COVID-19 Vaccine Hesitancy among the Non Medical Adult Population Attending a Tertiary Care Hospital of Kolkata, India: A Cross-sectional Study
Correspondence Address :
Dr. Soumitra Mondal,
S4/5, Srabonia Bason, FC-Block, Sector-III Saltlake,
Kolkata-700106, West Bengal, India.
Introduction: Vaccines play an important role in the fight against diseases whose cure is unavailable. In the battle against pandemics such as Coronavirus Disease 2019 (COVID-19), the vaccine is the only available course of prevention. The hesitancy has been found all over the world, while some find it against their religious values, others are concerned about safety, or have doubts about its efficacy. Some are hesitant due to fear of needles while some show brass negligence. Being the second most populated country globally and a developing nation, India had faced its fair share of struggles with her citizens vaccinated. Even a minute percentage of people accounts for millions; hence, it is of utmost importance to get to the root of the causes of delay in vaccination.
Aim: To find the causes of delay or hesitancy among the people attending COVID-19 vaccination centre of a tertiary care hospital of Kolkata, (a year after vaccines were introduced to the general population).
Materials and Methods: A cross-sectional study was performed in the COVID-19 vaccination centre of Medical College Kolkata, West Bengal, India, from 14th January 2022 to 14th April 2022. Total 74 non medical (not related to healthcare work) people who had come for 1st or 2nd dose of COVID-19 vaccination were included in the study. A prestructured, pretested, prevalidated questionnaire was used to collect data from the participants of the study. The Likert scale comprising of nine questions were used to assess hesitancy. Data were analysed using Chi-square test. Binary logistic regression was done to confirm any predictability of occupation, literacy rate, age and gender on vaccine hesitancy.
Results: The participants comprised of 45 (60.8%) females and 29 (39.2%) males, aged between 18 to 60 years with the mean age of 33.75±11.06 years. The participants included 22 (29.7%) people, who had just taken their first dose. Twenty six (35.1%) participants were hesitant. The most common causes of hesitancy were individuals’ fear of the vaccine and its impact on general health, unavailability of slots for vaccination and reluctance. Out of total, 58 (78.4%) people had faith in vaccines made in India and 48 (64.9%) persons believed that the vaccine would provide complete protection against COVID-19.
Conclusion: People were mainly concerned about safety issues as adequate and reliable information was not available to them. Some of them ignored the importance of vaccination, while some could not get vaccinated due to the unavailability of slots.
Coronavirus disease-2019, Disease prevention, Severe acute respiratory sydrome coronavirus 2, Vaccine acceptance
The novel coronavirus disease, Coronavirus Disease-2019 (COVID-19) has become the fifth documented pandemic since the 1918 flu pandemic (1). The COVID-19 disease originated from the Huanan Seafood Wholesale Market, Wuhan, Hubei province, China and the subsequent outbreak of pneumonia cases occurred in Wuhan City from late December 2019 (1). Since its emergence, it has spread to almost every country around the globe within a few months. World Health Organisation (WHO) declared the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection a pandemic on 11th March 2020 (2). Due to it’s contagiously and longer incubation period, a worldwide lockdown was initiated. The virus was targeting the lungs and likely bound with the angiotensin-converting enzyme 2 receptor, which is highly expressed in the nasal epithelial cell [3,4] and undergoes local replication and propagation, along with the infection of ciliated cells in the conducting airways. After that, it involves upper respiratory tract resulting in symptoms like fever, dry cough. But, COVID-19 has a wide range of clinical presentations, varying from asymptomatic carrier state to viral pneumonia in addition to various extrapulmonary manifestations including cardiac, nervous, renal, gastrointestinal and coagulation systems (5),(6),(7),(8),(9).
Amidst all the adversity, a race for a cure or a vaccine for the disease had already begun in different countries (10),(11),(12),(13),(14). This soon brought a couple of vaccines into the light that was clinically working. Although vaccination has been proved to be effective against several diseases in the past, ‘taking a jab’ was still voluntary. Amongst the rising tides of COVID-19 patients, the vaccination seemed to be the only protection one can have until a cure was discovered. However, vaccination was not accepted by different sections of society, while some saw it as unacceptable in terms of religious grounds, others were not sure if it was safe (10). A wide range of rumours and unscientific remedies have surfaced which caused more harm than any good. There had been promotions by anti-vaxxers on the different social platforms, who promoted against taking the vaccination (8). There has been a fair share of studies done regarding hesitancy in various countries (12),(13),(14) but instead of general population Indian studies involved specific groups like medical students (12). So, present study focused on personnel, who were not involved in medical profession any way.
Vaccination in India had begun on 16th January 2021. In the first phase, the vaccination programme for health workers and frontline workers; the second phase of vaccination started on 1st March and vaccines were made available for people of 60 years or above age and people having comorbidities of age 45 years and above. From 1st April, all people of age 45 and above were eligible for vaccination. In the third phase, vaccines were available for all adults (18+) from 1st May (15). The Government of India had increased the duration between the two doses of the available vaccines on the advice of the National Expert Group on Vaccine Administration for COVID-19 (NEGVAC) (16). On a much more recent note, the vaccination for 15-18 years old has begun on 3rd January 2022. In spite of prompt introduction of mass vaccination India with the world’s second-largest population (1.38 billion in 2020) is still struggling to reach a satisfactory level of vaccination (17).
The hesitancy among the general population of one of the most diverse and largest populations of the world needs to be known, understood and resolved at the earliest to prevent another global lockdown. Given the diversity of the peoples in India, the nature and causes of delay are expected to be versatile too. Thus, the present study embarks to find the causes of hesitancy to avail of vaccine in the eligible age group, a year after vaccines were introduced to the general population.
A cross-sectional study was conducted in the COVID-19 vaccination centre of Medical College Kolkata, West Bengal, India, from 14th January, 2022 to 14th April, 2022 for a duration of three months. The study was approved by the Institutional Ethics Committee (MC/KOL/IEC/NON-SPON/1257/01/2022 dated 13.01.2022). Written consent was taken from each participant after thoroughly explaining the study and its utility and complete confidentiality of their responses. No personal identification details were asked or taken from them. Those who could not read were explained orally in their mother tongue and then consent was taken in presence of a witness.
Inclusion criteria: Non medical (not related to healthcare work) people aged ≥18 years and who had come for 1st or 2nd dose of COVID-19 vaccination were included in the study.
Exclusion criteria: The people receiving the booster/precautionary dose, aged <18 years and people who refused to participate in the study were excluded from the study.
Sample size calculation: The sample size for the cross-sectional study was calculated using formula:
The prevalence of hesitancy was taken as 22.5% from previous study (14). The precision (L) was taken to be 10%. The results so obtained were 67. We calculated the final sample size by taking a 10% non response rate to get the sample size as 74.
Data were collected from the participants in a self-administered interview guide prepared by the investigators. Questions for hesitancy scale were framed and face and content validity was achieved with the help of experts from public health.
Internal consistency of the questionnaire as determined by Chronbach’s alpha was satisfactory (0.71). The questionnaire was translated in local languages (Hindi and Bengali) by linguist. Those who were illiterate and yet decided to participate in the study were asked to listen to the questions dictated by the investigators in their mother tongue as written in different sets of questionnaires of different languages. Care has been taken to explain the participants the exact meaning of the questions and reassuring that their opinion is completely confidential without influencing their answer in the slightest.
The ‘Hesitancy’ was determined from a set of nine questions using the Likert scale. The questions assessed individuals’ opinions but more specifically look into their trust level about each parameter of the COVID-19 vaccine, the parameters considered were efficacy, community benefit, time of arrival, safety, side-effects in the long-term or short-term, hindrances to day to day activity. These parameters were chosen by studying previous articles and the most prevailing causes of hesitancy were selected (12),(14),(18). The answers were scored from 1-to 5, ranging from ‘Strongly Disagree’ to ‘Strongly Agree’. The summation of the scores of all the nine questions was used as the final value to determine hesitancy. A minimum value of 36 was required to be obtained for the participant to be ‘non hesitant’. The minimum value was achievable only, if all the 9 questions were answered to “Agree” or atleast five questions “strongly agree” and rest “undecided”. All values below 36, were assumed to be hesitant in taking COVID-19 vaccines for the purpose of the present study only.
Demographic variables like age, gender, religion and educational status were included for comparison purpose. Which dose (1st or 2nd) the recipient is having is also considered as an independent variable. Apart from hesitancy questionnaire, one open ended question was also asked to understand the reason of delay in receiving vaccination. A person can state more than one reason for delay and similar responses were clubbed and listed finally.
The data were analysed using Statistical Package for Social Sciences version 20.0. Central dispersion measures were calculated for continuous variables. Demographic data were represented in frequency and percentage. The Chi-square test and risk estimation were done to find any significant association between demographic variables and hesitancy. Alpha error was taken at 5% level to consider one association significant. Binary logistic regression was done to confirm any predictability of occupation, literacy rate, age and gender on vaccine hesitancy.
The study participants comprised of 45 (60.8%) women and 29 (39.2%) men, aged between 18 to 60 years with the mean age being 33.75±11.06 years. Among the study population 27 (36.48%) of people had not completed secondary education. Only 14 (18.9%) of the people were graduates and above. Out of total, 22 (29.7%) of the participants had just taken their first dose of the COVID-19 vaccine and 26 (35.1%) of the recipients who had come for the vaccination were still hesitant (Table/Fig 1).
As per the nine item Likert scale for hesitancy, it was seen that mean score obtained was more then four (regarded as non hesitant) for five out of those nine items. It was lowest (3.66±0.96) for the agreement on the efficacy of foreign made vaccines. The study revealed that 35 (47.3%) of the participants had faith in vaccines of foreign origin while 58 (78.4%) believed vaccines made in India were more effective. (Table/Fig 2). The overall idea of the vaccine among the participants reveals that 48 (64.9%) of them believe that, it would provide complete protection against COVID-19.
No significant association were found between hesitancy and age (p-value=0.26), gender (p-value=0.55), educational qualification (p-value=0.34), religion (p-value=0.07) and dose taken (p-value=0.22) (Table/Fig 3).
Some of the most common causes of delay in vaccination were: the individual’s fear of the vaccine in 11 (14.9%) and its impact on general health in 22 (29.7%), unavailability of slots for vaccination in 14 (18.9%) and reluctance in 13 (17.7%). Whereas, 10 (13.5%) of the participants were concerned about the long-term side effects and 9 (12.2%) are completely unaware of any changes that the vaccine may or may not produce (Table/Fig 4).
The questionnaire containing nine questions, was considered to study the participants’ opinion regarding vaccine efficacy, community benefit, time of arrival, safety, side-effects in the long-term or short-term, hindrances to day to day activity. It is our understanding that if a subject lacks confidence in either of the above said parameters he is hesitant about the vaccine even if he takes the jab. The participant’s trust in the newly developed vaccine is stressed in this study and even a single doubt compromises their faith in the overall vaccine. India has the world’s second-largest population. Hence, the vaccine requirement for India is proportionately higher than any developed nation. The vaccines for SARS-CoV-2 were developed rapidly and were available in the market faster than any other vaccine in the past. However, while these vaccines were still in different phases of trials the developing nations could not risk buying them as the worldwide lockdown had struck them hard. In the meantime, the developed nation bought the lion’s share of the vaccines available in their testing phases itself. Thus 60-80% of developed nations’ citizens were vaccinated while countries like India, and Africa are still struggling to acquire and vaccinate their people (18),(19). One of the major reasons for delayed vaccination found in this study was the unavailability of slots for vaccination. A massive demand, and limited resources accompanied by poor distribution cause wastage of vaccines leading to an immense crisis of vaccines at centres (18),(19). This explains one of the reasons for the delay.
Vaccine safety has been a serious concern among people of all countries. The vaccines were being acquired even before they had completed all phases of the clinical trial. The virus was new and highly contagious with very little known about its pathophysiology. The entire disease and its treatment were vague to the general masses. The mass hysteria created more doubts than preventions. Side-effects of vaccines were one major reason for delayed vaccination and hesitancy as evident from the results. The doubt about the effectiveness of the vaccines was reflected across the world and is evident in several studies (20),(21),(22),(23),(24),(25). The present study showed that 12.2% of the participants are completely unaware or do not believe in the effectiveness of the vaccine and 13.5% were concerned about the long-term effects that the vaccine may produce. In the massive population of India, even small percentages account for millions of people, which in turn, reflects a significant number of concerned people all over the earth.
The present study participants comprise 60.8% females which was contrary to previous hesitancy studies done in India (24),(25). However, it is as par with recent studies done on dental students globally (26) and university students in Italy (25). In the present study, no significant association with any of the demographical factors such as age, sex, religion and education level was found. This is quite rare as other studies have shown significant association with economic status, gender or literacy rate (25),(27).
Vaccine safety and efficacy were the most common reasons for delay even though significant time had passed after the introduction of COVID-19 vaccines. Among the various reasons, reluctance occupied a significant portion. The participants claimed to have no reason for the delay, they just did not want to take a vaccine. Whether this hesitancy has a deeper cause like fear of needles is unexplored, however, a significant number of people are included in reluctance. Such reluctance is quite likely to make future battles against pandemics tougher. Unless there are some deep-lying roots to this reluctance, one may assume that it is sheer irresponsibility on their side. They are not only compromising themselves, but also their family and their community. A summarised comparison of findings of the present study and previous similar studies (19),(22),(23),(25),(27),(28),(29) are given in (Table/Fig 5).
Present study was a monocentric study, so comparison of the views of people from other regions could not be done. The present study reflected the hesitancy of only those people who arrived at the tertiary healthcare facility in Kolkata. It is important to compare, how similar or dissimilar the views of people attending tertiary care facilities in other regions (like North Bengal) to discover any new causes of hesitancy or any other issues like geographical barriers that may cause delays in vaccination. The hesitancy scale in present study works in an ‘all or none’ policy. Authors were unable to grade the levels of hesitancy, as it would require more elaborate questioning of the participants followed by addressing other scales of determining stress and trust levels. The people who came to the vaccination centre were mostly under a time crunch or were not the most co-operative people either.
The results of present study revealed that 29.7% of study subjects were receiving first dose of vaccine after more than eight months of initiation of vaccination program. This is alarming and points towards their hesitancy for receiving vaccine. As per the hesitancy score also, it was found about one-third of the subjects hesitant about this vaccine. Fear of the adverse events following vaccination, unavailability of slots due to mandatory online registration was stated to be main reasons of this delay. This study was hospital based and conducted on people attending the vaccination centre. Hence, large community based studies are recommended to discover any new causes of hesitancy or any other issues like geographical barriers that may cause delays in vaccination, including those who were more hesitant and not even attending the vaccination centre.
Date of Submission: May 05, 2022
Date of Peer Review: Jun 20, 2022
Date of Acceptance: Sep 16, 2022
Date of Publishing: Nov 01, 2022
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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