Prevalence, Knowledge and Potential Determinants of COVID-19 Vaccine Acceptability Among University Students in the United Arab Emirates: Findings and Implications

Abstract

Objective: To evaluate the prevalence, knowledge, attitude and acceptance of the COVID-19 vaccines and related factors among university students in the United Arab Emirates.

Methods: Analytical cross-sectional study undertaken among a convenient sample of medical and non-medical colleges of Ajman University using a self-administrated questionnaire. The questionnaire included demographic data as well as assessing knowledge of COVID-19, attitudes and acceptance of COVID-19 vaccines.

Results: A total of 467 students participated in the study and completed the questionnaire. A total of 181 (38.8%) participants reported that they have been vaccinated against COVID-19 virus, principally with the Sinopharm vaccine (84%). Vaccination against the COVID-19 virus was less prevalent among Arabic nationalities compared to other nationalities, but more prevalent among students from health science colleges compared to those from non-health science colleges. The acceptance rate of COVID-19 vaccine among study participants was 56.3%, exacerbated by worries regarding unforeseen problems (65.5%, 306), general mistrust (47.3%, 221) and unforeseen impacts (35.1%, 164). The average knowledge score was 60.1%, with 142 (30.4%) having poor knowledge, 127 (27.2%) acceptable knowledge and 198 (42.4%) good knowledge. There were common misconceptions about symptoms including nausea and diarrhoea, as well as the route of transmission, with half believing antibiotics are effective treatment.

Conclusion: There was variable knowledge of COVID-19 among students. Misconceptions need addressing going forward. To enhance COVID-19 vaccination uptake in the country and worldwide, health education targeting diverse sociodemographic categories should be prioritized.

Introduction

COVID-19 has now spread worldwide with over 230 million infected and over 4 million deaths by September.¹ In the United Arab Emirates, there has been over 733,000 cases reported and 2000 deaths as of 22 September 2021.²

Most people who get infected with COVID-19 will experience mild-to-moderate symptoms and recover without special treatment; however, an appreciable number will still have severe illness until vaccination rates increase, with this often-continuing post discharge, and some will die.^3–6

The virus that causes COVID-19 is mainly transmitted through droplets generated when an infected person coughs, sneezes, or exhales.^7,8 Countries within Africa and Asia that introduced preventative measures early appeared to have lower prevalence and morbidity rates than countries than introduced such measures later on such as Western European countries certainly during the early stages of the pandemic.^9–11

The knowledge, attitude and practices of an illness that is infectious will always be influenced by several factors that depend on the gravity and spread as well as case fatality rates. While knowledge, attitude and practices have been increasing regarding COVID-19 since the start of the pandemic, there is still an incomplete picture regarding its pathophysiology and treatment.^12–14 This is important as there has been considerable fear of contracting COVID-19 among populations, with effective vaccines potentially helping to reduce this.^15,16 There are currently over 176 vaccines in their early development and 66 in clinical trials, while 10 have already reached the final stage and are being tested on patients.^17,18

The Ministry of Health in UAE has currently accepted four vaccines (Sinopharm, AstraZeneca, Pfizer-BioNTec, and Sputnik V). Each one has been developed in a different vaccine platform.¹⁹

We are aware of concerns regarding COVID-19 vaccine acceptance, building on general concerns to vaccines fuelled by social media.^20–30 This is perhaps not surprising given the general level of misinformation there has been regarding COVID-19 including the hype surrounding the use of hydroxychloroquine for management and prevention, which led to deaths in some countries.^31,32 In addition, the novel technology used enhances scepticism among some since there is no prior experience or success with such vaccines. Alongside this, the speed of the development and registration of the vaccines, which took less than a year, with worries about potential effectiveness and safety in routine clinical use.^33–35 However, it is vital for any successful vaccination campaign that concerns with vaccines which fuel vaccine hesitancy rates are addressed to maximise their clinical and economic benefits.^26,36–38

Published studies have shown a range of vaccine hesitancy rates across countries and populations. In their global survey, Lazarus et al found that vaccine acceptance rates ranged from 90% in China to less than 55% in Russia.²⁸ In their systematic review, Sallam (2021) also found considerable variation among the general adult population, with acceptance rates ranging from 97% in Ecuador to 28.4% in Jordan and 23.6% in Kuwait.²³ Studies in sub-Saharan Africa suggest acceptance rates of 51%, with rates of 67% in Saudi Arabia.³⁹ There have been similar variations in the acceptance of the COVID-19 vaccine among healthcare workers (HCWs). In his systematic review, Sallam documented acceptance rates varying from 78.1% in Israel to only 27.7% in the Congo.^23,40 Other published studies have shown similar variations among HCWs.^41–44 We have also seen considerable variation among students including health science students across countries, with vaccine hesitancy rates higher in low- and middle-income countries.^12,45

Positive reasons for accepting the vaccine include helping society including enhancing the health and the financial situation of a country.^46,47 Reasons for hesitancy include issues of mistrust/confidence in the vaccine and the Government, available information and recommendations, as well as issues of their effectiveness and safety.^29,30,48,49 Encouragingly, hesitancy rates appear to decrease as more information becomes available.²⁹

Additional factors that influence decision-making regarding the acceptance of the vaccine include attitude, sociodemographic factors including the level of education, political views, and beliefs regarding COVID-19.^50–54

We believe to date there have been limited studies assessing vaccine hesitancy in the United Arab Emirates (UAE) although there have been concerns with high rates of vaccine hesitancy among the population in Arab countries as well as among parents of young adults.^23,55–57 However, this is not universal.^58–60 Consequently, our aim was to evaluate the acceptance of the COVID-19 vaccination and the related factors among university students in UAE. We chose university students for this initial study as a number of these people will become influential in the future. This includes those studying health sciences and potentially treating patients.

Methods Study Design and Setting

Using an analytical cross-sectional study approach,^57,61 the prevalence, knowledge, attitude and acceptance of the COVID-19 vaccination were assessed among students of Ajman University. Potential participants were sent a link to the online questionnaire via email, and the data were collected from 6 March to 20 August 2021.

Study Participants (Inclusion and Exclusion Criteria)

The target population was the students, both UAE nationals and non-national residents, at Ajman University. The inclusion criteria were 1) aged 18 and above and 2) willing to participate in the study.

Questionnaire Development

The questionnaire used in this study was derived from a review of similar studies that evaluated participants' knowledge of and attitude towards the COVID-19 vaccine.^62,63 Based on this review, existing surveys were adapted to develop a structured self-administered questionnaire that evaluated all key research points and was suitable for the target population. Subject experts were asked to review and assess the questionnaire's design, content, relevance, readability and comprehensibility. Subsequently, three pharmacy lecturers at Ajman University (AU) validated the questionnaire, and some minor changes were made in response to their feedback. An additional pilot study of the questionnaire was then performed before it was fully implemented. The pilot study and the consequent changes to the instrument ensured its reliability and robustness. The responses from the pilot study's 23 participants were not included in the final analysis. The reliability of the questionnaire was assessed using Cronbach's α, which was found to be 0.79, indicating that the internal consistency was acceptable.

Questionnaire Scoring

The prevalence of vaccination against COVID-19 virus was identified by the answer to the question of "Have you been vaccinated against COVID-19 virus". The acceptance of vaccination against COVID-19 virus was measured by the answer to the question of "It is important to take the vaccine to protect the people from COVID-19". Knowledge about COVID-19 was measured by 24 questions distributed as follows: eight questions evaluated the most likely COVID-19 symptoms, six questions assessed COVID-19 transmission and 10 questions assessed general knowledge about COVID-19. Questions evaluating COVID-19 symptoms and transmission included three items with categorical responses: (yes /no/do not know) wile general knowledge questions included three items with categorical responses: (true /false/do not know).

Correct answers were given a score of 1 point, while a wrong answer was scored 0 points. Questions evaluating attitudes concerning the COVID-19 vaccine included nine items with categorical responses: (agree/disagree). Knowledge scores were calculated for each respondent by summing the grading for the correct responses.

In this study, three cut-off limits were used for grading the knowledge scores based on quadrants. The level of knowledge considered poor if the total knowledge score range was less than 13 (25th quartile), acceptable if scores ranged from 13 to 17 (26–75th quartile) and good if they were greater than 17 points (>75th quartile).

Sample Size and Sampling Technique

Since the prevalence of acceptability of COVID-19 vaccines is 60% according to Albahri et al,⁶³ we set the alpha level to 5% in order to generate 95% confidence intervals. In addition, the precision (D) of the mentioned 95% confidence intervals was set to 5% in order to maximize the spectrum of the 95% at 10%. As a result, we calculated the minimum acceptable sample size needed as n = 527 candidates if we assumed a nonresponse rate of approximately 30%.

With support from the Admission and Registration Department of Ajman University in the form of an Excel datasheet containing staff and student names, colleges, study years, and email addresses, we contacted potential respondents. We used a simple random-sample selection method, wherein we randomly selected the study population using their identification (ID) number. Subsequently, the selected respondents were stratified according to their college and department.

Questionnaire Administration

The questionnaire was designed to be self-administered by the participants, who were randomly preselected using the method outlined earlier and who received a web-based electronic link via email. The questionnaire's first page described the study's nature and purpose. If respondents moved on to the next page, it was considered that they had given their consent to participate. Non-respondents were sent monthly reminders via email, and all participants received a thank-you message upon completion of the study. No incentives were offered to the respondents in return for their participation.

Ethical Consideration

The study was approved the Ajman University Institutional Ethical Review Committee. The study's aim was clearly presented on the questionnaire cover page, and all respondents were informed that their participation was completely voluntary. Participants were considered to have given their consent if they proceeded to the second page of the questionnaire. The participants' identities were not recorded, and the confidentiality of their data was guaranteed.

Statistical Analysis

The data were analysed using the SPSS version 26. Qualitative variables were summarized using frequencies and percentages. Chi square test and univariate logistic regression analysis were used to investigate the association between the vaccination against COVID-19 virus and significant factors. Similarly, multivariate logistic regression was used to evaluate the associations between the acceptance of vaccination against COVID-19 virus and related significant factors. A p value <0.05 was chosen as the criteria to make decisions regarding statistical significance.

Results Demographic and Baseline Characteristics

A total of 467 students participated in the study and completed the questionnaire (Table 1). The majority of participants were female (n=358, 76.7%). Arabian students (n=383, 82%) constituted the largest ethnic group in the study and most of them were aged below 25 years (80.9%). Of the total participants, 69 (14.8%) were first-year students, 101 (21.6%) second-year students, 100 (21.4%) third-year students, 125 (26.8%) were fourth-year students, 18 (3.9%) were fifth-year students and 54 (11.6%) were master students. Study areas included business administration (18%), 40 (8.6%) dentistry, 17 (3.6%) education and basic sciences, 122 (26.1%) engineering, 31 (6.6%) medicine, 24 (5.1%) information technology, 9 (1.9%) law and 22 (4.7%) mass communication and humanities.

Table 1 Number and Percentages of the Questions of Demographic Characteristics of Study Participants (n=467)

COVID-19 Vaccination Status, Types and Related Perceptions

A total of 181 (38.8%) [95% CI: 34.3–43.2] of the participants reported they had been vaccinated against the COVID-19 virus. Of the 181 participants, 1 (0.6%) received AstraZeneca vaccine, 152 (84%) received the Sinopharm vaccine, 22 (12.2%) received the Pfizer vaccine and 6 (3.3%) did not know what vaccine type they received. The acceptance rate of COVID-19 vaccine among the study participants was 56.3% with a 95% confidence interval ranging between 51.8% and 60.8% (Table 2).

Table 2 Number and Percentages of Questions on Vaccination Status Among Study Participants (n=467)

Vaccination against the COVID-19 virus was less prevalent among Arabic nationalities (OR 0.269; 95% CI 0.080–0.910) compared to other nationalities, but more prevalent among students from health science colleges (OR 1.802; 95% CI 1.214–2.675) compared to those from non-health science colleges (Table 3).

Table 3 COVID-19 Vaccination Status According to Demographic Characteristics

Participants' Knowledge About COVID-19, Symptoms and Transmission

The average knowledge score was 60.1% with a 95% confidence interval (CI) [58.6%, 61.5%]. Of the total participants, 142 (30.4%) have poor knowledge, 127 (27.2%) have acceptable knowledge and 198 (42.4%) have good knowledge.

The results of this study showed misunderstanding of the most common symptoms of COVID-19. More than half participants wrongly identified that nausea, vomiting, diarrhea and no symptoms as most common symptoms of COVID-19. Similarly, the study participants reported poor knowledge regarding the transmission routes of COVID-19. Nearly half participants wrongly identified that airborne, waterborne and insects as the common transmission routes of COVID-19 (Table 4).

Table 4 Number and Percentages of the Questions on Knowledge About COVID-19 Symptoms and Transmission

Another area of concern is that half of the participants believed that antibiotics are an effective treatment for COVID-19 and 58.9% of them believed in evidence that vaccines against pneumonia will protect you against the COVID-19 (Table 5).

Table 5 Number and Percentages of the Questions on General Knowledge About COVID-19

Participants' Attitude About COVID-19 Vaccination

Table 6 shows the participants' perception towards COVID-19 vaccination. Of the total subjects, 65.5% (n=306) worried about unforeseen impacts, 35.1% (n=164) have general mistrust of the benefits of vaccines and 47.3% (n=221) reported the preference of natural immunity. Among the participants, 66% perceived that the government would make the vaccine available free for all citizens, 23.1% believed that most people will refuse to take the COVID-19 vaccine once it's licensed in their country and 35.8% reported that side-effects will prevent them from taking the vaccine. Moreover, 61.7% of the respondents perceived that pharmaceutical companies are going to develop safe and effective COVID-19 vaccines and 34.9% agreed that their decision on taking the vaccine would change depending on the country of manufacture.

Table 6 Number and Percentages of the Questions on Attitude About COVID-19 Vaccination

Factors Associated with the Acceptance of COVID-19 Vaccination

Table 7 displays the multivariate logistic regression analysis for the factors that contributed to the acceptance of COVID-19 Vaccine. The results of this procedure showed individuals with good knowledge about COVID-19 were more likely to accept the vaccine (OR 1.9; 95% CI 1.2–2.94).

Table 7 Multivariate Regression Analysis for the Factors Associated with Acceptance of COVID-19 Vaccine

Individuals who believed that pharmaceutical companies are going to develop safe and effective COVID-19 (OR 5.1; 95% CI 3.2–8.1), and individuals whom their decision on taking the vaccine will change depending on the country of manufacture (OR 2; 95% CI 1.2–3.3), showed a higher acceptance for vaccination against COVID-19 virus However, significantly decreased level of vaccination against COVID-19 virus were observed among students who had mistrust of the vaccines' benefits (OR 0.406; 95% CI 0.245–0.673), were concerned with potential side effects associated with vaccines (OR 0.309; 95% CI 0.31–0.82) and had a preference of natural immunity (OR 0.342; 95% CI 0.213–0.99).

Discussion

We believe this is the first study in the UAE reporting the knowledge, attitude, and practices of students towards the COVID-19 vaccine. The acceptance rate of COVID-19 vaccine among the study participants was 56.3%, with prevalence rates higher among students from the health sciences versus other study areas. This is similar to studies in Japan and the UK, which showed that 62.1% and 64% of the participants were very likely to receive a vaccine against COVID-19, respectively.^46,64 This was enhanced in Japan by 74.9% of participants believing that the vaccine is highly effective.⁶⁴ Similarly, 50.5% of HCWs in Saudi Arabia,⁶⁵ and 49% of participants in Chile would accept the vaccine.²⁹ However, the rates seen in the UAE were considerably higher than 35% among personnel at Jordan University Hospital,⁵⁷ and 27.7% among HCWs in the Democratic Republic of Congo.⁴⁰ Other studies though have shown higher rates of vaccine update than seen in our study. Lim et al found that only 32% if graduate students expressed vaccine hesitancy,⁶⁶ with Riad et al ascertaining worldwide that only 13.9% of the dental students would reject the COVID-19 vaccine.⁶⁷ Barello et al also ascertained that 86.1% of the students in Italy would take the vaccine for COVID-19, with no significant difference between acceptance among healthcare students versus non-healthcare students.¹² Similarly, Almaki et al ascertained that 90.4% of the students in Saudi Arabia would be happy to be vaccinated once they became available.⁵⁹

In this study, the average knowledge score was 60.1%, with 69.6% of participants having good and acceptable knowledge. This is similar to studies undertaken in Egypt and Bangladesh indicating high knowledge towards COVID-19.^68,69 However, other studies have much higher knowledge rates with the vast majority (99.5%) of those surveyed in Northern Nigeria having good knowledge of COVID-19 with similarly high rates (90%) among students in Jordan with social media and the internet key information sources.^60,70 We believe the numerous awareness campaigns regarding coronavirus that the university has undertaken contributed to the high scores in our study; however, further research is needed before we can say anything with certainty. Of concern though, is that 30.1% of the students surveyed had poor knowledge, which we believe came from non-scientific resources given the level of misinformation circulating regarding the vaccines.^71–74 Higher rates of poor knowledge though were seen in a study Nigeria where 96.0% of those surveyed had poor knowledge of the disease, with again social media as the main source of information.⁷⁵

There was also concern with the level of misunderstanding of the most common symptoms of COVID-19 in our study. More than half of the participants mistakenly identified nausea, vomiting, diarrhoea, and no symptoms as the most common symptoms of COVID-19. Similarly, study participants reported poor knowledge regarding the transmission routes of COVID-19. Nearly half of the participants mistakenly identified that airborne, waterborne and insects as the common transmission routes of COVID-19. This compares with findings in Jordan where 72.8% of those surveyed knew that vomiting is not a common symptom of COVID-19, with 61% saying this about diarrhoea.⁵⁹ In our study, common symptoms such as fever, cough, and shortness of breath were chosen by 86.1%, 83.1%, and 88% respectively of those surveyed as common symptoms of COVID-19, with higher rates in Jordan at 94.5%, 90.5%, and 91.9%, respectively. Encouragingly, antibiotic use was only seen as proper in our study by 19.1% of those surveyed, appreciably lower than the rate of 79.4% reported in Jordan.⁵⁹ This is welcomed since only a small minority of patients with COVID-19 have concomitant bacterial or fungal infections necessitating antibiotics, with overuse likely to drive up antimicrobial resistance rates and costs.^38,76–78

Encouragingly as well, 66% of the participants perceived that the government would make the vaccine available free for all citizens, with 61.7% perceiving pharmaceutical companies will develop safe and effective COVID-19 vaccines. Whilst there have been studies ascertaining levels of willingness-to-pay for COVID-19 vaccines, uptake will be enhanced if available without any patient co-payments.^79,80 However, this could be difficult to sustain long-term potentially requiring a hybrid approach among countries based on income levels and risk.^81–83 23.1% believed that most people will refuse to take COVID-19 vaccine once licensed. This is exacerbated by 35.8% reporting that side effects would prevent them from taking the COVID-19 vaccine, and 34.9% agreeing that their decision on taking the vaccine would change depending on the country of manufacture. These issues need to be addressed going forward to reduce vaccine hesitancy as more vaccines become available. This compares with a study in China where 83.3% of participants were willing to take the vaccine once available, with 76.5% believing that the vaccine is beneficial for their health. However, 74.9% showed some concerns and attitudes that was neutral regarding the adverse effects from potential vaccines.⁸⁴

The multivariable analysis indicated a lack of confidence towards the COVID-19 vaccine depending on the country of origin, with 76.5% of participants preferring a vaccine that is domestically manufactured instead of imported.⁸⁴

We are aware our study has several limitations. Firstly, it is a self-reported cross-sectional study and dependent on the participants' honesty and recall ability. Consequently, the findings may be subject to recall bias and influenced by the surroundings during that period. Second, it was an online survey. Consequently, only those participants with access to the internet were able to participate in the study. Finally, in this study, psychological factors regarding the vaccine and any hesitancy were not fully evaluated. These included key issues such as individuals' engagement in extensive information searching as well as discussion with peers and other social media activities. On the other hand, the strengths of our study include the large sample size and its nature to ascertain multiple outcomes and exposures. Consequently overall, we believe our findings are robust providing initial direction to all key stakeholders in the UAE going forward as more groups are surveyed.

Conclusion and Recommendations

In conclusion, the participants had a good knowledge regarding the infection. Concerns with the vaccine were mainly due to its potential side effects and limited trial data on the benefits of the vaccine. To enhance COVID-19 vaccination uptake in the country and worldwide, health education targeting diverse sociodemographic categories should be prioritized. Greater knowledge regarding the effectiveness and side-effects of the vaccine will help with studies showing vaccine hesitancy reduces over time as more knowledge becomes available.^30,54,85,86 This can be facilitated by increasing education among students since we are aware that credible vaccine promoters including physicians can enhance uptake rates.^87,88,89

Acknowledgement

The authors extend their appreciation to Researchers Supporting Project number (RSP-2021/119), King Saud University, Riyadh, Saudi Arabia for funding this work.

Disclosure

The authors declare that they have no conflict of interest to disclose.

References

1. World meter corona virus. COVID-19 corona virus pandemic; September 22, 2021 Available from: https://www.worldometers.info/coronavirus/.AccessedDecember29, 2021 .

2. Coronavirus Update (Live): 122,672,917 Cases and 2,707,289 Deaths from COVID-19 Virus Pandemic - World meter [Internet]. Worldometers.info; 2021. Available from: https://www.worldometers.info/coronavirus/#countries.AccessedDecember29, 2021 .

3. Ministry of Health and WHO respond to first case of COVID-19 in Laos [Internet]. Who.int; 2021 [cited March 19, 2021]. Available from: https://www.who.int/laos/news/detail/24-03-2020-ministry-of-health-and-who-respond-to-first-case-of-covid-19-in-laos.AccessedDecember29, 2021 .

4. O’Driscoll M, Ribeiro Dos Santos G, Wang L, et al. Age-specific mortality and immunity patterns of SARS-CoV-2. Nature. 2021;590(7844):140–145. doi:10.1038/s41586-020-2918-0

5. Garrigues E, Janvier P, Kherabi Y, et al. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. J Infect. 2020;81(6):e4–e6. doi:10.1016/j.jinf.2020.08.029

6. Wang F, Kream RM, Stefano GB. Long-term respiratory and neurological sequelae of COVID-19. Med Sci Monitor. 2020;26:e928996. doi:10.12659/MSM.928996

7. Klompas M, Baker MA, Rhee C. Airborne transmission of SARS-CoV-2: theoretical considerations and available evidence. JAMA. 2020;324(5):441–442. doi:10.1001/jama.2020.12458

8. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020;382(16):1564–1567.

9. Ogunleye OO, Basu D, Mueller D, et al. Response to the novel Corona Virus (COVID-19) pandemic across Africa: successes, challenges, and implications for the future. Front Pharmacol. 2020;11:1205. doi:10.3389/fphar.2020.01205

10. Sefah I, Ogunleye O, Essah D, et al. Rapid assessment of the potential paucity and price increases for suggested medicines and protection equipment for COVID-19 across developing countries with a particular focus on Africa and the implications. Front Pharmacol. 2021;11:2055. doi:10.3389/fphar.2020.588106

11. Afriyie DK, Asare GA, Amponsah SK, Godman B. COVID-19 pandemic in resource-poor countries: challenges, experiences and opportunities in Ghana. J Infect Dev Ctries. 2020;14(8):838. doi:10.3855/jidc.12909

12. Barello S, Nania T, Dellafiore F, Graffigna G, Caruso R. ‘Vaccine hesitancy’among university students in Italy during the COVID-19 pandemic. Eur J Epidemiol. 2020;35(8):781–783. doi:10.1007/s10654-020-00670-z

13. Malande OO, Musyoki MM, Meyer JC, Godman BB, Masika J. Understanding the Pathophysiology of COVID-19: a review of emerging Concepts. EC Paediatr. 2021;10(4):22–30.

14. Abubakar AR, Sani IH, Godman B, et al. Systematic review on the therapeutic options for COVID-19: clinical evidence of drug efficacy and implications. Infect Drug Resist. 2020;13:4673–4695. doi:10.2147/IDR.S289037

15. Cerda AA, García LY. Factors explaining the fear of being infected with COVID-19. In: Health Expectations; 2021.

16. Lopez Bernal J, Andrews N, Gower C, et al. Effectiveness of the Pfizer-BioNTech and Oxford-AstraZeneca vaccines on covid-19 related symptoms, hospital admissions, and mortality in older adults in England: test negative case-control study. BMJ. 2021;373:n1088. doi:10.1136/bmj.n1088

17. Haque A, Pant AB. Efforts at COVID-19 vaccine development: challenges and successes. Vaccines. 2020;8(4):739. doi:10.3390/vaccines8040739

18. World Health Organaisation. The COVID-19 vaccine tracker and landscape compiles detailed information of each COVID-19 vaccine candidate in development by closely monitoring their progress through the pipeline. Available from: https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines.AccessedDecember29, 2021 .

19. Mahase E. Covid-19: Russia approves vaccine without large scale testing or published results. BMJ. 2020;13:370.

20. Kayode OR, Babatunde OA, Adekunle O, Igbalajobi M, Abiodun AK. COVID-19 Vaccine hesitancy: maximising the extending roles of community pharmacists in Nigeria in driving behavioural changes in public health interventions. J Infect Dis Epidemiol. 2021;7:205.

21. Dror AA, Eisenbach N, Taiber S, et al. Vaccine hesitancy: the next challenge in the fight against COVID-19. Eur J Epidemiol. 2020;35(8):775–779. doi:10.1007/s10654-020-00671-y

22. Khan YH, Mallhi TH, Alotaibi NH, et al. Threat of COVID-19 vaccine hesitancy in Pakistan: the need for measures to neutralize misleading narratives. Am J Trop Med Hyg. 2020;103(2):603–604. doi:10.4269/ajtmh.20-0654

23. Sallam M, Dababseh D, Eid H, et al. High rates of COVID-19 vaccine hesitancy and its association with conspiracy beliefs: a study in Jordan and Kuwait among other Arab countries. Vaccines. 2021;9:1. doi:10.3390/vaccines9010042

24. Puri N, Coomes EA, Haghbayan H, Gunaratne K. Social media and vaccine hesitancy: new updates for the era of COVID-19 and globalized infectious diseases. Hum Vaccin Immunother. 2020;16(11):2586–2593. doi:10.1080/21645515.2020.1780846

25. Wilson SL, Wiysonge C. Social media and vaccine hesitancy. BMJ Global Health. 2020;5(10):e004206. doi:10.1136/bmjgh-2020-004206

26. Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. Attitudes to vaccination: a critical review. Soc Sci Med. 2014;112:1–11. doi:10.1016/j.socscimed.2014.04.018

27. Salmon DA, Dudley MZ. It is time to get serious about vaccine confidence. Lancet. 2020;396(10255):870–871. doi:10.1016/S0140-6736(20)31603-2

28. Lazarus JV, Ratzan SC, Palayew A, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nat Med. 2021;27(2):225–228. doi:10.1038/s41591-020-1124-9

29. Cerda AA, García LY. Hesitation and refusal factors in individuals’ decision-making processes regarding a coronavirus disease 2019 vaccination. Front Public Health. 2021;9:626852. doi:10.3389/fpubh.2021.626852

30. Biswas MR, Alzubaidi MS, Shah U, Abd-Alrazaq AA, Shah Z. A scoping review to find out worldwide COVID-19 vaccine hesitancy and its underlying determinants. Vaccines. 2021;9(11):1243. doi:10.3390/vaccines9111243

31. Godman B. Combating COVID-19: lessons learnt particularly among developing countries and the implications. Bangladesh J Med Sci. 2020;19:S103–8.

32. Abena PM, Decloedt EH, Bottieau E, et al. Chloroquine and hydroxychloroquine for the prevention or treatment of COVID-19 in Africa: caution for inappropriate off-label use in healthcare settings. Am J Trop Med Hyg. 2020;102(6):1184–1188. doi:10.4269/ajtmh.20-0290

33. Kazi Abdul M, Khandaker Mursheda F. Knowledge, attitude and acceptance of a COVID-19 vaccine: a global cross-sectional study. J Bus Soc Sci. 2020;6:23.

34. Paudel S, Palaian S, Shankar PR, Subedi N. Risk perception and hesitancy toward COVID-19 vaccination among healthcare workers and staff at a medical college in Nepal. Risk Manag Healthc Policy. 2021;14:2253–2261. doi:10.2147/RMHP.S310289

35. Saied SM, Saied EM, Kabbash IA, Abdo SAE. Vaccine hesitancy: beliefs and barriers associated with COVID-19 vaccination among Egyptian medical students. J Med Virol. 2021;93(7):4280–4291. doi:10.1002/jmv.26910

36. Nguyen T, Henningsen KH, Brehaut JC, Hoe E, Wilson K. Acceptance of a pandemic influenza vaccine: a systematic review of surveys of the general public. Infect Drug Resist. 2011;4:197–207. doi:10.2147/IDR.S23174

37. de Figueiredo A, Simas C, Karafillakis E, Paterson P, Larson HJ. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study. Lancet. 2020;396(10255):898–908. doi:10.1016/S0140-6736(20)31558-0

38. Godman B, Egwuenu A, Haque M, et al. Strategies to improve antimicrobial utilization with a special focus on developing countries. Life. 2021;11(6):528. doi:10.3390/life11060528

39. Acheampong T, Akorsikumah EA, Osae-Kwapong J, Khalid M, Appiah A, Amuasi JH. Examining vaccine hesitancy in Sub-Saharan Africa: a survey of the knowledge and attitudes among adults to receive COVID-19 vaccines in Ghana. Vaccines. 2021;9(8):814. doi:10.3390/vaccines9080814

40. Nzaji MK, Ngombe LK, Mwamba GN, et al. Acceptability of vaccination against COVID-19 among healthcare workers in the Democratic Republic of the Congo. Pragmat Obs Res. 2020;11:103. doi:10.2147/POR.S271096

41. Patelarou E, Galanis P, Mechili EA, et al. Factors influencing nursing students’ intention to accept COVID-19 vaccination: a pooled analysis of seven European countries. Nurse Educ Today. 2021;104:105010. doi:10.1016/j.nedt.2021.105010

42. Kwok KO, Li KK, Wei WI, Tang A, Wong SYS, Lee SS. Editor’s choice: influenza vaccine uptake, COVID-19 vaccination intention and vaccine hesitancy among nurses: a survey. Int J Nurs Stud. 2021;114:103854. doi:10.1016/j.ijnurstu.2020.103854

43. Verger P, Scronias D, Dauby N, et al. Attitudes of healthcare workers towards COVID-19 vaccination: a survey in France and French-speaking parts of Belgium and Canada, 2020. Euro Surveill. 2021;26(3):2002047.

44. Biswas N, Mustapha T, Khubchandani J, Price JH. The nature and extent of COVID-19 vaccination hesitancy in healthcare workers. J Community Health. 2021:1–8. doi:10.1007/s10900-020-00805-z

45. Kanyike AM, Olum R, Kajjimu J, et al. Acceptance of the coronavirus disease-2019 vaccine among medical students in Uganda. Trop Med Health. 2021;49(1):37. doi:10.1186/s41182-021-00331-1

46. Sherman SM, Smith LE, Sim J, et al. COVID-19 vaccination intention in the UK: results from the COVID-19 vaccination acceptability study (CoVAccS), a nationally representative cross-sectional survey. Hum Vaccin Immunother. 2020;25:1–10.

47. Malik AA, McFadden SM, Elharake J, Omer SB. Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine. 2020;26:100495. doi:10.1016/j.eclinm.2020.100495

48. Wiysonge CS, Ndwandwe D, Ryan J, et al. Vaccine hesitancy in the era of COVID-19: could lessons from the past help in divining the future? Hum Vaccin Immunother. 2021:1–3. doi:10.1080/21645515.2021.1893062

49. Harapan H, Wagner AL, Yufika A, et al. Acceptance of a COVID-19 Vaccine in Southeast Asia: A Cross-Sectional Study in Indonesia. Front Public Health. 2020;8:381.

50. Bell S, Clarke R, Mounier-Jack S, Walker JL, Paterson P. Parents’ and guardians’ views on the acceptability of a future COVID-19 vaccine: a multi-methods study in England. Vaccine. 2020;38(49):7789–7798. doi:10.1016/j.vaccine.2020.10.027

51. Leng A, Maitland E, Wang S, Nicholas S, Liu R, Wang J. Individual preferences for COVID-19 vaccination in China. Vaccine. 2021;39(2):247–254. doi:10.1016/j.vaccine.2020.12.009

52. Detoc M, Bruel S, Frappe P, Tardy B, Botelho-Nevers E, Gagneux-Brunon A. Intention to participate in a COVID-19 vaccine clinical trial and to get vaccinated against COVID-19 in France during the pandemic. Vaccine. 2020;38(45):7002–7006. doi:10.1016/j.vaccine.2020.09.041

53. Gagneux-Brunon A, Detoc M, Bruel S, et al. Intention to get vaccinations against COVID-19 in French healthcare workers during the first pandemic wave: a cross-sectional survey. J Hosp Infect. 2021;108:168–173. doi:10.1016/j.jhin.2020.11.020

54. Walkowiak MP, Walkowiak D. Predictors of COVID-19 vaccination campaign success: lessons learnt from the pandemic so far. a case study from Poland. Vaccines. 2021;9(10):1153. doi:10.3390/vaccines9101153

55. Qunaibi EA, Helmy M, Basheti I, Sultan I. A high rate of COVID-19 vaccine hesitancy in a large-scale survey on Arabs. eLife. 2021;10:e68038.

56. Musa S, Dergaa I, Abdulmalik MA, Ammar A, Chamari K, Saad HB. BNT162b2 COVID-19 vaccine hesitancy among parents of 4023 young adolescents (12–15 years) in Qatar. Vaccines. 2021;9(9):981. doi:10.3390/vaccines9090981

57. Aloweidi A, Bsisu I, Suleiman A, et al. Hesitancy towards COVID-19 vaccines: an analytical cross-sectional study. Int J Environ Res Public Health. 2021;18(10):10. doi:10.3390/ijerph18105111

58. Alamer E, Hakami F, Hamdi S, et al. Knowledge, attitudes and perception toward COVID-19 vaccines among adults in Jazan Province, Saudi Arabia. Vaccines. 2021;9(11):1259. doi:10.3390/vaccines9111259

59. Almalki MJ, Alotaibi AA, Alabdali SH, et al. Acceptability of the COVID-19 vaccine and its determinants among university students in Saudi Arabia: a cross-sectional study. Vaccines. 2021;9(9):943. doi:10.3390/vaccines9090943

60. Alzoubi H, Alnawaiseh N, Al-Mnayyis A, Lubad MA, Aqel A, Al-Shagahin H. COVID-19-knowledge, attitude and practice among medical and non-medical university students in Jordan. J Pure Appl Microbiol. 2020;14(1):17–24. doi:10.22207/JPAM.14.1.04

61. Habib MA, Dayyab FM, Iliyasu G, Habib AG. Knowledge, attitude and practice survey of COVID-19 pandemic in Northern Nigeria. PLoS One. 2021;16(1):e0245176. doi:10.1371/journal.pone.0245176

62. El-Elimat T, AbuAlSamen MM, Almomani BA, Al-Sawalha NA, Alali FQ. Acceptance and attitudes toward COVID-19 vaccines: a cross-sectional study from Jordan. PLoS One. 2021;16(4):e0250555. doi:10.1371/journal.pone.0250555

63. Albahri AH, Alnaqbi SA, Alshaali AO, Alnaqbi SA, Shahdoor SM. COVID-19 vaccine acceptance in a sample from the United Arab Emirates general adult population: a cross-sectional survey, 2020. Front Public Health. 2021;9:614499.

64. Machida M, Nakamura I, Kojima T, et al. Acceptance of a COVID-19 VAccine in Japan during the COVID-19 pandemic. Vaccines. 2021;9(3):210. doi:10.3390/vaccines9030210

65. Qattan A, Alshareef N, Alsharqi O, Al Rahahleh N, Chirwa GC, Al-Hanawi MK. Acceptability of a COVID-19 vaccine among healthcare workers in the Kingdom of Saudi Arabia. Front Med. 2021;8:83. doi:10.3389/fmed.2021.644300

66. Lim LJ, Lim AJW, Fong KK, Lee CG. Sentiments regarding COVID-19 vaccination among graduate students in Singapore. Vaccines. 2021;9(10):1141. doi:10.3390/vaccines9101141

67. Riad A, Abdulqader H, Morgado M, et al. Global prevalence and drivers of dental students’ COVID-19 vaccine hesitancy. Vaccines. 2021;9(6):566. doi:10.3390/vaccines9060566

68. Abdelhafiz AS, Mohammed Z, Ibrahim ME, et al. Knowledge, perceptions, and attitude of Egyptians towards the novel coronavirus disease (COVID-19). J Community Health. 2020;45(5):881–890. doi:10.1007/s10900-020-00827-7

69. Islam MS, Siddique AB, Akter R, et al. Knowledge, attitudes and perceptions towards COVID-19 vaccinations: a cross-sectional community survey in Bangladesh. medRxiv. 2021. doi:10.1101/2021.02.16.21251802

70. Reuben RC, Danladi MM, Saleh DA, Ejembi PE. Knowledge, attitudes and practices towards COVID-19: an epidemiological survey in North-Central Nigeria. J Community Health. 2020;7:1–4.

71. Haque M, Godman B. Key findings regarding COVID 19 in Bangladesh and wider and their implications. Bangladesh J Med Sci. 2021;20:S199–205.

72. Islam MS, Kamal AM, Kabir A, et al. COVID-19 vaccine rumors and conspiracy theories: the need for cognitive inoculation against misinformation to improve vaccine adherence. PLoS One. 2021;16(5):e0251605. doi:10.1371/journal.pone.0251605

73. Sallam M, Dababseh D, Eid H, et al. Low COVID-19 vaccine acceptance is correlated with conspiracy beliefs among university students in Jordan. Int J Environ Res Public Health. 2021;18(5):5. doi:10.3390/ijerph18052407

74. Chowdhury N, Khalid A, Turin TC. Understanding misinformation info Demic during public health emergencies due to large-scale disease outbreaks: a rapid review. Z Gesundh Wiss. 2021;1–21. doi:10.1007/s10389-021-01565-3

75. Enitan SS, Oyekale AO, Akele RY, et al. Assessment of knowledge, perception and readiness of Nigerians to participate in the COVID-19 vaccine trial. Int J Vaccines Immun. 2020;4(1):1–3.

76. Langford BJ, So M, Raybardhan S, et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020;26(12):1622–1629. doi:10.1016/j.cmi.2020.07.016

77. Langford BJ, So M, Raybardhan S, et al. Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis. Clin Microbiol Infect. 2021;27(4):520–531. doi:10.1016/j.cmi.2020.12.018

78. Hsu J. How covid-19 is accelerating the threat of antimicrobial resistance. BMJ. 2020;369:m1983. doi:10.1136/bmj.m1983

79. Sprengholz P, Betsch C. Comment on: “Willingness to Pay for a COVID-19 Vaccine”. Appl Health Econ Health Policy. 2021;19(4):619–621. doi:10.1007/s40258-021-00656-2

80. Dias-Godói IP, Tadeu Rocha Sarmento T, Afonso RE, et al. Acceptability and willingness to pay for a hypothetical vaccine against SARS CoV-2 by the Brazilian consumer: a cross-sectional study and the implications. Expert Rev Pharmacoecon Outcomes Res. 2021:1–11. doi:10.1080/14737167.2021.1931128

81. Harapan H, Wagner AL, Yufika A, et al. Willingness-to-pay for a COVID-19 vaccine and its associated determinants in Indonesia. Hum Vaccin Immunother. 2020;16(12):3074–3080. doi:10.1080/21645515.2020.1819741

82. Cerda AA, García LY. Willingness to pay for a COVID-19 vaccine. Appl Health Econ Health Policy. 2021;19(3):343–351. doi:10.1007/s40258-021-00644-6

83. García LY, Cerda AA. Authors’ Reply to Sprengholz and Betsch: “Willingness to Pay for a COVID-19 Vaccine”. Appl Health Econ Health Policy. 2021;19(4):623–624. doi:10.1007/s40258-021-00657-1

84. Chen M, Li Y, Chen J, et al. An online survey of the attitude and willingness of Chinese adults to receive COVID-19 vaccination. Hum Vaccin Immunother. 2021;25:1–10.

85. Riad A, Schünemann H, Attia S, et al. COVID-19 Vaccines Safety Tracking (CoVaST): protocol of a multi-center prospective cohort study for active surveillance of COVID-19 vaccines’ side effects. Int J Environ Res Public Health. 2021;18(15):7859. doi:10.3390/ijerph18157859

86. Riad A, Pokorná A, Klugarová J, et al. Side effects of mRNA-based COVID-19 vaccines among young adults (18–30 years old): an independent post-marketing study. Pharmaceuticals. 2021;14(10):1049. doi:10.3390/ph14101049

87. Jin Q, Raza SH, Yousaf M, Zaman U, Siang JMLD. Can communication strategies combat COVID-19 vaccine hesitancy with trade-off between public service messages and public skepticism? Experimental evidence from Pakistan. Vaccines. 2021;9(7):757. doi:10.3390/vaccines9070757

88. Wang P-W, Ahorsu DK, Lin C-Y, et al. Motivation to have COVID-19 vaccination explained using an extended protection motivation theory among university students in china: the role of information sources. Vaccines. 2021;9(4):380. doi:10.3390/vaccines9040380

89. Faasse K, Newby J. Public perceptions of COVID-19 in Australia: perceived risk, knowledge, health-protective behaviors, and vaccine intentions. Psychol. 2020;11:551004.