Short Communication

Acceptance of COVID-19 Vaccine and Related Factors in Iran: A Cross-sectional Study

Introduction

COVID-19 vaccine is the most effective approach to control pandemic.¹ Studies showed that if a vaccine is available, high and effective coverage of vaccination needs to be accepted by the individuals.² In addition to the problems in vaccine distribution in different countries, vaccine hesitancy is one of the most challenges ahead, as World Health Organization (WHO) identifying it as one of the top 10 global health threats in 2019. Although clinical trials have shown that vaccines are effective and safe, there are various reasons for vaccine hesitancy, including distrust of governments, concerns about vaccine side effects and misinformation about vaccines in the media.^3-6 A global study reports that in 90% of countries people are hesitant about getting the vaccine and generally hesitancy about vaccine varied between 8% to 15%.^7-11 Therefore, in each country the public health officials must pay special attention to this issue.

low vaccine acceptance can slow down the vaccination and delay control of COVID-19 pandemic. It also imposes an enormous burden on governments and medical staff. In Iran, as in other countries, there is misinformation about the vaccine which affects the vaccine acceptance. So it is necessary to conduct studies to identify the factors affecting vaccine acceptance and provide solutions to improve public acceptance. Accordingly, this study designed to investigate COVID-19 vaccine acceptance and associated factors among Iranian population.

Materials and Methods

We did a cross-sectional study that conducted between 28 February 2021 and 18 March 2021.

PASS software version 11 was used to determine the sample size. So considering a margin of error 5% and confidence level 95%, the sample size was determined 1043.

Using proportional stratified sampling method, the participants were selected from 5 city (Birjand, Tabas, Nehbandan, Ferdows and Boshrouyieh) of South Khorasan province of Iran. Using Cochran’s formula (with precision of 0.01 and 95% confidence level) validity and reliability was determined (Cronbach’s alpha= 0.78). This survey was produced by Pors Line, an Iranian online survey platform (https://survey.porsline.ir/s/76HZY9K).

We shared the link of survey through social media (WhatsApp and Telegram channel).

The questions of questionnaire consisted of several sections: demographic characteristics of participants, vaccine acceptance, barriers of vaccine acceptance, people’s attitudes about the coronavirus and coronavirus vaccine. Exclusion criteria were people over 85 years and under 18 years. Analysis of data were conducted with SPSS software version 13. Normal distributions were evaluated using Kolmogorov–Smirnov test. The analytical procedure consisted of two tests. First, chi-square test was used to examine relationship between vaccine acceptance and demographic characteristics. Also simple linear regression was used to investigate role of barriers on vaccine acceptance. Significance level was considered to be 0.05. Descriptive statistics were presented as frequencies (n) and percentage (%).

Results

Total number of participants in this study was 1043. The highest number of respondents was belonged to Tabas city 663 (63.6). The majority of respondents were in the age range 19-30 years. 442 (42.4) of participants, were male and 601 (57.6) were female. Most of the participants were married 728 (69). Moreover most respondents had a bachelor’s degree 447 (42.9). Most of the participants in this study were employed in government jobs 39.5% and 38.6% of them were unemployed. 831(79.7) of the participants had no comorbidities and most of them had no history of infection with COVID-19.

The majority of people stated that COVID-19 is a serious and important disease 910 (87.3) and they said that they were more likely to get COVID-19 633 (60.7). Table 1 indicates acceptance of COVID-19 vaccine among the participants. Most of respondents strongly agreed with this subject: {If you know that getting the COVID-19 vaccine will protect you against this disease, be sure to get vaccinated} 555(53.3) and 332(31.9) of them agreed. This indicates that 888 (85.2) of participants were sure about self-vaccination and only 154 (14.8) of them disagreed or they had not decided. In the second and third questions was asked that: 886 (85) of people agreed with these questions: If you know that the COVID-19 vaccine will protect your family and community from disease, be sure to get vaccinated and If you know that the COVID-19 vaccine will return the community to normal, you will be vaccinated. Furthermore in response to {I follow all health protocols and inject the vaccine} 675 (64.8) of respondents strongly agreed or agreed. 372 (35.7) of participants preferred to use internal vaccine and only 209 (20.1) of them preferred foreign vaccine, 310 (29.8) did not decide about it and 150 (14.4) of participants said type of vaccine is not important. Most of participants said that if a vaccine is confirmed by the WHO, they will inject it 764 (73.3) which shows people’s trust in World Health Organization (WHO). Results indicated that vaccination acceptance was higher in participants that were over 41 years old. Moreover, the rate of vaccine admission was higher in men than women and in proportion to the increase in education level, rate of vaccine acceptance also increases.

Table 2 shows the barriers associated with acceptance of COVID-19 vaccination. One of the concerns in most people about vaccine injections was the side effects of vaccine. In our study, in response to the question {I’m worried about the side effects of the COVID-19 vaccine}, most of participants agreed or strongly agreed 806 (77.3). I think COVID-19 vaccine is dangerous for me: only 396 (38) of respondents agreed with this sentence, and about 361 (34.7) of them were neither agree nor disagree, and 219 (21) were opposed to this. Another thing that is considered to be one of the barriers associated with COVID-19 vaccination is the cost of the vaccine, also fear of getting COVID-19 through vaccine injection. In our study, more than 312 (30) of people agreed with these sentences: I’m worried to get COVID-19 from the vaccine and I have to charge much money for this vaccine. Also a small percentage of respondents were afraid of injections 166 (16). 378 (36.3) of respondents were agree or strongly agree with this sentence: I believe in natural remedies and traditional medicine to treat COVID-19 disease. It seems that the role of religious beliefs as an obstacle in vaccination is very low and only 70 (6.8) of people agreed or strongly agreed with: I do not get the COVID-19 vaccine because of my religious beliefs. Most participants were opposed or strongly opposed with this sentence: I do not get the vaccine because I am not at high risk 661 (63.4).

Simple linear regression has been used to investigate role of barriers on vaccine acceptance. Table 3 shows result of Simple linear regression: According to the obtained results, the following linear relationship can be expressed based on regression analysis: Acceptance of vaccine = 4.17-0.16 × Barriers of vaccine acceptance the above relationship shows if the barriers increase one unit, vaccine acceptance will decrease 0.16 (R² = 0.03, F= 41.08).

Discussion

Results of this study showed that the rate of vaccine acceptance among respondents was 85.2% which was higher than other studies. In a global study that conducted in 19 countries, 13142 participants entered in this study to determine acceptance of the COVID-19 vaccine. 71.5% of respondents said that they would be likely to take vaccine if an effective and safe vaccine was available. 48.1% of participants reported that they would inject the vaccine if their employer recommended it. In Asian countries such as China, Korea and Singapore, more than 80% of people wanted to take COVID-19 vaccine.¹² In a study conducted in France, 25% of the French adult population did not want to take COVID-19 vaccine and the main reason they stated was that the vaccine was not safe.¹³These differences in vaccine acceptance between different countries can delay control of the COVID-19 pandemic.

Vaccine acceptance is influenced by beliefs of the people and social factors. For example, in a recent study in several countries, the authors found that Africans experienced medical distrust due to racial discrimination and were less likely to receive the vaccine. Also it has been found that in middle-income countries people are more likely to receive the vaccine.¹⁴

Results of our study showed that the majority of participants who wanted to receive the vaccine were over 41 years old and also the rate of vaccination was higher in men than women. In line with this evidence in a global study by Lazarus et al older people were more likely to get the vaccine whereas respondents that were in the age range of 25-54 and 55-64 years reported that they would inject the vaccine if their employer recommended it.¹²

In compliance with our results, Troiano and Nardi indicated that vaccine acceptance was higher in men than women.¹⁵ Whereas Lazarus et al reported that this rate was higher in women than men.¹² The results of our study showed that as the level of education increases, the same rate of vaccine acceptance among participants increases which may be related to increasing the level of knowledge and awareness of individuals. In line with this evidence, Salali and Uysal in Turkey reported that low levels of education were associated with low vaccine acceptance.¹⁶

Vaccine acceptance in people who had not been infected with COVID-19 and participants with a history of COVID-19 disease was same. In line with this, Lazarus et al showed that there was no difference between two groups in receiving vaccine.¹²

Various factors affect the acceptance of vaccine and people have concerns about vaccine. Recognizing these concerns and designing appropriate strategies to solve them increases overall coverage of the COVID-19 vaccine. One of the most important reasons for rejecting the vaccine is the concerns about side effects of vaccine.¹ Results of our study showed that the most important reason for refraining from vaccination was concern about its side effects. Contrary to our results, a recent study conducted in Iran and several countries showed that the most important reason for rejecting the vaccine was lack of confidence in the vaccine.¹⁴

In our study, about 77.3% of participants were concerned about the side effects of the vaccine, and this seems to be one of the most important barriers to vaccination. One study by Akarsu et al indicated that the most reasons of COVID-19 vaccine rejection were fear of vaccine, side effects and distrust in vaccine efficacy.¹⁷In compliance with previous study, Pugliese-Garcia et al reported that fear of infection with the COVID-19 through vaccination and the belief that the vaccine was ineffective were among the most important reasons for not receiving the vaccine.¹⁸Lazarus et al reported that religious motivation was a negative factor in vaccine acceptance,¹² while the results of our study showed that religious beliefs are not barriers of vaccine acceptance. One of our hypotheses was that people with comorbidities would be more likely to receive the vaccine, and the results showed that vaccine acceptance in this group was higher than healthy individuals. In a study by Harapan et al in Indonesia, people at higher risk for COVID-19 were more likely to be vaccinated.²

Also, one of the unique features of our study was evaluating of people’s attitude about type of vaccine. The results showed that most people were willing to receive the Iranian vaccine. Our study had some limitations, such as the use of only online questionnaires instead of face-to-face interview Also another limitation was the small number of the studied population, so it is suggested that future studies be conducted in a larger statistical population.

Conclusion

Results of this study showed that there are several factors affects COVID-19 vaccine acceptance. One of the most important factor is the fear of the COVID-19 vaccine side effects. Age, sex and level of education also affected vaccine acceptance. Results of this study can promote vaccine acceptance.

Acknowledgements

This work was supported by a grant from Birjand University of Medical Sciences.

Author’s Contribution

Conceptualization: Mostafa Abdollai.

Data curation: Mostafa Abdollai, Ayub Ayar.

Formal analysis: Mohammad Khorashadizadeh.

Funding acquisition: Mostafa Abdollai.

Investigation: Mostafa Abdollai, Ayub Ayar.

Methodology: Mostafa Abdollai, Ayub Ayar.

Project administration: Mostafa Abdollai.

Resources: Mostafa Abdollai, Ayub Ayar.

Supervision: Hamideh Kouhpeikar.

Validation: Mostafa Abdollai, Ayub Ayar. Hamideh Kouhpeikar.

Visualization: Hamideh Kouhpeikar.

Writing–original draft: Hamideh Kouhpeikar.

Writing–review & editing: Hamideh Kouhpeikar.

COI-statement

The authors declare that they have no conflict of interest.

Data Availability

The findings of this study will be available upon request from the corresponding author.

Ethical Approval

This study was approved by the ethics committee of Birjand University of Medical Sciences (IR.BUMS.REC.1399.485).

Funding

This study was funded by Birjand University of Medical Sciences.

Research Highlights

References

1. Beliefs and barriers associated with COVID-19 vaccination among the general population in Saudi Arabia. BMC Public Health 2021; 21(1):1438. doi: 10.1186/s12889-021-11501-5 [Crossref]
2. Acceptance of a COVID-19 vaccine in Southeast Asia: a cross-sectional study in Indonesia. Front Public Health 2020; 8:381. doi: 10.3389/fpubh.2020.00381 [Crossref]
3. Developing Covid-19 Vaccines at Pandemic Speed. N Engl J Med 2020; 382(21):1969-1973. doi: 10.1056/NEJMp2005630 [Crossref]
4. Askarian M, Fu L, Taghrir MH, Borazjani R, Shayan Z, Taherifard E, et al. Factors Affecting COVID-19 Vaccination Intent Among Iranians: COVID-19 Vaccination Acceptance. 2020. Available at SSRN: https://ssrn.com/abstract=3741968.
5. Measuring trust in vaccination: a systematic review. Hum Vaccin Immunother 2018; 14(7):1599-609. doi: 10.1080/21645515.2018.1459252 [Crossref]
6. Vaccine hesitancy and perceived behavioral control: a meta-analysis. Vaccine 2020; 38(33):5131-8. doi: 10.1016/j.vaccine.2020.04.076 [Crossref]
7. Willingness of future A/H7N9 influenza vaccine uptake: a cross-sectional study of Hong Kong community. Vaccine 2015; 33(38):4737-40. doi: 10.1016/j.vaccine.2015.07.046 [Crossref]
8. Vaccine hesitancy around the globe: analysis of three years of WHO/UNICEF Joint Reporting Form data-2015-2017. Vaccine 2018; 36(26):3861-7. doi: 10.1016/j.vaccine.2018.03.063 [Crossref]
9. Prevalence of influenza vaccine hesitancy at a tertiary care hospital in Riyadh, Saudi Arabia. J Infect Public Health 2018; 11(4):491-9. doi: 10.1016/j.jiph.2017.09.002 [Crossref]
10. Prevalence of vaccine hesitancy among expectant mothers in Houston, Texas. Acad Pediatr 2018; 18(2):154-60. doi: 10.1016/j.acap.2017.08.003 [Crossref]
11. Parental vaccine hesitancy in Italy–results from a national survey. Vaccine 2018; 36(6):779-87. doi: 10.1016/j.vaccine.2017.12.074 [Crossref]
12. A global survey of potential acceptance of a COVID-19 vaccine. Nat Med 2021; 27(2):225-8. doi: 10.1038/s41591-020-1124-9 [Crossref]
13. The French public’s attitudes to a future COVID-19 vaccine: the politicization of a public health issue. Soc Sci Med 2020; 265:113414. doi: 10.1016/j.socscimed.2020.113414 [Crossref]
14. Peoples’ attitude toward COVID-19 vaccine, acceptance, and social trust among African and Middle East countries. Health Promot Perspect 2021; 11(2):171-8. doi: 10.34172/hpp.2021.21 [Crossref]
15. Vaccine hesitancy in the era of COVID-19. Public Health 2021; 194:245-51. doi: 10.1016/j.puhe.2021.02.025 [Crossref]
16. Salali GD, Uysal MS. COVID-19 vaccine hesitancy is associated with beliefs on the origin of the novel coronavirus in the UK and Turkey. Psychol Med. 2020: 1-3. 10.1017/s0033291720004067
17. While studies on COVID-19 vaccine is ongoing, the public’s thoughts and attitudes to the future COVID-19 vaccine. Int J Clin Pract 2021; 75(4):e13891. doi: 10.1111/ijcp.13891 [Crossref]
18. Factors influencing vaccine acceptance and hesitancy in three informal settlements in Lusaka, Zambia. Vaccine 2018; 36(37):5617-24. doi: 10.1016/j.vaccine.2018.07.042 [Crossref]