Public Health in Practice 3 (2022) 100258

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Public Health in Practice

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Factors related to COVID-19 vaccine hesitancy in Saudi Arabia

Yaser A. Al Naam a, Salah H. Elsafi a, *, Zeyad S. Alkharraz a, Thekra N. Almaqati a,
Ahmed M. Alomar b, Ibrahim A. Al Balawi c, Arulanantham Z. Jebakumar d, Aisha A. Ghazwani a,
Saleh S. Almusabi a, Sattam Albusaili e, Fahad A. Mashwal a, Eidan M. Al Zahrani f
a
Department of Clinical Laboratory Sciences, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
b
Department of Clinical Laboratory Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
c
Vice Deanship of Postgraduate Studies and Research, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
d
Advanced Clinical Simulation Center, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
e
Academic Affairs, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia
f
College Deanship, Prince Sultan Military College of Health Sciences, Dhahran, Saudi Arabia

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: To assess the amount of vaccine hesitancy and its determinants in relation to various demographic,
Vaccine hesitancy social, and personal characteristics among the Saudi population.
COVID-19 Study design: Cross-sectional study.
Pandemic
Methods: we utilized a structured questionnaire on a five point-Likert scale that included immunization process
Saudi Arabia
awareness, perception towards immunization and factors leading to vaccine refusal.
Results: The study included 5965 participants characterized according to various demographical factors. The
participant’s knowledge, perception, and the factors affecting the decision of taking the vaccine were calculated.
About 40.7% had enough information about COVID-19 vaccines and were willing to take it. The participant’s
perception towards COVID-19 vaccines is proportional to their knowledge and varied with the personal char­
acteristics. Factors influencing vaccine use varied also with personal characteristics. Intent to be vaccinated was
higher among older age groups, advanced education, retirees, and higher income persons (P < 0.001). Moreover,
the influence of heterogeneity in personal perception towards COVID-19 vaccines has been discussed. Vaccine
barriers scores were significantly higher among lower educational and income levels (P = 0.004). The leader’s
influence on vaccine decision was high (p < 0.001). The side effects of COVID-19 vaccine is the most important
barrier to vaccine acceptance. Knowledge and perception score were consistently and significantly higher among
the group who received their information from official websites, followed by those who had used both websites
and social media (p < 0.001).
Conclusion: Additional approaches will be needed to effectively meet the needs of the hesitant population,
particularly the safety and efficacy concerns, the speed of vaccine development, and the distrust in government
and health organizations.

1. Introduction disease. Availability of vaccine alone does not always indicate its use by
the public [1]. The public’s reluctance to be vaccinated or refusal of
Worldwide, strict control measures have been adopted to contain the available vaccines undoubtedly contributes to its low acceptability [2].
deadly COVID-19 pandemic, including mass vaccine administration. It is In 2009, when a vaccine for influenza H1N1 vaccine was made available
well known that herd immunity limits the person-to-person spread of during the pandemic, the vaccination coverage was far below expecta­
disease when a large portion of a community becomes immune to a tions, ranging from 0.4 to 59% across 22 countries [3].

* Corresponding author. Clinical Laboratory Science, Prince Sultan Military College of Health Science, P.O. Box 33048, Dammam, 31448, Saudi Arabia.
E-mail addresses: [email protected] (Y.A. Al Naam), [email protected], [email protected] (S.H. Elsafi), [email protected]
(Z.S. Alkharraz), [email protected] (T.N. Almaqati), [email protected] (A.M. Alomar), [email protected] (I.A. Al Balawi), [email protected].
sa (A.Z. Jebakumar), [email protected] (A.A. Ghazwani), [email protected] (S.S. Almusabi), [email protected] (S. Albusaili),
[email protected] (F.A. Mashwal), [email protected] (E.M. Al Zahrani).

https://doi.org/10.1016/j.puhip.2022.100258
Received 5 December 2021; Received in revised form 29 March 2022; Accepted 16 April 2022
Available online 22 April 2022
2666-5352/© 2022 The Authors. Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Y.A. Al Naam et al. Public Health in Practice 3 (2022) 100258

A June 2020 survey carried out in 19 countries to determine the grouped under three parameters that included immunization process
possible COVID-19 vaccine compliance rates and causes of hesitancy awareness (4 questions), perception towards immunization (5 ques­
indicated a wide range of potential acceptance rates from 55% to 90% in tions), and factors leading to vaccine refusal (8 questions).
Russia and China, respectively [4]. A heterogeneous purposive sample of the community who were more
Previous reports have shown that the level and causes of vaccine than 18 years old and were residing in Saudi Arabia during the COVID-
hesitancy are complex and varied by the vaccine itself, geographic re­ 19 pandemic were included in the study. Questions were first validated
gion, health system, availability and accessibility and can be influenced through a pilot test of 61 participants, who were not included in the
by emotional, cultural, social, and political factors as much as cognitive study. Data collected from the pilot test were evaluated for the internal
ones [5]. Reasons for vaccine hesitancy also vary greatly according to consistency reliability of the questionnaire using Cronbach’s alpha
personal characteristic and demographical factors [6]. reliability coefficient, which demonstrated a value of 0.80.
Accurate knowledge and awareness largely affect vaccine acceptance The questionnaire was administered to the participants by a web link
or hesitancy [7]. Lack of knowledge may result in misperceptions that through various social media applications and was made available from
lead to vaccine hesitancy. Other individual factors influencing vaccine February 1 to 31 April 28, 2021.
acceptance are related to the beliefs and perceptions towards disease
prevention. Knowledge and perceptions towards immunization and 2.1. Statistical analysis
prevention of diseases were frequently mentioned in the literature
among the factors that might contribute to vaccine hesitancy [8]. The participants’ knowledge and perception were measured by
Previous particular vaccine experience such as knowledge of some­ questions on a five-point Likert scale rating, ranging from strongly agree
one who suffered from a vaccine preventable disease or an adverse event (5), agree (4), neutral (3), disagree (2), and strongly disagree (1). The
following immunization may also influence hesitancy or willingness to mean score of every question was calculated out of five. The average
vaccinate. Historical influences of a previously unaccepted vaccine can scores of the immunization process awareness were calculated out of 20
also bring about vaccine hesitancy. Trust in government and healthcare points for the four related questions. The average scores of the partici­
providers brings about trust in vaccines and vaccination campaigns. A pant’s perception towards immunization were calculated out of 25
previous study revealed that higher levels of trust in government in­ points for the five related questions. The average scores of the factors
formation sources are more likely to improve vaccine acceptance upon leading to vaccine refusal by the respondents were measured out of 40
employer’s advice [4]. points for the eight related questions.
Complex immunization procedures contribute largely to vaccine Descriptive statistics (frequencies) were completed for all items. The
hesitancy. Perceptions of the potential risks and side effects of vacci­ results were analyzed with the use of SPSS software version 20.0 (SPSS,
nation can affect vaccine acceptance. Moreover, risk awareness, Chicago, Illinois). Internal consistency reliability of the questionnaire
advance education level and higher household income have been shown was measured by Cronbach’s alpha, where coefficients of ≥0.7
to increase the vaccine acceptance. demonstrate acceptable internal consistency. We used bivariate corre­
The media environment can negatively influence vaccination lation between the knowledge, perception, and the factors affecting the
acceptance and contribute to vaccine hesitancy [9]. Influential leaders, COVID-19 vaccine use decision, and one way ANOVA to test the sig­
immunization campaign leadership, and anti- or pro-vaccination groups nificant differences due to various demographic variables. The statistical
can also influence the vaccine coverage. Religion, culture, gender, significance was set at P < 0.05 for all analyses.
socio-economic are also among the vaccine hesitancy contributing fac­
tors [10]. Other factors may include vaccine accommodation facilities, 3. Results
perception of the pharmaceutical industry, personal experience with
vaccination, including fear of pain [11]. Reliability and/or source of Younger age groups of 18–24, 25–34, 35–44, and 45–54, were rep­
supply of vaccine and/or vaccination equipment were also mentioned. resented by 22.0%, 27.5%, 22.4%, and 17.5%, respectively (Table 1).
Moreover, the schedule of the vaccination program and mode of delivery Whereas older age groups of 55–64, 65–74, and 75+ were represented
(e.g., routine program or mass vaccination campaign) can affect the by 8.7%, 1.8%, and 0.2%, respectively. The results indicated an almost
vaccine acceptance [12]. Generally, females, the young, and those of equal representation of males and females of 49.2% and 50.8, respec­
lower income or education level were consistently associated with less tively. The majority of the participants (94.1%) were Saudi citizen. The
intention to be vaccinated [13]. majority of the respondents had a university degree (65.7%) or post­
Characterizing COVID-19 vaccine intentions, perceptions, and trust graduate studies (20.8%), whereas those with primary, elementary, and
in local government and healthcare providers that influence vaccine high schools education were represented by 0.3%, 1.4%, and 11.7%,
decision-making are essential [14]. respectively. The majority of the participants were employed (52.6%),
The extent of COVID-19 vaccine hesitancy by the Saudi community is while unemployed, retirees, and students were represented by 16.8%,
not yet known. Therefore, this study has been proposed to assess the 10.8%, and 19.8%, respectively. Most of the participant belonged to the
amount of vaccine hesitancy and its determinants among the Saudi middle classes with a monthly household’s income of 5001–10000 SAR,
population. 10001–20000 SAR, and 20001–40000 SAR, represented by 22.0%,
32.3%, and 22.2%, respectively, whereas lower income of less than 5000
2. Methods SAR, higher incomes of 40001–60000 SAR, and greater than 60001 SAR
were represented by 8.3%, 6.3%, and 9.0%, respectively. Of the total
This cross-sectional study utilized a structured questionnaire participants of the study 32.5% reported that they had obtained their
designed according to the study’s objectives by the research group information about COVID-19 vaccine from either official websites
following an extensive review of the literature. (governmental/non-governmental), 13.6% from social media (Face­
The Ethics Review Board of Prince Sultan Military College of Health book/Twitter/WhatsApp), 47.2% from both sources. Additionally, 6.8%
Sciences, Dhahran approved this study (IRB Number IRB-2021-CLS- reported a multiple of sources that included broadcasting (television/
001). Every participant signed a written informed consent. radio) journals (newspapers/magazines) and other sources (Family/
The questionnaire includes the demographical variables such as age, Friends/Schools).
gender, nationality, educational level, employment status, and monthly The participant’s response to the questionnaire in a five point-Likert
household income. scale is shown in Table 2. The participant’s knowledge, perception, and
The second part includes 17 statements on a five-point Likert scale the factors affecting the decision of vaccine use were calculated as the
ranging from strongly agree to strongly disagree. These questions were total of those who strongly agreed or agreed and their average score (out

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Y.A. Al Naam et al. Public Health in Practice 3 (2022) 100258

Table 1 Table 3
Demographic factors of the total participants (n = 5965). The participant’s knowledge, perception, and the factors affecting the decision
Demographic Characteristics Frequency Percentage
of COVID-19 vaccine acceptance as the total of those who strongly agreed or
agreed and their average score (out of 5) on the 5-point Likert scale (n = 5965).
Age group
18–24 1310 22.0 SA + Out of
25–34 1639 27.5 A 4
35–44 1337 22.4 Knowledge
45–54 1044 17.5 I have enough information about COVID-19 vaccines and their 40.7 3.24
55–64 517 8.7 safety and are willing to take it.
65–74 105 1.8 COVID-19 vaccines are important for the prevention of the 65.6 3.80
75 and above 13 0.2 infection
Gender It is important to get vaccinated to protect others 72.0 3.97
Male 2932 49.2 COVID-19 vaccines are effective and safe 57.3 3.60
Female 3033 50.8 Time spent on developing safe and effective COVID-19 vaccines 38.1 3.10
Nationality was enough
Saudi 5611 94.1 Perception
Non – Saudi 354 5.9 I believe COVID-19 vaccine is more important than other 39.6 3.16
Employment vaccines
Employed 3137 52.6 I trust pharmaceutical companies in providing safe and effective 46.6 3.32
Student 1180 19.8 COVID-19 vaccine.
Retired 646 10.8 If COVID-19 cases decline, vaccines are no longer needed 24.1 2.61
Unemployed 1002 16.8 I would rather wait to see what other people do 46.6 3.10
Monthly Income (SAR) Factors affecting the vaccine acceptance decision
Below 5000 493 8.3 Media influence 38.6 3.18
5001–10000 1311 22.0 Leader encouragement 59.9 3.70
10,001–20,000 1925 32.3 Religion beliefs 11.3 1.93
20,001–40,000 1325 22.2 Schedule, and long waiting time 26.0 2.64
40.001–60,000 375 6.3 The side effects of COVID-19 vaccine 43.5 3.27
>60,001 536 9.0 Fear of needle 12.8 2.16
Data Source Vaccine campaign location 17.9 2.36
Websites 1932 32.5 Previous vaccine refusal history 24.1 2.73
Social Media 808 13.6
Websites & Social Media 2806 47.2
Others 402 6.8
COVID-19 vaccine use by everyone was agreed upon by 65.6% (3.80)
and 72% (3.97) agreed on the importance of vaccination to protect
others. Out of the total participants 57.3% (3.60) classified COVID-19
Table 2 vaccine as safe. Only 38.1% (3.10) indicated that the time spent on
The participant’s response to the COVID-19 questionnaire in a five point-Likert developing safe and effective COVID-19 vaccine was enough. About
scale (n = 5965). 39.6% (3.16) believed that COVID-19 vaccine is more important than
SA A N D SD other vaccines. In addition, 46.6% (3.32) trusted pharmaceutical com­
Knowledge panies in providing safe and effective COVID-19 vaccine. Only 24.1%
I have enough information about COVID- 11.8 28.9 35.8 18.6 5.0 (2.61) thought that if COVID-19 cases declined, vaccines are no longer
19 vaccines and their safety and willing needed. A substantial number of 46.6% preferred to wait to see what
to take it. other people do with regard to the vaccine acceptance. Out of the total
COVID-19 vaccines are important for the 33.8 31.8 19.4 10.9 4.1
prevention of the infection
respondents, 38.6% (3.18 out of 5) of the participants agreed that the
It is important to get vaccinated to protect 38.3 33.7 17.5 7.6 3.0 media had influenced their vaccine use decision. The leader’s influence
others on vaccine decision was reported by 59.9% (3.7 out of 5). The influence
COVID-19 vaccines are effective and safe 22.9 34.4 26.9 11.2 4.6 of religion on vaccine use decision was reported by 11.3% of the par­
Time spent on developing safe and 10.8 27.3 31.0 22.4 8.5
ticipants (1.93 out of 5). The side effects of COVID-19 vaccine is an
effective COVID-19 vaccines was enough
Perception important barrier to taking the vaccine reported by 43.5% of the par­
I believe COVID-19 vaccine is more 14.3 25.3 30.0 22.7 7.6 ticipants (3.27 out of 5). Complicated procedure and long waiting time
important than other vaccines reported by 26.0% of the participants (2.64 out of 5). Moreover, 24.1%
I trust pharmaceutical companies in 15.4 31.2 31.4 14.0 8.0 (2.73 out of 5) reported that previous vaccine refusal history influenced
providing safe and effective COVID-19
vaccine.
their decision to be vaccinated. Other minor vaccine barriers included
If COVID-19 cases decline, vaccines are no 7.6 16.5 19.4 42.9 13.6 vaccine campaign location (17.9% and 2.36 out of 5), fear of needle
longer needed (12.8%, and 2.16 out of 5), and the least one was religion influence
I would rather wait to see what other 18.4 28.2 27.4 21.4 4.6 (11.3% and 1.93 out of 5).
people do
Table 4 showed average knowledge score (out of 25), perception (out
Factors affecting the vaccine acceptance decision
The decision to get vaccinated is affected by of 20), and barriers (out of 40) and the significance difference of these
• Media 17.1 21.5 32.8 19.9 8.7 parameters with respect to various demographical factors.
• Leader encouragement 33.9 26.0 21.7 12.7 5.6 The average knowledge scores of male is higher than the females
• Religion beliefs 4.1 7.2 8.0 39.2 41.5 being 15.78 and 15.57, respectively. Knowledge significantly increased
• Schedule, and long waiting time 8.8 17.2 20.9 35.8 17.4
as age and education level increased. No marked difference was noticed
• The side effects of COVID-19 vaccine 18.5 25.0 26.5 24.5 5.5
• Fear of needle 3.8 9.0 12.3 49.3 25.6 with either nationality, employment, or household income. Similarly,
• Vaccine campaign location 5.4 12.5 16.0 45.2 20.9 the perception scores of males was higher than their female peers, being
• Previous vaccine refusal history 7.0 17.1 29.2 35.3 11.4 14.71 and 14.22, respectively. The average perception scores signifi­
cantly increased as the age advanced. The average perception scores
significantly varied with employment status, and household income, but
of 5) on the 5-point Likert scale (see Table 3).
not with nationality and education levels. Retirees and students showed
About 40.7% (3.24 out of 5) reported they had enough information
better perception than the employed ones. The unemployed group
about COVID-19 vaccines and were willing to take it. The importance of

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Table 4
Average knowledge, perception, and barriers against COVID-19 vaccines with the 95% confidence interval (CI) and significance level (P) of the participants according
to various demographical variable (n = 5965).
Variables No. Average knowledge score out of 25 (95% CI) P Average perception score out of 20 (95% CI) P value Average barriers score out of 40
(95% CI)

Age group
18–24 1310 15.64 (15.49–15.79) 0.001 14.79 (14.58–15.00) <0.001 21.69 (21.42–21.97) <0.001
25–34 1639 15.49 (15.36–15.62) 14.05 (13.86–14.24) 21.76 (21.51–22.00)
35–44 1337 15.65 (15.52–15.79) 14.27 (14.08–14.47) 22.27 (22.00–22.54)
45–54 1044 15.93 (15.78–16.08) 14.57 (14.37–14.78) 22.38 (22.10–22.67)
55–64 517 15.87 (15.69–16.06) 14.99 (14.70–15.28) 21.67 (21.27–22.06)
65–74 105 15.93 (15.49–16.38) 15.49 (14.93–16.05) 22.26 (21.27–23.25)
≥75 13 15.23 (12.22–18.24) 15.31 (12.80–17.82) 24.38 (19.53–29.23)
Total 5965 15.68 (15.61–15.74) 14.46 (14.37–14.56) 21.97 (21.85–22.10)
Gender
Male 2932 15.78 (15.69–15.88) 0.002 14.71 (14.58–14.84) <0.001 21.98 (21.79–22.16) 0.962
Female 3033 15.57 (15.48–15.67) 14.22 (14.09–14.36) 21.97 (21.80–22.14)
Nationality
Saudi 5611 15.66 (15.60–15.73) 0.119 14.48 (14.38–14.58) 0.150 21.90 (21.77–22.03) <0.001
Non Saudi 354 15.88 (15.60–15.17) 14.18 (13.79–14.58) 23.19 (22.63–23.75)
Education level
Primary 18 15.52 (15.37–15.66) 0.007 14.35 (14.14–14.56) 0.091 24.11 (20.92–27.30 0.001
Elementary 82 15.79 (15.25–16.33) 14.43 (14.32–14.55) 22.73 (21.88–23.58)
High school 699 15.96 (15.76–16.16) 14.75 (14.49–15.02) 22.46 (22.11–22.82)
University 3920 15.67 (15.59–15.75) 14.78 (14.11–15.45) 21.97 (21.81–22.12)
Postgraduate 1243 16.28 (14.38–18.18) 15.56 (13.86–17.26) 21.64 (21.35–21.93)
Total 5962 15.68 (15.61–15.74) 14.46 (14.37–14.55) 21.97 (21.85–22.10)
Employment
Employed 3137 15.69 (15.60–15.78) 0.189 14.46 (14.33–14.59) <0.001 22.11 (21.93–22.28) 0.170
Student 1180 15.67 (15.52–15.83) 14.64 (14.41–14.86) 21.77 (21.47–22.06)
Retiree 646 15.83 (15.64–16.01) 15.08 (14.84–15.33) 21.85 (21.48–22.21)
Unemployed 1002 15.54 (15.38–15.71) 13.87 (13.64–14.10) 21.89 (21.60–22.17)
Total 5965 15.68 (15.61–15.74) 14.46 (14.37–14.56) 21.97 (21.85–22.10)
Average monthly household income (SAR)
<5000 493 15.65 (15.39–15.92) 14.05 (13.71–14.39) 0.004 22.69 (22.24–23.14) <0.001
5001–10000 1311 15.59 (15.45–15.73) 14.24 (14.03–14.44) 22.57 (22.30–22.84)
10001–20000 1925 15.76 (15.64–15.87) 14.55 (14.38–14.71) 21.94 (21.72–22.16)
20001–40000 1325 15.62 (15.49–15.74) 14.54 (14.34–14.74) 21.51 (21.25–21.78)
40001–60000 375 15.65 (15.37–15.92) 14.78 (14.41–15.14) 21.54 (21.03–22.04)
>60000 536 15.78 (15.56–16.00) 14.69 (14.39–14.99) 21.42 (21.00–21.83)
Total 5965 15.68 (15.61–15.74) 0.423 14.46 (14.37–14.56) 21.97 (21.85–22.10)

reported the least perception score. Vaccine barriers scores are signifi­ obtained in the US where more males intended to get the vaccine than
cantly higher among non-Saudis than the indigenous population. Lower females [14,15]. Knowledge significantly increased as age and educa­
educational levels showed significantly higher barriers scores. Similarly, tion level increased. Younger age groups have been identified before as
the barrier’s scores significantly increased as the average households one of the factors associated with lower intention to vaccinate [14]. No
income decreased. No difference was seen in the barriers scores with marked difference was noticed with either nationality, employment, or
gender and employment status. household income. Similarly, the perception scores of males was higher
Knowledge and perception scores were consistently and significantly than their female peers, being 14.71 and 14.22, respectively. Intent to
higher among the group who received their information from official get vaccinated was higher among those over 60 years of age and those
(governmental/nongovernmental) websites, followed by those who had with a Bachelor’s degree or higher, similar to previous reports [14].
used websites and social media. The use of social media alone resulted in However, another study in the US noted that the intention to take the
the least knowledge and perception scores (Table 5). vaccine is not always translated into positive behavior [16]. Moreover,
Vaccine hesitancy is higher consistently and significantly higher the influence of heterogeneity in personal perceptions towards
among the group who received their information from the social media. COVID-19 vaccines has been reported before [17]. The average
The most common hesitancy reason mentioned among the group perception scores of our respondents significantly varied with age,
who received their information from the social media were the side ef­ employment status, and household income, but not with nationality and
fects of COVID-19 vaccine, complex procedure and negative previous education levels. Retirees and students showed better perception than
vaccine experience. the employed ones. The unemployed group reported the lowest
perception score. The importance of COVID-19 vaccine acceptance by
4. Discussion everyone was agreed upon by 65.6% and 72% agreed on the importance
of vaccination in protecting others. A study in Australia indicated that
Our findings indicated that the awareness level about the importance 80% of their respondents agreed that being vaccinated for COVID-19
of COVID-19 vaccine among the participants is average. About 40.7% would protect them from infection [18].
reported they had enough information about COVID-19 vaccines and The decision to receive a vaccine is influenced by a number of the
were willing to take it. A study conducted among the United States factors including the individual’s perception of the vaccine and the so­
adults prior to the implementation of the vaccine campaign indicated cial environment. The low vaccine acceptance rates are more often
that half of them intended to get a vaccine when made available while attributed to awareness, perceptions of risk from both the disease and
40% were uncertain and the rest preferred to wait and learn [14]. Our the vaccine, access to health care trust, social norms, and beliefs
study indicated that the average knowledge scores of male is higher than regarding the efficacy of vaccine [19–22].
the females being 15.78 and 15.57, respectively. Similar findings were Out of the total participants, 57.3% believed that COVID-19 vaccine

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Y.A. Al Naam et al. Public Health in Practice 3 (2022) 100258

Table 5 indicated that between 50% and 60% of all respondents were willing to
The participant’s knowledge, perception, and the factors affecting the decision take a COVID-19 vaccine, with wide variations across countries [13,28].
of COVID-19 vaccine acceptance according to their information source and A previous study in Saudi Arabia indicated that 64.7% of the total re­
significance level (P). spondents expressed their willingness to take the vaccine when made
Wn= SM n MX n On P available [29]. The side effects of COVID-19 vaccine is an important
1932 = = = barrier to vaccine acceptance reported by 43.5% of the participants
808 2806 402
[30]. Complex procedure and long waiting time was reported by 26.0%
Knowledge of the participants in a similar manner to a previous report [31].
I have enough information 3.42 2.92 3.20 3.28 <0.001 About 24.1% reported that previous vaccine refusal history influ­
about COVID-19 vaccines and
their safety and I am willing to
enced their decision to be vaccinated. Experience from the influenza
take it. vaccines have shown vaccine acceptance has not been optimal, and this
COVID-19 vaccines are 3.97 3.59 3.78 3.67 <0.001 new vaccine, even though it is not approved, is already showing
important for the prevention layperson skepticism compounded by political influences [16]. A pre­
of the infection
vious study indicated a strong relationship between influenza vaccine
It is important to get vaccinated 4.10 3.79 3.95 3.88 <0.001
to protect others history and COVID-19 skepticism.
COVID-19 vaccines are effective 3.79 3.36 3.55 3.49 <0.001 Other minor vaccine barriers included vaccine campaign location
and safe (17.9%), fear of the needle (12.8%), and the least one was religion in­
Time spent on developing safe 3.22 3.15 3.01 3.03 <0.001 fluence (11.3%). Although variation in COVID-19 vaccination rates is
and effective COVID-19
also seen between religious groups [32], Islam has no prohibition to
vaccines was enough
Perception vaccination. There have been several gatherings of Muslim leaders,
I believe COVID-19 vaccine is 3.28 3.14 3.10 3.04 <0.001 scholars, and philosophers to address the theological implications of the
more important than other vaccine. In the Muslim community, the COVID-19 vaccine has been
vaccines
portrayed as a “Western plot” to sterilize Muslim women [33]. It is
I trust pharmaceutical 3.51 3.13 3.26 3.25 <0.001
companies in providing safe therefore important to proactively investigate the likely predictors of
and effective COVID-19 COVID-19 hesitancy among religious groups and start to mobilize key
vaccine actors within existing religious, scientific, and political structures to­
If COVID-19 cases decline, 2.5 2.9 2.6 2.5 <0.001 ward a common goal of vaccination.
vaccines are no longer needed
Knowledge and perception scores were consistently and significantly
I would rather wait to see what 3.20 3.54 3.40 3.22 <0.001
other people do higher among the group who received their information from official
Factors affecting the vaccine acceptance decision (governmental/nongovernmental) websites, followed by those who had
• Media 3.04 3.39 3.23 3.10 <0.001 used websites and social media. The use of social media alone resulted in
• Leader encouragement 3.90 3.51 3.65 3.48 <0.001
the least knowledge and perception scores.
• Religion beliefs 1.96 1.99 1.89 2.00 0.024
• Complex procedure, schedule, 2.63 2.76 2.63 2.52 0.006
Since the availability of COVID-19 vaccine, there has been a broad
and long waiting time range of disinformation and conspiracy theories about its side effects
• The side effects of COVID-19 3.14 3.47 3.30 3.23 <0.001 and effectiveness that led to mistrust and hence contributed to vaccine
vaccine hesitancy [34]. The positive impact of social media in disseminating and
• Fear of needle 2.20 2.31 2.08 2.20
encouraging influenza vaccine intake has been reported before [35].
<0.001
• Vaccine campaign location 2.41 2.39 2.31 2.41 0.019
• Previous vaccine refusal 2.71 2.87 2.70 2.67 0.001 Another study has revealed an association between the use of social
history media and public doubts about vaccine safety. There is a considerable
relationship between foreign disinformation and decreasing rate of
W = Official websites, SM = Social Media, MX = Mixed sources. O = others
(broadcasting, press, schools, families, and friends). vaccination [36]. A substantial group of the UK adult population have
expressed their intention to use social media and personal messaging
applications to encourage others to get COVID-19 vaccine [37]. Overall,
is safe. Concerns over vaccine safety was mentioned frequently among
people who use all media sources, are more likely than other who use
the factors leading to its hesitancy [23]. Only 38.1% thought that the
less media types to be associated with the encouragement of vaccina­
time spent on developing safe and effective COVID-19 vaccine was
tion. Our study indicated that vaccine hesitancy is higher consistently
enough. There has been a fear that the rapid production of COVID-19
and significantly higher among the group who received their informa­
vaccine, based on an underpowered trial, might result in a weakly
tion from the social media. A previous study revealed a significant
effective vaccine that might lead to catastrophic consequences [24].
relationship between social media and public doubts of vaccine safety
Vaccine barriers scores in our study were significantly higher among
[36].
non-Saudis than the indigenous population. Lower educational levels
The most common hesitancy reason mentioned among the group
showed significantly higher barriers scores. Similarly, the barrier’s
who received their information from the social media were the side ef­
scores significantly increased as the average households income
fects of COVID-19 vaccine, complex procedure and negative previous
decreased. However, no difference was seen in the barriers scores with
vaccine experience. Rumors and conspiracy theories may lead to
gender and employment status.
mistrust contributing to vaccine hesitancy [34]. Similar studies con­
The leader’s influence on vaccine decision was reported by 59.9%.
ducted before in Saudi Arabia indicated that the main factors resulted in
Public health and healthcare practitioners, political leaders and poli­
vaccine hesitancy included lack of knowledge, perception toward vac­
cymakers, and communication experts can substantially contribute to
cine effectiveness, and safety concerns [38–41].
COVID-19 vaccine rollout [25]. There will be a need to involve com­
This study clearly indicated that the intention to take the COVID-19
munity leaders with the promotion of a vaccine including cultural,
vaccine varied across demographics, awareness, beliefs, and successful
religious, and political leaders. Leadership may play an important role in
implementation of a COVID-19 campaign.
denying the misleading information that resulted in the mistrust of
Immunization programs can meet the immediate needs of the ac­
vaccines. For example, public health leaders have to advise the public on
ceptors by making vaccines available and accessible. However, addi­
the expected vaccine side effects [14]. The influence of religion on
tional approaches will be needed to effectively meet the needs of the
vaccine use decision was reported by 11.3% of the participants.
hesitant population, particularly the safety and efficacy concerns, the
Vaccine hesitancy varied worldwide [26,27]. Worldwide surveys
speed of vaccine development, and the distrust in government and

5
Y.A. Al Naam et al. Public Health in Practice 3 (2022) 100258

health organizations [14]. Because of low trust in healthcare providers [9] S. Goldstein, N.E. MacDonald, S. Guirguis, J. Eskola, X. Liang, M. Chaudhuri, et al.,
Health communication and vaccine hesitancy, Vaccine 33 (2015), https://doi.org/
and public health, other sources such as community leaders may be
10.1016/j.vaccine.2015.04.042.
effective in amplifying these messages. Emphasizing equity in reaching [10] S.S. Alsubaie, I.M. Gosadi, B.M. Alsaadi, N.B. Albacker, M.A. Bawazir, N. Bin-Daud,
those most vulnerable to COVID-19 and the value of vaccination as a et al., Vaccine hesitancy among Saudi parents and its determinants. Result from the
step toward protecting the community would speak to those who hold WHO SAGE working group on vaccine hesitancy survey tool, Saudi Med. J. 40
(2019).
egalitarian and communitarian worldviews. Vaccine use, and its uni­ [11] E. Dubé, D. Gagnon, E. Nickels, S. Jeram, M. Schuster, Mapping vaccine hesitancy-
versal acceptance, is a social challenge that requires the consideration of Country-specific characteristics of a global phenomenon, Vaccine 32 (2014),
several human factors [25]. https://doi.org/10.1016/j.vaccine.2014.09.039.
[12] T.O. Afifi, S. Salmon, T. Taillieu, A. Stewart-Tufescu, J. Fortier, S.M. Driedger,
The major limitation of this study is that despite the recruitment of Older adolescents and young adults willingness to receive the COVID-19 vaccine:
the participants through a heterogeneous purposive sample, the ma­ implications for informing public health strategies, Vaccine (2021), https://doi.
jority of them belonged to higher educational levels and middle or org/10.1016/j.vaccine.2021.05.026.
[13] E. Robinson, A. Jones, I. Lesser, M. Daly, International estimates of intended
higher classes of income. The study’s findings would have been better uptake and refusal of COVID-19 vaccines: a rapid systematic review and meta-
generalized if more lower classes of education and income were more analysis of large nationally representative samples, Vaccine 39 (2021), https://doi.
represented. org/10.1016/j.vaccine.2021.02.005.
[14] D.A. Salmon, M.Z. Dudley, J. Brewer, L. Kan, J.E. Gerber, H. Budigan, et al.,
COVID-19 vaccination attitudes, values and intentions among United States adults
Funding prior to emergency use authorization, Vaccine 39 (2021), https://doi.org/
10.1016/j.vaccine.2021.03.034.
[15] S.E. Kreps, D.L. Kriner, Factors influencing Covid-19 vaccine acceptance across
This work received no fund subgroups in the United States: evidence from a conjoint experiment, Vaccine
(2021), https://doi.org/10.1016/j.vaccine.2021.04.044.
Authors’ contributions [16] A. Coustasse, C. Kimble, K. Maxik, COVID-19 and vaccine hesitancy: a challenge
the United States must overcome, J. Ambul. Care Manag. 44 (2021), https://doi.
org/10.1097/JAC.0000000000000360.
Yaser Al Naam, Salah Elsafi, Eidan, Ibrahim Al Balawi, Eidan Al [17] J. Shaw, T. Stewart, K.B. Anderson, S. Hanley, S.J. Thomas, D.A. Salmon, et al.,
Zahrani: Conceptualization, Formal analysis, Writing - original draft, Assessment of U.S. health care personnel (HCP) attitudes towards COVID-19
vaccination in a large university health care system, Clin. Infect. Dis. 2021 (2019),
Writing - review & editing. https://doi.org/10.1093/cid/ciab054.
Zeyad Alkharraz, Thekra Almaqati, Arulanantham Z. Jebakumard: [18] H. Seale, A.E. Heywood, J. Leask, M. Sheel, D.N. Durrheim, K. Bolsewicz, et al.,
Formal analysis, Writing - review & editing. Examining Australian public perceptions and behaviors towards a future COVID-19
vaccine, BMC Infect. Dis. 21 (2021), https://doi.org/10.1186/s12879-021-05833-
Ahmed M. Alomar, Aisha A. Ghazwani, Saleh S. Almusabi, Sattam
1.
Albusaili, Fahad A. Mashwal: Data collection, Formal analysis, Writing - [19] E.I. Alfageeh, N. Alshareef, K. Angawi, F. Alhazmi, G.C. Chirwa, Acceptability of a
review & editing. covid-19 vaccine among the saudi population, Vaccines 9 (2021), https://doi.org/
10.3390/vaccines9030226.
[20] G. Troiano, A. Nardi, Vaccine hesitancy in the era of COVID-19, Publ. Health
Ethics statement (2021) 194, https://doi.org/10.1016/j.puhe.2021.02.025.
[21] M. Sallam, Covid-19 vaccine hesitancy worldwide: a concise systematic review of
vaccine acceptance rates, Vaccines 9 (2021), https://doi.org/10.3390/
Ethical clearance was obtained from the Ethics Review Board of
vaccines9020160.
Prince Sultan Military College of Health Sciences; Dhahran approved [22] S. Pullan, M. Dey, Vaccine hesitancy and anti-vaccination in the time of COVID-19:
this study (IRB Number IRB-2021-CLS-001). a Google Trends analysis, Vaccine 39 (2021), https://doi.org/10.1016/j.
vaccine.2021.03.019.
[23] C. Lin, P. Tu, L.M. Beitsch, Confidence and receptivity for covid-19 vaccines: a
Declaration of competing interest rapid systematic review, Vaccines 9 (2021), https://doi.org/10.3390/
vaccines9010016.
[24] V.M. Vashishtha, P. Kumar, Development of SARS-CoV-2 vaccines: challenges,
The authors declare that they have no known competing financial risks, and the way forward, Hum. Vaccines Immunother. 17 (2021), https://doi.
interests or personal relationships that could have appeared to influence org/10.1080/21645515.2020.1845524.
[25] M. Schoch-Spana, E.K. Brunson, R. Long, A. Ruth, S.J. Ravi, M. Trotochaud, et al.,
the work reported in this paper.
The public’s role in COVID-19 vaccination: human-centered recommendations to
enhance pandemic vaccine awareness, access, and acceptance in the United States,
References Vaccine (2020), https://doi.org/10.1016/j.vaccine.2020.10.059.
[26] S. Lane, N.E. MacDonald, M. Marti, L. Dumolard, Vaccine hesitancy around the
globe: analysis of three years of WHO/UNICEF Joint Reporting Form data-
[1] M. Fadda, E. Albanese, L.S. Suggs, When a COVID-19 vaccine is ready, will we all
2015–2017, Vaccine 36 (2018), https://doi.org/10.1016/j.vaccine.2018.03.063.
be ready for it? Int. J. Publ. Health 65 (2020) https://doi.org/10.1007/s00038-
[27] H.J. Larson, C. Jarrett, E. Eckersberger, D.M.D. Smith, P. Paterson, Understanding
020-01404-4.
vaccine hesitancy around vaccines and vaccination from a global perspective: a
[2] R. Reintjes, E. Das, C. Klemm, J.H. Richardus, V. Keßler, A. Ahmad, Pandemic
systematic review of published literature, 2007-2012, Vaccine 32 (2014), https://
public health paradox”: time series analysis of the 2009/10 influenza A/H1N1
doi.org/10.1016/j.vaccine.2014.01.081.
epidemiology, media attention, risk perception and public reactions in 5 European
[28] E. Robertson, K.S. Reeve, C.L. Niedzwiedz, J. Moore, M. Blake, M. Green, et al.,
countries, PLoS One 11 (2016), e0151258, https://doi.org/10.1371/journal.
Predictors of COVID-19 vaccine hesitancy in the UK household longitudinal study,
pone.0151258.
Brain Behav. Immun. 94 (2021), https://doi.org/10.1016/j.bbi.2021.03.008.
[3] J. Mereckiene, S. Cotter, J.T. Weber, A. Nicoll, F. D’Ancona, P.L. Lopalco, et al.,
[29] M. Al-Mohaithef, B.K. Padhi, Determinants of covid-19 vaccine acceptance in Saudi
Influenza A(H1N1)pdm09 vaccination policies and coverage in Europe, Euro
Arabia: a web-based national survey, J. Multidiscip. Healthc. 13 (2020), https://
Surveill. 17 (2012) 1–10, https://doi.org/10.2807/ese.17.04.20064-en.
doi.org/10.2147/JMDH.S276771.
[4] J.V. Lazarus, S.C. Ratzan, A. Palayew, L.O. Gostin, H.J. Larson, K. Rabin, et al.,
[30] K. Sonawane, C.L. Troisi, A.A. Deshmukh, COVID-19 vaccination in the UK:
A global survey of potential acceptance of a COVID-19 vaccine, Nat. Med. 27
addressing vaccine hesitancy, Lancet Reg. Heal. - Eur. 1 (2021), https://doi.org/
(2021) 225–228, https://doi.org/10.1038/s41591-020-1124-9.
10.1016/j.lanepe.2020.100016.
[5] N.E. MacDonald, J. Eskola, X. Liang, M. Chaudhuri, E. Dube, B. Gellin, et al.,
[31] A.B. Coe, M.H. Elliott, S.B.S. Gatewood, J.V.R. Goode, L.R. Moczygemba,
Vaccine hesitancy: definition, scope and determinants, Vaccine 33 (2015)
Perceptions and predictors of intention to receive the COVID-19 vaccine, Res. Soc.
4161–4164, https://doi.org/10.1016/j.vaccine.2015.04.036.
Adm. Pharm. (2021), https://doi.org/10.1016/j.sapharm.2021.04.023.
[6] A. Fisher, S. Mbaeyi, A. Cohn, Addressing vaccine hesitancy in the age of COVID-
[32] Office of National Statistics, Coronavirus and Vaccination Rates in People Aged 70
19, Acad. Pediatr. 21 (2021), https://doi.org/10.1016/j.acap.2021.03.013.
Years and over by Socio-Demographic Characteristic, England - Office for National
[7] G.J. Nowak, K. Sheedy, K. Bursey, T.M. Smith, M. Basket, Promoting influenza
Statistics, 2021, pp. 1–11.
vaccination: insights from a qualitative meta-analysis of 14 years of influenza-
[33] I. Ali, The COVID-19 pandemic: making sense of rumor and fear: Op-Ed, Med.
related communications research by U.S. Centers for Disease Control and
Anthropol. Cross Cult. Stud. Health Illness 39 (2020), https://doi.org/10.1080/
Prevention (CDC), Vaccine 33 (2015), https://doi.org/10.1016/j.
01459740.2020.1745481.
vaccine.2015.04.064.
[34] M.S. Islam, A.H.M. Kamal, A. Kabir, D.L. Southern, S.H. Khan, S.M. Murshid Hasan,
[8] È. Dubé, A. Farrands, T. Lemaitre, N. Boulianne, C. Sauvageau, F.D. Boucher, et al.,
et al., COVID-19 vaccine rumors and conspiracy theories: the need for cognitive
Overview of knowledge, attitudes, beliefs, vaccine hesitancy and vaccine
inoculation against misinformation to improve vaccine adherence, PLoS One 16
acceptance among mothers of infants in Quebec, Canada, Hum. Vaccines
(2021), https://doi.org/10.1371/journal.pone.0251605.
Immunother. 15 (2019), https://doi.org/10.1080/21645515.2018.1509647.

6
Y.A. Al Naam et al. Public Health in Practice 3 (2022) 100258

[35] N. Ahmed, S.C. Quinn, G.R. Hancock, V.S. Freimuth, A. Jamison, Social media use [39] S.M. Alshahrani, S. Dehom, D. Almutairi, B.S. Alnasser, B. Alsaif, A.
and influenza vaccine uptake among White and African American adults, Vaccine A. Alabdrabalnabi, et al., Acceptability of COVID-19 vaccination in Saudi Arabia: a
36 (2018), https://doi.org/10.1016/j.vaccine.2018.10.049. cross-sectional study using a web-based survey, Hum. Vaccines Immunother. 17
[36] S.L. Wilson, C. Wiysonge, Social media and vaccine hesitancy, BMJ Glob. Health 5 (10) (2021) 3338–3347, https://doi.org/10.1080/21645515.2021.1936869.
(2020), https://doi.org/10.1136/bmjgh-2020-004206. [40] K. Al-Mansour, S. Alyahya, F. AbuGazalah, K. Alabdulkareem, Factors affecting
[37] A. Chadwick, J. Kaiser, C. Vaccari, D. Freeman, S. Lambe, B.S. Loe, et al., Online COVID-19 vaccination among the general population in Saudi arabia, Healthcare
social endorsement and covid-19 vaccine hesitancy in the United Kingdom, Soc. (Basel) 9 (9) (2021) 1218, https://doi.org/10.3390/healthcare9091218.
Media Soc. 7 (2021), https://doi.org/10.1177/20563051211008817. [41] Y.S. Alqahtani, Acceptability of the COVID-19 vaccine among adults in Saudi
[38] B.R. Narapureddy, K. Muzammil, M.Y. Alshahrani, A.G. Alkhathami, A. Alsabaani, arabia: a cross-sectional study of the general population in the Southern region of
A.M. AlShahrani, et al., COVID-19 vaccine acceptance: beliefs and barriers Saudi arabia, Vaccines (Basel) 10 (1) (2021) 41, https://doi.org/10.3390/
associated with vaccination among the residents of KSA, J. Multidiscip. Healthc. 24 vaccines10010041.
(14) (2021) 3243–3252, https://doi.org/10.2147/JMDH.S340431.