On Monday March 2, 2020, the first case of coronavirus was announced by the Ministry of Health (MOH) in a citizen who returned from Iran via the Kingdom of Bahrain. In line with the precautionary measures, MOH immediately dispatched its infection control team to perform medical and laboratory examinations, which confirmed the citizen’s infection with the virus.[1–5] The COVID-19 virus spreads primarily via respiratory droplets containing the virus are inhaled or directly contact with the infected people or contaminated surfaces. The COVID-19 pandemic has spread quickly over nations within the world. It’s disturbed the lives and livelihoods of all communities and is causing major challenges to vulnerable individuals. It also has a far-reaching and negative impact on the economy and also the well-being of the population. For decades, vaccination is cited as one of the most effective ways of controlling infectious diseases. However, whereas most individuals immunize agreeing to the suggested plan, this success is being challenged by individuals and groups who favor delaying or deny immunizations. Examples of reluctant people incorporate parents delaying vaccinations for their newborn child, teenagers (or their guardians) who select not to immunize against human papillomavirus (HPV), pregnant ladies choosing not to vaccinate against flu or shingles, the elderly choosing not to vaccinate against flu or shingles, and even HCPs not vaccinating against influenza. COVID-19 vaccination reduces the risk of COVID-19 and its potentially severe complications and can help reduce your risk of catching and spreading. All COVID-19 vaccines currently authorized to be used in the United States helped protect people against COVID-19, including severe illness, in clinical trial settings. So far, studies that have looked at how COVID-19 immunizations work in real-world conditions (vaccine viability considers) have shown up that these vaccines are working well.[9,10] As vaccines got the approval to be utilized, it became important within the method of deploying them to explore the community’s knowledge and attitude toward such intervention. This can easily identify factors influencing vaccine hesitancy or acceptance, and hence it will help to deeply recognize the features that influence the public in adopting healthy practices and responsive behavior toward COVID-19 generally and, specifically, accepting vaccines. In 2020 only one study was published that determinants of COVID-19 Vaccine Acceptance in Saudi Arabia, it was conducted in a major city (Riyadh, Dammam, Jeddah, and Abha) and it was before introduced COVID-19 vaccine, show that (64.7%) intended to uptake the hypothetical vaccine, only (7%) reported hesitancy towards the COVID-19 vaccine, and (28.2%) were reported “not sure” about their intention.[11,12] To achieve the required herd immunity to manage viral transmission and stop the pandemic, vaccinating more than 82% of the population is crucial and requires strong acceptance and low hesitation levels throughout the population. Therefore, identifying factors related to vaccine acceptance and hesitancy are needed to implement policy changes and help public health experts identify a conceptual framework and educational campaign aimed toward increasing this awareness within the general population. A global survey in 19 world countries has shown that rates of hesitancy concerning a vaccine against the SARS-CoV-2 range from 11.4% (China) to 45.1% (Russia), of which are not negligible numbers. In the COVID-19 pandemic context, it is important to mitigate the impact of misinformation on the decision not to get vaccinated.[15,16] The results of the current study could help develop new strategies to raise awareness, correct misconceptions, and improve acceptance toward COVID-19 vaccines, and increase individuals’ ability to detect fake news through education and communication programs.
Materials and Methods
This cross-sectional study was conducted among target people who are more than 11 years old in Saudi Arabia, Qassim Region, using snowball sample study. Considering social distancing and preventive measures, data were collected online, through a self-reported questionnaire attached in appendix 1, using Google form, and with high social media usage among the population in Qassim Region, the link to the survey was distributed to respondents, via WhatsApp groups.
Sample size and selection of sample
The study was designed to obtain the maximum data from as many respondents as possible. According to the latest KSA census, the Qassim region has a population of (1,488,285). A representative sample of the population was worked out using:
n = Z2*P (1-P) d2
N = Sample size.
Z = Confidence level, which is 1.96.
p = Excepted prevalence, which is 50%.
D = Absolute error, which is 5%.
The estimated sample size was 384, whereas our final sample size was 403.
The questionnaire was developed by (Archana Kumari, Piyush Ranjan, development and validation of a questionnaire to assess knowledge, attitudes, practices, and concerns regarding COVID-19 vaccination among the general population). We obtained consent from the authors and made some modifications to match the study area. The questionnaire was conducted in English, and then translated from English to Arabic. The first section of the online questionnaire provides a brief orientation about the study, its purpose, and right to refuse participation. Those who agreed would be asked to sign informed consent. The second section collected information about the sociodemographic status of the participants, including age, gender, nationality, education level, and whether they received the COVID-19 vaccine. The final section involved evaluating the knowledge and attitudes of the participants toward the COVID-19 vaccine.
Al-Qassim regional review board approval and the Qassim University Research Ethics Committee were obtained for this study before carrying on with it. Participants signed an informed consent that explained the purpose of the study and the rights of the participant for confidentiality and to withdraw at any time without any responsibility towards the study team. We assured the participants by assigning each one to be a code number for analysis only.
We entered the date collected from the questionnaire into the Statistical Package for Social Sciences (SPSS, version 25.0). We measured the P value and the 95% confidence intervals. The P value < 0.05 was take as the fixed point for statistical significance. The Chi-square x2 tests were used for categorical variables and T-test for continuous variables.
Data analysis of Covid-19 vaccination survey
Statistical tools and methods
Statistical Package of (SPSS v. 26) was used to describe the basic features of the data in the study, through frequencies, percentages. T-independent sample test and ANOVA test were used to find the differences in mean score of attitude and practices according to sociodemographic variables. Pearson correlation test used to test the relation between the knowledge, attitude, and practice toward COVID-19. Pearson’s Chi-squared test (c2) were used to find the association between the level of knowledge and the level of measure of life satisfaction for participants with their socio-demographic variables; Since Pearson’s Chi-square test (c2) is a statistical test applied to sets of categorical data to test the independence of two variables, expressed in a contingency table. Independence means that knowing the value of the row variable does not change the probabilities of the column variable (and vice versa). Another way of looking at independence is to say that the row percentages (or column percentages (remain constant from row to row (or column to column).[19,20]
Table 1 shows that the total sample size was (413), 72.9% were female while 27.1% were male, 98.5% were Saudi, while 1.5% were non-Saudi, the highest age group was (20-40 years) by 65.6% of the total sample. About education, 69.0% had university degree. Finally, 53.8% of the total participants had taken second dose of COVID-19 vaccine, 33.4% had taken first dose while 12.8% hadn’t [Table 1].
Knowledge of COVID-19 vaccines
Table 2 shows the participant’s responds to the 10 questions of the knowledge of the COVID-19 vaccination. Total score ranged between 0 to 10. Poor level considered for total score (0 to 5) and good level considered for total score (6 to 10). Results shows that 305 participants out of 413 which represent 73.8% of the total sample had good knowledge, while 108 participants out of 413 which represent 26.2% had poor knowledge of COVID-19 vaccines [Table 2].
Attitudes scale towards COVID-19 vaccines
Table 3 shows the participant’s responds to the 11 items of the attitudes towards COVID-19 vaccination. The highest mean of scores was 4.56 out of 5 point scale for those who think that the vaccine is freely available, followed by mean score 4.27 for those who think vaccination is a social responsibility, followed by 4.22 out of 5 for those who agreed that many people have been vaccinated, while the least mean score was 3.66 for those how healthcare professional/doctor recommended them to had the vaccine. Overall mean score for positive attitudes was 4.03 out of 5-point Likert scale, with std. deviation of 0.757 which represent about 80.6% of the total sample had positive attitudes towards COVID-19 vaccination [Table 3].
Practices towards COVID-19 vaccines
Table 4 shows the participant’s responds to the 5 questions of the practices towards COVID-19 vaccination. The highest mean score was 4.20 out of 5 for the item: (When it is my turn to get the vaccine, I want to take it), followed by 4.10 for (I advise my family and friends to get the vaccine), followed by 3.57 for those who did not agree about (I would rather get immunity the natural way (by getting an infection/asymptomatic infection) than getting vaccinated), followed by 3.42 for those who did not agree about (After taking the COVID-19 vaccine, I do not have to take precautions such as wearing a mask, sterilization, and social distancing), while the least mean score was 3.33 for (I want to get the vaccine even if I have to pay for it). Overall, mean score for positive practices was 3.72 out of 5-point Likert scale, which represent about 74.4% of the total sample had positive practices towards COVID-19 vaccination [Table 4].
Sources of information that influence opinion about COVID-19 vaccines
Table 5 shows the participant’s responds to the 5 sources of information that influence opinion about COVID-19 vaccines. The highest mean score was 2.36 out of 3 for: (Government body), followed by 2.19 for (Social media such as Facebook, Instagram, and WhatsApp), followed by 2.08 for (Healthcare Provider), followed by 2.6 for (Through talking with friends and family), while the least mean score was 1.90 for (News from a national channel/radio). Overall mean score for the factors that improve acceptance toward COVID-19 vaccines was 2.12 out of 3-point Likert scale, which represent about 70.7% of the total sample had high agreements about the sources of information that influence their opinion about COVID-19 vaccines.
Barriers of COVID-19 vaccination for risk groups and the general public
Table 6 shows the participant’s responds to 6 items about the barriers of COVID-19 vaccination. The highest mean score was 3.58 out of 5 for the item: (Possibility of unexpected future effects of the vaccine), followed by 3.48 for (The speed of adoption and development), followed by 3.38 for (Dangerous/immediate side effects after vaccination), followed by 3.15 for (The vaccine is ineffective), followed by 3.07 for (The vaccine was promoted for commercial gain for companies), while the least mean score was 2.83 for (The vaccine may be false or fake). Overall, mean score for barriers was 3.25 out of 5-point Likert scale, which represent about 65% of the total sample had high agreements level towards the barriers of COVID-19 vaccination.
Relationships between KAP scores and demographic factors
1. Association between knowledge level and demographic variables
Table 7 shows the results of Chi-square tests for association between knowledge level and demographic variables, which indicate that there is a statistically significant association (p < 0.05) between the level of knowledge and both of education level and take the COVID-19 vaccine, university had higher level of good knowledge by 83.3%, and who taken the COVID-19 vaccine by 85.1%. Otherwise there is no statistically significant association between the knowledge and other demographic (p > 0.05). This is due to the convergence of percentages among groups.
2. Differences in the mean score of attitude according to demographic variables
Table 8 shows the results of T and ANOVA tests for differences in the mean score of attitude according to demographic variables. Results indicate that there are a statistically significant difference (p < 0.05) in mean score of attitude according to gender in favor of male, and who take Covid-19 vaccination, in favor of second dose. Otherwise, there is no statistically significant difference between other demographic (p > 0.05) due to the convergence of mean score among groups [Table 8].
Differences in the mean score of practices about COVID-19 vaccination according to demographic variables
Table 9 shows the results of T and ANOVA tests for differences in the mean score of practices according to demographic variables. Results indicate that there are statistically significant differences (p < 0.05) in the mean score of the practices according to take the COVID-19 vaccination; in favor of those who token the second dose with highest mean score for practices about COVID-19 vaccination (3.8874). Otherwise there is no statistically significant difference between other demographic (p > 0.05) due to the convergence of mean score among groups [See. Table 9].
Association between the knowledge, attitude, and practice toward COVID-19 among the Qassim population
Table 10 shows the results of correlation matrix between the study variables. Results indicate that there is three statistically significant relation. The highest correlation coefficient was found between the attitude and practice with (r = 0.664, P < 0.01), followed by the relation between the attitude and Knowledge with (r = 0.353, P < 0.01), followed by the relation between knowledge and practices with (r = 0.328, P < 0.01). The strength of the correlation describe as follow: 0.0-0.19 “very weak”, 0.20-0.39 “weak”, 0.40-0.59 “moderate”, 0.60-0.79 “strong”, and 0.80-1.0 “very strong”.[19,20] [See. Table 10].
According to public filings, more than 118 companies and scientific research institutions around the world are working on 214 COVID-19 vaccine projects. As of June 2021, at least one country had approved a total of 13 vaccines, including two mRNA vaccines as well as inactivated virus vaccines. Nevertheless, discussions over the public’s approval or rejection of the vaccine’s products have been fueled by concerns about the rapid development of COVID-19 vaccines or their safety. These debates include doubt about the vaccine’s efficacy as well as conspiracy theories about the virus’s emergence. In fact, the literature has reported a range of vaccination acceptance rates ranging from 43 to 93% over time and across countries.[23,24] Several factors have been reported to influence the general public’s perception of the COVID-19 vaccine, including adverse health consequences, a lack of adequate knowledge about the vaccine’s safety and efficacy, long-term complications, and a lack of trust in the current healthcare system.
In our study, 53.8% of the total participants had taken second dose of COVID-19 vaccine, 33.4% had taken first dose while 12.8% hadn’t. Overall mean score for positive attitudes was 4.03 out of 5-point Likert scale, with std. mean score for positive practices was 3.72 out of 5-point Likert scale, which represent about 74.4% of the total sample had positive practices towards COVID-19 vaccination. Previous Saudi study reported acceptance rate (64.7%) as well as several western countries[25–28] including the US (69%), Japan (65.7%), and the UK (64–71.7%)[27,28] compared to a lower rate reported in Kuwait (53.1%). In an earlier study, it was observed that 33% of US respondents showed hesitancy to taking the COVID-19 vaccine. Similarly, around 31% of Turkish participants in an online survey indicated a refusal to be vaccinated against COVID-19. About 23% of Oman’s study participants in another study expressed concern over the safety of the COVID-19 vaccine. Another study on Saudi population found total acceptance (vaccinated and intending to be vaccinated) in study was 79.2%, which is higher than what has been reported in another study that demonstrated 64.72% acceptance intention to COVID-19. A previously reported study showed that more participants ranked the efficacy of COVID-19 vaccine as moderate or low. However, data from the current study showed that 67% of the study participants had positive perceptions on the currently available COVID-19 vaccines given in Saudi Arabia which was consistent with a recent worldwide systematic review about vaccination willingness in which they found that about 66% have a positive attitude toward COVID-19 vaccines. A more recent and global study also showed that a high percentage of vaccine acceptance was reported among individuals who reported trust in their government compared to those with less trust. This study also showed that individuals who reported higher levels of trust in information from government sources including healthcare sectors were more likely to accept the vaccines. These data highlight the importance of enhancing the trust between healthcare sectors and populations which can be achieved by increasing transparency and making more efforts to approach the community. It may be argued that the results may be an overestimation of the acceptance to be vaccinated, since the respondents are predominantly highly educated individuals. Sequentially, the sample is not representative of the normal mix of the population. Another study had an acceptable level of knowledge toward COVID-19 vaccines: 74.4% answered correctly more than 50% of the knowledge questions.; participants were able to answer correctly questions related to vaccines’ effect, doses, expected adverse drug events, immunity timeframe after vaccination, as well as protective measures postvaccination. These results can be further explained by the demographic characteristics of our sample that included young, highly educated respondents who are known to be more familiar with technology and consequently have better access to social media platforms, compared to elderly participants. The knowledge level in this study was higher than that reported in a recent study in Bangladesh which used the same methodology and showed an overall rate of correct vaccine knowledge answers of 57%.
Regarding the source of information, our results revealed that highest mean score was 2.36 out of 3 for: (Government body), followed by 2.19 for (social media such as Facebook, Instagram, and WhatsApp), followed by 2.08 for (Healthcare Provider), followed by 2.6 for (Through talking with friends and family), while the least mean score was 1.90 for (News from a national channel/radio). A study reported that participants sought information on COVID-19 vaccines from various sources including scientists and scientific releases, the MoPH website, the World Health Organization, pharmacists, and primary care physicians. Thus, respondents were using credible information sources. However, a significant number still relied on television, social platforms, and even friends and family members to get information. Similar rates for using trusted and unreliable sources of COVID-19 information have been previously reported in Lebanon Other studies published in Middle Eastern countries, particularly Jordan and Kuwait reported getting information about COVID-19 vaccines from television (31.7%), social media platforms (30.1%), compared to only 36.4% from trusted sources, this can lead to a high level of misinformation and sequentially may increase hesitancy toward vaccinations. The most common sources of information for vaccines in another study were social media (67%) and television (56%). Certainly, trust is an essential and modifiable factor in the successful uptake of a COVID-19 vaccine. These findings were supported by Al Hanawi MK et al. in a recent KAP study conducted in Saudi Arabia and Egypt, which showed high perception results regarding the main source of information related to the COVID-19 pandemic: social media (85.8% and 80.0%, respectively) and television (35.7% and 80.8%, respectively). Regarding barriers to vaccine, our study shows the participant’s responds to 6 items about the barriers of COVID-19 vaccination. The highest mean score was 3.58 out of 5 for the item: (Possibility of unexpected future effects of the vaccine), followed by 3.48 for (The speed of adoption and development), followed by 3.38 for (Dangerous/immediate side effects after vaccination), followed by 3.15 for (The vaccine is ineffective), followed by 3.07 for (The vaccine was promoted for commercial gain for companies), while the least mean score was 2.83 for (The vaccine may be false or fake). This was comparable to a study reported common barriers for refusing to receive the vaccines included participants’ concern about the vaccines’ potential long-term serious side effects (66.7%), the short time allocated to vaccines’ clinical trials (48.9%), the effects of new technologies (mRNA) used in the vaccine production (35.3%), and short-term side effects of the vaccines including allergic reactions (26%). Another study reported that participants’ most common reasons for rejection were vaccine efficacy, safety, side effects, its convenience, and price. These participants also hold the belief that the vaccine is not necessary, that natural exposure to infections gave the safest protection, that there has been insufficient testing of COVID-19 vaccines, that authorities are motivated by financial gain rather than the health of people, and had conspiracy beliefs and believed that COVID-19 has been exaggerated.
Our study indicated a statistically significant association (p < 0.05) between the level of knowledge and both of education level and take the COVID-19 vaccine, university had higher level of good knowledge by 83.3%, and who taken the COVID-19 vaccine by 85.1%. Also, a statistically significant difference (p < 0.05) in mean score of attitudes according to gender in favor of male, and who take COVID-19 vaccination, in favor of second dose. There is a statistically significant difference (p < 0.05) in the mean score of the practices according to take the COVID-19 vaccination; in favor of those who token the second dose with highest mean score for practices about COVID-19 vaccination (3.8874). A systematic review showed similar trends when identifying populations that are most vulnerable to being insufficiently vaccinated due to high hesitancy. Themes identified to contribute to high hesitancy were most prominently associated with certain sociodemographic variables. Such variables included income (e.g., being low-income population), age (e.g., younger patients were more hesitant, partially as they perceived being at lower risk compared to elders, education (e.g., having a lower education degree, area of residence (e.g., those in rural areas were more hesitant, reported race and/or ethnicity (e.g., those who identified as minorities). Accordingly, studies conducted in different countries of the world, the most determinate of intention to use COVID-19 vaccine are age, parity, occupational status, gender, marital status, educational status, income, perceived risk of COVID-19 infection, a healthcare worker, attitude towards, knowledge of COVID-19, being sick with COVID-19, the pre-existence of chronic disease.[44–46] Another study found the vaccine acceptance rate significantly higher among adults (age 30 years and above) and older groups (53.83%) than the younger population. The reason for comparatively more vaccine acceptance among the more aging population is most likely because COVID-19 affected the adult and more senior people. This group faced the highest death toll. A similar result was found in a study conducted in the United States. Significant predictors of participant knowledge in another study were age, gender, educational level, and income level.[49,50] This finding is supported by other studies that have found that older, female, and more educated respondents are more knowledgeable about emerging communicable diseases.[49,50] Another study also found that education, age, and income have been documented to be highly relevant to knowledge. Another study suggested that greater emphasis should be placed on mass media, to target low-income, low-educated, young people, and men to improve public knowledge on the COVID pandemic, through awareness-raising interventions. Finally, the study findings may be useful to inform policymakers and healthcare professionals, on further public health interventions, awareness-raising, policies, and health education programs. The findings suggest that targeted health education interventions should be directed to this particular vulnerable population at high risk of contracting COVID-19.
This study concluded that the participants’ high knowledge of COVID-19 translates into good and safe practices, during the COVID-19 pandemic. Public health workers worldwide should concentrate on enlightening and building faith among the unsure and reluctant population regarding security, effectiveness, and adverse effects of the COVID-19 vaccine.
- Study is useful to the policymakers and healthcare professionals
- Vaccine acceptance programs of COVID-19 are important.
- Health education interventions should be directed to population of Qassim
- Saudi Arabia at high risk of COVID-19 transmission.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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