Global COVID-19 Vaccine Acceptance Rate: Systematic Review and Meta-Analysis

Materials And Methods

This systematic review was conducted under the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [17].

2.1 Eligibility criteria

Studies that met the following inclusion criteria were included in the systematic review and meta-analysis. The inclusion criteria considered in this review include: -

Study Population: All populations regardless of their age, occupation, ethnicity, gender, etc.
Outcomes The articles aimed to determine the hesitancy and/or acceptance of COVID-19 vaccines that provided a quantitative outcome.
Language: Studies written in English.
Types of articles: Peer-reviewed full text, original, and published articles.
Publication year: Studies published since after the emergency of COVID-19 to the study period (March 2021).
Study region / location: Not specified (no limitation).

However, unpublished manuscripts or preprints; editorial papers; reports; short communication; review articles; the article did not provide quantitative results or did not aim to determine acceptance and / or hesitancy of the COVID-19 vaccine.

2.2 Information sources and search strategy

Article searches were performed using key terms of review such as COVID-19, vaccine hesitancy, vaccine acceptance and intention to vaccine, and Medical Subject Headings (MeSH) in combination with Boolean logic operators (“AND”, “OR”, and “NOT”) through various electronic databases from PubMed/Medline, Scopus or Science direct, Web of Science, Embase, CINAHL, and Google scholars. Furthermore, the articles were searched directly from Google. On the other hand, references within eligible papers were screened for additional articles. There was no specific date for the search of the articles for each database. For example, the articles were searched from first February to March 29, 2021 from PubMed, Scopus, Embase, and Google scholars while the search on Web of Science, CINAHL, and Google was made from 15 February to 31 March 2021.

The Embase search strategy was made as follows: (1) COVID 19 ' OR ‘COVID 19’/exp OR Coronavirus OR coronavirus/exp OR ‘2019 nCOV’ OR ‘2019 nCOV’/exp OR ‘severe acute respiratory syndrome coronavirus 2' / exp OR 'SARS-COV-2' OR 'SARS-COV 2/exp; (2) Vaccine OR vaccine/exp OR Vaccination OR Vaccination/exp OR Immunization OR Immunization/exp; (3) acceptance OR acceptance /exp; OR ‘hesitance’ OR ‘hesitance/exp’ OR ‘refusal OR ‘refusal/exp’;(4) 1 AND 2 AND 3.

The PubMed search strategy was performed as follows: (1) 'Coronavirus' [MeSH Terms] OR 'Coronavirus' [All Fields] OR 'Coronavirus' [All Fields] OR 'COVID-19' [All Fields] OR 'SARS-2' [All Fields] OR 'Severe acute respiratory syndrome coronavirus 2' [All Fields] OR '2019 nCOV' [All Fields] OR 'SARS COV-2' [All Fields] OR 'Coronavirus' [All Fields] AND; (2) 'Vaccines' [MeSH Terms] OR 'Vaccine' [All Fields] OR 'Vaccinations' [All Fields] OR 'Vaccines' [All Fields] OR 'Vaccines' [All Fields]; (3) “acceptance” [MeSH Terms] OR “hesitancy” [All Fields] OR “refusal” [All Fields] OR “accepted” [All Fields] OR “willingness to accept” [All Fields]; (4) 1 AND 2 AND 3.

The Scopus and Web of Science search strategy was made using a combination of keywords and Boolean functions: (1) (COVID-19 * OR Coronavirus* OR nCOV * OR SARS COV-2; (2) Vaccines *OR Vaccination *OR vaccinates); (3) (acceptance *OR hesitancy *OR refusal* OR accepted *OR willingness to accept; (4) 1 AND 2 AND 3) or 1 AND (2 OR 3)

The search strategy from Google Scholars and Google was done using keywords such as (Coronavirus, nCOV, SARS COV-2, COVID-19) AND (Vaccines OR Vaccination OR Vaccinates); (3) (acceptance OR hesitancy OR refusal OR accepted OR willingness to accept; (4) 1 AND 2 AND 3.

Articles published since the emergency of COVID-19 to March 2021 (from inception to March 2021) were searched from the included electronic databases according to their own searching strategies. The search was carried out from the first February 2021 to the last March 2021.

2.3 Study Selection

The study selection process was performed using the PRISMA flow chart, indicating the number of articles included in the review and articles excluded from the study with the reasons. Following the search for articles through selected electronic databases, duplicate studies were removed using the ENDNOTE software version X5 (Thomson Reuters, USA). After removing duplicate articles, the authors (DAM, YAA, and YMD) independently selected the articles based on the titles and abstracts applying the inclusion criteria. Furthermore, the full text of the relevant articles was further read in detail and the inclusion criteria independently evaluated by the authors. Any disagreements made with respect to the inclusion of studies were resolved by consensus after discussion. Finally, studies that met the criteria were included in the systematic review and meta-analysis.

2.4 Data Extraction

The data were extracted by the authors (DAM, YAA, and YMD) independently. Predetermined tabular format consisting of study characteristics including publication year, survey period, country where the study was conducted, number of respondents and outcome (COVID-19 vaccine acceptance/hesitancy rate using Microsoft Excel, 2016). Any disagreement made between the authors was resolved through discussion after the same procedures were repeated.

2.5 Data Quality Assessment/Management

The selected articles were subjected to a rigorous independent assessment using a standardized critical assessment tool, Joanna Briggs Institute (JBI) Critical Assessment Tools for prevalence studies [18]. The evaluation tools have the following nine evaluation criteria/ parameters; (1) appropriate sampling frame; (2) proper sampling technique; (3) adequate sample size; (4) description of the study subject and setting description; (5) sufficient data analysis; (6) use of valid methods for identified conditions; (7) valid measurement for all participants; (8) use of appropriate statistical analysis and (9) adequate response rate.

The authors ((DAM, YAA, and YMD)) assessed the quality of the included studies. Based on the items in the above appraisal tool, the articles were classified as high quality (80% and above), moderate (60–80% score), and low quality (< 60% score). Articles with a score ≥ 60% were included in the review, while those with a low quality were excluded from the study (Supplementary Materials I). Finally, the disagreements made among the authors were resolved by discussion and repeating the same procedures.

2.5 Outcome Measures

The term 'vaccine hesitancy' refers to 'delay in acceptance or refusal of vaccines despite the availability of vaccine services' [6, 19, 20]. In this review, for articles that did not provide general acceptance of the vaccine among study participants, the prevalence of vaccine acceptance was calculated based on the response of the participants. The participant responded strongly agree, agree, completely agree, accept all, accept some, accept, and yes to the questions were considered as accepted. Finally, the prevalence was calculated based on the frequency of responses and the total number of respondents. The same principle was applied to the studies that reported the result based on the Likert scale and others (Fig. 1).

2.1 Statistical Procedures and Data Analysis

The pooled prevalence / acceptance rate of the COVID-19 vaccine was performed using Comprehensive Meta-Analysis (CMA) version 3.0 statistical software. Forest plot and random-effects model were used to determine and visualize the pooled acceptance rate of the COVID-19 vaccine (supplementary file II).

The Cochran Q test (Q) and I Squared test (I² statistics) were used to evaluate the heterogeneity between the included articles. The, heterogeneity was classified into low (I² index < 25%), medium (I² index ranging from 25–75%), and high heterogeneity (I² index > 75%). The random-effects model was used to analyze the data. Furthermore, subgroup analysis was performed based on the year of publication, survey period (when the study was conducted), and study areas. Publication bias between the included studies was evaluated using funnel plots (Fig. 2). A P-value of < 0.05 was considered as evidence of publication bias. Sensitivity analysis was done to determine differences in pooled effects by dropping studies that were found to influence the summary estimates. Furthermore, meta-regression was conducted to determine the bias as the result of high heterogeneity in the current study.

Results

3.1 Study Selection

Four thousand and sixty-nine articles, short communications, and editorial articles were searched through electronic databases from PubMed/MEDLINE, Scopus/Science direct, Web of Science, Embase, CINAHL, and Google scholars. The search for the articles was done from February to March 2021. After the search for the articles, 992 duplicate articles were excluded. Furthermore, 1,905 articles were excluded after initial selection based on abstracts and titles. Furthermore, 389 articles were excluded after eligibility for full text articles (n = 421). Finally, a total of 30 articles were included in the systematic review and meta-analysis (Fig. 3).

3.2 Characteristics of the included articles

In this review, a total of 58,629 study participants were included in 30 original full-text articles throughout the world and published from 2020 to 2021. Regarding the countries of the world where the studies were conducted, five articles [14, 24, 25, 33, 42] were published in China, four articles [2, 21, 31, 41] in the United States, two articles [26, 40] in Turkey, two in Saudi Arabia [,32,38], and one in each Republic of Congo [22], Malaysia [23], Japan [27], Qatar [30], Poland [11], Cameroon [7], Israel [34], Mexico [36], Malta [37], Scotland [6], Kuwait [32], Indonesia [39], and Jordan [32]. The included studies were cross-sectional studies with a sample size ranging from 123 [37] to 7,821[30] study participants.

The quality of the articles was evaluated based on the Joanna Briggs Institute (JBI) Critical Assessment Tool for prevalence studies [18]. The overall global acceptance rate of the COVID-19 vaccine regardless of occupation was 58.6% and ranged from 15.4% [7] to 94.3% [23]. Seventeen (53.1%) of the included articles were published in 2021, while 15 (44.9%) of the articles were published in 2020 (Table 1).

Table 1

Overall characteristics of the articles included in the systematic review and meta-analysis, 2021.
Authors	Data collection period	Publication year	Sample Size	Acceptance rate	Hesitance rate	Country
Shekhar et al [2]	October to November, 2020.	2021	4080	36	64	United State
Malik et al [21]	May, 2020	2020	672	67	33	United state
Ditekemena [22]	August to September, 2020	2021	4131	55.9	44.1	Republic of congo
Wong et al [23]	April, 2020	2020	1159	94.3	5.7	Malaysia
Wong et al [24]	July to august, 2020	2021	1200	42.2	57.8	China
Kose et al [26]	September, 2020	2020	1138	68.6	31.4	Turkey
Yoda, et al [27]	September, 2020	2021	1100	65.7	34.3	Japan
Freeman [28]	September to October, 2020	2021	5114	71.7	28.3	United Kingdom
Williams et al [29]	April, 2020	2020	527	86	34	United Kingdom
Alabdulla, [30]	October to November, 2020	2021	7821	60.48	39.52	Qatar
Reiter [31]	May, 2020	2020	2006	69	31	United State
Wang et al [25]	August to September, 2020	2021	2047	34.8	65.2	China
Gerussi et al [15]	September to November, 2020	2021	599	40.8	59.2	Italy
Sallam et al [32]	December, 2020	2021	154	31.8	68.2	Saudi Arabia
Feleszko et al [11]	June, 2020	2021	1066	37.0	63	Poland
Dinga et al [7]	May to August, 2020	2021	2512	15.4	84.6	Cameroon
Wang et al [33]	March, 2020	2020	2058	91.3	8.7	China
Dror et al [34]	March to April, 2020	2020	1112	75	25	Israel
Dickerson et al, 2021[35]	October to December, 2020	2021	535	29	71	United Kingdom
Lazarus et al [36]	June, 2020	2020	699	76.2	23.8	Mexico
Gretch et al [37]	September, 2020	2020	123	61.8	38.2	Malta
Al-Mohaithef & Padhi, [38]	Not stated	2020	992	64.7	35.3	Saudi Arabia
Williams et al [6]	August 2020	2021	2016	77.5	22.5	Scotland
Sallam et al [32]	December 2020	2021	771	23.6	76.4	Kuwait
Harapan et al [39]	March to April 2020	2020	1359	93.3	6.7	Indonesia
Akarsu et al [40]	June to July, 2020	2020	759	49.7	50.3	Turkey
Khubchandani et al [41]	June, 2020	2021	1878	79	22	United State
Chen [42]	May to June, 2020	2021	3195	83.8	16.2	China
Palamenghi et al [43]	Not specified (not stated)	2020	1004	59.0	41.0	Italy
Wang, 2020[14]	March, 2020	2020	2058	52.2	47.8	China
Sallam et al [32]	December, 2020	2021	2173	28.4	71.6	Jordan
Bell et al, 2020[44]	April to May, 2020	2020	1252	55.8	44.2	England

3.3 COVID-19 Vaccine Acceptance

The meta-analysis was performed using Comprehensive Meta-Analysis (CMA) Version 3 statistical software (https://www.meta-analysis.com/index.php ; Biostat, Englewood, NJ, USA) to determine the global pooled prevalence / acceptance rate and the hesitancy rate of the COVID-19 vaccine.

3.3.1 The Overall Pooled Prevalence /Rate of COVID-19 Vaccine Acceptance

The pooled prevalence rate for the acceptance of the COVID-19 vaccine was found to be 61.1%[ 95% CI of 53.8 to 67.9%]; I² = 99.6% with a P-value = 0.003 (Fig. 4).

3.3.2 Subgroup analysis of the pooled prevalence rate of COVID-19 vaccine acceptance

Based on the subgroup analysis, the overall pooled prevalence rate of acceptance of the COVID-19 vaccine was 63.7% [95% CI 56.8, 69.5%]. However, after the subgroup analysis was performed based on the publication year, the prevalence of the acceptance rate of the COVID-19 vaccine in 2020 and 2021 was 74.2% [95% CI: 66.5, 80.7%] and 47.9% [95% CI: 37.8, 58.2%], respectively (Fig. 5).

However, based on the subgroup analysis of the acceptance of the COVID-19 vaccine by the country where the study was conducted, the combined prevalence of the acceptance rate of the COVID-19 vaccine was 56.1% [95% CI 55.4, 56.7%]. The lowest acceptance rate of the COVID-19 vaccine acceptance rate [15.4%;95% CI: 14.0, 16.9%] was reported by the study conducted in Cameroon, while the highest prevalence [94.3% ;95% CI: 92.8, 95.5%] was reported by the study conducted in Malaysia (Figure, 6).

Furthermore, after analyzing the subgroups based on the survey period, the combined prevalence of the COVID-19 vaccine acceptance rate was 57.4% [95% CI: 50.1, 64.5%]. The prevalence of acceptance of the COVID-19 vaccine from March to May 2020, June to August 2020, and September to December 2020 was 80.0% [95% CI: 68.8, 87.9%], 58.6% [95% CI: 38.0, 76.6%] and 46.3% [95% CI: 37.4, 55.8%], respectively (Figure, 7).

3.4 Publication bias

3.4.1 Sensitivity analysis

Sensitivity analysis was performed by removing low outcomes, high outcomes, and small sample size. However, the sensitivity analysis did not show a substantial change in the prevalence of COVID- 19 acceptance compared to the pooled prevalence without sensitivity analysis [61.1% (95% CI 53.8 to 67.9%)] (Table 2).

Table 2

Results of the sensitivity analysis for the acceptance of COVID-19 worldwide prevalence.
Criteria used	Prevalence	Heterogeneity	95% Confidence interval		P-value
Criteria used	Prevalence	Heterogeneity	Upper limit	Lower limit
After removing two articles with small sample size	62.0%		54.5	69.0	< 0.001
After removing one low outcome	62.7%		55.9	69.1	< 0.001
After removing three high outcomes	55.8%		48.6	62.7	0.115

3.4.2 Meta-Regression

In addition to sensitivity analysis, the cause of heterogeneity was assessed using meta-regression to test the following variables: sample size, year of publication, and outcomes. Overall, the meta-regression result did not show no published bias or undetected publication bias (P > 0.05) (Table 3)

Table 3

Results of meta-regression for the acceptance of COVID-19 worldwide prevalence.
Criteria used	Coefficient	Std. Err.	z	P>\|z\|	[95% Confidence Interval]
Sample size	-2.98e^− 21	.0000595	-0.00	1.000	-0001166	.0001166
Effect size	1	.5054019	-0.00	0.048	0094305	1.99057
Publication year	7.45e^− 17	.2710247	0.00	1.000	− .5311986	.5311986
Test of residual homogeneity: P > 0.05).

Discussion

We conducted a systematic review and meta-analysis of data from 32 studies that included 58,629 study participants and found a pooled prevalence of vaccine acceptance of 61.1% (95% CI of 53.8 to 67.9%). As a result of high heterogeneity, the sensitivity analysis and meta-regression were used to assess the cause of high heterogeneity and found no substantial change in the prevalence of COVID-19 vaccine acceptance.

The utility of the vaccine to control COVID-19 pandemics depends on the acceptance of the vaccine [45]. Currently, vaccine hesitancy represents a serious threat to global health. Similarly, the current review found that the worldwide pooled prevalence of COVID-19 vaccine acceptance was 61.1% with 95% CI: 53.8–67.9%, which was lower than the finding of the global survey reported 71.5% COVID-19 acceptance rate [46]. The possible reason for the disparity in the prevalence estimate could be variation in the population studied or the survey period. The former study mainly conducted in the specific study period, whereas the present study finding depends on the study conducted from the emergency of COVID-19 to this study period.

Based on the subgroup analysis of the acceptance of the COVID-19 vaccine acceptance rate, the overall pooled acceptance rate of the COVID-19 vaccine was 63.7%. The lowest acceptance rate of the COVID-19 vaccine, 15.4% [95% CI 14.0, 16.9%] was reported by the study conducted in Cameroon, while the highest prevalence, 94.3% [95% CI 92.8, 95.5%] was reported by the study conducted in Malaysia. Furthermore, the review found a slight difference in the pooled prevalence of the acceptance rate of the COVID-19 vaccine between the studies conducted in China [65.2% (95% CI 40.2, 83.9%)], the United Kingdom [64.9% (95% CI 33.8, 87.0%)], and the United States [63.7% (95% CI 40.0, 82.2%)] (Fig. 8). The variation in the estimate of the vaccine acceptance rate may be due to the difference in the information and sociodemographic characteristics of the study participants.

The decline in the acceptance rate of the vaccine can lead to poor management of COVID-19 pandemics. The review found that the acceptance rate for the COVID-19 vaccine declined from 74.2% (in 2020) to 47.9% (in 2021), which was in line with the finding of another study that reported a decrease in the acceptance rate of the COVID-19 vaccine from more than 70.0% in March to less than 50% in October [47]. The current study found the pooled acceptance rate of the COVID-19 vaccine from March to May 2020 [80.0% (95% CI: 68.8, 87.9%)], June to August 2020 [58.6% (95% CI: 38.0, 76.6%)] and September to December 2020 [46.3% (95% CI: 37.4, 55.8%)] (Fig. 9).

These results showed that the rate/prevalence of acceptance of the COVID-19 vaccine decreased from 80.0–46.3% and 8 out of 10 respondents were willing to accept the COVID-19 vaccine from March to May 2020, while about 6 out of 10 respondents were willing to accept the COVID-19 vaccine from September to December 2020. The current study is supported by various studies (country or region specific) that reported a decline in willingness to accept the COVID-19 vaccine [6, 13, 14].

In general, the review found the declining acceptance rate of the vaccine and recommended the need to take appropriate action to manage the COVID-19 pandemic. Thus, local and international governments should take appropriate action in collaboration with nongovernmental organizations and community members to build trust in the community and to ensure adequate vaccination coverage. Furthermore, transparent and effective communications are essential to reduce misinformation and vaccination hesitancy, build trust, and ensure adequate vaccination coverage will be reached [8].

Limitations

There was an unequal distribution of the studies conducted across the world. Furthermore, the acceptance rates of the COVID-19 vaccine in many countries of the world were not included as a result of the lack of studies that met the eligibility criteria. Furthermore, cross-sectional studies were included and causal relationships between the acceptance rate of the COVID-19 vaccine and the determinant factors cannot be established.

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