COVID-19 Vaccination in the Gaza Strip: a Cross-sectional Study of Vaccine Coverage, Hesitancy, and Associated Risk Factors Among Community Members and Healthcare Workers

doi:10.21203/rs.3.rs-1439743/v1

Background: The Gaza Strip, like other settings of complex humanitarian emergencies, faces immense challenges in vaccinating its population against COVID-19. This study was conducted in October 2021 and aimed to estimate coverage of COVID-19 vaccination, levels of vaccine hesitancy, and associations with risk factors among the adult population and healthcare workers (HCWs).

Methods: The study used a mixed methods design comprised of a cross-sectional survey of adults, purposive survey of HCWs, and qualitative discussions with key informants and community members. Quantitative data was summarized as univariable descriptive statistics with unweighted and weighted point estimates. Logistic regression was used to evaluate associations of risk factors with vaccination status and vaccine hesitancy.

Results: A total of 1,075 individuals were reached in the survey, of whom 906 were community members. Population-weighted vaccine coverage was estimated to be 49.08% (95% CI: 43.10-55.08). 89.35% of HCWs were vaccinated. Population-weighted vaccine hesitancy was estimated to be 34.08% (95% CI: 28.14-40.56) among both vaccinated and unvaccinated respondents, and 67.24% (95% CI: 49.04-81.41) among the unvaccinated. In logistic regression vaccination was independently associated with male sex (aOR 1.88, 95% CI: 1.20-2.95), older age (40 or more years old) (aOR: 1.92, 95% CI: 1.73-2.13), higher education (aOR 2.19, 95% CI: 1.51-3.17), and confidence in the safety of the vaccine (aOR 13.8, 95% CI: 10.1-18.8). Risk factors for hesitancy were similar, however hesitant individuals were more likely to obtain vaccine information from family members (aOR: 1.20, 95% CI: 1.00-1.67) and less likely to trust healthcare providers (aOR: 0.58, 95% CI: 0.49-0.68). Qualitative interviews corroborated the survey results, although skepticism expressed by HCWs interviewed raises the possibility of hidden hesitancy.

Conclusions: The continued emergence of SARS-CoV-2 variants reinforces the importance of achieving high levels of vaccination coverage globally – a uniquely challenging objective in Gaza. This study estimated half of Gaza’s adult population received at least one dose of any COVID-19 vaccine by October 2021, and the majority of unvaccinated individuals were hesitant. Disparities in vaccination across the territory’s demographic groups underscores the need for targeted outreach to these populations and messaging through community-based channels to permeate social networks of the unvaccinated.

COVID-19

vaccine

hesitancy

Gaza Strip

Palestine

humanitarian settings

healthcare workers

The development of highly efficacious vaccines against the SARS-CoV-2 virus in 2020 was heralded as a potential end to the pandemic that has caused more than 5.69 million deaths globally as of February 2022 [1]. However even where vaccines are widely available, roll-out has proceeded slowly due to persistent vaccine hesitancy among vaccine target groups. Vaccine hesitancy is defined by the WHO as “delay in acceptance or refusal of vaccination despite availability of vaccination services” [2]. Varying levels of vaccine hesitancy are reported globally; a review from February 2021 reported vaccine hesitancy across more than 30 assessed countries ranging from 10.0–57.8% [3, 4]. Among countries in the Middle East, data on vaccine acceptance is sparse, or relies on data collection using methods like web-based surveys that may exclude certain population groups, potentially resulting in biased estimates. A non-representative, web-based survey in Kuwait found vaccine hesitancy at 26% [5], while another online survey from December 2020 estimated vaccine acceptance at 31.8% in Saudia Arabia, 38.4% in Jordan, and 23.6% in Kuwait [6]. It is also critical to understand drivers of vaccine hesitancy to address barriers to uptake among populations who remain skeptical, misinformed, or fearful of vaccine risks. Surveys conducted to date have identified factors such as government trust, sex, education level, risk perception, and use of social media for COVID-19 information, among others, to be associated with vaccine hesitancy [4, 6, 7].

Gaza Strip, the 362 sq km Palestinian territory bordering Israel and Egypt, faces immense challenges with the vaccine roll-out given its fractured and poorly resourced health system and political obstacles to the importation of medical supplies [8, 9]. By January 2022, it is estimated that 26% of the population has been vaccinated since the campaign started in February 2021 based on Palestinian Ministry of Health statistics [10]. Little data exists on vaccine hesitancy and its risk factors in Gaza; a web-based survey conducted in October 2020 found 63% of respondents would accept the vaccine, with women and young adults less likely to be vaccine hesitant [9]. However to our knowledge no recent data has been collected since the vaccination campaign began, and no population-representative study has been conducted.

The international non-governmental organization International Medical Corps (IMC) commissioned an external consultant epidemiologist to conduct a mixed methods vaccine hesitancy study in the Gaza Strip. The study was carried out between October 1–30, 2021 across all governorates Gaza in collaboration with IMC partners, Ministry of Health (MoH) key informants, and community leaders. The study aimed to investigate community members’ and healthcare workers’ perceptions of the COVID-19 vaccine; barriers and enablers associated with vaccine acceptance; and an updated estimate of COVID-19 vaccination coverage along with predictors of uptake. The results of the study provide new evidence on HCW and population perceptions that can inform COVID-19 services and information campaigns in Gaza.

The study was conducted using a closed-ended survey coupled with key informant interviews and focus group discussions with community members to investigate factors associated with vaccine uptake and hesitancy among healthcare workers and the general population of Gaza.

Quantitative methods

We carried out a population-based, cross-sectional survey of households across all five governorates. Multi-stage, stratified cluster sampling was used to select a representative sample of households for the community-based survey. Based on Gaza’s population demographics (1.99 million residents in 2019) we estimated the study population size to be 1,034,800 adults 18 years and over [11]. The sample size was calculated using EpiInfo (CDC) (v7.2.4.0) for a population survey with parameters set at 95% level of confidence, 50% estimated proportion, 5% margin of error, and a design effect of 2. Given lack of data from previous population surveys in Gaza, a conservative non-response rate of 15% was added. The resulting sample size was 884 households, while 906 were actually surveyed. For the HCW component of the survey, we visited five health care facilities that are financially supported by IMC and provide different levels of healthcare: Caritas Gaza Health Center (primary), Ahli Arab Hospital (secondary), Saint John’s Eye Hospital (specialized), Karama Hospital (secondary), and European Gaza Hospital (a governmental Hospital where hospitalized COVID-19 cases are treated). Based on the limited number of HCWs in each facility and the restriction to IMC-supported facilities, we estimated a feasible sample size of between 30 to 40 HCWs per facility. 169 HCWs were ultimately interviewed as interest in completing the survey was high.

Multi-stage stratified sampling was used to select households for the community-based survey. First, we compiled a list of geo-locations¹ and the type of location (urban, rural, and refugee camp) for all governorates using administrative data. From this list, we used simple random sampling to select two urban geo-locations, two refugee camps, and two rural geo-locations. In the second stage, we used simple random sampling to select four clusters (administrative units comprised of blocks in the camp settings and neighborhoods in the urban and rural areas) from each geo-location for a total of 24 clusters. The total sample size of 903 households was proportionally allocated to each selected cluster based on the population size of Gaza’s governorates [11] (see Supplemental File 1). At the third stage, simple random sampling was employed to select households in the selected clusters using the Palestinian Central Bureau of Statistics’ (PCBS) demographic list and with replacement if a house was unoccupied. Within each household, the enumerators selected a household member who was eligible for the vaccine – those above 18 years of age – and expressed availability for the study. The targeting of adults through convenience sampling within households was justified based on experience in Gaza that that members of the household share similar attitudes and behaviors.

For the HCW component of the survey, respondents were identified through a combination of convenience and purposive sampling. Based on consultations with the facility administrators, HCWs were approached to be interviewed based on their availability to respond as well as the position held to ensure representation from a broad cadre of health providers. IMC enumerators administered the survey to the selected HCWs in person at the facilities.

A questionnaire (see Supplemental File 2) was developed based on the World Health Organization (WHO) recommended vaccine hesitancy assessment methodology [12]. Table 1 presents the variables considered in the analysis. The questionnaire was translated into Arabic, and administered using the electronic data collection platform KoBoCollect (UNOCHA). Enumerators entered data using tablets, and data was reviewed for completion and consistency on a daily basis.

Table 1

Thematic areas investigated through vaccine hesitancy instruments
Primary outcome measures and determinants	Variables
Primary outcome: Vaccination status	Vaccinated: Defined as a head of household above 18 years-old who received at least one dose of any COVID-19 vaccine prior to the survey
Primary outcome: Vaccine hesitancy	Vaccine hesitant: defined as lack of intent to receive a COVID-19 vaccine².
Demographic variables	Sex Age Governorate Highest level of education Health care worker vs. community member
Information sources and needs	Perception of adequate information on COVID-19 vaccine Information needs (eligibility, timeline, side effects, effectiveness, registration) Current information sources (HCWs, CHWs, radio, television, newspapers, social media, friends and colleagues, local leaders, religious leaders, civil society organizations) Trusted sources (HCWs, CHWs, local leaders, religious leaders, family, neighbors and relatives, organizations, media, radio, television) Use of social media and types Sharing information on social media
Perceived risk	Self-perceived risk to get COVID-19 infection Self-perceived risk to develop severe disease following COVID-19 infection Perception of safety of the COVID-19 vaccine Past event with a vaccine dissuades from receiving the vaccine Knowledge of someone with severe outcome from not being vaccination Preference for herd immunity / natural immunity Belief in better ways to prevent COVID-19 than the vaccine

HCWs = healthcare workers, CHWs = community health workers

Qualitative methods

We also collected qualitative data to gather deeper insights on barriers to vaccine acceptance for triangulation with the household. We conducted in-depth qualitative interviews with key informants (KIs) and focus group discussions (FGDs) with community members using custom interview guides developed for the qualitative component (Supplemental file 2).

Seven in-depth interviews were conducted with KIs who included public health officials (2), a clinician, religious leaders (2), a school director, and a community leader (“mokhtar”). Interviews focused on KIs’ current knowledge and information sources on COVID-19 vaccines, and their perceptions of the public’s vaccine acceptance. Key informants were identified using purposive sampling based on consultation between the consultant epidemiologist leading the data collection and IMC technical staff.

Ten FGDs were conducted across the five governorates with different interest groups, including patients with chronic conditions, people with disabilities, younger and older adults, and elderly community. Each group was convened separately according to sex and consisted of between 7–14 people. Cumulatively 103 people (53 females, 50 males) were consulted through FGDs. Discussions focused on enablers and barriers to vaccine uptake, including current information sources, level of trust in vaccines and the health system, key community influencers on vaccination, and recommendations for improving demand for vaccines. Participants for the focus groups were identified through purposive sampling based on consultations with focal points at the facilities attended by members of the interest groups. Young adults were identified from Al Azhar University and Al Ata’a Society, while patients with chronic diseases, people with disabilities, and other adults were identified from four civil society organizations located in three governorates. See supplemental File 3 for futher information on participants in qualitative discussions.

Data collection

Ten survey enumerators (5 men, 5 women) and 2 focus group facilitators (1 male, 1 female) with clinical backgrounds were recruited to collect the qualitative and quantitive data, with six teams formed consisting of two members each. The research consultant provided a one-day training on the quantitative and qualitative tools, interview and sampling protocols, and COVID-19 prevention measures, and followed up regularly during data collection. Oral informed consent was sought from all participants in the surveys, KIIs, and qualitative discussions using standard formats. Two staff members from IMC’s monitoring, evaluation, accountability and learning (MEAL) department supervised all data collection in the field, providing daily on-job support and data quality assurance. The teams were required to adhere to COVID-19 preventive measures recommended by the WHO and IMC (physical distancing, mask-wearing, and hand hygiene) during data collection.

Data analysis

The primary outcomes used in the analysis were “COVID-19 vaccination status” and “COVID-19 vaccine hesitancy”. Individuals were classified as vaccinated if they responded “yes” to the question, “Have you already received COVID-19 vaccine?” with at least one dose of any vaccine considered vaccinated. Vaccine hesitancy was classified based on response to the question “If the vaccine was available, would you get it?” according to the SAGE Working Group definition of vaccine hesitancy [2]. For the primary analysis, COVID-19 “vaccine acceptance” was defined as having a “yes” response to the question or being previously vaccinated. “Vaccine hesitancy” was categorized having a response of either “no” or “don’t know”. In sub-analysis, vaccine hesitancy was analysed for the unvaccinated population only using the same response categorization.

Analyses were conducted using R version 4.0.5 [13] and RStudio version 1.4.1106 [14] with the packages survey [15] for all statistics and gtsummary [16] for the tables. All statistics described in the Results sections represent population-weighted estimates. Data were weighted to the population using 2017 administrative data provided to IMC by the Palestinian Central Bureau of Statistics, using cluster sampling weights and household weights, and to account for stratification by type of geo-location (rural, urban, and refugee camp). As population in each cluster was not available, cluster weights within each selected geo-location were calculated using average cluster population in the selected geo-location (Supplemental File 4).

Demographic characteristics of the survey respondents are presented in Table 2. Demographic characteristics are presented as both unweighted and weighted univariable statistics, stratified by vaccination status (Table 3) and vaccine hesitancy status (Table 6). Univariable descriptive statistics with both unweighted and weighted results are presented for all other variables in Tables 4 (vaccination status) and 6 (vaccine hesitancy). Distributions of demographic characteristics and risk factor variables were compared using chi-square test with Rao & Scott's second-order correction.

Qualitative data from interviews and focus group discussions (FGDs) was summarized in Word (MS 21) based on review of trends in statements related to vaccine hesitancy and vaccine uptake barriers and enablers. Results of qualitative interviews are triangulated against the survey results.

¹Geo-locations are comparable to administrative level 3, below the governorate level.

²This survey item had three possible responses (yes, no, unsure). For this analysis, two definitions of hesitancy were applied. For the main analysis, COVID-19 “vaccine acceptance” was defined as someone who either 1) received the vaccine or 2) answered “yes” to the question, “If you could get a COVID-19 vaccine this week, would you get it?”. In sub-analysis, “vaccine hesitancy” was restricted to the non-vaccinated population and categorized as not being vaccinated and having a response of either “no” or “unsure”, according to SAGE Working Group definition of vaccine hesitancy as “delay in acceptance or refusal of vaccination despite the availability of vaccination services.”

Respondent Characterics

1,075 people (906 community members and 169 health professionals) participated in the survey (Table 1). Females represented 45% of total respondents. The geographic distribution of community member respondents generally mirrors the population of Gaza; the largest proportion of respondents were from Gaza City (29%) and the lowest from Rafah (9%). 53% of community members and 95% of HCWs held a university-level education.

Table 2

Demographic characteristics of survey respondents
Characteristic	Overall, N = 1,075¹	Community Member, N = 906	HCW, N = 169
Age, n (%)
18–39	659 (61.30)	527 (58.17)	132 (78.11)
40+	416 (38.70)	379 (41.83)	37 (21.89)
Geo-location, n (%)
Gaza City	313 (29.12)	313 (34.55)	0 (0.00)
Healthcare Facility	169 (15.72)	0 (0.00)	169 (100.00)
Jabalia	190 (17.67)	190 (20.97)	0 (0.00)
Khanyunis	173 (16.09)	173 (19.09)	0 (0.00)
Nuseirat	133 (12.37)	133 (14.68)	0 (0.00)
Rafah	97 (9.02)	97 (10.71)	0 (0.00)
Strata, n (%)
Camp	323 (30.05)	323 (35.65)	0 (0.00)
Healthcare Facility	168 (15.63)	0 (0.00)	168 (99.41)
Rural	163 (15.16)	162 (17.88)	1 (0.59)
Urban	421 (39.16)	421 (46.47)	0 (0.00)
Sex, n (%)
Female	480 (44.65)	408 (45.03)	72 (42.60)
Male	595 (55.35)	498 (54.97)	97 (57.40)
Highest education level, n (%)
Primary or None	83 (7.72)	81 (8.94)	2 (1.18)
Secondary or College / Vocational	353 (32.84)	347 (38.30)	6 (3.55)
University	639 (59.44)	478 (52.76)	161 (95.27)
¹n (%)

Vaccine status and characteristics

Population-weighted vaccination coverage was 49.08% (95% CI: 43.10-55.08). Table 3 presents the unweighted and weighted distribution of the characteristics of the population by vaccination status. Males were more likely to be vaccinated than females (54.87% vs 41.45%, OR: 1.72 [95% CI: 1.37–2.16]). Older adults (40 years and older) were more likely to be vaccinated than younger adults (52.96 vs 47.04%, OR: 1.31 [95% CI: 1.14–1.51]). There was an increasing trend in vaccination with higher levels of education; respondents with university degrees were twice as likely to be vaccinated compared to those with primary or no education (OR: 2.12, 95% CI: 1.85–2.42) and those with secondary or college/vocational education were 28% more likely to be vaccinated than those with primary or no formal education (OR: 1.27, 95% CI: 1.03–1.57).

Table 3

Demographic characteristics by vaccination status, community members only
	Received Vaccine (Unweighted)			Received Vaccine (Weighted)
Characteristic	no, N = 451¹	yes, N = 455¹	p-value²	no³	yes³	p-value²
Age			0.008			0.032
18–39	282 (53.51%)	245 (46.49%)		53.83%	46.17%
40+	169 (44.59%)	210 (55.41%)		47.04%	52.96%
Sex			< 0.001			0.018
Female	238 (58.33%)	170 (41.67%)		58.55%	41.45%
Male	213 (42.77%)	285 (57.23%)		45.13%	54.87%
Highest education level			< 0.001			0.007
Primary or None	49 (60.49%)	32 (39.51%)		62.70%	37.30%
Secondary or College / Vocational	194 (55.91%)	153 (44.09%)		56.88%	43.12%
University	208 (43.51%)	270 (56.49%)		44.25%	55.75%
Governorate			0.66
Gaza City	159 (50.80%)	154 (49.20%)
Jabalia	101 (53.16%)	89 (46.84%)
Khanyunis	80 (46.24%)	93 (53.76%)
Nuseirat	62 (46.62%)	71 (53.38%)
Rafah	49 (50.52%)	48 (49.48%)
Strata			0.12
Camp	163 (50.46%)	160 (49.54%)
Rural	69 (42.59%)	93 (57.41%)
Urban	219 (52.02%)	202 (47.98%)
¹n (%)
²chi-squared test with Rao & Scott's second-order correction
³%

Table 4 presents the unweighted and weighted distribution of risk factors by vaccination status and Table 5a presents the unadjusted odds ratios. Certain perceptions of the risks and trade-offs of the COVID-19 vaccination were associated with vaccination status. The vaccinated had 15 times higher odds of considering the vaccines safe (OR: 15.4 [95% CI: 12.1–19.50]). They were also less likely to express concerns about side effects and less likely prefer natural immunity to the vaccine. The unvaccinated reported concerns specifically about physical disability (27.98%) and death (59.20%) at higher levels than the unvaccinated, while concerns about fever, body aches, and infertility were commonly reported.

Table 4

Knowledge, beliefs, and other factors associated with vaccination status, community members only
	N	Received Vaccine (Unweighted)			Received Vaccine (Weighted)
Characteristic		no, N = 451¹	yes, N = 455¹	p-value²	no¹	yes¹	p-value²
Have enough information about COVID-19 vaccine	906			< 0.001			0.009
Yes		36.09%	63.91%		37.29%	62.71%
No or Don't know		58.93%	41.07%		61.10%	38.90%
Information needed	905
Eligibility criteria		52.79%	47.21%	0.21	50.09%	49.91%	0.84
Timeline for vaccine roll-out		54.69%	45.31%	0.42	56.18%	43.82%	0.18
Knowing when it's my turn to get the vaccine		73.58%	26.42%	< 0.001	69.49%	30.51%	0.007
Doses needed		56.00%	44.00%	0.070	57.14%	42.86%	0.057
Risks and side effects		52.28%	47.72%	< 0.001	52.51%	47.49%	0.22
Effectiveness of the vaccines		50.15%	49.85%	0.75	51.03%	48.97%	0.92
How to register for the vaccine		74.29%	25.71%	< 0.001	62.05%	37.95%	0.038
Common source of information about health and vaccines	904
Health care providers		45.00%	55.00%	< 0.001	47.00%	53.00%	0.21
Community health care workers		44.34%	55.66%	0.071	45.58%	54.42%	0.26
Radio		57.66%	42.34%	0.077	52.37%	47.63%	0.67
Television		52.42%	47.58%	0.30	54.48%	45.52%	0.38
Newspapers		43.48%	56.52%	0.54	37.96%	62.04%	0.072
Mass events		71.43%	28.57%	< 0.001	79.47%	20.53%	0.014
Family		58.99%	41.01%	0.002	56.04%	43.96%	0.12
Neighbors, friends, colleagues		59.03%	40.97%	< 0.001	59.32%	40.68%	0.008
Local leaders		39.13%	60.87%	0.30	36.73%	63.27%	0.27
Religious leaders		33.33%	66.67%	0.044	34.51%	65.49%	0.028
Social media		51.52%	48.48%	0.22	50.80%	49.20%	0.95
Organizations		31.08%	68.92%	< 0.001	33.96%	66.04%	0.10
Trusted source of information	906
Health care providers		45.12%	54.88%	< 0.001	47.40%	52.60%	0.053
Community health care workers		46.46%	53.54%	0.25	47.16%	52.84%	0.19
Local leaders		66.67%	33.33%	0.41	53.51%	46.49%	0.96
Religious leaders		45.45%	54.55%	0.77	51.33%	48.67%	0.99
Family members		59.52%	40.48%	0.20	56.24%	43.76%	0.24
Neighbors, friends, colleagues		66.67%	33.33%	0.016	72.42%	27.58%	0.10
Organizations		34.69%	65.31%	< 0.001	36.14%	63.86%	0.067
Media		66.09%	33.91%	< 0.001	62.30%	37.70%	0.17
Radio		44.00%	56.00%	0.56	64.77%	35.23%	0.067
Television		54.65%	45.35%	0.34	57.50%	42.50%	0.31
Other		58.62%	41.38%	0.16	53.92%	46.08%	0.61
Trust health providers and CHWS to provide with accurate information about the COVID-19 vaccine	903			< 0.001			0.007
No or Don't know		60.77%	39.23%		62.67%	37.33%
Yes		42.83%	57.17%		43.70%	56.30%
Somewhat		58.37%	41.63%		57.01%	42.99%
Follow social media platforms to get info about vaccine	906			> 0.99			0.81
No or Don't know		49.77%	50.23%		52.18%	47.82%
Yes		49.78%	50.22%		50.61%	49.39%
Social media platforms used to get info about vaccine	685
Facebook		50.30%	49.70%	0.052	50.99%	49.01%	0.057
Twitter		43.09%	56.91%	0.10	38.48%	61.52%	0.057
Instagram		51.72%	48.28%	0.43	51.00%	49.00%	0.87
YouTube		47.53%	52.47%	0.51	46.97%	53.03%	0.14
Shares information related to vaccine on social media network	863	35.84%	64.16%	< 0.001	34.70%	65.30%	0.061
How do you know info about vaccine from social media is true	906			< 0.001			0.003
I do not verify		64.73%	35.27%		68.79%	31.21%
Other		55.22%	44.78%		49.23%	50.77%
Verify from reputable website or health care provider		41.62%	58.38%		41.70%	58.30%
Do leaders (religious, political, teachers, health care workers) in your community support the COVID-19 vaccines?	525			0.061			0.62
No or Don't know		55.80%	44.20%		51.79%	48.21%
Yes		46.51%	53.49%		49.53%	50.47%
Most people you know interested in getting the COVID-19 vaccine?	906			< 0.001			< 0.001
No or Don't know		65.25%	34.75%		68.58%	31.42%
Yes		33.55%	66.45%		33.88%	66.12%
Somewhat		52.65%	47.35%		53.64%	46.36%
How many people in your community are concerned about COVID-19 in the community	691			0.022			0.015
Few or some people, less than half		53.85%	46.15%		49.17%	50.83%
Most people		58.22%	41.78%		66.55%	33.45%
Some people – more than half		46.44%	53.56%		45.51%	54.49%
COVID-19 vaccines will or are being rolled out equitably in community	902			0.056			0.17
No or Don't know		56.25%	43.75%		53.98%	46.02%
Yes		48.21%	51.79%		49.86%	50.14%
Knows somebody that had a serious negative reaction to a vaccine that makes them reluctant to get COVID-19 vaccine	905			< 0.001			0.052
Yes		59.03%	40.97%		60.15%	39.85%
Somewhat		54.78%	45.22%		54.11%	45.89%
No or Don't know		43.43%	56.57%		43.19%	56.81%
Consider COVID-19 vaccines safe	905			< 0.001			0.001
No or Don't know		73.13%	26.87%		77.16%	22.84%
Yes		17.39%	82.61%		17.95%	82.05%
Somewhat		40.54%	59.46%		38.22%	61.78%
Concerned about risks or side effects with COVID-19 vaccines	906			< 0.001			< 0.001
No or Don't know		22.27%	77.73%		21.43%	78.57%
Yes		67.23%	32.77%		71.92%	28.08%
Somewhat		28.66%	71.34%		28.46%	71.54%
Type of risks or side effects concerned about	693
Fever		57.91%	42.09%	0.89	63.78%	36.22%	0.56
Body aches		59.25%	40.75%	0.46	64.84%	35.16%	0.28
Infertility		65.06%	34.94%	0.039	67.44%	32.56%	0.11
Physical disability		70.11%	29.89%	< 0.001	78.18%	21.82%	0.007
Death		70.23%	29.77%	< 0.001	73.18%	26.82%	0.035
Other		63.81%	36.19%	0.20	68.05%	31.95%	0.15
Type of COVID vaccine preferred	905			< 0.001			0.001
Other		0.00%	100.00%		0.00%	100.00%
No preference		70.25%	29.75%		70.99%	29.01%
Pfizer		41.14%	58.86%		44.13%	55.87%
Sputnik		38.22%	61.78%		36.37%	63.63%
Moderna		14.29%	85.71%		13.91%	86.09%
Unsure		75.86%	24.14%		87.14%	12.86%
Sinopharm		63.64%	36.36%		46.72%	53.28%
Believe there are other (better) ways to prevent COVID-19 instead of vaccine	906			< 0.001			0.033
No or Don't know		30.03%	69.97%		27.78%	72.22%
Yes		65.85%	34.15%		68.60%	31.40%
Somewhat		42.76%	57.24%		49.78%	50.22%
Better ways to prevent COVID-19 instead of vaccine	448
Social distance		64.99%	35.01%	0.38	67.60%	32.40%	0.49
Handwashing		65.13%	34.87%	0.55	68.79%	31.21%	0.82
Infection prevention and control		67.34%	32.66%	0.55	72.31%	27.69%	0.15
Ventilation		67.31%	32.69%	0.54	71.95%	28.05%	0.060
Wearing face masks		64.39%	35.61%	0.22	67.05%	32.95%	0.10
Know any person with a serious disease / disability that happened because they were NOT vaccinated	905			0.25			0.66
Yes		45.26%	54.74%		47.31%	52.69%
No or Don't know		50.65%	49.35%		51.80%	48.20%
Think it is better to get COVID-19 and develop natural immunity than to get the vaccine	905			< 0.001			< 0.001
No		29.34%	70.66%		30.33%	69.67%
Don't know		58.82%	41.18%		52.89%	47.11%
Yes		73.42%	26.58%		73.76%	26.24%
Somewhat		48.84%	51.16%		50.14%	49.86%
Think you are at risk to get COVID-19	905			0.36			0.58
No		42.70%	57.30%		51.39%	48.61%
Don't know		50.00%	50.00%		46.86%	53.14%
Yes		50.67%	49.33%		51.30%	48.70%
Think you can get seriously ill, hospitalized or die if you get COVID-19	906			0.034			0.78
No		44.57%	55.43%		49.41%	50.59%
Don't know		53.90%	46.10%		52.63%	47.37%
Yes		52.73%	47.27%		51.26%	48.74%
	¹%
	²chi-squared test with Rao & Scott's second-order correction

More than 80% of both groups believed they were at risk from COVID-19 infection, which did not vary significantly among the vaccinated and unvaccinated population (p > 0.05). Less than one-third believed they were at risk of severe illness and hospitalization (OR: 0.86, 95% CI: 0.59–1.24). This suggests perceptions of risk of infection are universally high; however, people do not believe they are at risk of developing serious disease, and this perception is more widely held among the unvaccinated population.

Generally, there was wide consensus in the focus group discussions on the benefits of the vaccine, which did not vary among the different demographic groups consulted.

“If there were no vaccine, the disease would have significantly spread; thanks to God and the vaccine, the vaccine reduced the disease. In the beginning, we heard that the vaccine was not perfect, and we [were] afraid, but later we have received it. – FGD, adult male, Diwan Community, Middle Governorate

Perceptions of adequate vaccine information and the channels used to access information differed among the vaccinated and unvaccinated population. 54.62% of vaccinated individuals reported having enough information about the vaccine, while 31.30% of the unvaccinated believed they received sufficient information. Those who reported having inadequate information had 60% lower odds of being vaccinated (OR: 0.38. [95% CI 0.20–0.52). Among both vaccinated and unvaccinated individuals, information on side effects and effectiveness of the vaccines was the most requested information, with more than 85% of both groups requesting this information. Notably slightly more than 11% of the unvaccinated expressed interest in information on how to register for the vaccine (Table 8).

Sources of information on COVID-19 vaccines varied among vaccinated and unvaccinated respondents. Social media was the most common source of information overall (61.64% among the vaccinated and 61.33% among the unvaccinated). Among the respondents receiving information from social media, nearly all used Facebook and around half referenced Instagram. However when asked about information sources on the vaccine, media including social media, television, radio and newspapers were not associated with vaccine status in the weighted analysis (p-value < 0.05). There was no difference in social media use among vaccinated and unvaccinated individuals or in the use of specific platforms.

Other common sources were healthcare workers (65.31% of the vaccinated vs 55.83% of the unvaccinated, p = 0.21); neighbors, friends, and colleagues (35.40% of the vaccinated vs 49.73% of the unvaccinated, p < 0.01); and family (30.26% of the vaccinated vs 37.18% of the unvaccinated, p = 0.12). Those who were vaccinated were more likely to report commonly receiving information on the vaccine from newspapers, religious leaders, civil society organizations, and to trust the information received from healthcare providers (OR p-values < 0.05). The unvaccinated were more likely to receive information from mass events, family, and neighbors, friends, and colleagues (OR p-values < 0.05).

Similar to community members, KIs widely cited health authorities as trustworthy sources of information. A school director interviewed stated that he trusted the Ministry of Health, but does not trust Facebook and YouTube because many videos portray the virus as a conspiracy.

“The available information was superficial and not in-depth about the necessity of vaccination because it reduces the harmful effects of the virus.” – KII, School Director, Gaza

A community leader (Mokhtar) also expressed confidence in the MoH and official health sources:

“I follow the news, websites, health bulletins, MoH, WHO in numbers of infected people and deaths, the causes or complications resulting from not receiving the vaccine.”- KII, Mokhtar, Gaza

Multivariable regression provided further evidence for demographic characteristics as independent determinants of vaccination status (Table 5b). In the adjusted model, vaccination was around twice as likely among males (aOR: 1.88, 95% CI: 1.20–2.95), older compared to younger adults (aOR: 1.92, 95% CI: 1.73–2.13), and the university educated compared to those with primary or no education (aOR: 2.10, 95% CI: 1.51–3.17). The vaccinated were less likely to report having insufficent information on the vaccine (aOR: 0.62, 95% CI: 0.48–0.80) as well as more likely to consider the vaccines safe (aOR: 13.8 (10.1–18.8) or somewhat safe (aOR: 5.41, 95% CI: 3.69–7.94). However perception of severe risk was not independently significantly associated with vaccination status (aOR 0.86, 95% CI: 0.59–1.24), nor were sources of information, after controlling for demographic characteristics and other risk factors.

Table 5

a. Unadjusted Odds ratios of vaccine receipt by respondent characteristics, weighted
Characteristic	OR (95% CI)¹	p-value
Sex		< 0.001
Female	—
Male	1.72 (1.37 to 2.16)
Age		< 0.001
18–39	—
40+	1.31 (1.14 to 1.51)
Highest education level		< 0.001
Primary or None	—
Secondary or College / Vocational	1.27 (1.03 to 1.57)
University	2.12 (1.85 to 2.42)
Have enough information about COVID-19 vaccine		< 0.001
Yes	—
No or Don't know	0.38 (0.28 to 0.52)
Information needed
Eligibility criteria	1.07 (0.56 to 2.05)	0.83
Timeline for vaccine roll-out	0.79 (0.60 to 1.04)	0.087
Knowing when it's my turn to get the vaccine	0.42 (0.33 to 0.55)	< 0.001
Doses needed	0.72 (0.58 to 0.89)	0.003
Risks and side effects	0.59 (0.30 to 1.15)	0.12
Effectiveness of the vaccines	0.98 (0.69 to 1.39)	0.91
How to register for the vaccine	0.61 (0.46 to 0.80)	< 0.001
Common source of information about health and vaccines
Health care providers	1.49 (0.91 to 2.45)	0.12
Community health care workers	1.29 (0.90 to 1.84)	0.17
Radio	0.94 (0.70 to 1.24)	0.64
Television	0.81 (0.55 to 1.20)	0.30
Newspapers	1.71 (1.16 to 2.52)	0.007
Mass events	0.25 (0.14 to 0.44)	< 0.001
Family	0.73 (0.55 to 0.98)	0.033
Neighbors, friends, colleagues	0.55 (0.46 to 0.66)	< 0.001
Local leaders	1.82 (0.76 to 4.35)	0.18
Religious leaders	2.04 (1.43 to 2.92)	< 0.001
Social media	1.01 (0.70 to 1.47)	0.94
Organizations	2.35 (1.13 to 4.88)	0.022
Trusted source of information
Health care providers	1.54 (1.17 to 2.03)	0.002
Community health care workers	1.23 (0.97 to 1.56)	0.088
Local leaders	0.56 (0.37 to 0.84)	0.005
Religious leaders	0.74 (0.46 to 1.19)	0.22
Family members	0.80 (0.59 to 1.08)	0.14
Neighbors, friends, colleagues	0.37 (0.16 to 0.87)	0.022
Organizations	0.90 (0.03 to 28.6)	0.95
Media	0.98 (0.17 to 5.84)	0.99
Radio	0.59 (0.32 to 1.06)	0.077
Television	2.05 (1.23 to 3.40)	0.006
Other	0.88 (0.57 to 1.36)	0.57
Follow social media platforms to get info about vaccine		0.79
No or Don't know	—
Yes	1.06 (0.67 to 1.68)
Social media platforms used to get info about vaccine	0.09 (0.01 to 0.64)	0.016
Facebook	1.82 (1.23 to 2.70)	0.003
Twitter	0.97 (0.72 to 1.32)	0.85
Instagram	1.21 (1.00 to 1.45)	0.046
YouTube		0.004
Shares information related to vaccine on social media network	—
No	2.20 (1.29 to 3.75)
Yes		0.60
How do you know info about vaccine from social media is true		< 0.001
I do not verify	—
Other	2.27 (1.87 to 2.76)
Verify from reputable website or health care provider	3.08 (2.31 to 4.11)
Think you can get seriously ill, hospitalized or die if you get COVID-19		< 0.001
No	—
Don't know	15.4 (12.2 to 19.6)
Yes	5.46 (3.56 to 8.38)
Consider COVID-19 vaccines safe		< 0.001
No or Don't know	—
Yes	2.27 (1.87 to 2.76)
Somewhat	3.08 (2.31 to 4.11)
¹OR = Odds Ratio, CI = Confidence Interval

Table 5

b. Adjusted Odds ratios of vaccine receipt by respondent characteristics
Characteristic	OR (95% CI)¹	p-value
Sex		0.006
Female	—
Male	1.88 (1.20 to 2.95)
Age		< 0.001
18–39	—
40+	1.92 (1.73 to 2.13)
Highest education level		< 0.001
Primary or None	—
Secondary or College / Vocational	1.39 (0.92 to 2.09)
University	2.19 (1.51 to 3.17)
Have enough information about COVID-19 vaccine		< 0.001
Yes	—
No or Don't know	0.62 (0.48 to 0.80)
Common source of information about health and vaccines
Health care providers (ref: no)	1.03 (0.50 to 2.14)	0.93
Family (ref: no)	1.11 (0.66 to 1.86)	0.70
Social media (ref: no)	0.86 (0.62 to 1.19)	0.37
Trust health care providers for information on COVID-19 vaccine	1.24 (1.00 to 1.54)	0.052
Consider COVID-19 vaccines safe		< 0.001
No or Don't know	—
Yes	13.8 (10.1 to 18.8)
Somewhat	5.41 (3.69 to 7.94)
Think you can get seriously ill, hospitalize or die if you get COVID-19		0.62
No	—
Don't know	1.02 (0.78 to 1.32)
Yes	0.86 (0.59 to 1.24)
¹OR = Odds Ratio, CI = Confidence Interval

Vaccine hesitancy and risk factors

Vaccine hesitancy was 34.08% (95% CI: 28.14–40.56) among both vaccinated and unvaccinated respondents³, and 67.24% (95% CI: 49.04–81.41) among the unvaccinated (n = 449)⁴. Table 6 presents the unweighted and weighted distribution of the characteristics of the population by vaccine hesitancy status. Among the overall population, males were less likely to report hesitancy (OR: 0.66 [95%CI: 0.59–0.75]). Other demographic characteristics were not significantly associated with vaccine hesitancy (p > 0.05) (Table 6).

Table 6

Demographic characteristics by vaccine hesitancy status, community members only
	Vaccine Hesitant (Unweighted)			Vaccine Hesitant (Weighted)
Characteristic	no, N = 604¹	yes, N = 300¹	p-value²	no³	yes³	p-value²
Age			0.075			0.22
18–39	339 (64.45%)	187 (35.55%)		63.15%	36.85%
40+	265 (70.11%)	113 (29.89%)		69.63%	30.37%
Sex			0.082			0.006
Female	259 (63.79%)	147 (36.21%)		60.68%	39.32%
Male	345 (69.28%)	153 (30.72%)		69.90%	30.10%
Highest education level			0.001			0.18
Primary or None	40 (50.00%)	40 (50.00%)		46.80%	53.20%
Secondary or College / Vocational	227 (65.42%)	120 (34.58%)		63.26%	36.74%
University	337 (70.65%)	140 (29.35%)		71.58%	28.42%
Governorate			0.060
Gaza City	199 (63.58%)	114 (36.42%)
Jabalia	124 (65.96%)	64 (34.04%)
Khanyunis	132 (76.30%)	41 (23.70%)
Nuseirat	87 (65.41%)	46 (34.59%)
Rafah	62 (63.92%)	35 (36.08%)
Strata			0.14
Camp	211 (65.73%)	110 (34.27%)
Rural	119 (73.46%)	43 (26.54%)
Urban	274 (65.08%)	147 (34.92%)
¹n (%)
²chi-squared test with Rao & Scott's second-order correction
³%

Table 7 presents the unweighted and weighted distribution of the risk factors for vaccine hesitancy and Table 8a provides the unadjusted Odds Ratios. The main factors the vaccine hesitant reported as barriers to getting the vaccine were stress associated with the vaccine (50.99%), lack of social acceptance (31.08%), and lack of information on the vaccines (20.41%). Notably, these were not statistically different from barriers reported by non-hesitant individuals suggesting it represents a broader trend.

Table 7

Knowledge, beliefs and other factors associated with vaccine hesitancy, community members only
	N	Vaccine hesitant (Unweighted)			Vaccine hesitant (Weighted)
Characteristic		no, N = 604¹	yes, N = 300¹	p-value²	no, N = 925,538¹	yes, N = 478,414¹	p-value²
Have enough information about COVID-19 vaccine	904			< 0.001			0.041
Yes		76.58%	23.42%		77.33%	22.67%
No or Don't know		60.26%	39.74%		57.40%	42.60%
Information needed	903
Eligibility criteria		63.61%	36.39%	0.15	64.86%	35.14%	0.85
Timeline for vaccine roll-out		64.06%	35.94%	0.63	65.72%	34.28%	0.96
Knowing when it's my turn to get the vaccine		52.83%	47.17%	0.027	55.66%	44.34%	0.035
Doses needed		60.57%	39.43%	0.053	59.23%	40.77%	0.094
Risks and side effects		65.45%	34.55%	0.045	65.53%	34.47%	0.77
Effectiveness of the vaccines		66.86%	33.14%	0.92	66.45%	33.55%	0.30
How to register for the vaccine		48.57%	51.43%	< 0.001	56.45%	43.55%	0.052
Common source of information about health and vaccines	902
Health care providers		70.34%	29.66%	0.003	70.02%	29.98%	0.062
Community health care workers		70.62%	29.38%	0.19	68.52%	31.48%	0.44
Radio		55.86%	44.14%	0.009	58.08%	41.92%	0.10
Television		63.20%	36.80%	0.13	60.51%	39.49%	0.42
Newspapers		60.87%	39.13%	0.54	62.45%	37.55%	0.45
Mass events		54.10%	45.90%	0.029	47.28%	52.72%	0.10
Family		59.53%	40.47%	0.009	58.14%	41.86%	0.029
Neighbors, friends, colleagues		57.93%	42.07%	< 0.001	58.14%	41.86%	0.070
Local leaders		78.26%	21.74%	0.24	83.43%	16.57%	0.42
Religious leaders		77.78%	22.22%	0.16	78.77%	21.23%	0.11
Social media		67.93%	32.07%	0.41	67.80%	32.20%	0.12
Organizations		83.11%	16.89%	< 0.001	80.50%	19.50%	0.042
Trusted source of information	904
Health care providers		71.96%	28.04%	< 0.001	70.49%	29.51%	0.006
Community health care workers		69.03%	30.97%	0.42	66.66%	33.34%	0.82
Local leaders		83.33%	16.67%	0.39	98.54%	1.46%	0.012
Religious leaders		54.55%	45.45%	0.39	48.67%	51.33%	0.53
Family members		47.62%	52.38%	0.007	53.47%	46.53%	0.039
Neighbors, friends, colleagues		43.75%	56.25%	< 0.001	40.78%	59.22%	0.065
Organizations		80.27%	19.73%	< 0.001	79.91%	20.09%	0.007
Media		53.04%	46.96%	< 0.001	56.90%	43.10%	0.035
Radio		64.00%	36.00%	0.76	40.82%	59.18%	0.010
Television		61.63%	38.37%	0.28	57.24%	42.76%	0.43
Other		54.39%	45.61%	0.040	54.77%	45.23%	0.058
Trust health providers and CHWS to provide with accurate information about the COVID-19 vaccine	901			< 0.001			0.005
No or Don't know		45.38%	54.62%		44.80%	55.20%
Yes		77.86%	22.14%		77.87%	22.13%
Somewhat		55.47%	44.53%		56.82%	43.18%
Follow social media platforms to get info about vaccine	904			0.35			0.16
No or Don't know		64.25%	35.75%		61.44%	38.56%
Yes		67.64%	32.36%		67.03%	32.97%
Social media platforms used to get info about vaccine:	683
Facebook		67.31%	32.69%	0.19	66.75%	33.25%	0.015
Twitter		69.92%	30.08%	0.55	76.21%	23.79%	0.19
Instagram		67.05%	32.95%	0.79	65.91%	34.09%	0.63
YouTube		64.20%	35.80%	0.28	67.31%	32.69%	0.93
Shares information related to vaccine on social media network	861	78.61%	21.39%	< 0.001	83.85%	16.15%	0.014
How do you know info about vaccine from social media is true	904			< 0.001			0.006
I do not verify		47.92%	52.08%		45.71%	54.29%
Other		60.45%	39.55%		65.37%	34.63%
Verify from reputable website or health care provider		76.98%	23.02%		77.04%	22.96%
Do leaders (religious, political, teachers, health care workers) in your community support the COVID-19 vaccines?	525			0.009			0.24
No or Don't know		60.14%	39.86%		63.92%	36.08%
Yes		72.09%	27.91%		71.03%	28.97%
Most people you know interested in getting the COVID-19 vaccine	904			< 0.001			0.017
No or Don't know		47.88%	52.12%		47.70%	52.30%
Yes		85.62%	14.38%		85.61%	14.39%
Somewhat		64.31%	35.69%		61.11%	38.89%
How many people in your community are concerned about COVID-19 in the community	689			0.024			0.35
Few or some people, less than half		55.94%	44.06%		60.32%	39.68%
Most people		66.07%	33.93%		61.78%	38.22%
Some people – more than half		68.94%	31.06%		69.98%	30.02%
COVID-19 vaccines will or are being rolled out equitably in community	900			0.023			0.27
No or Don't know		59.66%	40.34%		62.59%	37.41%
Yes		68.65%	31.35%		67.19%	32.81%
Knows somebody that had a serious negative reaction to a vaccine that makes them reluctant to get COVID-19 vaccine	903			< 0.001			0.17
Yes		57.49%	42.51%		57.53%	42.47%
Somewhat		60.87%	39.13%		59.00%	41.00%
No or Don't know		73.45%	26.55%		74.52%	25.48%
Consider COVID-19 vaccines safe	903			< 0.001			0.007
No or Don't know		43.00%	57.00%		41.46%	58.54%
Yes		95.17%	4.83%		96.19%	3.81%
Somewhat		79.39%	20.61%		78.03%	21.97%
Concerned about risks or side effects with COVID-19 vaccines	904			< 0.001			0.003
No or Don't know		89.05%	10.95%		90.53%	9.47%
Yes		52.83%	47.17%		49.04%	50.96%
Somewhat		83.54%	16.46%		82.41%	17.59%
Risks or side effects concerned about	692
Fever		61.66%	38.34%	0.37	55.57%	44.43%	0.76
Body aches		60.42%	39.58%	0.83	55.62%	44.38%	0.49
Infertility		49.40%	50.60%	0.001	43.48%	56.52%	0.014
Physical disability		46.82%	53.18%	< 0.001	40.03%	59.97%	0.009
Death		47.69%	52.31%	< 0.001	44.25%	55.75%	0.073
Other		54.29%	45.71%	0.19	53.52%	46.48%	0.39
Type of COVID vaccine preferred	903			< 0.001			0.004
Other		100.00%	0.00%		100.00%	0.00%
No preference		37.92%	62.08%		38.22%	61.78%
Pfizer		79.02%	20.98%		76.28%	23.72%
Sputnik		83.77%	16.23%		85.30%	14.70%
Moderna		85.71%	14.29%		86.09%	13.91%
Unsure		41.38%	58.62%		37.28%	62.72%
Sinopharm		72.73%	27.27%		87.09%	12.91%
Believe there are other (better) ways to prevent COVID-19 instead of vaccine	904			< 0.001			0.016
No or Don't know		84.35%	15.65%		85.35%	14.65%
Yes		52.13%	47.87%		50.59%	49.41%
Somewhat		74.31%	25.69%		68.15%	31.85%
Better ways to prevent COVID-19 instead of vaccine	447
Social distance		53.19%	46.81%	0.30	51.68%	48.32%	0.25
Handwashing		53.18%	46.82%	0.41	49.45%	50.55%	0.35
Infection prevention and control		49.25%	50.75%	0.28	47.70%	52.30%	0.27
Ventilation		50.96%	49.04%	0.65	45.96%	54.04%	0.29
Wearing face masks		53.71%	46.29%	0.20	50.57%	49.43%	0.99
Know any person with a serious disease / disability that happened because they were NOT vaccinated	903			0.008			0.22
Yes		76.64%	23.36%		79.21%	20.79%
No or Don't know		65.01%	34.99%		63.09%	36.91%
Think it is better to get COVID-19 and develop natural immunity than to get the vaccine	903			< 0.001			0.005
No		85.46%	14.54%		85.55%	14.45%
Don't know		57.35%	42.65%		55.39%	44.61%
Yes		45.22%	54.78%		46.42%	53.58%
Somewhat		67.44%	32.56%		64.41%	35.59%
Remember past events that would discourage them from getting COVID-19 vaccine	449	30.43%	69.57%	0.36	31.16%	68.84%	0.52
Think you are at risk to get COVID-19	903			0.11			0.30
No		65.17%	34.83%		63.04%	36.96%
Don't know		55.71%	44.29%		55.03%	44.97%
Yes		68.01%	31.99%		67.39%	32.61%
Think you can get seriously ill, hospitalized or die if you get COVID-19	904			0.014			0.072
No		69.57%	30.43%		64.97%	35.03%
Don't know		60.00%	40.00%		60.70%	39.30%
Yes		70.31%	29.69%		72.77%	27.23%
Barriers for receiving COVID-19 vaccine	448
Availability		28.57%	71.43%	0.72	48.21%	51.79%	0.15
Distance to vaccination point		34.62%	65.38%	0.86	42.59%	57.41%	0.30
Cost		NA%	NA%		NA%	NA%
Not a priority group		31.03%	68.97%	0.81	13.55%	86.45%	0.23
Lack of information about how / where to get it		31.63%	68.37%	0.74	35.19%	64.81%	0.57
Too stressful		31.71%	68.29%	0.65	30.33%	69.67%	0.10
Staff attitude		33.33%	66.67%	0.98	34.61%	65.39%	0.92
Not socially acceptable		13.49%	86.51%	< 0.001	15.07%	84.93%	0.063
None		32.65%	67.35%	0.95	38.87%	61.13%	0.37
Would get / have gotten the vaccine if employer recommended	449			< 0.001			0.089
No		18.24%	81.76%		21.09%	78.91%
Unsure		14.71%	85.29%		9.32%	90.68%
Yes		49.55%	50.45%		48.71%	51.29%
	¹%
	²chi-squared test with Rao & Scott's second-order correction

Common sources of vaccine information among the hesitant population were social media (58.18%); HCWs (53.29%); friends, neighbors and colleagues (52.52%); and family (41.55%). Notably, those classified as hesitant were more likely to report family (OR: 1.68, 95% CI 1.29–2.17); friends, neighbors and colleagues (OR: 1.83, 95% CI: 1.19–2.83); radio (OR: 1.48, 95% CI: 1.07–2.04); and mass events (OR 2.28, 95% CI: 1.12–4.62) as important sources of information, and less likely to mention HCWs (OR: 0.64, 95% CI: 0.47–0.86); religious leaders (OR: 0.51: 0.28–0.92); and civil society organization (OR: 0.41, 0.24–0.69). They were also more likely to trust family (OR: 1.75, 1.28–2.40); neighbors, friends and colleagues (OR: 3.04, 1.37–6.74); and the media (OR: 1.56, 1.23–1.98) for information on COVID-19 vaccines. They were less likely to trust HCWs (OR: 0.55, 0.46–0.65) and local leaders (OR: 0.03, 0.00-0.22) for accurate vaccine information.

Perceptions of vaccine safety and effectiveness also appear to impact vaccine hesitancy. Those classified as hesitant were far less likely to consider the vaccines safe (2.33% vs 30.34%, OR: 0.03 [95% CI: 0.01–0.16]). Around 80% of both hesitant and non-hesitant groups believed they were at risk of getting COVID-19 ; however the hesitant were less likely to consider themselves at risk of severe disease or hospitalization if they contract COVID-19 (OR: 0.69, 95% CI: 0.50–0.97). Limited percentages of both groups perceived risk of serious outcome.

In focus group discussions, some community members voiced skepticism of the efficacy of the vaccines, linking their roll-out to financial opportunism; however there was no consensus as others referenced the vaccine being free of charge.

“From my point of view, I see that it is financial and trade between countries… the world and people have become a field of experiments. [The] Israeli Yedioth Ahraonoth newspaper published two days ago that vaccination is not effective at all.” – Female FGD participant, Persons with Disabilities (PWD) Association, Gaza Governorate

“I believe that [the vaccine is not related to] trade because if it were a trade, we would have had the vaccination on our behalf. If it were a trade, we would have paid money to take it.” – Female FGD participant, PWD Association, Gaza Governorate

In multivariable regression, the adjusted models showed demographic factors as well as certain information sources and risk perceptions are independently associated with vaccine hesitancy (Table 7b). The vaccine hesitant were less likely to be male (aOR: 0.58, 95% CI: 0.40–0.84), older compared to younger adults (aOR: 0.47, 95% CI: 0.28–0.80), and university educated compared to primary or no education (aOR: 0.32, 95% CI: 0.25–0.42). The vaccine hesitant were more likely to mention family as a common source of information on the vaccines (aOR: 1.29, 95% CI: 1.00-1.67), and less likely to trust HCWs for vaccine information (aOR: 0.58, 95% CI: 0.49–0.68). Perception of vaccine safety and serious personal risk from COVID-19 are also independently related to vaccine hesitancy. Those who consider the vaccine safe had 97% lower odds of being hesitant (aOR: 0.03, 95% CI: 0.01–0.15), while those who believed in the possibility of serious illness from COVID-19 were had 38% lower odds of being hesitant (aOR: 0.62, 95% CI: 0.37–1.04).

Table 7

b. Odds ratios of vaccine hesitancy (Adjusted)
Characteristic	OR (95% CI)¹	p-value
Sex		0.004
Female	—
Male	0.58 (0.40 to 0.84)
Age		0.005
18–39	—
40+	0.47 (0.28 to 0.80)
Highest education level		< 0.001
Primary or None	—
Secondary or College / Vocational	0.45 (0.22 to 0.93)
University	0.32 (0.25 to 0.42)
Have enough information about COVID-19 vaccine		0.11
Yes	—
No or Don't know	1.39 (0.93 to 2.07)
Common source of information about health and vaccines
Health care providers (ref: no)	1.01 (0.74 to 1.39)	0.93
Family (ref: no)	1.29 (1.00 to 1.67)	0.051
Social media (ref: no)	0.81 (0.60 to 1.10)	0.18
Trusted source of information: Health care providers	0.58 (0.49 to 0.68)	< 0.001
Think you can get seriously ill, hospitalized or die if you get COVID-19		0.005
No	—
Don't know	1.08 (0.76 to 1.53)
Yes	0.62 (0.37 to 1.04)
Consider COVID-19 vaccines safe		< 0.001
No or Don't know	—
Yes	0.03 (0.01 to 0.15)
Somewhat	0.21 (0.18 to 0.25)
¹OR = Odds Ratio, CI = Confidence Interval

Vaccine hesitancy among the non-vaccinated

In sub-analysis, risk factors for vaccine hesistancy were considered for the population of unvaccinated individuals (Table 8). Vaccination outreach efforts will need to specifically target the currently unvaccinated population who are hesitant (~ 67% of this sub-group). In this population, there was not enough evidence that sex, age, or educational background were associated with hesitancy (p-value > 0.05). There was little variation in the information requested and information sources accessed among hesitant and non-hesitant individuals. The most common sources of information among those classified as hesitant were social media (58.32%), HCWs (53.21%), neighbors, friends and colleagues (52.29%), and family (43.28%).

Table 8

Factors associated with vaccine hesitancy, non-vaccinated community members only
	N	Vaccine hesitant (Unweighted)			Vaccine hesitant (Weighted)
Characteristic		no, N = 149¹	yes, N = 300¹	p-value²	no¹	yes¹	p-value²
Age	449			0.88			0.41
18–39		63.09%	62.33%		56.69%	62.58%
40+		36.91%	37.67%		43.31%	37.42%
Sex	449			0.033			0.68
Female		59.73%	49.00%		48.40%	49.89%
Male		40.27%	51.00%		51.60%	50.11%
Highest education level	449			0.018			0.41
Primary or None		5.37%	13.33%		5.98%	14.97%
Secondary or College / Vocational		49.66%	40.00%		44.79%	41.85%
University		44.97%	46.67%		49.24%	43.18%
Have enough information about COVID-19 vaccine	449			0.58			0.30
Yes		30.87%	28.33%		37.74%	28.76%
No or Don't know		69.13%	71.67%		62.26%	71.24%
Information needed	449
Eligibility criteria		33.56%	37.00%	0.47	46.59%	53.75%	0.58
Timeline for vaccine roll-out		8.05%	7.67%	0.89	17.02%	12.82%	0.35
When it's my turn to get the vaccine		9.40%	8.33%	0.71	14.14%	12.06%	0.59
Doses needed		19.46%	23.00%	0.39	25.10%	30.53%	0.50
Risks and side effects		90.60%	88.33%	0.47	94.12%	89.80%	0.12
Effectiveness of the vaccines		76.51%	74.33%	0.62	84.62%	81.19%	0.27
How to register for the vaccine		10.74%	12.00%	0.69	11.05%	12.47%	0.75
Common source of information about health and vaccines	448
Health care providers		59.73%	57.53%	0.66	62.75%	53.21%	0.16
Community health care workers		20.81%	20.74%	0.99	12.33%	13.66%	0.54
Radio		10.07%	16.39%	0.073	8.61%	16.61%	0.067
Television		28.19%	33.11%	0.29	27.28%	35.24%	0.43
Newspapers		0.67%	3.01%	0.12	0.05%	1.71%	0.018
Mass events		10.07%	9.36%	0.81	9.16%	9.03%	0.97
Family		26.17%	29.10%	0.52	29.06%	43.28%	0.15
Neighbors, friends, colleagues		34.90%	43.48%	0.083	44.04%	52.29%	0.51
Local leaders		2.68%	1.67%	0.47	3.36%	1.38%	0.51
Religious leaders		2.68%	2.68%	> 0.99	4.55%	3.41%	0.63
Social media		68.46%	56.52%	0.015	66.73%	58.32%	0.058
Organizations		14.09%	8.36%	0.061	15.36%	10.30%	0.17
Trusted source of information	449
Health care providers		71.14%	58.33%	0.009	73.03%	58.60%	0.14
Community health care workers		23.49%	23.33%	0.97	22.87%	26.79%	0.69
Local leaders		2.01%	0.33%	0.075	1.12%	0.02%	0.012
Religious leaders		0.00%	1.67%	0.11	0.00%	1.20%	0.35
Family members		2.01%	7.33%	0.021	4.05%	9.51%	0.075
Neighbors, friends, colleagues		3.36%	9.00%	0.029	4.72%	10.81%	0.082
Organizations		14.77%	9.67%	0.11	14.47%	9.17%	0.45
Media		14.77%	18.00%	0.39	13.40%	15.69%	0.40
Radio		1.34%	3.00%	0.29	0.82%	4.70%	0.012
Television		9.40%	11.00%	0.60	9.12%	12.88%	0.58
Other		4.70%	8.67%	0.13	2.81%	7.78%	0.069
Trust health providers and CHWS to provide with accurate information about the COVID-19 vaccine	448			< 0.001			0.001
No or Don't know		5.37%	23.75%		6.66%	25.71%
Yes		71.14%	38.13%		67.87%	33.96%
Somewhat		23.49%	38.13%		25.48%	40.33%
Follow social media platforms to get info about vaccine	449			0.20			0.15
No or Don't know		20.81%	26.33%		15.69%	22.34%
Yes		79.19%	73.67%		84.31%	77.66%
Social media platforms used to get info about vaccine	339
Facebook		99.15%	99.10%	0.96	99.67%	99.93%	0.25
Twitter		13.56%	16.74%	0.44	15.49%	12.84%	0.49
Instagram		41.53%	38.91%	0.64	44.09%	47.97%	0.78
YouTube		16.10%	26.24%	0.034	18.32%	21.91%	0.45
Shares information related to vaccine on social media network	421	17.86%	13.17%	0.20	16.82%	6.94%	0.005
How do you know info about vaccine from social media is true	449			< 0.001			0.16
I do not verify		20.13%	41.67%		24.76%	46.56%
Other		14.09%	17.67%		13.72%	15.54%
Verify from reputable website or health care provider		65.77%	40.67%		61.52%	37.90%
Do leaders (religious, political, teachers, health care workers) in your community support the COVID-19 vaccines?	257			0.082			0.45
No or Don't know		23.40%	33.74%		24.83%	32.43%
Yes		76.60%	66.26%		75.17%	67.57%
Most people you know interested in getting the COVID-19 vaccine	449			< 0.001			0.036
No or Don't know		22.82%	45.00%		27.78%	43.95%
Yes		38.93%	14.67%		39.38%	14.48%
Somewhat		38.26%	40.33%		32.83%	41.57%
How many people in your community are concerned about COVID-19 in the community	356			0.003			0.17
Few or some people, less than half		11.97%	26.36%		15.20%	31.45%
Most people		46.15%	31.80%		40.77%	26.16%
Some people – more than half		41.88%	41.84%		44.03%	42.39%
COVID-19 vaccines will or are being rolled out equitably in community	447			0.23			0.63
No or Don't know		18.79%	23.83%		23.28%	26.78%
Yes		81.21%	76.17%		76.72%	73.22%
Knows somebody that had a serious negative reaction to a vaccine that makes them reluctant to get COVID-19 vaccine	449			0.056			0.26
Yes		31.54%	40.67%		34.84%	42.93%
Somewhat		12.08%	15.00%		14.85%	21.93%
No or Don't know		56.38%	44.33%		50.31%	35.14%
Consider COVID-19 vaccines safe	448			< 0.001			0.074
No or Don't know		42.95%	76.25%		49.16%	74.25%
Yes		17.45%	3.34%		17.38%	2.08%
Somewhat		39.60%	20.40%		33.46%	23.67%
Concerned about risks or side effects with COVID-19 vaccines	449			0.009			0.14
No or Don't know		15.44%	7.67%		19.21%	7.48%
Yes		71.14%	83.33%		69.81%	83.79%
Somewhat		13.42%	9.00%		10.97%	8.73%
Types of risks or side effects concerned about	402
Fever		57.94%	51.81%	0.25	58.26%	58.56%	0.95
Body aches		66.67%	61.23%	0.30	73.25%	66.99%	0.17
Infertility		19.05%	30.43%	0.017	16.85%	36.95%	0.068
Physical disability		23.02%	33.33%	0.037	23.34%	31.23%	0.090
Death		49.21%	65.58%	0.002	47.90%	64.35%	0.17
Other		15.08%	17.39%	0.56	23.16%	21.99%	0.74
Type of COVID vaccine preferred	448
Other		0.00%	0.00%		0.00%	0.00%
No preference		12.75%	49.83%		17.25%	53.89%
Pfizer		49.66%	25.75%		47.01%	27.47%
Sputnik		28.19%	10.37%		27.00%	9.54%
Moderna		0.00%	1.67%		0.00%	1.73%
Unsure		6.71%	11.37%		5.48%	6.75%
Sinopharm		2.68%	1.00%		3.26%	0.63%
Believe there are other (better) ways to prevent COVID-19 instead of vaccine	449			< 0.001			0.039
No or Don't know		30.20%	16.33%		28.51%	15.14%
Yes		53.69%	71.33%		51.93%	67.67%
Somewhat		16.11%	12.33%		19.56%	17.19%
Better ways to prevent COVID-19 instead of vaccine	294
Social distance		85.00%	82.24%	0.58	86.75%	84.33%	0.67
Handwashing		78.75%	75.70%	0.58	75.60%	81.53%	0.45
Infection prevention and control		41.25%	47.20%	0.36	57.90%	55.56%	0.83
Ventilation		47.50%	47.66%	0.98	52.95%	59.28%	0.60
Wearing face masks		78.75%	75.70%	0.58	73.25%	79.59%	0.25
Trust health providers and CHWS to provide with accurate information about the COVID-19 vaccine	448			< 0.001			0.001
No or Don't know		5.37%	23.75%		6.66%	25.71%
Yes		71.14%	38.13%		67.87%	33.96%
Somewhat		23.49%	38.13%		25.48%	40.33%
Know any person with a serious disease / disability that happened because they were NOT vaccinated	449			0.006			0.13
Yes		20.13%	10.67%		26.73%	10.22%
No or Don't know		79.87%	89.33%		73.27%	89.78%
Think it is better to get COVID-19 and develop natural immunity than to get the vaccine	448			< 0.001			0.18
No		39.19%	19.00%		39.21%	17.81%
Don't know		7.43%	9.67%		2.94%	7.63%
Yes		39.19%	57.33%		43.45%	57.73%
Somewhat		14.19%	14.00%		14.39%	16.83%
Remember past events that would discourage them from getting COVID-19 vaccine	449	32.89%	37.33%	0.36	35.22%	40.21%	0.47
Think you are at risk to get COVID-19	449			0.001			0.22
No		4.70%	10.33%		7.73%	9.80%
Don't know		2.68%	10.33%		0.89%	11.49%
Yes		92.62%	79.33%		91.38%	78.72%
Think you can get seriously ill, hospitalized or die if you get COVID-19	449			0.004			0.010
No		34.90%	37.33%		34.33%	41.62%
Don't know		25.50%	37.33%		23.76%	35.17%
Yes		39.60%	25.33%		41.90%	23.20%
Barriers for receiving COVID-19 vaccine	448
Availability		2.70%	3.33%	0.72	3.39%	1.75%	0.11
Distance to vaccination point		6.08%	5.67%	0.86	2.88%	1.62%	0.21
Cost		0.00%	0.00%		0.00%	0.00%
Not a priority group		6.08%	6.67%	0.81	2.52%	7.11%	0.27
Lack of information about how / where to get it		20.95%	22.33%	0.74	19.50%	19.06%	0.90
Too stressful		35.14%	37.33%	0.65	43.82%	50.20%	0.091
Staff attitude		3.38%	3.33%	0.98	3.55%	3.39%	0.95
Not socially acceptable		11.49%	36.33%	< 0.001	11.07%	30.41%	0.078
None		10.81%	11.00%	0.95	19.09%	14.42%	0.39
Would get / have gotten the vaccine if employer recommended	449			< 0.001			0.092
No		19.46%	43.33%		22.43%	40.43%
Unsure		6.71%	19.33%		4.12%	21.32%
Yes		73.83%	37.33%		73.44%	38.25%
	¹%
	²chi-squared test with Rao & Scott's second-order correction

Table 8

a. Odds ratios of vaccine hesitancy (Unadjusted)
Characteristic	OR (95% CI)¹	p-value
Sex		< 0.001
Female	—
Male	0.66 (0.59 to 0.75)
Age		0.12
18–39	—
40+	0.75 (0.52 to 1.08)
Highest education level		< 0.001
Primary or None	—
Secondary or College / Vocational	0.51 (0.17 to 1.54)
University	0.35 (0.21 to 0.59)
Have enough information about COVID-19 vaccine		< 0.001
Yes	—
No or Don't know	2.53 (1.48 to 4.32)
Information needed
Eligibility criteria	1.10 (0.43 to 2.85)	0.84
Timeline for vaccine roll-out	1.01 (0.73 to 1.40)	0.95
Knowing when it's my turn to get the vaccine	1.61 (1.25 to 2.09)	< 0.001
Doses needed	1.47 (1.08 to 2.01)	0.016
Risks and side effects	1.15 (0.48 to 2.75)	0.75
Effectiveness of the vaccines	0.88 (0.71 to 1.08)	0.21
How to register for the vaccine	1.56 (1.18 to 2.07)	0.002
Common source of information about health and vaccines
Health care providers	0.64 (0.47 to 0.86)	0.004
Community health care workers	0.87 (0.65 to 1.18)	0.37
Radio	1.48 (1.07 to 2.03)	0.017
Television	1.41 (0.68 to 2.93)	0.35
Newspapers	1.17 (0.82 to 1.67)	0.39
Mass events	2.28 (1.12 to 4.62)	0.023
Family	1.68 (1.29 to 2.17)	< 0.001
Neighbors, friends, colleagues	1.83 (1.19 to 2.82)	0.006
Local leaders	0.38 (0.04 to 3.19)	0.37
Religious leaders	0.51 (0.28 to 0.92)	0.025
Social media	0.81 (0.67 to 0.98)	0.031
Organizations	0.41 (0.24 to 0.69)	< 0.001
Trusted source of information
Health care providers	0.54 (0.46 to 0.65)	< 0.001
Community health care workers	0.95 (0.67 to 1.35)	0.79
Local leaders	2.87 (1.99 to 4.14)	< 0.001
Religious leaders	1.52 (0.61 to 3.76)	0.37
Family members	1.75 (1.28 to 2.40)	< 0.001
Neighbors, friends, colleagues	3.05 (1.37 to 6.77)	0.006
Organizations	0.02 (0.00 to 0.18)	< 0.001
Media	2.05 (0.26 to 16.0)	0.49
Radio	1.56 (1.23 to 1.99)	< 0.001
Television	0.43 (0.34 to 0.56)	< 0.001
Other	1.65 (1.19 to 2.29)	0.003
Follow social media platforms to get info about vaccine		0.063
No or Don't know	—
Yes	0.78 (0.61 to 1.01)
Social media platforms used to get info about vaccine
Facebook (ref: no)	18.8 (3.81 to 92.8)	< 0.001
Twitter (ref: no)	0.58 (0.30 to 1.11)	0.10
Instagram (ref: no)	1.10 (0.78 to 1.55)	0.60
YouTube (ref: no)	0.98 (0.69 to 1.40)	0.93
Shares information related to vaccine on social media network		< 0.001
no	—
yes	0.32 (0.21 to 0.50)
How do you know info about vaccine from social media is true		< 0.001
I do not verify	—
Other	0.45 (0.34 to 0.58)
Verify from reputable website or health care provider	0.25 (0.19 to 0.34)
Think you can get seriously ill, hospitalized or die if you get COVID-19		< 0.001
No	—
Don't know	1.20 (0.87 to 1.67)
Yes	0.69 (0.50 to 0.97)
Consider COVID-19 vaccines safe		< 0.001
No or Don't know	—
Yes	0.03 (0.01 to 0.16)
Somewhat	0.20 (0.17 to 0.23)
¹OR = Odds Ratio, CI = Confidence Interval

Non-vaccinated, vaccine hesitant individuals were more likely to believe there are better ways to prevent COVID-19 (67.67% vs 51.93% of non-hesitant individuals). In the focus group discussions people expressing hesitancy about the vaccines questioned their benefit. One participant doubted the vaccines would be effective against COVID-19 in the long-term due to regular need for boosters.

“I do not think that the vaccine is safe because I see the already vaccinated people could be infected, and we have to be vaccinated every six months. We were immunized when we were young, which was once or twice, not every six months like Corona.” - Male FGD participant, PWD Association, Gaza Governorate

While the study was not powered to investigate risk factors for the unvaccinated sub-group, perceptions of vaccine safety and concerns about risks of side effects were marginally not significant in the weighted analysis, unlike in the combined population of vaccinated and unvaccinated individual. However perception of individual risk varied, with 23.20% of hesitant individuals vs 41.90% of non-hesitant individuals believing they were at risk of serious disease or hospitalization if they contracted COVID-19 (p = 0.010).

Vaccination and vaccine hesitancy among healthcare workers

In further sub-analysis we examined vaccine uptake and risk factors for hesitancy among HCWs. 89% (n = 151) of the HCWs surveyed were vaccinated (Table 9). Among the non-vaccinated HCWs only 5% (n = 9) were vaccine hesitant. Given the small number of vaccine hesitant among HCWs, few inferences can be made. However the explanations for hesitancy appear to mirror that of the population. HCWs who were hesitant were less likely to consider the vaccines safe (89% did not consider them safe compared to 11% of non-hesitant HCWs) and more likely to express concerns about side effects (89% compared to 26% of non-hesitant HCWs).

Table 9

Factors associated with vaccine hesitancy, HCWs only
	N	Vaccine Hesitant
Variable		no, N = 160¹	yes, N = 9¹	p-value²
Have enough information about COVID-19 vaccine, n (%)	169			0.73
Yes		101 (95)	5 (4.7)
No or Don't know		59 (94)	4 (6.3)
Information needed, n (%)	169
Eligibility criteria		35 (92)	3 (7.9)	0.42
Timeline for vaccine roll-out		12 (92)	1 (7.7)	0.52
When it's my turn to get the vaccine		13 (93)	1 (7.1)	0.55
Doses needed		31 (94)	2 (6.1)	0.69
Risks and side effects, n (%)		106 (92)	9 (7.8)	0.059
Effectiveness of the vaccines, n (%)		106 (94)	7 (6.2)	0.72
How to register for the vaccine, n (%)		7 (88)	1 (12)	0.36
Common source of information about health and vaccines, n (%)	169
Health care providers		132 (96)	6 (4.3)	0.37
Community health care workers		45 (94)	3 (6.2)	0.71
Radio		2 (100)	0 (0)	> 0.99
Television		14 (93)	1 (6.7)	0.58
Newspapers		2 (67)	1 (33)	0.15
Mass events		1 (100)	0 (0)	> 0.99
Family		3 (100)	0 (0)	> 0.99
Neighbors, friends, colleagues		4 (80)	1 (20)	0.24
Local leaders		1 (100)	0 (0)	> 0.99
Religious leaders		2 (100)	0 (0)	> 0.99
Social media		51 (91)	5 (8.9)	0.16
Organizations		59 (97)	2 (3.3)	0.49
Trusted source of information, n (%)	169
Health care providers		118 (96)	5 (4.1)	0.26
Community health care workers		30 (94)	2 (6.2)	0.68
Local leaders		0 (NA)	0 (NA)
Religious leaders		0 (NA)	0 (NA)
Family members		0 (0)	1 (100)	0.053
Neighbors, friends, colleagues		2 (67)	1 (33)	0.15
Organizations		55 (98)	1 (1.8)	0.27
Media		10 (83)	2 (17)	0.13
Radio		2 (100)	0 (0)	> 0.99
Television		5 (100)	0 (0)	> 0.99
Other		15 (94)	1 (6.2)	0.60
Trust health providers and CHWS to provide with accurate information about the COVID-19 vaccine, n (%)	169			< 0.001
No or Don't know		9 (64)	5 (36)
Yes		106 (99)	1 (0.9)
Somewhat		45 (94)	3 (6.2)
Follow social media platforms to get info about vaccine, n (%)	169			> 0.99
No or Don't know		42 (95)	2 (4.5)
Yes		118 (94)	7 (5.6)
Social media platforms used to get info about vaccine, n (%)	125
Facebook		114 (94)	7 (5.8)	> 0.99
Twitter		18 (95)	1 (5.3)	> 0.99
Instagram		38 (95)	2 (5.0)	> 0.99
YouTube		29 (91)	3 (9.4)	0.37
Shares information related to vaccine on social media network, n (%)	166	53 (98)	1 (1.9)	0.27
How do you know info about vaccine from social media is true, n (%)	168			0.034
I do not verify		17 (81)	4 (19)
Other		11 (100)	0 (0)
Verify from reputable website or health care provider		131 (96)	5 (3.7)
Do leaders (religious, political, teachers, health care workers) in your community support the COVID-19 vaccines?, n (%)	107			> 0.99
No or Don't know		20 (100)	0 (0)
Yes		84 (97)	3 (3.4)
Most people you know interested in getting the COVID-19 vaccine, n (%)	169			0.072
No or Don't know		35 (88)	5 (12)
Yes		87 (97)	3 (3.3)
Somewhat		38 (97)	1 (2.6)
How many people in your community are concerned about COVID-19 in the community, n (%)	135			0.80
Few or some people, less than half		50 (96)	2 (3.8)
Most people		37 (92)	3 (7.5)
Some people – more than half		41 (95)	2 (4.7)
COVID-19 vaccines will or are being rolled out equitably in community, n (%)	169			0.058
No or Don't know		40 (89)	5 (11)
Yes		120 (97)	4 (3.2)
Knows somebody that had a serious negative reaction to a vaccine that makes them reluctant to get COVID-19 vaccine, n (%)	167			0.049
Yes		24 (86)	4 (14)
Somewhat		20 (95)	1 (4.8)
No or Don't know		114 (97)	4 (3.4)
Consider COVID-19 vaccines safe, n (%)	169			< 0.001
No or Don't know		18 (69)	8 (31)
Yes		74 (100)	0 (0)
Somewhat		68 (99)	1 (1.4)
Concerned about risks or side effects with COVID-19 vaccines, n (%)	169			< 0.001
No or Don't know		75 (99)	1 (1.3)
Yes		42 (84)	8 (16)
Somewhat		43 (100)	0 (0)
Types of risks or side effects concerned about, n (%)	92
Fever		44 (92)	4 (8.3)	> 0.99
Body aches		55 (93)	4 (6.8)	0.45
Infertility		16 (84)	3 (16)	0.35
Physical disability		10 (83)	2 (17)	0.28
Death		10 (62)	6 (38)	< 0.001
Other		18 (82)	4 (18)	0.090
Type of COVID vaccine preferred, n (%)	169			0.35
Other		0 (NA)	0 (NA)
No preference		16 (89)	2 (11)
Pfizer		93 (97)	3 (3.1)
Sputnik		40 (91)	4 (9.1)
Moderna		8 (100)	0 (0)
Unsure		3 (100)	0 (0)
Sinopharm		0 (NA)	0 (NA)
Believe there are other (better) ways to prevent COVID-19 instead of vaccine, n (%)	169			0.48
No or Don't know		79 (96)	3 (3.7)
Yes		52 (91)	5 (8.8)
Somewhat		29 (97)	1 (3.3)
Better ways to prevent COVID-19 instead of vaccine	57
Social distance		45 (94)	3 (6.2)	0.17
Handwashing		45 (92)	4 (8.2)	0.54
Infection prevention and control		22 (88)	3 (12)	0.64
Ventilation		18 (90)	2 (10)	> 0.99
Wearing face masks		42 (91)	4 (8.7)	> 0.99
Know any person with a serious disease / disability that happened because they were NOT vaccinated, n (%)	167			0.27
Yes		52 (98)	1 (1.9)
No or Don't know		106 (93)	8 (7.0)
Think it is better to get COVID-19 and develop natural immunity than to get the vaccine, n (%)	169			0.12
No		87 (98)	2 (2.2)
Don't know		22 (96)	1 (4.3)
Yes		38 (88)	5 (12)
Somewhat		13 (93)	1 (7.1)
Remember past events that would discourage them from getting COVID-19 vaccine, n (%)	18	1 (25)	3 (75)	0.58
Think you are at risk to get COVID-19, n (%)	168			0.63
No		5 (100)	0 (0)
Don't know		11 (92)	1 (8.3)
Yes		143 (95)	8 (5.3)
Think you can get seriously ill, hospitalized or die if you get COVID-19, n (%)	169			> 0.99
No		67 (94)	4 (5.6)
Don't know		53 (95)	3 (5.4)
Yes		40 (95)	2 (4.8)
Barriers for receiving COVID-19 vaccine, n (%)	18
Availability		0 (NA)	0 (NA)
Distance to vaccination point		1 (50)	1 (50)	> 0.99
Cost		0 (NA)	0 (NA)
Not a priority group		0 (0)	1 (100)	> 0.99
Lack of information about how / where to get it		1 (33)	2 (67)	> 0.99
Too stressful		1 (100)	0 (0)	> 0.99
Staff attitude		0 (NA)	0 (NA)
Not socially acceptable		0 (0)	1 (100)	> 0.99
None		1 (100)	0 (0)	> 0.99
Would get / have gotten the vaccine if employer recommended, n (%)	18			0.35
No		3 (38)	5 (62)
Unsure		0 (0)	1 (100)
Yes		6 (67)	3 (33)
	¹Frequency (%)
	²Fisher's exact test

³Respondents who answered “No” or “Not sure” to the question, “If you could get the COVID-19 vaccine this week, would you get it? were classified “hesitant”. Those answering “Yes” as well as currently vaccinated people were classified “non-hesitant.”

⁴Currently unvaccinated respondents who answered “No” or “Not sure” to the question, “If you could get the COVID-19 vaccine this week, would you get it? “ were classified “hesitant”, while those answering “Yes” were classified “non-hesitant.” Currently vaccinated individuals were excluded.

This study provides one of the first in-depth investigations of COVID-19 vaccine coverage and hesitancy from a conflict-affected setting. We estimated vaccine coverage to be 49.09% (95% CI: 43.10-55.08) among the general population. The study’s large sample size also enables reasonable sub-group estimates of vaccination coverage that reveal disparities in access to vaccination. We found the populations less likely to be vaccinated were females (41.45% of females vs 58.55% of males) and those less educated (37.30% of those with primary or no education vs 55.75% of those with university education). While global data is lacking on vaccine distribution among traditionally marginalized populations, our study’s findings suggest the worldwide systemic inequities regularly observed in public health may be taking place with COVID-19 vaccination as well [17].

We estimated the vaccine hesitant consist of 34.08% (95% CI: 28.14–40.56) of the adult population of Gaza, which is similar to the estimate from the web-based survey (37%) carried out in October 2020 [9]. Temporal data from VHS studies have generally found levels of hesitancy decreasing within countries over time corresponding to the roll-out of vaccines [3]. The apparent lack of change in COVID-19 vaccine confidence in Gaza during 2021 raises concern about the coverage and effectiveness of early vaccine promotion efforts.

Among the non-vaccinated, 67.24%, were classified vaccine hesitant, suggesting they will be difficult to reach through supply availability alone. Characteristics of the vaccine hesitant in Gaza mirror global findings, with less education as well as lower perception of serious risk from COVID-19 linked to vaccine hesitancy [18, 19]. Among the non-vaccinated group, those classified as hesitant were less likely to consider the vaccine safe and less likely to believe they were at risk of severe disease – suggesting their perceived risk of vaccination outweighed perceived risk of infection. They are also more likely to rely on family and friends information – a finding that mirrors the global scoping review conducted by Biwas et al [3]. Conversely, perception of personal benefit and effectiveness of the vaccines, as well as lower concern about side effects, appears to positively influence vaccination. In community focus group discussions, participants with chronic diseases widely expressed support for vaccination suggesting a successful integration of messaging on comorbidity risks among this this group.

Research remains conflicting on relative levels of vaccine hesitancy among different demographic groups. Recent studies from the Middle East have reported females more likely to be vaccine hesitant, which our study similarly found [5, 19, 20]. However, among the non-vaccinated population of our study, sex was not associated with vaccine hesitancy, suggesting there may different barriers to accessing vaccines among unvaccinated women. Age was also not associated with vaccine hesitancy among the non-vaccinated in Gaza, whereas other studies have found younger groups as more vaccine hesitant or less motivated to pursue vaccination [18]. Our study was not powered to investigate risk factors among the unvaccinated population, though, and it is possible that a larger survey of this group would identify further variation.

We found high COVID-19 vaccination coverage (89%) among HCWs, similar to global reports [21, 22]. Despite the smaller number of HCWs interviewed for our study and use of purposive sampling, the high level of uptake is likely a valid representation given the vaccine mandates for this group. From June 2021, the de facto government of Gaza Strip required staff of the MoH and other agencies to be vaccinated dagainst COVID-19. Therefore among this group, vaccination is not necessarily a valid measure of vaccine hesitancy; a non-negligible proportion of HCWs expressed doubts about certain aspects of the vaccine. More than 15% of HCWs stated they do not consider the vaccine safe or do not know, while one-quarter of HCW respondents reported concern about side effects. Among non-vaccinated HCWs, perception of insuffient vaccine safety and efficacy appear to be major determinants of hesitancy. Our qualitative interviews also suggest there may be more skepticism of vaccines among clinicians than is readily apparent in the survey data. Recent articles by El Kibbi et al. and Heyerdahl et al. raised concerns on “unspoken vaccine hesitancy” among HCWs in the Middle East, which our own study’s findings modestly support as a subject worth monitoring [23, 24].

A major strength of our study is its broad scope which covers vaccine coverage estimates, vaccine hesitancy, comparisons among sub-groups of the populations, and risk factors associated with both vaccination and vaccine hesitancy. The findings can be used to develop more persuasive and effective information campaigns, and to proactively address the concerns of vaccine hesitant sub-groups through the information channels they most commonly use and trust. Subsequent research in Gaza could examine changes in vaccine hesitancy over time and evaluate the effectiveness of outreach campaigns and social messaging based on evidence of drivers of vaccine hesitancy.

Limitations

Limitations of the study center on the use of a standard global tool for assessment of vaccine hesitancy and confidence. As such, not all reasons for hesitancy were factored into the survey and questions were not customized to the context of the Gaza Strip. We did not inquire about previous SARS-CoV-2 infection and history of COVID-19 disease, comorbidities, movement restrictions in Gaza, the recent conflict, and other individual and local factors that could influence to vaccine hesitancy. The reliance on convenience sampling of primary survey respondents within households rather than purely random sampling of adult household members may have affected the prevalence values obtained if the characteristics of available household members or self-selected household members differ from the general population.

Similarly, we collected hesitancy information from healthcare workers to investigate coverage and hesitancy among this at-risk group of frontline responders. The respondents were selected from a purposive sample of health facility clinical staff, so the findings cannot be extrapolated to the population of HCWs although we believe the findings reflect well their perspectives based on on-the-ground experience. The standard tool was not customized for the interviews with healthcare workers, so certain factors more relevant to this population – such as clinical and epidemiological knowledge, patient care experience, and employer mandates - that correlate with vaccine acceptance were not assessed here

The recurrent and rapid emergence of COVID-19 variants reinforces the urgency to accelerate vaccination efforts in under-resourced and conflict-prone settings like the Gaza Strip. Scientists have linked recent variants such as Delta and Omicron to low and inequitable vaccination coverage globally, indicating the need for both supply- and demand-oriented strategies to combat the pandemic [25, 26]. Our study complements previous research on the latter through an investigation of vaccination coverage and vaccine hesitancy in the difficult public health setting of the Gaza Strip. It is one of the first population-representative studies of these topics in the Middle East and is also the first to be carried out in Gaza since the vaccine roll-out.

Just half of adults in Gaza had received at least one dose of a vaccine by October 2021. Disparities in vaccination coverage were apparent across the territory’s social and demographic groups; vaccination campaigns should subsequently target those who are less likely to be vaccinated including women and those with lesser socio-economic status. HCWs are a widely trusted information channel on COVID-19 vaccines among the vaccinated and unvaccinated, although less trusted among those who are hesitant. The latter accessed information from family, friends, neighbors, and colleagues at higher levels than the vaccinated and non-hesitant. This suggests the importance of disseminating accurate messages through community-based channels to permeate social networks of the unvaccinated and to address misinformation from these sources. Community engagement to promote vaccines should emphasize messaging on vaccine effectiveness and minimal risk of serious side effects, both of which were major concerns voiced by the unvaccinated and vaccine hesitant.

CHW Community Health Worker

FGD Focus Group Discussion

HCW Healthcare Workers

KI Key Informant

KII Key Informant Interview

OR Odds Ratio

PCBS Palestinian Central Bureau of Statistics

PWD Persons with Disabilities

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author’s institution on reasonable request.

Acknowledgements

We are immensely grateful for the efforts of IMC-Gaza colleagues Dr. Methqal Hassouna and Ghada Zahran, who supported the implementation of the study, as well as the data collection team. From IMC headquarters, Drs. Jill John-Kall, Zawar Ali and Javed Ali provided valuable contributions to the design and mobilization of the study. We also would like to express our gratitude to the healthworkers who agreed to be interviewed and to the key informants for their insights on COVID-19 and vaccination trends in the Gaza Strip. Finally, our deepest appreciation goes to the community members of Gaza who willingly shared their time and perspectives on this topic that is critical to ending the pandemic.

Funding

This study was funded by International Medical Corps using private donations obtained for the global humanitarian response to COVID-19. International Medical Corps staff and the research consultant were responsible for all aspects of the study and the funders had no role in the study design, data collection, analysis or report writing.

Contributions

JM participated in the conception, data analysis, interpretation and drafted the manuscript; JHE was the lead consultant overseeing ethical review, data acquisition, and preliminary analysis; NM participated in data acquisition and supervision and was the primary contact for obtaining population data from the PCBS used in analysis; NK participated in statistical analysis, interpreting the results, and substantial editing of the manuscript.

Ethics declarations

Ethics Approval and Consent to Participate

The study was conducted in accordance with relevant research guidelines and regulations. All participants in household surveys, key informant interviews, and focus group discussions provided oral informed consent. The study protocol was reviewed and approved by the Helsinki Committee of the Palestinian Health Research Council (Number: PHRC/HC/998/21).

Consent for publication

Not applicable.

Competing interests

All authors declare that they have no competing interests.

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No competing interests reported.

COVID-19 Vaccination in the Gaza Strip: a Cross-sectional Study of Vaccine Coverage, Hesitancy, and Associated Risk Factors Among Community Members and Healthcare Workers

Status:

Version 1

Abstract

Background

Methods

Quantitative methods

Qualitative methods

Data collection

Data analysis

Results

Respondent Characterics

Vaccine status and characteristics

Vaccine hesitancy and risk factors

Vaccine hesitancy among the non-vaccinated

Vaccination and vaccine hesitancy among healthcare workers

Discussion

Limitations

Conclusion

List Of Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1