Factors associated with the unwillingness of Jordanians, Palestinians and Syrians to be vaccinated against COVID-19

Background The COVID-19 pandemic is expected to continue to inflect immense burdens of morbidity and mortality, not to mention the sever disruption of societies and economies worldwide. One of the major challenges to managing COVID-19 pandemic is the negative attitudes towards vaccines and the uncertainty or unwillingness to receive vaccinations. We evaluated the predictors and factors behind the negative attitudes towards COVID-19 vaccines in 3 countries in the Middle East. Methods A cross-sectional, self-administered survey was conducted between the 1st and the 25th of December, 2020. Representative sample of 8619 adults residing in Jordan, West Bank, and Syria, completed the survey via the Web or via telephone interview. The survey intended to assess intent to be vaccinated against COVID-19 and to identify predictors of and reasons among participants unwilling/hesitant to get vaccinated. Results The total of the 8619 participants included in this study were the ones who answered the question on the intent to be vaccinated. Overall, 32.2% of participants (n = 2772) intended to be vaccinated, 41.6% (n = 3589) didn’t intend to get vaccinated, and 26.2% (n = 2258) were not sure. The main factors associated with the willingness to take the vaccine (yes responses) included females, 18–35 years old, Syrians and Jordanians, a large family size, and having received a flu vaccine last year. Reasons for vaccine hesitancy included the lack of rigorous evaluation of the vaccine by the FDA and the possible long-term health risks associated with the vaccines (the wait-and-see approach). Conclusion This survey, conducted in December when the number of cases and deaths per day due to COVID-19 were at or near peak levels of the initial surge in the three regions under investigation. The survey revealed that most of survey’s participants (67.8%) were unwilling/hesitant to get vaccinated against COVID-19 with the lack of trust in the approval process of the vaccine being the main concern; the two main characteristics of those participants were more than 35 years old and participants holding a Bachelor’s degree or higher. Targeted and multi-pronged efforts will be needed to increase acceptance of COVID-19 vaccine in Jordan, West Bank and Syria.


Introduction
The COVID-19 disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is continuing to become a major and rapid global threat, in particular with the emergence of the different variants. As of January, 24th, 2021, the pandemic is affecting more than 218 countries and territories, and approximately 98.9 million people and leading to nearly 2.1 million deaths worldwide [1]. The pandemic has unprecedented strain on healthcare resources, undermined economic activity worldwide, and instilled fear into the general population [2,3]. The pandemic will depend on acquiring immunity in approximately 67% of the population (herd immunity) through natural means, or by allowing a large proportion of the population to become infected, increasing the strain on the healthcare system and the economy [4]. Hence, a predominant vaccination is essential for managing the pandemic, although it is not yet clear what would be the degree and the duration of protection the available vaccines will offer [5]. However, the current pandemic is occurring among a widespread mistrust in the safety and effectiveness of vaccines globally [6], thousands of people have protested around the world against mass vaccination [7].
Vaccine hesitancy and disinformation in many countries are major challenges to achieving coverage and population immunity [5,6]. Anti-vaccination groups in Jordan, West Bank, and Syria, among several other nations, are now lobbying against the vaccines, so governments and public health agencies should be prepared to increase vaccine awareness so that the majorities will get vaccinated in those three regions. We assessed intent to be vaccinated against COVID-19 among a representative sample of adults among Jordanians, Palestinians, and Syrians located in 3 regions sharing the same borders, culture, traditions, beliefs, however, the political and economical instability in Syria and Palestine which caused a major decline in the health system might have affected the peoples' attitudes toward the vaccine. In addition, we have identified the predictors of intent to decline or hesitancy to get vaccinated and the possible reasons behind it.

Ethics statement
The study has been approved by the Institutional Research Board/Ethical Committee at the American University of Madaba approval number (H20007) by a formal written consent. The study objectives and methods were fully explained to the participants.

Participants and survey administration
We surveyed a nationally representative sample of adults residing in Jordan, West Bank, and Syria via a survey prepared in Google form in English translated to the local Arabic language which was then circulated via the web or through a phone interview. The Data was analyzed using IBM SPSS version 23.0. Informed consent was obtained at the beginning of the survey. The survey data was collected between the 1st till the 25 th of December, 2020.

Measures
We assessed intent to be vaccinated for the SARS-CoV-2 with the question, "Would you get vaccinated for coronavirus once it gets available in your country?" followed by the response options 'yes', 'no', and 'not sure'. Participants who responded 'no' or 'not sure' were asked to choose one or more of the following reasons for their answer: "I don't believe in vaccines"; "I need additional information since vaccine wasn't rigorously evaluated by FDA"; "I will wait till other people try it first"; "I don't think the coronavirus is a threat"; "I always get side effects when I get vaccinated"; and "Other reasons".
Data on participant characteristics were provided by participants and included age, sex, nationality and geographic location, educational level, household size, marital status, employment status, receipt of influenza vaccination in the prior year, and the intention of getting the influenza vaccine this year.

Statistical analysis
Frequencies were calculated to summarize participants' characteristics and percentages. Crosstabulations and y 2 tests were used to estimate unadjusted associations of participant characteristics with the 3 possible outcomes of intent to get vaccinated. To better distinguish characteristics associated with responses of 'not sure' versus 'yes' and characteristics associated with responses of 'no' versus 'yes', we also calculated separate y 2 tests and associated P values for these 2 sets of comparisons, with a p-value � 0.05 is statistically significant.
To estimate corresponding adjusted (univariate) associations, we used univariate logistic regression between the acceptances of vaccine versus the refusal (no) or the hesitation (not sure) to identify the influencing factors, with the odds ratio (RRR), and a 95% confidence interval (CI) being calculated.

Results
Survey respondents represented a random sample of the populations of 3 Middle Eastern countries; Jordan, West Bank and Syria. Most participants (87.2%) completed the survey via the Web; the remainder (12.8%) completed it via telephone interview. All results presented here are based on the 8619 participants who responded to the question on the intent to be vaccinated.
Most participants (70.6%) perceived that the best way to fight COVID-19 is by wearing a mask and washing hands, 60.6% by social distancing, and 45.8% by vaccination. Additional options for this question and their frequencies are listed in Table 2. Only 32.2% of the participants intend to get vaccinated against COVID-19, while the highest percentage of participants  Table 3). Table 4 summarizes the results for the 27 regressions: one set of nine univariate regressions for the outcomes of the question regarding the intent to get vaccinated against the demographic variables and if the participant had a flu vaccine last year.
People aged 36-55, 56-70 and >70 were less likely to get the vaccine than those who aged 18-35. This difference was the strongest (the relative risk ratio (RRR) = 7.5; 95% confidence interval (CI) (6.5, 8.5) when responses from the middle age cohort and those from the youngest age cohort were compared ( Table 4). The same trend was observed with gender, females were more likely to accept the vaccine with RRR of 2.1 (95% CI (1.9, 2.3)). Jordanians were much more likely to get vaccinated (RRR of 1.5 (95% CI (1.4, 1.7)) than Palestinians but less than Syrians (RRR of 0.7 (95% CI (0.6, 0.8)). Higher levels of education were strongly associated negatively with vaccine acceptance, participants a high school diploma or less were ten-fold more intended to be vaccinated than participants with graduate degrees (RRR of 10.3 (95% CI (8.2, 12.9)). Increase in family size of participants reflected positively on the level of acceptance to the vaccine, family size of �4 had RRR of 1.5 (95% CI (1.3, 1.7)), the same trend was observed with participants who had the flu vaccine last year (RRR of 1.3 (95% CI (1.1, 1.4)).

Discussion
The current research aimed at assessing the intent to be vaccinated against COVID-19 among a representative sample of 8619 adults among Jordanians, Palestinians, and Syrians, residing in three countries with high COVID-19 burdens in the Middle East. It also aimed at identifying the predictors of intent to decline or hesitation to get vaccinated against the disease. About one third of the participants (32.2%) intended to be vaccinated, 41.6% declined, and 26.2% were hesitant (Table 2), this is especially striking considering that the survey was conducted during December 2020, when the number of cases and deaths per day due to COVID-19 were at or near peak levels of the initial surge in the three regions. The far-from-willingness to accept the vaccine among the three nationalities is very concerning. Furthermore, reporting one's willingness, rejection or hesitancy to get vaccinated might not be necessarily a predictor, as vaccine decisions are multifactorial and can change over time. Groups most at risk of mistrust in vaccines are the same groups who also are at increased risk for illness and death from COVID-19; older ages. While Predictors to the intent to be vaccinated were: young ages (18-35) with about 7.5-fold more of getting vaccinated than 36-55 years old, females, Syrians and Jordanians, a family size of �4, and having received a flu vaccine last year ( Table 3). The surprising fact was the refusal of getting vaccinated increased with the level of education; participants with a high school diploma or less were more than 10-fold willing to get vaccinated than graduate degree holders (Master's and PhD) (RRR of 10.3 95% CI (8.2, 12.9)), indicating that the refusal of vaccine was not arbitrary but most likely based on specific concerns among educated participants. The reasons for vaccine rejection and hesitancy included the lack of rigorous evaluation of the vaccine by the FDA and hesitancy till many other people try it first (wait-and-see approach), consistent with many other drug studies around the world under normal health situation. Refusal and hesitancy to vaccination is a common global concern, also it is one of the top ten threats to global health in 2019 according to the World Health Organization [8].
The lack of scientific knowledge and the mistrust in the pharmaceutical industry are thought to be important predictors for vaccine hesitancy. This research was performed in third world countries where immunization is a requirement for school entry as in many countries [9]. Vaccine refusal could have secular and geographical trends, for example, in the USA when nonmedical vaccine exemptions were allowed, the mean exemption rate was doubled [10] this resulted in increasing the individual risk for contagious diseases for instance children that were exempted from vaccinations were 35 times at higher risk to develop measles [11] In the last months, a huge anti-vaccine content was shared on the social media [9,10] additionally many social media bloggers in the Arab World shared their concerns about the COVID-19 vaccine. Facebook is becoming the population reliable and easy source of medical information with more than 2.2 billion active monthly users [12].
Health Care Providers have an essential influential role in vaccine persuasion. In two studies, individuals were twice as likely to consider vaccines safe after their health care provider counseling [13,14].
The population concerns regarding a potential COVID-19 vaccine efficacy and safety should be the content of interventional educational programs done by the authorities to enhance vaccination rates [15].
Therefore there is an urgent need to familiarize health care providers with the different social media platforms to enhance communication with the population [16]. Recent evidence supports the use of balanced content with a suitable and interactive approach while avoiding complex scientific information [17].
Strengths of our study are that the large, nationally representative sample allows generalization of our findings in each of the three countries under study, and the timing of the survey administration coincided with a peak time of the pandemic in three regions, making the findings particularly timely and prominent.
Our study also has limitations. First, we questioned individuals about their intent to be vaccinated before the vaccination was yet available. It is possible that if more information regarding a potential vaccine was known, some participants might have changed their responses. Second, our study lacked the question(s) to determine what additional information the participant needed about the vaccine to form a solid opinion regarding the acceptance of the potential vaccine.
Although our survey was conducted between the 1 st and the 25 th of December, 2020, yet the numbers of fully vaccinated percentages among the three countries, as reported between the 13 th till the 28 th of Sep, 2021, were only 31.88% of the total population in Jordan, 14.52% in the West Bank, and 1.66% in Syria [18]. Future research is required to better access the types of assurances the public needs to be vaccinated, especially when the numbers of COVID-19 cases in three countries are still high.