians were more willing to take vaccines in the initial survey and Victorians were more willing in the later period.38
Anationwide survey conducted in China reported that people staying in the central region were more willing when compared to people living in southern areas.29
Race
A study conducted in the US to determine the factors associated with vaccine acceptance shows that Asians are more willing to take the vaccine(2); a survey conducted among the employees in two hospitals in Philadelphia reported that Asians are more willing, next comes the white people than in Hispanics and blacks34 Non-Kuwaitis were more likely to accept the vaccine than Kuwaitis in a cross- sectional study conducted among the general adult population in Kuwait.19
Studies conducted in the USA, North Carolina, U.K, Philadelphia show that black Americans and black people from Africa were less willing to take the vaccine when compared to other racial people.3, 34, 44, 57, 58 lower influenza uptake and lower Covid 19 vaccine acceptance were reported among black Americans living in the USA than nearly all other racial groups3 and in another conducted in the US, non-Latin black were less willing to vaccinate.3, 43
Following blacks, the Pakistani/ Bangladeshi were the next most hesitant group followed by mixed ethnicity as reported in a longitudinal study conducted in the UK. 44 A cross-sectional study among health care workers in Los Angeles showed that Asians or Latinos were less likely to accept the covid-19 vaccine. 47 Pakistani heritage respondents from Branford were less willing to get themselves vaccinated when compared to white British respondents.52 The people of Maori ethnicity living in New Zealand show less vaccine acceptance when compared to Asians and people of other ethnicities.51 People from minority ethnic groups living in the UK reported lesser acceptance of vaccines.63
Place of stay
Cross-sectional studies conducted among Chinese adults and in Indonesia have reported that people living in urban areas are more willing to accept the vaccine when compared to rural areas15, 30, 61 In contrast to these studies, a study conducted in Japan reported that participants from rural areas were more willing to vaccinate than those from central areas.35 In the study in Congo, 94% of people from Kasai central, and 85% people of from Kasai oriental were ready to take the vaccine.13
High rates of vaccine hesitancy were reported among people living in the western region of Saudi Arabia48 A study in the USA to determine the factors associated with vaccine acceptance reported that there were notable geographic differences in vaccine acceptance in different regions in the USA.3
Doctor’s advice
Studies conducted in China, Australia, and the USA3, 28, 43 reported that participants were more willing and show high vaccine acceptance if they were recommended by their doctors and a study.
conducted in the US reported that, participants preferred vaccine uptake in their primary doctor’s office or clinic and pharmaceutical offices.62
COVID-19 infection
In Saudi Arabia, it was seen that the people believed that those who were concerned about acquiring the disease were more likely to get themselves vaccinated.11 In Congo, the people who tested positive for Covid-19 were more likely to take the vaccine.13 In Tanta, Egypt 77.7% of participants who had a fear of infecting Covid were more motivated to take the vaccines.18 In Kuwait individuals who reported that they are likely to contact Covid were more accepting of vaccines.19 There was a 66% of vaccine acceptance among family members of people who have a previous of current SARs infection in Italy20 There was a 95.6% acceptance who perceived the risk of covid-19 in Indonesia.30 In France, there was a 60.9% acceptance among people who did not feel the risk of COVID-19 infection whereas there was an 85.8% acceptance among people who felt the risk of covid-19 infection.33 There was a positive correlation among perceived severity and intent to take vaccine among the people from South Carolina.42
Cost of vaccines
It was seen in a study from China that 59.9% of participants mentioned taking the decision to take vaccine based on the price of the vaccine6 In Chile, 92.4% of participants were willing to pay for the vaccines if needed.7 In Shenzhen, China 80% were ready to take the vaccine only if it was free of cost10 In China, mainland people are said to accept vaccines based on the price of the vaccine.16 In Egypt, 68% of participants said they won’t take the vaccine if it is not free.18 In Italy, those who are willing to pay are more likely to get themselves vaccinated.24 In Wuhan, China 82% of participants agreed to take vaccines only if they are affordable.29 In the USA indicated the participants mentioned that they would pay out-of-pocket for a COVID-19 vaccine. The price and proportion of people ready to pay was $0 (30%), $1-$19 (15%), $20-$49 (20%), $50-$99 (14%), $100-$199(10%), and $200+ (11%).43
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 vaccinated43 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 vaccinated54 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
The Common Perception About Covid-19 Vaccines
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
Effectiveness and Efficacy of Vaccine
A cross-sectional study conducted among Chinese factory workers reported that if the vaccine efficacy is 80% more than 60% of the participants were willing to accept and confident about the vaccine10 and the same was reported in studies conducted in Japan, the UK,(34,43) and among pregnant and mothers of a young children-a study conducted in 16 countries.17 Vaccine acceptance was more among participants with an increase in trust and belief in the efficacy of the vaccine was noticed in studies conducted in China, Kuwait.15, 16, 19 studies conducted in Hong Kong -China, more than 50% of the participants suspected the efficacy of the vaccines8 and there were more than 70% concerns and doubts raised on the ineffectiveness of vaccines were reported in studies conducted in Egypt, Kuwait, Italy.18, 19, 20 A less than 20% of concerns about vaccine ineffectiveness were reported in studies conducted in the US, Italy, France, Spain, 46, 50, 59, 62 and around 30% were reported in a study conducted in Philadelphia.34
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
Conclusion
In almost all countries the individuals who were married and had children were more likely to get themselves vaccinated but they were hesitant to get their children vaccinated. In China, the preference for domestic vaccines increased over the period of time. In almost all studies the vaccine acceptance was more in the case of people who perceived the risk of Covid-19 infection than those who did not. There was more acceptance to vaccines if they were free but in the USA 11% of people were ready to pay more than 200$ for vaccines. Women and the unemployed and the young were more hesitant to go for vaccination.
It can be seen that the health belief model and protection motivation theory, have identified the factors influencing vaccine acceptance and hesitancy, they are safety and side effects, effectiveness and efficiency, age & gender, mistrust, religious beliefs, development of the vaccine, etc., these are some major issues stated by a greater number of people.
Thus, the misconceptions regarding vaccines are a major reason for vaccine hesitancy among the public. So, the government has to put in efforts to improve vaccine acceptance among the public through transparency to information, behavior change communication strategies, and improving awareness.
