Acceptance, Hesitancy, and Refusal of Coronavirus Disease 2019 Vaccine and Associated Factors in the Population of Libya: A Cross-Sectional Study

Abstract

Background and Aims: 

To obtain herd immunity and control the coronavirus disease 2019 (COVID-19) infection, a large proportion of the population must be vaccinated. However, not everyone in Libya believes in the necessity or safety of COVID-19 vaccines. Therefore, understanding the reasons and variables impacting vaccine hesitation in the Libyan population will assist in developing strategies to reduce this hesitation and achieve better vaccination levels in the country. This study aimed to investigate the acceptance, hesitancy, and refusal of the COVID-19 vaccine and the factors that influence COVID-19 vaccine hesitancy and denial in the Libyan population.

Methods: 

A cross-sectional survey using a snowball sampling strategy to collect data was conducted between February and May 2022. Descriptive statistics and the Chi-square test were used for data analysis. Study questionnaires were distributed using social media.

Results: 

The overall COVID-19 vaccine acceptance was 39.7%, vaccine hesitancy was 36.6%, and vaccine refusal was 23.6% among the study participants. The highest refusal rate was among participants aged 12–24 years, 49 out of 91 (53.8%). Vaccine refusal was similar in males and females; however, vaccine acceptance was higher among females than males. Vaccine acceptance was higher in people with a higher graduate degree than those less educated (P = 0001).

Conclusion: 

Our findings show that vaccine hesitancy was 36.6% and vaccine refusal was 23.6% among the study participants. The study identified reasons for vaccine hesitancy and refusal and proposed education programs to address misbeliefs about the COVID-19 vaccine, allowing people to make informed decisions.

INTRODUCTION

The significant preventative measures have been implemented to combat the spread of the ongoing coronavirus disease 2019 (COVID-19) infection caused by the severe acute respiratory syndrome coronavirus 2, since the outbreak was declared a worldwide pandemic by the World Health Organization on March 11, 2020.^[1] Perhaps, the most important preventative measure is developing and implementing a safe and effective vaccination against this disease.

In Libya, the first COVID-19 case was recorded on March 24, 2020.^[2] After that, the number of cases increased even up to a 100 cases/day. However, due to the preventative measures adopted by the health authorities, such as the free national vaccination program in April 2021, targeted all residents aged 12 years and above.^[3] The epidemiological situation is stable, and the number of new cases has declined substantially.^[4]

To achieve community protection against COVID-19 by vaccination to the point where the infection is significantly less likely to turn into large outbreaks, a sufficiently large proportion of the population needs to be immunized.^[5] However, as of today, June 12, 2022, only 1,142,804 (17%) of the target population are fully vaccinated (have had two doses of the COVID-19 vaccine).^[6] However, in Libya, many Libyan residents refuse to be vaccinated for various reasons. Those might be a barrier to establishing an adequate herd immunization in the Libyan population.

This study aimed to investigate how widespread COVID-19 vaccination hesitancy and refusal is among the Libyan population, as well as to look into common reasons and examine the demographic factors that influence COVID-19 vaccine acceptance, hesitancy, and refusal among the population.

METHODS

Study setting

This cross-sectional study was conducted among Libyan residents between February and May 2022. Libya is a North African country with a population of around 6,931,061 million (49.27% are females) as estimated in the latest national census in 2020. The country is on the Mediterranean coast and has an international border with Egypt on the east, Niger and Chad on the south, Sudan on the southeast, and Tunisia and Algeria on the west. The country’s economy mainly depends on oil revenues, limited agriculture, and other small industries. Libya has one of the highest per capita incomes in Africa, and the literacy rate in the country is 91.29%.^[7] However, civil wars have deteriorated the Libyan population’s socioeconomic situation and health-care quality in the recent years.^[8]

Sampling

The data were collected using a snowball sampling approach.^[9] An anonymous online questionnaire prepared in a Google form about COVID-19 vaccination was modified from a previous study^[10] and disseminated through the social media platforms in Libya.

We adopted this technique since traveling between Libyan regions was not easy during the study, especially between eastern, western, and southern regions, partly due to the country’s vast size and partly due to the country’s frequent closing due to intermittent unrest since the 2011 uprising.^[8]

The study team from different Libyan cities and regions distributed the study questionnaire using the commonly used social media platforms, i.e., Facebook, WhatsApp, Telegram, and Twitter. The questionnaire was pilot tested to check the clarity of the questions.

The following statement was included in the questionnaire: “this survey is intended to investigate the acceptance, hesitancy, and refusal of covid-19 vaccine and associated factors. The questionnaire seeks personal and demographic data such as age, sex, marital status, education level, occupation, monthly income, history of COVID-19 infection, presence of comorbidities, willingness to be vaccinated, and source of COVID-19 vaccine information. Your responses are anonymous and confidential. By completing your response, you agree to participate in this study.”

Participants could respond only once to the questionnaire. Only individuals who were permanent residents aged 12 and above (the youngest age group targeted by the national COVID-19 immunization program) and had not yet received their COVID-19 vaccine were allowed to participate in the survey. The participants were classified into three age categories: 12–24 years old (school and university age), 25–64 years old (people of working age), and >65 years old (retirement age).

Sample size

The population of Libya is about 6,931,061 as estimated in 2020 by the country’s Bureau of Statistics and Census (Bureau of Statistics and Census, 2020).^[11] OpenEpi software (a web-based, open-source, epidemiological software) was utilized to calculate the appropriate sample size; 385 samples were sufficient to conduct this study at a confidence level of 95%.^[12]

Analysis of data

The data were described using descriptive statistics. A Chi-square test was used to highlight any statistically significant result among variables, where P < 0.05 was considered statistically significant in all tests. Data analysis was undertaken using SPSS computer software for Windows version 23, (SPSS Inc., Chicago, IL, USA) and using the Microsoft Office Excel 2016 program.

Ethical approval

The Ethical Committees of Tobruk University, Libya, approved the study protocol (No: 22.7.1.0032). The data obtained from the participants were anonymous. Participants were asked to give their informed consent before they started filling in the online questionnaire.

RESULTS

A total of 385 individuals participated in this study; 135 of the total participants (35.1%) aged 12–24 years, 207 (53.8%) were aged 25–64 years, and 43 (11.2%) were aged ≥ 65 years. The majority of the participants (208, 54.3%) have their undergraduate degrees, 73 (19.1%) participants are in the secondary school stage, 62 (16.1%) participants have their postgraduation certificates, 33 (8.6%) participants are in preparatory school, and nine (2.3%) participants are illiterate. Of the female participants, 233 (60.5%) and 136 (35.3%) were married. 322 (83.6%) participants live in the urban areas.

The participants’ socioeconomic status was divided according to the monthly income (in Libyan Dinar, [LD]) into three categories: low-socioeconomic status (LSES) – participants’ monthly income ≤500 LD, middle socioeconomic status (MSES) – participants monthly income ranged from 500 to 1500 LD, and upper socioeconomic status (USES) – participants whose monthly income was >1500 LD. Of all participants, around 86 (22.3%) were classified as LSES, 190 participants (49.4%) were classified as MSES, and 109 participants (28.3%) were classified as USES. The overall COVID-19 vaccine acceptance among all participants was 39.7%, vaccine hesitancy was 36.6%, and vaccine refusal was 23.6% [Table 1].

Table 1: Basic demographic characteristics of the study participants

Among all participants, 31.4% of the participants relied on social media as the main source of information about the COVID-19 vaccine, 26% of participants relied on scientific websites, 23.9% on the televisons, 16.9% of the participants relied on their friends and family members, and 1.8% of participants depended on newspapers and magazines as the main source of information about COVID-19 vaccine. For nearly half (49.6%) of the age group of 12–24 years, social media was the main source of information about the COVID-19 vaccine [Figure 1].

Figure 1: Sources of information regarding COVID-19 vaccine among the participants

Demographic factors associated with acceptance, hesitancy, and refusal

The vaccine acceptance rate was higher among older age groups (25–64 years and 65 years and older) than it was among younger age groups (12–24 years) (P < 0001). The vaccine acceptance rate was higher among participants with postgraduate education levels than those with less academic levels of education (P < 0001). However, surprisingly, illiterate participants have a higher acceptance rate of COVID-19 vaccination. There was no significant difference in vaccination acceptance between female and male participants (P = 0.047), between people living in the urban and rural areas, and between people of socioeconomic status [Table 2]. Compared to other age groups, the rate of vaccine refusal among the younger age group (12–24 years) was higher (P < 0001) [Table 2].

Table 2: Factors linked to the willingness to accept the coronavirus disease 2019 vaccination

Reasons for not getting vaccinated

About 13% (50) of the participants heard terrible news regarding the COVID-19 vaccine, while 34 (8.8%) had underlying medical conditions and 31 (8.1%) did not have enough time to go and get vaccinated. The most common reason for not getting vaccinated among the study participants (130; 33.8%) was the fear of adverse reactions that the vaccine may cause; however, 69 (17.9%) participants thought the vaccine was ineffective in preventing the disease. In addition, there were small percentages of other reasons, such as the vaccine will cause infertility issues, and I was previously infected with COVID-19, I am delaying the vaccine because I would like to observe potential adverse effects from others, concerns of getting an infection when I have COVID-19 vaccine, pregnant/breastfeeding, and fear of (nanochips) implantation through the vaccine [Table 3].

Table 3: Reasons for not getting vaccinated

DISCUSSION

Vaccine hesitancy refers to “delay in acceptance or refusal of vaccination despite the availability of vaccination services.”^[13] It is a growing problem that prevents countries from achieving and sustaining high population immunization rates. Therefore, it was deemed essential to study this problem in our country and identify underlying factors that influence it.

Vaccine hesitancy is a widespread global problem, as previously reported by several international studies with different percentages of refusal rates.^[14] To the best of our knowledge, no studies have previously investigated the hesitancy and refusal of the COVID-19 vaccines in the population of Libya. Our study reported the overall vaccine acceptance of 39.7%, vaccine hesitancy of 36.6%, and vaccine refusal of 23.6% among the study participants.

The refusal rate in our study was similar in males and females, increased with decreasing age, and was notably higher among the age group of 12–24 years, nearly half (49.6%) of which procured information about the COVID-19 vaccine through social media. Studies demonstrate the crucial role of social media in influencing people’s attitudes toward COVID-19 vaccination; misinformation and practices that are not in accordance with public health advice are widely distributed through social media.^[15] A growing number of young people use social media as the main source of information to get health-related information.^[16] Therefore, using social media platforms by the country’s health authorities to educate people can effectively promote vaccine acceptance, especially among this age group.

In this study, we identified several reasons behind the participants’ hesitance: inaccurate information and misbeliefs about the COVID-19 vaccine [Table 3].

Providing accurate information on the safety and effectiveness of the COVID-19 vaccine and addressing misbeliefs about the COVID-19 vaccine may be critical in dealing with the main concerns of people who are hesitant to be vaccinated and allowing people to make informed decisions.

Vaccine hesitancy and refusal are barriers to achieving higher immunization levels against COVID-19 among the population of Libya. There is a need to launch an effective COVID-19-related health education program that can propagate scientific information about the vaccination of COVID-19.

The study limitations include: snowball technique has disadvantages, such as nonrandom selection, and people’s tendency to recommend the questionnaire to individuals they know who may have similar thoughts and beliefs. Furthermore, because not everyone has Internet access or social media accounts, older people will be less likely to participate. However, the strategy was adopted to minimize the sudden travel due to the ongoing political instability while conducting the study. Moreover, using logistic regression with acceptance, refusal, or hesitancy as outcome variables and other variables as independent variables would immensely strengthened the study.

CONCLUSION

Our findings show that vaccine hesitancy was 36.6% and vaccine refusal was 23.6% among the study participants. The study identified “misinformation” and “misbelief” as reasons contributing to vaccine hesitancy and refusal. To achieve better vaccination levels in the country, we propose a campaign to circulate scientific information about the COVID-19 vaccine, which may convince hesitant members of the general population to accept vaccination.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.