The VH rate during the first two weeks of April 2021 was 45.7%, in a relatively educated study participants than a Pakistani general population. Studies conducted in early phases of the pandemic between March to April 2020 showed a high reception, above 90%, for potential vaccine acceptance in China, Malaysia and Indonesia (3, 23). Studies conducted in later phases of the pandemic from October to December 2020 showed a declining trend in acceptance rate in America, Jordan and Kuwait at 66.8%, 30.9% respectively, with Kuwait acceptance rate standing at only 29.4% (24–25). Studies conducted during vaccine rollout stage, from 2021 onwards, showed a 31.1% hesitancy rate in Italy in January 2021 when HCW had started receiving vaccinations. (26) In Japan in April 2021, almost 60% of the population was either unsure or in complete refusal to receive the vaccine. (27)
A study from Pakistan, that took place from December 2020 to March 2021, reported the VH of 35.8% that is less than the VH rate of this study (45.7%) (28). Whereas in comparison to a study done from January to March 2021, it was slightly lower than the reported VH rate of 47% (29). The reason for this could be the changing perceptions of studied population overtime, with VH rates increasing as the act of receiving a vaccine became reality and people’s fears surfaced. These findings are in line with a longitudinal study done within the US to see changes in Covid 19 vaccine acceptance; their findings showed a decreasing trend VH rates over 6 months, which could be attributed to information sources (30). A similar trend was seen in China with acceptance declining over time (31).
Our study was carried out in the initial days of vaccine distribution when allowance was only given to healthcare workers and citizens over 60 years of age; and the mean age of the study participants was 34.2 with majority (59.7%) being between the age of 25–44. This shows that most participants were not eligible to receive the vaccine so those who were, were more open to it. This is reflected in our study as well, the VH decreased with inappcreasing age (P-value: 0.049). This finding is concurrent with studies done in both China (31) and Canada (32) finding older individuals extremely willing to receive the vaccine.
Within the vaccinated population, majority (57%) were health care workers (HCW), however, among HCWs more than one third (31.2%) were still unwilling to receive the vaccine. A positive correlation was found between being a health care worker and hesitance to the vaccine after adjusting the PR 1.2 (0.83, 1.97). Studies done on vaccine acceptance rates in HCW in different countries are rare and show a wide range in rates; this disparity could be owed to cultural, political or religious differences. Data supporting our study has similarly appeared from Saudi Arabia and Palestine with VH in HCWS at 49.48% and 30.7% respectively (33–34). HCW were the first priority of WHO when vaccine resources were a concern as they serve as the first line to be affected and transmit the virus. This could have been a factor as receiving vaccine before others might have made the health care workers cautious to vaccination. In the study in Palestinian HCW vagueness of the efficacy and side effects were cited as the main cause of hesitancy (34).
Skepticism for the vaccine was determined through vaccine safety and vaccine trustworthiness. Majority (66%) had trouble trusting the vaccine along with a positive correlation (adjusted PR value of 1.0) between thinking the Covid vaccine is not safe and therefore were VH. This could be due to this study being carried out in the early phase of rollout, the speed of vaccine development and fake news circulation which is why reassurance and guidance by physicians was cited as an important factor to increase vaccine acceptance (76.2%). Over 60% of participants were worried about major side effects of the vaccine ranging from breathing problems, blood clotting, getting Covid 19, to death. A very small minority (23.4%) was unaware of the side effects from the vaccine. A major reasoning for differences in opinions could be the sources where people are getting their information as majority (51%) reported to get information from social media where sources are not fact checked and can lead to a snowball effect of escalating rumors (35). Not surprisingly, VH was most consistent in those believing that vaccine had major side effects (44.8%).
According to the Health Belief Model (HBM), perceived severity includes believing that the disease in question can cause serious harmful effects and according to our survey, most of the participants did believe that Covid 19 resulted in serious complications (36). This is complemented by the fact that the precautionary score calculated within our study was 7.5 and more than three quarter of participants complied to wearing masks in public and majority made use of hand sanitizers. Despite this, more than 60% of participants were concerned about the effectiveness of the vaccine in the first place. With the progression of the pandemic, people might have become more reliant on and comfortable with measures being taken already such as mask wearing, hand washing and sanitizers with the belief that such precautions are sufficient (31).
The belief that actively getting the disease or disease severity can be reduced by getting the vaccine was not assessed. This serves as a limitation for assessment of risk perception which is an important indicator within epidemiology to control infectious disease epidemics (34). Most of our participants were part of the educated strata who had both access to the internet plus basic skills to fill out the questionnaire in English language, hence the findings from our study cannot be generalized to the whole population as Pakistan has a literacy rate of 59% only and majority of the population don’t speak English language. Due to constraints of observing standard procedures during the pandemic our study had to be conducted via online surveys which could have decreased sample size and any information and reporting bias as there is no way of ensuring quality of collected information. Another issue is the timeline of our study, which can only capture the attitude at that particular moment, and perhaps with initiation of month of Ramadan. However, as time proceeds, new variants cropping up along with changes in policies and restrictions, the attitude towards vaccines could keep changing so further studies particularly those inculcating the HBM are needed. Despite all these limitations, we are confident that findings from our study could make way for better policies in Pakistan targeting towards increasing vaccine awareness through health education interventions, mitigating false propaganda related to vaccine on social media, clinician recommendations for COVID-19 vaccine to their patients and educate masses about the safety and effectiveness of COVID-19 vaccine. The vaccine trials and public release of safety and efficacy information and trust building activities could also reduce COVID-19 VH in our setting.
Our data suggests that VH related to COVID-19 is of utmost concern and needs serious action by the policy on communicating by government to address this issue. Pakistan has had consistent trepidations towards vaccines even before Covid- 19 hit. Pakistan is among the countries - Pakistan, Afghanistan and Nigeria where distrust in vaccines will increase over the year as religious extremism prevails here along with civil uncertainty. This leads to spreading of false information and propaganda, especially if one considers polio cases are still existent here (12). In order for Pakistan to overcome this hurdle the first step needs to be probing research on the relationship between political and religious polarity and vaccination beliefs.