Acceptance Towards COVID-19 Vaccination among the Lebanese Population: A Cross-Sectional Study

Acceptance Towards Vaccination among the Lebanese Population: A Cross-Sectional Study. Abstract Introduction: The emergence of the covid-19 pandemic has created major health risks to humanity, in turn, the world has been waiting for a solution to end this pandemic. This research aims to study the acceptance towards the covid-19 vaccine among the Lebanese population and investigate the factors affecting the decision towards the vaccine. Methods: To obtain a clear insight about the propensity of the Lebanese population to take the vaccine, a cross-sectional study was conducted, data collected through a questionnaire based on google forms and distributed among the population via social media platforms. Results: 86.3% of the population believe that the pandemic poses major health risks to the society in Lebanon. Moreover, the respondents consider the source of the vaccine as a major determinant to whether they will take the vaccine, in fact (73.3%) trust the Pfizer-BioNTech vaccine. However, 77.1% of the sample worry that the vaccine will have side effects. In addition, over 90% of the population was observed to be following the restrictions and measures implemented to stop the spread of the virus. Conclusion: Within the limitations of this study, we can conclude that this study is the earliest attempt to assess the acceptance toward COVID-19 vaccination among the Lebanese population. The Lebanese population showed a moderately high acceptance rate for the vaccination, however, there is a notable percentage that needs to be directly addressed with any future awareness campaign which are the youth, and the people with low socioeconomic status.

pharmaceutical companies have been working at unprecedented rates to develop a vaccine to fight against this global pandemic [9].
According to the WHO, only two mRNA vaccines have been approved by the United States Food and Drug Administration (FDA); Pfizer-BioNTech Covid-19 Vaccine on the 11 th of December 2020 and Moderna Covid-19 Vaccine on the 18 th . Several companies developed vaccines based on different modes of action [10]. The Oxford-AstraZeneca vaccine is a double-stranded DNA vaccine that uses a modified version of a chimpanzee adenovirus that has been used in many countries such as the UK as an emergency vaccine in December 2020 [10]. Besides, China developed the Sino-pharm

Covid-19 vaccine which is an Inactivated Coronavirus Vaccine
where the virus is modified by a protein-denaturing treatment to make it noninfectious [11]. On the microscopical level, Lebanon is a third world country with an estimated population of 6,825,445 that has been plagued with political turbulence and economic crisis over the past year and a half [12], on the 21 st of February 2020, Lebanon witnessed its first Covid-19 case and since then around hundreds of thousands (387.000 confirmed cases on the fourth of March 2021) of cases have been recorded [13].
The government has been trying to implement various restrictions to limit the number of cases from curfews to complete lockdown, these Covid-19 related regulations had repercussions on employment since in June 2020, one out of three were unemployed and one out of 5 had their salary reduced [14]. Regardless, as the regulations and recommendations administered by the WHO and the ministry of public health did not achieve their target, the number of confirmed cases is still increasing in an alarming manner [15]. The hospitals' Intensive Care Units (ICU) reached their maximum capacity and a shortage of medical supply needed has been witnessed. On the 28 th of January 2021, the minister of health, Dr. Hamad Hassan declared that the World Bank will be providing the government hospitals with 117 ICU beds for coronavirus patients [16]. Thus, it is being discussed that the vaccine is the sole method to limit the transmission and spread of the virus. The target of the ministry of health is to reach 70% of a vaccinated Lebanese population by the end of the year 2021-2022 by introducing the Pfizer-BioNTech and Oxford-AstraZeneca Covid-19 Vaccines while giving the priority to the elderly, the health workers, and susceptible patients [17]. However, concerns about the safety of the vaccine due to its fast development, short testing, its unknown long-term side effects, and the emergence of conspiracy theories and political underlying benefits have been raised. Misconceptions and misinterpretation about certain aspects of the pandemic have been circulating alarmingly. For instance, it is being discussed that the vaccine is being developed for monetary gains, while others believe that the purpose of the vaccine is to implant microchips into people's bodies [18]. As a result, these factors have affected the Lebanese population's acceptance and opinion regarding the proposed vaccines against the Covid-19. To date, this growing public health concern in Lebanon has received scant attention in the research literature. Therefore, this cross-sectional study examines the propensity to which the Lebanese population is willing to take the new covid-19 vaccine once available or not.
Thus, the importance of this research is to study the possibility of reaching a 70% herd immunity by vaccination [19].

Aim of the Research
This research aims to study the acceptance of COVID-19 vaccination among the Lebanese population, moreover, it aims to study the general attitude and behavior during the pandemic.

Study design
A cross-sectional study was conducted to collect the data. the data were collected through the collaboration between ResAid

Statistical analysis
Data were collected using online questionnaire (google forms) which will eliminate the error in data entry (data automatically transferred to Excel file) and the missing data (as participants will be notified about questions they missed). The data then were analyzed using descriptive and inferential statistical methods using SPSS V.22 software, Pearson's Correlation, T-test, ANOVA Test were used to analyze the data. multivariable regression model was done to test how the variables affect each other. Sample size was estimated using sample size calculator for cross-sectional studies, confidence interval was set at (5%), confidence level (5%), and the Lebanese population according to the latest statistics are (6.8m), and the results was that (384) sample were representative for the population. The final sample size was (1157) which increase the power of this study and reduced the confidence interval to (2.88).

Sample analysis and demographic variables
The final sample size consisted of (1157) participants,  Table   1 represents the sample demographic variables. Behavior during the pandemic  9%). Most of the sample will take the vaccine even if it is not free (51.9%), while (32.2%) will never take the vaccine even if it is free, and (15.8%) will only take a free vaccine.   Table 3, most questions are answered with "yes" from over (90%) of the sample, except for following a certain diet or taking supplements and vitamins (46.1%).

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The relation between the research variables
Inferential statistical analysis was used to test the relation between the different research variables. Pearson's correlation test was used to identify the correlation between the age variable and the willingness to take the vaccine, and the result is represented in Table 4, there is a significant positive correlation between the age and the willingness to take the vaccine among the sample

Discussion
The Covid-19 pandemic has reshaped our lives; therefore, it is considered that up till now, the vaccine is the best solution to eradicate the virus and stop its spread [20]. The Pfizer-BioNTech Covid-19 Vaccine arrived in Lebanon on the 14 th of February and was distributed to hospitals and vaccination centers [21]. Thus, it was incumbent to conduct a study that aims to investigate the level of acceptance of the SARS COV-2 vaccine among the Lebanese population and the various factors that affect their decision. Hence, the importance of this study stems from the fact that it is among the first to discuss the acceptance in Lebanon, moreover, the big sample size that participated in this study can help to generalize the results of this study. Of our sample, over half of the population (58.8%) are willing to take the vaccine. This result is in direct contrast to the results of other studies since the acceptance observed in Lebanon is lower than the one in Iraq (77.6%), China (91.3%), Saudi Arabia (64.7%), and the United States of America (69%). However, a survey conducted in England revealed a lower tendency to take the vaccine (55.8%) [22][23][24][25]. Most of the sample stated that they know someone who caught the coronavirus, and as a result, it is concluded that the virus poses major risks to society.
The findings suggest that most of the participants who perceive the virus as a threat might be more inclined to protect themselves from the pandemic, this is consistent with the results of a longitudinal study concerning the first year of the H1N1 Pandemic which stated that the risk of infection is directly related to the acceptance of vaccination [26]. This goes in line with the previous result that stated that 58.8% of the sample is willing to take the vaccine. However, this acceptance is related to the source of the vaccine for over two-thirds of the sample. The majority prefer to take the German American vaccine (BioNTech-Pfizer) while the Chinese vaccine; Sinopharm was the second most trusted vaccine among the Lebanese population, and the Russian vaccine Sputnik V was the latest. This repartition might be due to the 95% efficacy of the Pfizer vaccine and its mode of action which could be reassuring [26]. The preference for the Pfizer vaccine is consistent with the results of a cross-sectional study conducted in Indonesia in July 2020 which shows that higher acceptance towards vaccination was associated with the choice of a 95% effective vaccine [22]. this results can be directly related to psychological status [27], political trust, religious beliefs, and social status of the population [28]. Social determinants played a key role in the acceptance of the vaccine among the Lebanese population, gender, age, and higher socioeconomic status were significant factors affecting the willingness to take the vaccine, this can be explained as the following, COVID-19 pandemic affected seniors more than youth therefor, the older the person gets, the more willing to take the vaccine he/she becomes [29][30][31].
Furthermore, the socioeconomic status is higher when the education level is higher, and the higher education level can be a protective factor against the wrong information about the vaccination programs [32]. Similar results were found in many other studies, in Saudi Arabia, older age groups and education level were significantly associated with the vaccine acceptance, in other Arab community, males were more willing to accept the vaccine [33]. As stated earlier, the vaccination program is the only solution to pass the current pandemic and protect the communities around the world from a further speared of this virus and to protect the world economy from collapsing, therefore, the results of this study can be a cornerstone for the development and implications of the vaccination program in the Lebanese community, and it can give an in-depth overview for the groups that are least to accept the vaccine to start an awareness campaign aiming to raise the awareness toward COVID-19 vaccine. Further research might investigate the reason why the number of active Covid-19 cases keeps on increasing even if the participants are claiming to respect most of the safety measurements. Another further study could assess the updated data once people start getting the vaccine.

Conclusion
Within the limitations of this study, we can conclude that this study is the earliest attempt to assess the acceptance toward COVID-19 vaccination among the Lebanese population. The Lebanese population showed a moderately high acceptance rate for the vaccination, however, there is a notable percentage that needs to be directly addressed with any future awareness campaign which are the youth, and the people with low socioeconomic status. Most important factor affecting the acceptance level was the free vaccine, as the population are willing to take the vaccine if it was free.

Limitations of the Study
Due to the current pandemic situation, data were only collected in electronic form, which might be affected be selection bias, as most of the Lebanese population uses social media platform or emails are considered medium or high status on the socioeconomic scale, selection bias might be reduced when bigger sample size is collected which is the case of this study. Therefore, within these limitations, the results can draw an overview of the current situation with limited ability to generalize the results over all the Lebanese population, and further research should be done.

Consent for Publication
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