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Received: month date, 2021 - Accepted: November 25, 2021 - Published online: month date, 2021
narra j
Original Article
Original Article
Acceptance of COVID-19 vaccination at
different hypothetical efficacy and safety
levels in ten countries in Asia, Africa, and
South America
Dott F. Rosiello1, Samsul Anwar2, Amanda Yufika3, Rashed Y. Adam4, Mohajer IH.
Ismaeil5, Asma Y. Ismail6, Nesrine BH. Dahman7, Montacer Hafsi7, Manel Ferjani7,
Farah S. Sami8, Fatma A Monib9, Subramaniam R10, Sunil Anandu11, Md Ariful
Haque12, Lirane ED. Ferreto13, José TO. Aburto14, Jorge ET. Rojas14, Seyi S.
Enitan15, Akele R. Yomi16, Eyiuche D. Ezigbo17, Elham Babadi18, Edris Kakemam19,
Najma I. Malik20, Irfan Ullah21 and Malik Sallam22,23,24*
1Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy; 2Department of
Statistics, Faculty of Mathematics and Natural Sciences, Universitas Syiah Kuala, Banda Aceh, Indonesia; 3Department
of Family Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia; 4Omdurman Teaching
Hospital, Khartoum, Sudan; 5Faculty of Medicine, Alzaiem Alazhari University, Khartoum, Sudan; 6Department of
Internal Medicine, Faculty of Medicine, Sudan International University, Khartoum, Sudan; 7Faculty of Medicine of
Tunis, University of Tunis El Manar, Tunisia; 8Faculty of Medicine, Ain Shams University, Nasr City, Cairo, Egypt;
9Faculty of Medicine, Assiut University, Assiut, Egypt; 10Department of Public Health Dentistry, Indira Gandhi Institute
of Dental Sciences, Nellikuzhi, Kothamangalam, Kerala, India; 11Division of Veterinary Parasitology, ICAR-Indian
Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India; 12Department of Orthopedic Surgery, Yan’an
Hospital Affiliated to Kunming Medical University, Kunming, Yunnan, China; 13Department of Public Health and
Postgraduate Program in Applied Health Sciences, Faculty of Medicine, Western Paraná State University, Brazil;
14Faculty of Medicine, University of La Frontera, Temuco, Chile; 15Department of Medical Laboratory Science, Babcock
University, Ilishan-Remo, Ogun State, Nigeria; 16Department of Medical Laboratory Science, Afe Babalola University,
Ado Ekiti, Nigeria; 17Department of Medical Laboratory Sciences, Faculty of Health Sciences & Technology University of
Nigeria, Enugu State Nigeria; 18Research Fellow, Mayo Clinic, Rochester, USA; 19Iranian Center of Excellence in Health
Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran;
20Department of Psychology, University of Sargodha, Sargodha, Pakistan; 21Department of Internal Medicine, Kabir
Medical College, Gandhara University, Peshawar, Pakistan; 22Department of Pathology, Microbiology and Forensic
Medicine, School of Medicine, The University of Jordan, Amman Jordan; 23Department of Clinical Laboratories and
Forensic Medicine, Jordan University Hospital, Amman Jordan; 24Department of Translational Medicine, Faculty of
Medicine, Lund University, Malmö, Sweden
*Corresponding author: malik.sallam@ju.edu.jo
Abstract
Vaccine hesitancy, defined as the reluctance or rejection in receiving a vaccine despite its
availability, represents a major challenge to global health efforts aiming to control the
ongoing COVID-19 pandemic. Understanding the possible factors correlated with
COVID-19 vaccine hesitancy using a refined well-informed approach can be helpful to
address the phenomenon. The current study aimed to evaluate COVID-19 vaccine
acceptance rates using four hypothetical scenarios of varying levels of vaccine efficacy
and safety profiles in ten Asian, African and South American countries. These scenarios
included: 95% efficacy and 20% side effects (Vaccine A), 75% efficacy and 5% side effects
(Vaccine B); 75% efficacy and 20% side effects (Vaccine C) and 50% efficacy and 5% side
effects (Vaccine D). This study used a self-administered online survey that was
distributed during February–May 2021. The total number of study respondents was 1337
with countries of residence as follows: India (21.1%), Pakistan (12.9%), Sudan (11.2%),
Nigeria (9.3%), Iran (8.2%), Bangladesh and Brazil (7.9%), Chile (7.7%), Tunisia (7.6%),
and Egypt (6.2%). The overall acceptance rates for COVID-19 vaccination were variable
based on varying degrees of safety and efficacy as follows: 55.6% for Vaccine C, 58.3% for
Vaccine D, 74.0% for Vaccine A and 80.1% for Vaccine B. The highest levels of COVID-19
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Original Article
vaccine acceptance were observed in Brazil followed by Chile across the four different
safety and efficacy scenarios. The lowest COVID-19 vaccine acceptance rates were
reported in Egypt and Tunisia for the low safety scenarios (20% side effects), and the low
efficacy scenario (50% efficacy). The study revealed the potential effect of vaccine safety
and efficacy on the intention to get COVID-19 vaccination. At the same efficacy level,
higher possibility of side effects caused a large drop in COVID-19 vaccine acceptance
rate. This indicates the importance of accurate communication regarding vaccine safety
and efficacy on attitude towards the vaccine and intentions to get vaccinated. Regional
differences in COVID-19 vaccine acceptance were observed with the Middle East/North
African countries showing the lowest rates and the South American countries displaying
the highest vaccine acceptance rates.
Keywords: COVID-19, COVID-19 vaccine, acceptance, hesitancy, WHO SAGE
Introduction
The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), has been a major global health threat since first being declared as
a pandemic by the World Health Organization (WHO) in March 2020 [1, 2]. The mitigation
strategies and personal protective measures, such as movement restrictions, social distancing,
and face mask-wearing practices, have been implemented in various countries regarding
COVID-19 prevention [3]. Although such efforts have helped to minimize the spread of SARS-
CoV-2 infection and contributed to the epidemic curve flattening, the pandemic is still ongoing
[4]. The COVID-19 resurgence has been reported coinciding with societies, businesses, and
economies reopening [5, 6], suggesting the urgent need for long-term preventive measures.
Vaccines could be implemented as a long-term protective measure in controlling COVID-19 [7].
Vaccination is a fundamental strategy for controlling and preventing infectious diseases [8,
9]. Given a high rate of COVID-19-associated morbidity and mortality, various COVID-19
vaccines have been developed and manufactured [10, 11]. The first vaccine was developed in
March 2020 by Moderna [10], and as of October 2021, approximately 132 vaccines have
undergone clinical trials on humans; 13 vaccines in limited use; and 8 vaccines have been
permitted for full use at least in one country [12]. Despite the initiation of COVID-19 vaccination
since the beginning of 2021 [13], the total vaccine uptake globally, as of October 2021 was still
less than 50% [14]. Low COVID-19 vaccine coverage is multifactorial [15]; however, vaccine
hesitancy and acceptance significantly affected vaccine decision and vaccination drive [16-19].
Vaccine hesitancy, by the World Health Organization Strategic Advisory Group of Experts
(WHO SAGE), is defined as a “delay in acceptance or refusal of vaccination despite the ability of
vaccination services” [20].
Previous studies have demonstrated high heterogeneity in the willingness to accept
COVID-19 vaccines among different countries worldwide [17, 19]. Various sociodemographic
factors, including race, age, educational level, occupation and income; and attitudes and beliefs
in COVID-19 infection; trust in central government; mistrust or faltering in vaccines safeness;
employers’ mandate or recommendation; belief in conspiracy theories; vaccine effectiveness; as
well as vaccine-associated misinformation spread have significantly contributed to COVID-19
vaccine acceptance or hesitancy [17, 21-26]. Many investigations have been performed
regarding the acceptance of COVID-19 vaccines among societies in high-income countries
(HICs) [22, 25, 27-29]; however, similar studies in countries (LMICs) were still limited and did
not represent all LMICs [19]. In addition, vaccine distribution in HICs is relatively high, while in
LMICs, the distribution has been reportedly low [30]. Given the fact that vaccine uptake in
some LMICs, such as Sudan, Iraq, India is still low (<20%) [13], research regarding vaccine
acceptance among populations in these countries is highly important.
The differences in vaccine acceptance, causing differences in vaccine coverage among
countries, could potentially lead to the delay of the global control of the pandemic, ensuing in
the delay of societal and economic recovery [17]. This is particularly important considering the
continuous emergence of SARS-CoV-2 lineages with potential vaccine escape properties [31].
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Hence, determining the acceptance of COVID-19 vaccines within the community during the
pandemic is highly warranted. Understanding and addressing factors associated with the
willingness to accept a COVID-19 vaccine are crucial as they will help in formulating the best
approach or action to accelerate the global vaccination rate and increase vaccine coverage to
meet the requirements for population immunity worldwide [32]. The aim of this study was to
assess the acceptance of COVID-19 vaccines among communities in ten LMICs in Asia, Africa,
and South America during the COVID-19 pandemic, as well as to explore determinants of
vaccination.
Methods
Study setting and instrument
Between February to May 2021, an online self-administered survey was conducted in four Asian
countries (Bangladesh, India, Iran, and Pakistan), four African countries (Egypt, Nigeria,
Sudan, and Tunisia), and two countries in South America (Brazil and Chile). All the countries
are classified as low- or middle-income countries. The survey was hosted by SurveyMonkey and
to recruit the participants, the invitations to participate in the survey were distributed on three
social media and instant messaging platforms: Facebook, Twitter and WhatsApp. The survey
consisted of several sections. The first introductory section consisted of information about the
study and an informed consent page. Only those who agreed to participate could open the next
sections. The following sections comprised questions collecting information on demographic
characteristics, current health condition, perceived risk towards COVID-19, economic
disruption during COVID-19 pandemic, vaccine hesitancy, and attitudes towards social
distancing. Some of the questions were adopted from previous studies [17, 21, 33]. It required
approximately 10-15 minutes to complete the survey.
Response variables
The response variable of the study was acceptance of the hypothetical COVID-19 vaccines with
different efficacy and safety levels. To assess the COVID-19 vaccine acceptance, the respondents
were provided with a scenario: “Imagine that a new COVID-19 vaccine has just been developed.
It has received the same testing as the adult influenza vaccine. The government is offering it as a
free and optional vaccine.” To assess the effect of vaccine properties, they were asked whether
they would accept a COVID-19 vaccine if the vaccine is [95%, 75% or 50%] effective, with a [5%
or 20%] chance of side effects like fever or local pain. There were four combinations of vaccine
efficacies and the chances of the side effects provided: Vaccine A (95% effective with a 20%
chance of side effects); Vaccine B (75% effective with a 5% chance of side effects); Vaccine C
(75% effective with a 20% chance of side effects); and Vaccine D (50% effective with a 5%
chance of side effects). For each combination, two possible answers were provided: “Yes” and
“No” and no “Unsure” option was provided.
Explanatory variables
Some possible explanatory variables were collected and assessed. Demographic characteristics
were collected and grouped for statistical proposes in the following manner: age (less than 20,
21-30, 31-40, 41-50 and >51 years old), gender, urbanicity (rural and urban), monthly
household income (<US$ 500, $500-$999, $1,000-$1,999, $2,000-$2,999, $3,000-$4,999,
$5,000-$7,999 and ≥$8,000), religion (Islam, Christian (Protestant/Methodist/Lutheran/
Baptist), Catholic, Hindu, and others (Mormon, Greek or Russian Orthodox, Jewish, and
Buddhist), and types of job (healthcare-related sector and non- healthcare-related sector) and
types of occupation (self-employed, employed for wages, out of work for less or more than one
year, homemaker, student and retired or unable to work). Respondents were also asked whether
they had received a flu vaccination in the past 12 months and whether they had comorbidities
condition for COVID-19 such as hypertension, diabetes, cardiopulmonary diseases.
We also asked about the economic disruption experienced by respondents by asking two
questions: “How much your work changed as a result of the COVID-19 pandemic?” and “How
much your salary changed as a result of the COVID-19 pandemic?“ The possible answers for the
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first question were: ”I work fewer hours”, ”No change or not applicable (not working)”, ”I work
more hours“ and “I was let go from my job” while for the last question, three possible responses
were: “I am getting paid less“, “I am getting paid more“ or “No change“.
In addition, the attitude towards the benefit of vaccination and social distancing were
assessed. To assess the vaccine hesitancy, six questions belong to lack of vaccination benefits
construct from the WHO SAGE Vaccine Hesitancy Scale as used before [34] were used: (1)
“Vaccines are important for my health”; (2) “All routine vaccines recommended by the
healthcare workers are beneficial”; (3) “New vaccines carry more risks than older vaccines”; (4)
“The information I receive about vaccines from the government is reliable and trustworthy; and
(5) “Getting vaccines is a good way to protect me from disease”. To assess the towards the
benefits of social distancing, the respondents were asked to what extend they were agree or
disagree to three statements: (1) “Social distancing can protect you from COVID-19”; (b) “Social
distancing can protect your child or children from COVID-19 (if any)”; and (3) “Social
distancing can protect your parents from COVID-19”. The possible responses for each statement
were in 5-Likert scale from “Strongly agree”, ”Agree”, “Neither agree nor disagree”, “Disagree”
and “Strongly disagree”. For statistical purpose, the responses of the individual were classified
as “Disagree” (those who answered disagree and strongly disagree), “Neutral” (neither agree nor
disagree) and “Agree” (those who responded agree or strongly agree).
Statistical analysis
For each type of hypothetical COVID-19 vaccine, a two-step logistic regression was used to
determine the associated explanatory variables. During the first step, univariate analysis, the
odds ratios (ORs) and the 95% confidence interval (95%CI) were calculated separately (i.e.,
known as crude OR). In the next step, all explanatory variables with a p-value <0.05 during the
univariate were included and ORs (adjusted ORs and 95%CIs) were calculated together. For
each explanatory variable, a reference group was pre-determined. All analyses were conducted
using SPSS software (SPSS Inc., Chicago, IL, USA).
Results
Demographic characteristics
A total of 1,337 respondents were included in the final analysis of which the highest percentage
originated from India (21.1%), followed by Pakistan (12.9%) and Sudan (11.2%). The
characteristics of the respondents are presented in (Table 1). Briefly, more than half of the
respondents belonged to 21-30 age group and less than 5% of them aged older than 51 years old.
There was a small gender disproportional; 43.3% and 56.7% for male and female, respectively.
Most of the respondents (82.9%) were living in the urban areas and more than half of the
respondents (52.2%) were Muslims, followed by Hindu (15.9%). Based on self-reported
information on chronic comorbidities, there were 5.2%, 2.9%, 2.3% and 5.5% of the respondents
who reported having hypertension, diabetes mellitus, heart disease and pulmonary disease,
respectively.
COVID-19 vaccine acceptance rates
The COVID-19 vaccine acceptance rates were observed to be influenced by the vaccine based on
the efficacy and safety profiles. At the worst scenario provided (50% efficacy and 5% risk of side
effects), the acceptance rate was 58.3% (784/1337) (Table 1). The acceptance rate increased to
80.1% (1,078/1337) for the scenario where the vaccine has a 75% efficacy and 5% side effects
profile. In the scenario where vaccine efficacy was 75%, the acceptance rate was only 55.6%
when the safety profile was lower (the chance for having the side effects was 20%). When the
vaccine efficacy increased to 95% with 20% risk of side effects, the acceptance rate was 74.0%.
Across the four vaccine profiles, Brazil and Chile had the highest acceptance rate compared to
all other countries (Figure 1).
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Figure 1. COVID-19 vaccine acceptance rates in the ten countries involved in the study using the
four scenarios of varying vaccine efficacy and safety. Color represents the acceptance rate for a
COVID-19 vaccine, from 0 to 100%.
Vaccine acceptance and its explanatory variables
Data suggested the country, age group, monthly household income, religion, having
comorbidities such as hypertension, heart disease or pulmonary disease, changes in salary
during the COVID-19 pandemic, the participants’ view on vaccination benefits and having flu
vaccination in the past 12 months were associated with vaccine acceptance in varying degrees
(Table 2). Among of them, some explanatory variables were associated with all four vaccine
profiles. The respondents who agreed that vaccines are important for their health had higher
chance to accept COVID-19 vaccine with OR: 7.36; 95%CI: 2.82, 19.22 and OR: 5.32; 95%CI:
1.74, 16.25 for the best (Vaccine B, 75% efficacy and 5% side effects) and the worst hypothetical
COVID-19 vaccine (Vaccine D, 50% efficacy and 20% side effects), respectively. Compared to
those who did not agree that all recommended vaccines are beneficial for their health, those
who acknowledged the benefit of the vaccine for their health had higher odds of accepting all
vaccine profiles; OR: 2.05 and OR: 2.40 for the best (Vaccine B) and worst vaccine (Vaccine D)
scenarios, respectively. Compared to those who believe that new vaccines carry more risks than
older vaccines, those who did not hold such a belief had approximately two times higher odds of
accepting the COVID-19 vaccine with OR ranging between 1.99 and 2.11 for all four vaccine
profiles.
In addition, those who believed that the information provided by the government about
vaccines are reliable and trustworthy also had higher odds of accepting the vaccine compared to
those who believed that the information is not reliable and trustworthy with OR ranging
between 1.48 and 1.70 for different vaccine profiles. Having flu vaccination in the past 12
months was correlated with an increased chance for accepting the COVID-19 vaccine
approximately 2 times; the ORs varied among the vaccine profiles ranging between 1.71 and
2.30 (Table 2).
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Table 1. COVID-19 vaccine acceptance rates (n=1337)
Variable
n (%)
Vaccine acceptance rate
95% vaccine efficacy
20% side effect (A)
75% vaccine efficacy
5% side effect (B)
75% vaccine efficacy
20% side effect (C)
50% vaccine efficacy
5% side effect (D)
Acceptance
1337 (100.0)
990 (74.0)
1,078 (80.1)
744 (55.6)
784 (58.3)
Country
Pakistan
173 (12.9)
116 (67.1)
127 (73.4)
94 (54.3)
112 (64.7)
Brazil
106 (7.9)
102 (96.2)
104 (98.1)
101 (95.3)
101 (95.3)
Chile
103 (7.7)
94 (91.3)
98 (95.1)
85 (82.5)
80 (77.7)
Egypt
83 (6.2)
50 (60.2)
65 (78.3)
38 (45.8)
42 (50.6)
India
282 (21.1)
217 (77.0)
227 (80.5)
142 (50.4)
138 (48.9)
Iran
109 (8.2)
76 (69.7)
82 (75.2)
52 (47.7)
60 (55.0)
Nigeria
124 (9.3)
90 (72.6)
101 (81.5)
58 (46.8)
60 (48.4)
Bangladesh
106 (7.9)
76 (71.7)
78 (73.6)
51 (48.1)
56 (52.8)
Sudan
150 (11.2)
107 (71.3)
128 (85.3)
86 (57.3)
96 (64.0)
Tunisia
101 (7.6)
62 (61.4)
68 (67.3)
37 (36.6)
39 (38.6)
Age group (year)
<20
207 (15.5)
157 (75.8)
168 (81.2)
126 (60.9)
133 (64.3)
21-30
780 (58.3)
572 (73.3)
638 (81.8)
424 (54.4)
451 (57.8)
31-40
210 (15.7)
149 (71.0)
159 (75.7)
112 (53.3)
115 (54.8)
41-50
93 (7.0)
76 (81.7)
75 (80.6)
49 (52.7)
49 (52.7)
>51
47 (3.5)
36 (76.6)
38 (80.9)
33 (70.2)
36 (76.6)
Gender
Male
579 (43.3)
430 (74.3)
461 (79.6)
325 (56.1)
351 (60.6)
Female
758 (56.7)
560 (73.9)
617 (81.4)
419 (55.3)
433 (57.1)
Urbanicity
Rural
228 (17.1)
164 (71.9)
169 (74.1)
118 (51.8)
122 (53.5)
Urban
1109 (82.9)
826 (74.5)
909 (82.0)
626 (56.4)
662 (59.7)
Monthly household income (USD)
<500
488 (36.5)
338 (69.3)
375 (76.8)
243 (49.8)
274 (56.1)
500-999
267 (20.0)
198 (74.2)
216 (80.9)
147 (55.1)
151 (56.6)
1,000-1,999
175 (13.1)
132 (75.4)
147 (84.0)
103 (58.9)
105 (60.0)
2,000-2,999
128 (9.6)
94 (73.4)
103 (80.5)
70 (54.7)
69 (53.9)
3,000-4,999
104 (7.8)
81 (77.9)
97 (93.3)
73 (70.2)
78 (75.0)
5,000-7,999
85 (6.4)
68 (80.0)
69 (81.2)
47 (55.3)
51 (60.0)
≥8,000
90 (6.7)
79 (87.8)
71 (78.9)
61 (67.8)
56 (62.2)
Religion
Islam
698 (52.2)
473 (67.8)
534 (76.5)
344 (49.3)
385 (55.2)
Christian/Protestant/Methodist/Lutheran/Baptist
140 (10.5)
108 (77.1)
115 (82.1)
77 (55.0)
79 (56.4)
Catholic
118 (8.8)
98 (83.1)
104 (88.1)
83 (70.3)
82 (69.5)
Hindu
212 (15.9)
169 (79.7)
178 (84.0)
112 (52.8)
113 (53.3)
Atheist or agnostic
127 (9.5)
106 (83.5)
113 (89.0)
98 (77.2)
95 (74.8)
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Others
42 (3.1)
36 (85.7)
34 (81.0)
30 (71.4)
30 (71.4)
Healthcare-related job
No
706 (52.8)
513 (72.7)
575 (81.4)
391 (55.4)
422 (59.8)
Yes
631 (47.2)
477 (75.6)
503 (79.7)
353 (55.9)
362 (57.4)
Have hypertension
No a
917 (68.6)
693 (75.6)
733 (79.9)
526 (57.4)
539 (58.8)
Yes b
70 (5.2)
57 (81.4)
58 (82.9)
45 (64.3)
47 (67.1)
Do not know
350 (26.2)
240 (68.6)
287 (82.0)
173 (49.4)
198 (56.6)
Have diabetes
No a
991 (74.1)
742 (74.9)
801 (80.8)
560 (56.5)
584 (58.9)
Yes b
39 (2.9)
30 (76.9)
31 (79.5)
25 (64.1)
28 (71.8)
Do not know
307 (23.0)
218 (71.0)
246 (80.1)
159 (51.8)
172 (56.0)
Have heart disease
No a
909 (68.0)
692 (76.1)
734 (80.7)
524 (57.6)
539 (59.3)
Yes b
31 (2.3)
23 (74.2)
23 (74.2)
19 (61.3)
21 (67.7)
Do not know
397 (29.7)
275 (69.3)
321 (80.9)
201 (50.6)
224 (56.4)
Have pulmonary disease
No a
865 (64.7)
653 (75.5)
700 (80.9)
502 (58.0)
521 (60.2)
Yes b
73 (5.5)
55 (75.3)
58 (79.5)
41 (56.2)
48 (65.8)
Do not know
399 (29.8)
282 (70.7)
320 (80.2)
201 (50.4)
215 (53.9)
Occupation
Self-employed
125 (9.3)
94 (75.2)
102 (81.6)
73 (58.4)
76 (60.8)
Employed for wages
342 (25.6)
262 (76.6)
268 (78.4)
185 (54.1)
187 (54.7)
Out of work
57 (4.3)
47 (82.5)
50 (87.7)
34 (59.6)
35 (61.4)
Homemaker
23 (1.7)
18 (78.3)
20 (87.0)
16 (69.6)
14 (60.9)
Student
773 (57.8)
558 (72.2)
626 (81.0)
427 (55.2)
459 (59.4)
Retired or unable to work
17 (1.3)
11 (64.7)
12 (70.6)
9 (52.9)
13 (76.5)
Has how much your work changed as a result of the COVID-
19 pandemic?
I work fewer hours
232 (17.4)
167 (72.0)
179 (77.2)
117 (50.4)
140 (60.3)
No change and not applicable (not working)
816 (61.0)
601 (73.7)
665 (81.5)
453 (55.5)
471 (57.7)
I work more hours
253 (18.9)
196 (77.5)
202 (79.8)
155 (61.3)
152 (60.1)
I was let go from my job
36 (2.7)
26 (72.2)
32 (88.9)
19 (52.8)
21 (58.3)
Has how much your salary changed as a result of the
COVID-19 pandemic?
I am getting paid less
384 (28.7)
264 (68.8)
308 (80.2)
194 (50.5)
216 (56.3)
I am getting paid more
91 (6.8)
74 (81.3)
76 (83.5)
61 (67.0)
61 (67.0)
No changes
862 (64.5)
652 (75.6)
694 (80.5)
489 (56.7)
507 (58.8)
Vaccines are important for my health
Disagree or strongly disagree
18 (1.3)
9 (50.0)
7 (38.9)
6 (33.3)
4 (22.2)
Neither agree nor disagree
125 (9.3)
79 (63.2)
87 (69.6)
52 (41.6)
60 (48.0)
Agree or strongly agree
1194 (89.3)
902 (75.5)
984 (82.4)
686 (57.5)
720 (60.3)
All routine vaccines recommended by the healthcare
workers are beneficial
Disagree or strongly disagree
43 (3.2)
25 (58.1)
30 (69.8)
16 (37.2)
17 (39.5)
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Table 2. Determinants associated with COVID-19 vaccine acceptance (n=1337)
Neither agree nor disagree
187 (14.0)
122 (65.2)
134 (71.7)
78 (41.7)
91 (48.7)
Agree or strongly agree
1107 (82.8)
843 (76.2)
914 (82.6)
650 (58.7)
676 (61.1)
New vaccines carry more risks than older vaccines
Agree or strongly agree
477 (35.7)
329 (69.0)
365 (76.5)
236 (49.5)
256 (53.7)
Neither agree nor disagree
529 (39.6)
389 (73.5)
425 (80.3)
285 (53.9)
297 (56.1)
Disagree or strongly disagree
331 (24.8)
272 (82.2)
288 (87.0)
223 (67.4)
231 (69.8)
The information I receive about vaccines from the
government is reliable and trustworthy
Disagree or strongly disagree
222 (16.6)
153 (68.9)
169 (76.1)
115 (51.8)
117 (52.7)
Neither agree nor disagree
422 (31.6)
289 (68.5)
337 (79.9)
201 (47.6)
230 (54.5)
Agree or strongly agree
693 (51.8)
548 (79.1)
572 (82.5)
428 (61.8)
437 (63.1)
Getting vaccines is a good way to protect me from disease
Disagree or strongly disagree
27 (2.0)
15 (55.6)
15 (55.6)
9 (33.3)
6 (22.2)
Neither agree nor disagree
125 (9.3)
74 (59.2)
80 (64.0)
53 (42.4)
62 (49.6)
Agree or strongly agree
1185 (88.6)
901 (76.0)
983 (83.0)
682 (57.6)
716 (60.4)
Social distancing can protect yourself from COVID-19
Disagree or strongly disagree
18 (1.3)
11 (61.1)
12 (66.7)
4 (22.2)
11 (61.1)
Neither agree nor disagree
52 (3.9)
34 (65.4)
36 (69.2)
23 (44.2)
22 (42.3)
Agree or strongly agree
1267 (94.8)
945 (74.6)
1030 (81.3)
717 (56.6)
751 (59.3)
Social distancing can protect your child or children from
COVID-19
Disagree or strongly disagree
28 (2.1)
15 (53.6)
20 (71.4)
11 (39.3)
13 (46.4)
Neither agree nor disagree
58 (4.3)
42 (72.4)
41 (70.7)
29 (50.0)
33 (56.9)
Agree or strongly agree
1251 (93.6)
933 (74.6)
1017 (81.3)
704 (56.3)
738 (59.0)
Social distancing can protect your parents from COVID-19
Disagree or strongly disagree
21 (1.6)
13 (61.9)
14 (66.7)
6 (28.6)
10 (47.6)
Neither agree nor disagree
45 (3.4)
28 (62.2)
31 (68.9)
18 (40.0)
22 (48.9)
Agree or strongly agree
1271 (95.1)
949 (74.7)
1033 (81.3)
720 (56.6)
752 (59.2)
Having flu vaccination during the past 12 months
No
1054 (78.8)
756 (71.7)
833 (79.0)
543 (51.5)
582 (55.2)
Yes
283 (21.2)
234 (82.7)
245 (86.6)
201 (71.0)
202 (71.4)
Variable
95% vaccine efficacy
20% side effect (A)
75% vaccine efficacy
5% side effect (B)
75% vaccine efficacy
20% side effect (C)
50% vaccine efficacy
5% side effect (D)
OR (95% CI)
p
OR (95% CI)
p
OR (95% CI)
p
OR (95% CI)
p
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Original Article
Country
Pakistan (Reference, R)
1
1
1
1
Brazil
12.53 (4.39, 35.74)
<0.001
18.84 (4.47, 79.44)
<0.001
16.98 (6.59, 43.74)
<0.001
11.00 (4.25, 28.46)
<0.001
Chile
5.13 (2.42, 10.91)
<0.001
7.10 (2.72, 18.54)
<0.001
3.97 (2.20, 7.16)
<0.001
1.89 (1.08, 3.31)
0.025
Egypt
0.75 (0.43, 1.28)
0.286
1.31 (0.70, 2.44)
0.397
0.71 (0.42, 1.20)
0.201
0.56 (0.33, 0.95)
0.031
India
1.64 (1.08, 2.50)
0.021
1.50 (0.96, 2.34)
0.078
0.85 (0.58, 1.25)
0.410
0.52 (0.35, 0.77)
0.001
Iran
1.13 (0.68, 1.90)
0.639
1.10 (0.63, 1.91)
0.734
0.77 (0.47, 1.24)
0.278
0.67 (0.41, 1.09)
0.105
Nigeria
1.30 (0.78, 2.16)
0.309
1.59 (0.90, 2.80)
0.107
0.74 (0.47, 1.17)
0.199
0.51 (0.32, 0.82)
0.005
Bangladesh
1.25 (0.73, 2.11)
0.417
1.01 (0.58, 1.75)
0.974
0.78 (0.48, 1.27)
0.313
0.61 (0.37, 1.00)
0.049
Sudan
1.22 (0.76, 1.97)
0.407
2.11 (1.20, 3.71)
0.010
1.13 (0.73, 1.76)
0.589
0.97 (0.61, 1.53)
0.890
Tunisia
0.78 (0.47, 1.30)
0.343
0.75 (0.44, 1.28)
0.284
0.49 (0.29, 0.80)
0.005
0.34 (0.21, 0.57)
<0.001
Age group (year)
<20 (R)
1
1
1
1
21-30
0.88 (0.61, 1.25)
0.465
1.04 (0.70, 1.55)
0.834
0.77 (0.56, 1.05)
0.094
0.76 (0.56, 1.05)
0.095
31-40
0.78 (0.50, 1.20)
0.259
0.72 (0.45, 1.16)
0.178
0.74 (0.50, 1.08)
0.120
0.67 (0.46, 1.00)
0.049
41-50
1.42 (0.77, 2.63)
0.260
0.97 (0.52, 1.80)
0.916
0.72 (0.44, 1.17)
0.184
0.62 (0.38, 1.02)
0.059
>51
1.04 (0.49, 2.20)
0.913
0.98 (0.44, 2.19)
0.961
1.52 (0.76, 3.01)
0.234
1.82 (0.88, 3.79)
0.109
Gender
Male (R)
1
1
1
1
Female
0.98 (0.77, 1.26)
0.873
1.12 (0.85, 1.47)
0.415
0.97 (0.78, 1.20)
0.755
0.87 (0.69, 1.08)
0.198
Urbanicity
Rural (R)
1
1
1
1
Urban
1.14 (0.83, 1.57)
0.424
1.59 (1.14, 2.22)
0.007
1.21 (0.91, 1.61)
0.194
1.29 (0.97, 1.71)
0.085
Monthly household income (USD)
<500 (R)
1
1
1
1
500-999
1.27 (0.91, 1.78)
0.157
1.28 (0.88, 1.85)
0.197
1.24 (0.92, 1.67)
0.167
1.02 (0.75, 1.37)
0.914
1,000-1,999
1.36 (0.92, 2.02)
0.124
1.58 (1.00, 2.50)
0.048
1.44 (1.02, 2.05)
0.040
1.17 (0.82, 1.67)
0.377
2,000-2,999
1.23 (0.79, 1.90)
0.359
1.24 (0.76, 2.02)
0.382
1.22 (0.82, 1.80)
0.325
0.91 (0.62, 1.35)
0.650
3,000-4,999
1.56 (0.95, 2.58)
0.081
4.18 (1.89, 9.25)
<0.001
2.37 (1.51, 3.75)
<0.001
2.34 (1.45, 3.78)
<0.001
5,000-7,999
1.78 (1.01, 3.14)
0.047
1.30 (0.73, 2.33)
0.379
1.25 (0.79, 1.98)
0.350
1.17 (0.73, 1.87)
0.509
≥8,000
3.19 (1.65, 6.16)
0.001
1.13 (0.65, 1.95)
0.671
2.12 (1.32, 3.42)
0.002
1.29 (0.81, 2.04)
0.285
Religion
Islam (R)
1
1
1
1
Christian/Protestant/Methodist/Lutheran
/Baptist
1.61 (1.05, 2.46)
0.029
1.41 (0.89, 2.25)
0.147
1.26 (0.87, 1.81)
0.218
1.05 (0.73, 1.52)
0.782
Catholic
2.33 (1.41, 3.87)
0.001
2.28 (1.27, 4.09)
0.006
2.44 (1.60, 3.72)
<0.001
1.85 (1.22, 2.82)
0.004
Hindu
1.87 (1.29, 2.71)
0.001
1.61 (1.07, 2.41)
0.022
1.15 (0.85, 1.57)
0.366
0.93 (0.68, 1.26)
0.635
Atheist or agnostic
2.40 (1.47, 3.94)
0.001
2.48 (1.39, 4.44)
0.002
3.48 (2.24, 5.40)
<0.001
2.41 (1.57, 3.70)
<0.001
Others
2.85 (1.19, 6.87)
0.019
1.31 (0.59, 2.88)
0.509
2.57 (1.30, 5.11)
0.007
2.03 (1.02, 4.04)
0.043
Healthcare-related job
No (R)
1
1
1
1
Yes
1.17 (0.91, 1.49)
0.222
0.90 (0.68, 1.17)
0.424
1.02 (0.82, 1.27)
0.837
0.91 (0.73, 1.13)
0.373
Have hypertension
No a (R)
1
1
1
1
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Page 10 of 16
Original Article
Yes b
1.42 (0.76, 2.64)
0.271
1.21 (0.64, 2.31)
0.555
1.34 (0.81, 2.20)
0.259
1.43 (0.86, 2.40)
0.172
Do not know
0.71 (0.54, 0.93)
0.012
1.14 (0.83, 1.57)
0.407
0.73 (0.57, 0.93)
0.011
0.91 (0.71, 1.17)
0.476
Have diabetes
No a (R)
1
1
1
1
Yes b
1.12 (0.52, 2.39)
0.772
0.92 (0.42, 2.03)
0.835
1.37 (0.71, 2.68)
0.350
1.77 (0.87, 3.61)
0.113
Do not know
0.82 (0.62, 1.09)
0.178
0.96 (0.69, 1.32)
0.787
0.83 (0.64, 1.07)
0.147
0.89 (0.69, 1.15)
0.367
Have heart disease
No a (R)
1
1
1
1
Yes b
0.90 (0.40, 2.05)
0.804
0.69 (0.30, 1.56)
0.367
1.16 (0.56, 2.43)
0.686
1.44 (0.67, 3.10)
0.348
Do not know
0.71 (0.54, 0.92)
0.009
1.01 (0.75, 1.34)
0.964
0.75 (0.60, 0.96)
0.019
0.89 (0.70, 1.13)
0.333
Have pulmonary disease
No a (R)
1
1
1
1
Yes b
0.99 (0.57, 1.73)
0.977
0.91 (0.50, 1.65)
0.759
0.93 (0.57, 1.50)
0.756
1.27 (0.77, 2.10)
0.355
Do not know
0.78 (0.60, 1.02)
0.070
0.96 (0.71, 1.29)
0.762
0.73 (0.58, 0.93)
0.011
0.77 (0.61, 0.98)
0.034
Occupation
Self-employed (R)
1
1
1
1
Employed for wages
1.08(0.67, 1.74)
0.752
0.82 (0.49, 1.37)
0.446
0.84 (0.56, 1.27)
0.408
0.78 (0.51, 1.18)
0.238
Out of work for less 1 year AND more than
1 year
1.55 (0.70, 3.43)
0.279
1.61 (0.65, 4.01)
0.305
1.05 (0.56, 1.99)
0.874
1.03 (0.54, 1.95)
0.938
Homemaker
1.19 (0.41, 3.46)
0.753
1.50 (0.41, 5.49)
0.537
1.63 (0.63, 4.24)
0.318
1.00 (0.40, 2.49)
0.995
Student
0.86 (0.55, 1.32)
0.484
0.96 (0.59, 1.56)
0.870
0.88 (0.60, 1.29)
0.509
0.94 (0.64, 1.39)
0.764
Retired or unable to work
0.61 (0.21, 1.77)
0.359
0.54 (0.17, 1.69)
0.290
0.80 (0.29, 2.22)
0.669
2.10 (0.65, 6.80)
0.218
Has how much your work changed as a result
of the COVID-19 pandemic?
I work fewer hours (R)
1
1
1
1
No change or not applicable (not working)
1.09 (0.79, 1.51)
0.612
1.30 (0.92, 1.86)
0.141
1.23 (0.92, 1.64)
0.170
0.90 (0.67, 1.21)
0.475
I work more hours
1.34 (0.89, 2.02)
0.165
1.17 (0.76, 1.81)
0.472
1.56 (1.08, 2.23)
0.017
0.99 (0.69, 1.42)
0.952
I was let go from my job
1.01 (0.46, 2.22)
0.979
2.37 (0.80, 7.00)
0.119
1.10 (0.54, 2.22)
0.793
0.91 (0.45, 1.88)
0.819
Has how much your salary changed as a result
of the COVID-19 pandemic?
I am getting paid less (R)
1
1
1
1
I am getting paid more
1.98 (1.12, 3.50)
0.019
1.25 (0.68, 2.30)
0.472
1.99 (1.23, 3.22)
0.005
1.58 (0.98, 2.56)
0.062
No changes
1.41 (1.08, 1.84)
0.011
1.02 (0.75, 1.38)
0.901
1.28 (1.01, 1.63)
0.042
1.11 (0.87, 1.42)
0.397
Vaccines are important for my health
Disagree or strongly disagree (R)
1
1
1
1
Neither agree nor disagree
1.72 (0.64, 4.64)
0.286
3.60 (1.30, 9.99)
0.014
1.43 (0.50, 4.04)
0.506
3.23 (1.01, 10.36)
0.049
Agree or strongly agree
3.09 (1.22, 7.86)
0.018
7.36 (2.82, 19.22)
<0.001
2.70 (1.01, 7.24)
0.048
5.32 (1.74, 16.25)
0.003
All routine vaccines recommended by the
healthcare workers are beneficial
Disagree or strongly disagree (R)
1
1
1
1
Neither agree nor disagree
1.35 (0.69, 2.66)
0.383
1.10 (0.53, 2.26)
0.805
1.21 (0.61, 2.39)
0.588
1.45 (0.74, 2.85)
0.281
Agree or strongly agree
2.30 (1.24, 4.28)
0.009
2.05 (1.05, 4.01)
0.035
2.40 (1.28, 4.51)
0.006
2.40 (1.29, 4.47)
0.006
New vaccines carry more risks than older
vaccines
Agree or strongly agree (R)
1
1
1
1
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Page 11 of 16
Original Article
R: reference group
Neither agree nor disagree
1.25 (0.95, 1.64)
0.110
1.25 (0.93, 1.70)
0.141
1.19 (0.93, 1.53)
0.163
1.11 (0.86, 1.42)
0.431
Disagree or strongly disagree
2.07 (1.47, 2.92)
<0.001
2.06 (1.40, 3.02)
<0.001
2.11 (1.58, 2.82)
<0.001
1.99 (1.48, 2.58)
<0.001
The information I receive about vaccines from
the government is reliable and trustworthy
Disagree or strongly disagree (R)
1
1
1
1
Neither agree nor disagree
0.98 (0.69, 1.39)
0.910
1.24 (0.84, 1.84)
0.273
0.85 (0.61, 1.17)
0.314
1.08 (0.78, 1.49)
0.663
Agree or strongly agree
1.70 (1.22, 2.39)
0.002
1.48 (1.03, 2.14)
0.035
1.50 (1.11, 2.04)
0.009
1.53 (1.13, 2.08)
0.006
Getting vaccines is a good way to protect me
from disease
Disagree or strongly disagree (R)
1
1
1
1
Neither agree nor disagree
1.16 (0.50, 2.69)
0.728
1.42 (0.61, 3.30)
0.412
1.47 (0.61, 3.53)
0.386
3.44 (1.30, 9.11)
0.013
Agree or strongly agree
2.54 (1.17, 5.49)
0.018
3.89 (1.80, 8.44)
0.001
2.71 (1.21, 6.09)
0.016
5.34 (2.14, 13.34)
<0.001
Social distancing can protect yourself from
COVID-19
Disagree or strongly disagree (R)
1
1
1
1
Neither agree nor disagree
1.20 (0.40, 3.64)
0.744
1.13 (0.36, 3.53)
0.840
2.78 (0.80, 9.58)
0.106
0.47 (0.16, 1.40)
0.173
Agree or strongly agree
1.87 (0.72, 4.86)
0.200
2.17 (0.81, 5.85)
0.124
4.56 (1.49, 13.94)
0.008
0.93 (0.36, 2.41)
0.875
Social distancing can protect your child or
children from COVID-19
Disagree or strongly disagree (R)
1
1
1
1
Neither agree nor disagree
2.28 (0.89, 5.82)
0.086
0.97 (0.36, 2.61)
0.944
1.55 (0.62, 3.87)
0.352
1.52 (0.62 - 3.77)
0.363
Agree or strongly agree
2.54 (1.20, 5.40)
0.015
1.74 (0.76, 4.00)
0.193
1.99 (0.92, 4.28)
0.079
1.66 (0.78 - 3.52)
0.186
Social distancing can protect your parents
from COVID-19
Disagree or strongly disagree (R)
1
1
1
1
Neither agree nor disagree
1.01 (0.35, 2.95)
0.980
1.11 (0.37, 3.43)
0.857
1.67 (0.54, 5.10)
0.371
1.05 (0.37, 2.97)
0.923
Agree or strongly agree
1.81 (0.75, 4.42)
0.190
2.17 (0.87, 5.44)
0.098
3.27 (1.26, 8.47)
0.015
1.59 (0.67, 3.78)
0.290
Having flu vaccination during the past 12
months
No (R)
1
1
1
1
Yes
1.88 (1.35, 2.63)
<0.001
1.71 (1.18, 2.48)
0.005
2.31 (1.74, 3.06)
<0.001
2.02 (1.52, 2.69)
<0.001
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Page 12 of 16
Original Article
Discussion
The major result of the current study was the demonstration of how communication about
COVID-19 vaccine safety and efficacy can affect its acceptance. The current study collected data
from ten various LMICs across three different continents. In the majority of countries, COVID-
19 vaccine acceptance rates were observed to be higher for the scenarios where vaccine safety
and efficacy profiles were superior to other scenarios.
Specifically, at the scenarios of low possibility (5%) of side effects (e.g., fever or localized
pain), with an efficacy of 75%, the vaccine acceptance rates across the ten countries exceeded
67%. Such an acceptance rate is assumed to be close to the lower estimated limit that is
necessary to achieve population immunity, with subsequent control of SARS-CoV-2 spread [35,
36]. For the majority of the currently available COVID-19 vaccines, generally high levels of
efficacy (>80%) were reported, and the frequency of side effects was reported at variable levels;
however, the majority of which have also reported localized reactions existing for a brief period
[37-39]. Therefore, emphasizing that the spread of such messages about the safety of the
currently available COVID-19 vaccines can have a positive effect on influencing the public
intentions to get vaccinated [40].
In the context of COVID-19 vaccination, the speed with which various vaccine formulas was
developed has been linked to high levels of mistrust regarding its safety and subsequent fear of
side effects and vaccine hesitancy/rejection [41, 42]. Thus, the emphasis on the generally high
levels of vaccine safety as indicated by the results of clinical trials and the different studies at the
general population levels in various settings appears of utmost value to properly address the
phenomenon of COVID-19 vaccine hesitancy [43-45].
The current study also showed variable overall levels of COVID-19 vaccine acceptance as
follows: the highest acceptance rates were observed in the two South American countries
involved in this study (Brazil and Chile), while the lowest levels were observed in Egypt, Tunisia,
Iran and Bangladesh. This observation has been previously seen among the Middle East and
North Africa countries, where the phenomenon of COVID-19 vaccine hesitancy was more
pronounced in various studies [19, 46-48]. Many studies cited concerns about vaccine safety
among the study participants as the main reason behind vaccine hesitancy, which adds further
support to our findings [46, 49].
For example, in Egypt two previous studies that were conducted in late 2020 and early
2021 among healthcare workers showed high rates of COVID-19 vaccine hesitancy/rejection
[50, 51]. The first study found that the absence of enough clinical trials and the fear of side
effects of the vaccine (both prevalent among more than 90% of the hesitant participants) as the
most common reasons behind vaccine hesitancy/rejection [50]. The second also reported that
the willingness to get COVID-19 vaccination was positively correlated with the perception of
vaccine safety [51]. Another study from Egypt during January–March 2021 with 1,011
participants from the general public reported that COVID-19 vaccine acceptance rate was only
25% and a majority of participants expressed strong worries about unforeseen effects of the
vaccine [49].
Another important result that was consistent with previous studies was the observation of a
lower levels of COVID-19 vaccine acceptance rates in countries of the Middle East and North
Africa and the generally very high levels of vaccine acceptance in South American countries. An
early systematic review on the global rates of COVID-19 vaccine acceptance noticed similar
results and the low levels of vaccine acceptance in the Middle East region was attributed to
generally high levels of embrace of conspiracy beliefs regarding the origin of SARS-CoV-2 and
the COVID-19 vaccines [52-54]. For example a study that was conducted in December 2020
among participants from Arab countries (with a majority from Jordan and Kuwait), reported
that about a quarter of the participants believed that COVID-19 vaccines are intended to inject
microchips into recipients (27.7%) and that the vaccines are related to infertility (23.4%) [26].
This result was also seen among university students in Jordan, with a significant correlation
between vaccine conspiracy beliefs and vaccine hesitancy/rejection [53]. Such a low prevalence
of vaccine acceptance can also be linked to lower levels of confidence (in governments,
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pharmaceutical companies and healthcare providers), adversely affecting the intentions to get
vaccinated [55].
To the contrary, the highest levels of COVID-19 vaccine acceptance rates reported in this
study were seen in the two South American countries (Brazil and Chile). A previous study that
was conducted in February 2021, which investigated COVID-19 vaccine acceptance in various
countries of South America and the Caribbean reported generally high levels of vaccine
acceptance, which were in line with our results [56]. Specifically, COVID-19 vaccine acceptance
rate in Brazil was reported to be 83% compared to 95%-98% across the four different scenarios
of vaccine safety and efficacy profiles used in this study. In Chile, Urrunaga-Pastor et al,
reported a vaccine acceptance rate of 74%, compared to 95% for scenario of 75% efficacy with
5% side effects, and 78% for the scenario of 50% efficacy with 5% side effects [56]. In the low
fraction of hesitant individuals in the study by Urrunaga-Pastor et al, fear of side effects was
reported as a major contributing factor to lower intentions of COVID-19 vaccination [56].
The strength of the current study can be related to evaluation of the correlation of different
scenarios of COVID-19 vaccine safety and efficacy with intentions to get COVID-19 vaccination
at a multinational level. Limitations of the current study were inevitable and included low
sample size from a few countries (e.g., Egypt); however, the finding of similar trends in COVID-
19 vaccine acceptance rates compared to larger domestic studies support the findings of this
study. Another limitation inherent to online survey studies is related to potential sampling bias
towards people who are actively using social media platforms and who had proper internet
access.
Conclusion
The correlation between COVID-19 vaccination intentions with safety and efficacy of vaccines
was evident in this study. At the same efficacy level of 75%, the higher possibility of side effects
(fever, localized pain) was correlated with a noticeable decline (>20% drop) in COVID-19
vaccine acceptance rates in the majority of countries in this study. Such a result highlights the
potential importance of spreading clear, accurate messages regarding vaccine safety and
efficacy, which in turn can help to boost the general public confidence in COVID-19 vaccination.
Subsequently, this can help to address the challenges of successful COVID-19 vaccine roll out
observed in several LMICs worldwide that was hampered by the phenomenon of COVID-19
vaccine hesitancy and resistance. The lowest rates of COVID-19 vaccine acceptance were
observed in the Middle East/North African countries (Egypt, Tunisia, Iran) which requires
special attention and well-informed interventional measures to tackle such a widely prevalent
problem in the region.
Ethics approval
This study was approved by the Institutional Review Board of the Universitas Syiah Kuala -
Zainoel Abidin Hospital and National Health Research and Development Ethics Commission
(KEPPKN) of the Ministry of Health of the Republic of Indonesia (#1171012P).
Acknowledgments
We are deeply grateful for the support by collators
Conflict of interest
The authors declare that they have no competing interests.
Funding
This study was funded by Universitas Syiah Kuala (The Ministry of Education, Culture,
Research, and Technology) - H-Index Research Scheme Financial Year 2021 (169/UN11/SPK/
PNBP/2021).
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Page 14 of 16
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Underlying data
Derived data supporting the findings of this study are available from the first author on request.
How to cite
Rosiello DF, Anwar S, Yufika A, et al. Acceptance of COVID-19 vaccination at different
hypothetical efficacy and safety levels in ten countries in Asia, Africa, and South America. Narra
J 2021; 1(3): e55 - http://doi.org/10.52225/narra.v1i3.55.
References
1. Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E
, et al
. Clinical, laboratory and imaging features of
COVID-19: A systematic review and meta-analysis. Travel medicine and infectious disease 2020; 34:101623.
2. Harapan H, Itoh N, Yufika A
, et al
. Coronavirus disease 2019 (COVID-19): A literature review. Journal of infection and
public health 2020; 13(5):667-673.
3. Farsalinos K, Poulas K, Kouretas D
, et al
. Improved strategies to counter the COVID-19 pandemic: lockdowns vs.
primary and community healthcare, Toxicol. Rep. 8 (2021) 1–9. In.
4. COVID-19 coronavirus pandemic. Available from: https://www.worldometers.info/coronavirus/. Accessed: 1
September 2021.
5. Devi S. COVID-19 resurgence in Iran. Lancet (London, England) 2020; 395(10241):1896.
6. Shimizu K, Wharton G, Sakamoto H
, et al
. Resurgence of covid-19 in Japan. BMJ 2020;18;370:m3221.
7. Viana J, van Dorp CH, Nunes A
, et al
. Controlling the pandemic during the SARS-CoV-2 vaccination rollout. Nat
Commun 2021; 12(1):3674.
8. Harrison EA, Wu JW. Vaccine confidence in the time of COVID-19. Eur J Epidemiol 2020; 35(4):325-330.
9. Qualls N, Levitt A, Kanade N
, et al
. Community mitigation guidelines to prevent pandemic influenza—United States,
2017. Morb Mortal Wkly Rep 2017; 66(1):1-34.
10. Lurie N, Saville M, Hatchett R
, et al
. Developing Covid-19 vaccines at pandemic speed. N Engl J Med 2020;
382(21):1969-1973.
11. Sharpe HR, Gilbride C, Allen E
, et al
. The early landscape of coronavirus disease 2019 vaccine development in the UK
and rest of the world. Immunology 2020; 160(3):223-232.
12. Times TNY. Coronavirus Vaccine Tracker. Available from: https://www.nytimes.com/interactive/2020/science/
coronavirus-vaccine-tracker.html. Accessed: 11 October 2021.
13. WHO Coronavirus (COVID-19) Dashboard. Available from: https://covid19.who.int. Accessed: 4 March 2021.
14. Our Word in Data. Coronavirus Pandemic (COVID-19). 2020. Available from: https://ourworldindata.org/covid-cases.
Accessed: 11 October 2021.
15. Tagoe ET, Sheikh N, Morton A
, et al
. COVID-19 vaccination in lower-middle income countries: national stakeholder
views on challenges, barriers, and potential solutions. Front Public Health 2021:709127
16. Dhama K, Sharun K, Tiwari R
, et al
. COVID-19 vaccine hesitancy–reasons and solutions to achieve a successful global
vaccination campaign to tackle the ongoing pandemic. Hum Vaccin Immunother 2021;17(10):3495-3499.
17. Lazarus JV, Ratzan SC, Palayew A
, et al
. A global survey of potential acceptance of a COVID-19 vaccine. Nature Med
2021; 27(2):225-228.
18. Nossier SA. Vaccine hesitancy: the greatest threat to COVID-19 vaccination programs. J Egypt Public Health Assoc
202;96:18.
19. Sallam M. COVID-19 Vaccine hesitancy worldwide: a concise systematic review of vaccine acceptance rates. Vaccines
2021; 9(2):160.
20. MacDonald NE. Vaccine hesitancy: definition, scope and determinants. Vaccine 2015; 33(34):4161-4164.
21. 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.
22. Al-Mohaithef M, Padhi BK. Determinants of COVID-19 vaccine acceptance in Saudi Arabia: a web-based national
survey. J Multidiscip Healthc 2020; 13:1657.
Ro s i ello e t a l. N arra J 20 2 1 ; 1 ( 3): e 55 - h t t p://d oi. o r g/ 1 0 . 52225/na r ra.v 1i3.55
Page 15 of 16
Original Article
23. Jennings W, Stoker G, Bunting H
, et al
. Lack of trust, conspiracy beliefs, and social media use predict COVID-19
vaccine hesitancy. Vaccines 2021; 9(6):593.
24. Paul E, Steptoe A, Fancourt D. Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications
for public health communications. Lancet Regional Health-Europe 2021; 1:100012.
25. 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.
26. 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):41.
27. Malik AA, McFadden SM, Elharake J
, et al
. Determinants of COVID-19 vaccine acceptance in the US.
EClinicalMedicine 2020; 26:100495.
28. Fisher KA, Bloomstone SJ, Walder J
, et al
. Attitudes toward a potential SARS-CoV-2 vaccine: a survey of US adults.
Annals of internal medicine 2020; 173(12):964-973.
29. Shekhar R, Sheikh AB, Upadhyay S
, et al
. COVID-19 vaccine acceptance among health care workers in the United
States. Vaccines 2021; 9(2):119.
30. Arce JSS, Warren SS, Meriggi NF
, et al
. COVID-19 vaccine acceptance and hesitancy in low and middle income
countries, and implications for messaging. Nature Med 2021;27:1385-1394.
31. Dyson L, Hill EM, Moore S
, et al
. Possible future waves of SARS-CoV-2 infection generated by variants of concern
with a range of characteristics. Nat Commun 2021; 12(1):5730.
32. Salomoni MG, Di Valerio Z, Gabrielli E
, et al
. Hesitant or not hesitant? a systematic review on global COVID-19
vaccine acceptance in different populations. Vaccines 2021; 9(8):
33. Wagner A. COVID-19 Vaccine Hesitancy Surveys. In: Inter-university Consortium for Political and Social Research
Available from: https://doiorg/103886/E130422V2 2021 (31 August 2021).
34. Akel KB, Masters NB, Shih S-F
, et al
. Modification of a Vaccine Hesitancy Scale for use in adult vaccinations in the
United States and China. Hum Vaccin Immunother 2021;17(8):2639-2646.
35. Billah MA, Miah MM, Khan MN. Reproductive number of coronavirus: A systematic review and meta-analysis based
on global level evidence. PLOS ONE 2020; 15(11):e0242128.
36. Anderson RM, Vegvari C, Truscott J
, et al
. Challenges in creating herd immunity to SARS-CoV-2 infection by mass
vaccination. The Lancet 2020; 396(10263):1614-1616.
37. Pormohammad A, Zarei M, Ghorbani S
, et al
. Efficacy and safety of COVID-19 vaccines: a systematic review and
meta-analysis of randomized clinical trials. Vaccines 2021; 9(5):467.
38. Sharif N, Alzahrani KJ, Ahmed SN
, et al
. Efficacy, Immunogenicity and safety of COVID-19 vaccines: A systematic
review and meta-analysis. Front Immunol 2021; 12:7114170.
39. McDonald I, Murray SM, Reynolds CJ
, et al
. Comparative systematic review and meta-analysis of reactogenicity,
immunogenicity and efficacy of vaccines against SARS-CoV-2. npj Vaccines 2021; 6(1):74.
40. James EK, Bokemper SE, Gerber AS
, et al
. Persuasive messaging to increase COVID-19 vaccine uptake intentions.
vaccine 2021; S0264-410X(21)01368-2.
41. Ward JK, Alleaume C, Peretti-Watel P. The French public's attitudes to a future COVID-19 vaccine: The politicization
of a public health issue. Soc Sci Med (1982) 2020; 265:113414.
42. Limaye RJ, Sauer M, Truelove SA. Politicizing public health: the powder keg of rushing COVID-19 vaccines. Hum
Vaccin Immunother 2021;17(6):1662-1663.
43. Kumar D, Chandra R, Mathur M
, et al
. Vaccine hesitancy: understanding better to address better. Isr J Health Policy
Res. 2016; 5: 2.
44. Baraniuk C. Covid-19: How the UK vaccine rollout delivered success, so far. BMJ 2021; 372:n421.
45. Dagan N, Barda N, Kepten E
, et al
. BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting. N
Eng J Med 2021; 384(15):1412-1423.
46. Qunaibi EA, Helmy M, Basheti I
, et al
. A high rate of COVID-19 vaccine hesitancy in a large-scale survey on Arabs.
eLife 2021; 10: e68038
47. Kasrine Al Halabi C, Obeid S, Sacre H
, et al
. Attitudes of Lebanese adults regarding COVID-19 vaccination. BMC
Public Health 2021; 21(1):998.
48. Khaled SM, Petcu C, Bader L
, et al
. Prevalence and potential determinants of COVID-19 Vaccine hesitancy and
resistance in Qatar: results from a nationally representative survey of Qatari nationals and migrants between
December 2020 and January 2021. Vaccines 2021; 9(5):471.
Ro s i ello e t a l. N arra J 20 2 1 ; 1 ( 3): e 55 - h t t p://d oi. o r g/ 1 0 . 52225/na r ra.v 1i3.55
Page 16 of 16
Original Article
49. Omar DI, Hani BM. Attitudes and intentions towards COVID-19 vaccines and associated factors among Egyptian
adults. J Infect Public Health 2021; 14(10):1481-1488.
50. Fares S, Elmnyer MM, Mohamed SS
, et al
. COVID-19 Vaccination perception and attitude among healthcare workers
in Egypt. J Prim Care Community Health 2021; 12:21501327211013303.
51. El-Sokkary RH, El Seifi OS, Hassan HM
, et al
. Predictors of COVID-19 vaccine hesitancy among Egyptian healthcare
workers: a cross-sectional study. BMC Infect Dis 2021; 21(1):762.
52. Sallam M, Dababseh D, Yaseen A
, et al
. COVID-19 misinformation: Mere harmless delusions or much more? A
knowledge and attitude cross-sectional study among the general public residing in Jordan. PLOS ONE 2020;
15(12):e0243264.
53. 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): 2407.
54. Sallam M, Dababseh D, Yaseen A
, et al
. Conspiracy beliefs are associated with lower knowledge and higher anxiety
levels regarding COVID-19 among students at the university of Jordan. Int J Environ Res Public Health 2020;
17(14):4915.
55. Solís Arce JS, Warren SS, Meriggi NF
, et al
. COVID-19 vaccine acceptance and hesitancy in low- and middle-income
countries. Nat Med 2021; 27(8):1385-1394.
56. Urrunaga-Pastor D, Bendezu-Quispe G, Herrera-Añazco P
, et al
. Cross-sectional analysis of COVID-19 vaccine
intention, perceptions and hesitancy across Latin America and the Caribbean. Travel Med Infect Dis 2021; 41:102059.
