On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic (1, 2). SARS-CoV-2, the causative agent of COVID-19 is a respiratory virus transmitted from person-to-person via droplets. With the lack of antiviral treatment and vaccines, non-pharmaceutical interventions (NPIs) were implemented to slow the spread of the virus. These NPIs included closure of international borders and points of entry/exit, screening of travelers, implementation of strict lockdown measures, isolation of positive cases, use of hand hygiene, face coverings, and other personal protective equipment (3–5). Despite the implementation of these measures, the number of COVID-19 cases is still increasing worldwide (6). Therefore, vaccines remain the most effective way to prevent the spread of COVID-19 (6, 7).
Since the emergence of SARS-CoV-2, several vaccines were developed in an 11-month period, a record time (5, 6). Currently, there are 9 vaccines in early or limited use with 8 vaccines approved for full use (6, 8). Several platforms for the vaccines are currently in use; two companies developed mRNA-based vaccines: Pfizer/BioNtech and Moderna. These vaccines encode the spike glycoprotein of SARS-CoV-2 and offer an efficacy of 95% and 94.1%, respectively (9). The Johnson & Johnson’s Janssen COVID-19 vaccine and the AstraZeneca/Oxford (ChAdOx1) vaccines are based on a recombinant, replication-incompetent human adenovirus serotype 26 vector and chimpanzee adenovirus (ChAdOx1) vector encoding the spike glycoprotein of SARS-CoV-2 (8–13). Inactivated virus as well as protein-based vaccines have also been developed and many are in use. The record time of development of these vaccines generated a global hesitancy among many and is currently affecting the roll-out of vaccines to control the spread of the SARS-CoV-2 (5).
Vaccine hesitancy, defined as the “delay in acceptance or refusal of vaccines despite availability of vaccine services,” has been an ongoing challenge (5, 14). Vaccine hesitancy is caused by multiple factors and varies with time, place and vaccines (14, 15). These factors include complacency (individual perceptions of the risks versus the need for vaccination), convenience (availability, affordability and accessibility to vaccines), and confidence (trust in the safety and effectiveness of the vaccine and the delivering healthcare system, and in the decisions of policymakers) (14). The “3Cs” are helpful in understanding factors that contribute to vaccine hesitancy (14, 16). These include contextual influences (e.g. historic, socio-cultural, environmental, health system/ institutional, economic or political factors), individual and group influences (personal perception of the vaccine including knowledge, awareness, conspiracy beliefs, attitudes, or a personal experience with a vaccinated family member/friend), as well as vaccination influences (costs, mode of delivery, mode of administration, strength and knowledge of healthcare workers, risks, or benefits).
Various countries have conducted studies on COVID-19 vaccine hesitancy. The highest COVID-19 vaccine acceptance rates were reported in Ecuador (97%) (17), Malaysia (94%) (18), Indonesia (93%) (19) and China (91%) (20). High trust in government among these Asian countries is posited as to why these acceptance rates are so high (21). In the US, vaccine acceptance rates were reported among adults (between 57.5% and 68.5%) (21), medical students (75.5%) (22), dental students (56%) (23), and the general population (78%) (24). Unfortunately, COVID-19 vaccine acceptance rates in the Middle Eastern populations have been among the lowest worldwide: Lebanon (21%) (25), Jordan (28.4–37.4%) (16, 26, 27), followed by Qatar (43%) (28), Iraq (62%) (7), Saudi Arabia (65%) (29), Turkey (66%) (30), and Israel (75%) (31).
University and college students form an important part of every society. Students are considered insightful, influential, open-minded, educated, and responsive to public health issues (32). To investigate COVID-19 vaccine hesitancy among this important population, various studies were conducted in this region of the world among medical students (5) and university students in general (33, 34). However, to our knowledge, this is the first study to assess COVID-19 vaccine hesitancy among university students in Lebanon and no studies in the past have used a theoretical approach to elucidate their decision-making process. Therefore, the purpose of this study was to identify the readiness, behavioral intentions, and predictors of obtaining the COVID-19 vaccine among university students at the American University of Beirut.