Motivational Factors and Post Vaccination Symptoms among COVID-19 Vaccinated Beneficiaries at a Tertiary Care Hospital, West Bengal, India: A Cross-sectional Study
Correspondence Address :
Dr. Maumita De,
32/1 B, Garpar Road, Post Office: Amherst Street,
Kolkata-700009, West Bengal, India.
Introduction: Since the emergence of Coronavirus Disease 2019 (COVID-19) pandemic, there has been an intense burden on the health system and economy worldwide with millions of people being affected leading to several deaths. In this scenario vaccination seems to be a hope to control the pandemic. However, fear of adverse events following immunisation sometimes makes people hesitant about vaccination.
Aim: To assess the spectrum of post vaccination symptoms and also to identify the motivational factors along with their determinants at a tertiary care hospital, West Bengal, India.
Materials and Methods: A cross-sectional study was conducted in the COVID-19 Vaccination Centre at Nil Ratan Sircar Medical College and Hospital, Kolkata West Bengal, India (tertiary care hospital), from August 2021 to November 2021. A total of 448 vaccinated beneficiaries were enrolled in the study. Data collection was done by an online questionnaire, sent to the participants in their registered mobile numbers. Descriptive statistics and Chi-square tests were used for data analysis.
Results: Among 448 study participants, 262 (58.5%) were in 18-44 years of age group, 248(55.4%) female, 384 (85.7%) Hindu, 132 (29.5%) medical or paramedical students, 290 (64.7%) passed graduation and above and 306 (68.3%) belonged to nuclear family. About 228 (50.9%) beneficiaries reported post vaccination symptoms. Most common being local pain at injection site, found among 150 (65.8%) out of them. Most common motivational factors of COVID-19 vaccination were found to be fear of COVID-19 infection, reported by 274 (61.2%) participants, which showed significant difference with various age groups (p-value=0.001), religions (p-value=0.030), occupations (p-value<0.001) and educations (p-value=0.002). Statistical significant (p<0.05) differences were also found according to age, gender, co-morbidities, interval between vaccination and past COVID-19 infection and type of COVID-19 vaccine in relation to onset of post vaccination symptoms.
Conclusion: Following COVID-19 immunisation minor adverse events were reported. Monitoring of those adverse events will help in further responding and prompt action. Also, the knowledge about motivational factors is expected to reduce vaccine hesitancy among unvaccinated people.
Adverse events, Coronavirus Disease 2019, Immunisation, Pandemic
The current pandemic due to Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2), known as COVID-19,, has emerged as a catastrophe, putting immense pressure on the health and economic system worldwide (1),(2). In this scenario, effective vaccine seemed to offer the only hope (2),(3),(4).
In India, three vaccines, Covishield, Covaxin and Sputnik V, have got approval from the Drug Controller General of India (5). The vaccine schedule was two doses for each vaccine. Nationwide vaccination programme started on 16th January 2021 with healthcare workers being the first group of beneficiaries to receive the vaccine. It was gradually expanded to include the frontline workers, senior citizens and eventually to all adults (18 years and above) (5).
One of the greatest challenges of this vaccination programme was the acceptance of the vaccine by the general population. Undue fear of any adverse events and confusion about the efficacy of the vaccines were identified as the main determining factors for successful vaccination programme (6),(7),(9). Several studies based on the ‘health belief model’ and ‘protection motivation theory’ has revealed some factors affecting the vaccine acceptance viz. perception of risk due to the disease, safety, efficacy, cost of the vaccine, past history of vaccination, physician’s recommendation and the attitude and socio-demographic characteristics of the population (10),(11),(12),(13),(14).
Though vaccines are an important tool in public health, helping in prevention and control of several diseases, vaccination may lead to reactions like other drugs (3). Though, these reactions are mostly non severe, it interferes with a person’s confidence in vaccines. Various factors like awareness regarding vaccines, religious and socio-political issues, fear of associated risks and socio-economic factors may alter the attitude of an individual towards vaccination (15),(16),(17).
Several studies have been conducted to find the factors affecting willingness to get vaccinated, but most of them were community based studies (17),(18). Since this study was conducted among the beneficiaries vaccinated at a COVID-19 Vaccination Centre, it will help us to assess the motivating factors for vaccination and its determinants. This may help in raising public awareness. Fear of side effects is one of the important causes of vaccine hesitancy. Thus, knowledge regarding the post vaccination symptoms will help to educate the people regarding the adverse effects, which will help to allay the fear and increase the acceptance of COVID-19 vaccine, which may ultimately lead to increased coverage and curb the pandemic.
Hence, the following study was conducted to find out the Post Vaccination Symptoms (PVS) and to assess the motivational factors of COVID-19 vaccination among the beneficiaries attending the COVID-19 Vaccination Centre (CVC) of a tertiary care hospital in West Bengal, India.
A cross-sectional study was conducted in the COVID-19 Vaccination Centre at Nil Ratan Sircar Medical College and Hospital, Kolkata West Bengal, India (tertiary care hospital), from August 2021 to November 2021. After receiving Institutional Ethics Committee approval (Vide Memo No: NRSMC/IEC/04/2021, Dated: 20.07.2021), permission was sought for obtaining informed verbal consent from the participants considering the feasibility issues, since online questionnaire was sent. The participants were assured of their anonymity and confidentiality of the given information.
Inclusion criteria: The beneficiaries, who attended the COVID-19 Vaccination Centre and were vaccinated with atleast one dose of any COVID-19 vaccine were included in the study.
Exclusion criteria: Vaccinated person who were severely ill and also the beneficiaries or any of their family members who were unable to read, type and understand in English and also incompletely filled up the Google form were excluded from the study.
Sample size: Based on a study finding by Kamal D et al., 57% of recipients reported atleast one or more adverse events following COVID-19 immunisation, anticipated P was 57% (19). Assuming confidence level of 95% and absolute precision of 5%, the minimum required sample size was calculated as 392. Considering 10% non response rate, the minimum required sample size was 432. Beneficiaries attending the vaccination centre on any single day of the week were selected randomly. Considering average turnover to be 280 beneficiaries per day, the beneficiaries were selected by systematic random sampling and every 10th beneficiary was chosen. Hence, a sample size of 448 beneficiaries, who have filled up the questionnaires completely, was selected for final study.
A survey questionnaire was prepared by the authors initially after review of literature related to adverse events of COVID-19 vaccine (19),(20),(21) and motivational factors for COVID-19 vaccination (17). Content validity and face validity of this study tool was checked by the experts from Departments of Community Medicine, General Medicine and Respiratory Medicine. Reliability of the study questionnaire was assessed and Cronbach’s alpha value measured was 0.74. This pretested and predesigned questionnaire by means of online Google form was sent to the participants in their registered mobile numbers. The questionnaire consisted of five parts.
• First part: It consisted of six questions on socio-demographic variables
Type of family
• Second part: It included three questions related to clinical history of the patient:
Past history of COVID-19 infection
• Third part: It contained three questions on COVID-19 vaccination history:
Type of COVID-19 vaccine (Covishield or Covaxin, because these two vaccines were only available in the study Institution during data collection period),
Number of doses taken,
Interval between vaccination and
Past COVID-19 infection (if any).
• Fourth part: It included four questions pertaining to details of the post vaccination symptoms (if any), their onset of development and duration of symptoms.
• Fifth part: It incorporated question on motivational factors for vaccination, where 12 options like fear of disease or hospitalisation, availability of vaccine at free of cost, social media effect, self motivation, others etc. were given for ‘yes’ or ‘no’ subjective responses.
All collected data were compiled and analysed by MS Excel 16.0 and Epi info 7.2.4. Results were presented in proportions (%) and Chi-square test of significance was applied. The significance level was fixed as p-value <0.05.
In the present study, most of the participants like 262 (58.5%) were in 18-44 years of age group, 248 (55.4%) female, 384 (85.7%) were Hindu by religion. Among the vaccinated population maximum i.e. 132 (29.5%) were medical or paramedical students, 290 (64.7%) passed graduation and above and 306 (68.3%) belonged to nuclear family (Table/Fig 1).
A total 138 (30.8%) out of 448 study population were suffering from associated co-morbidities, whereas 10 (2.2%) people did not know about their disease status. Common co-morbidity was found to be hypertension 64 (14.3%) followed by diabetes 40 (8.9%), thyroid disease 26 (5.8%), heart disease 14 (3.1%), lung disease 8 (1.8%), renal disease and neurological disease 4 (0.9% each) (Table/Fig 2). Among 138 diseased subjects 116 (84.1%) were taking regular medications. Seventy two out of 448 (16.1%) of the participants had suffered from COVID-19 infections in the past before vaccination.
Among 448 participants 114 (25.4%) has taken Covaxin and 334 (74.6%) taken Covishield. Among all vaccinated persons 382 (85.3%) have completed second dose of vaccination. Out of 72 participants with past history of COVID-19 infections, most of them 60 (83.3%) have taken vaccines after 3 months of COVID-19 infection (Table/Fig 3).
It has been found that 228 (50.9%) out of 448 study population reported any post vaccination symptom. Most common symptom was found to be local pain at injection site 150 (65.8%) followed by tiredness or lethargy 10244.7%). Least common Post Vaccination Symptoms (PVS) reported to be breathing problem and painful swollen gland 2 (0.8% each) (Table/Fig 4). Most of the vaccinated patients like 178 (39.7%) developed PVS within 2 days of vaccination. As reported by the participants, most like 161 (35.9%) among them suffered from PVS for 1-3 days (Table/Fig 5).
Most common motivational factors of COVID-19 vaccination were found to be fear of COVID-19 infection 274 (61.2%), availability of vaccine at free of cost 153 (34.2%), self-motivated 140(31.3%) and fear of hospitalisation 120 (26.8%) (Table/Fig 6).
Factors related to Post Vaccination Symptoms (PVS): It has been found that onset of PVS among study population differ significantly (p-value<0.05) according to their age (p-value<0.001), gender (p-value=0.019), co-morbidities (p-value=0.014), interval between COVID-19 vaccination and past COVID-19 infection (p-value=0.006) and type of COVID-19 vaccine (p-value=0.010) (Table/Fig 7).
There is statistically significant difference (p-value <0.05) found in relation to duration of PVS with interval between COVID-19 vaccination and past COVID-19 infection (p-value <0.001) and also with type of COVID-19 vaccine (p-value=0.014) (Table/Fig 8).
Some background characteristics like age group, gender, religion, occupation, education and co-morbidities were statistically tested against most common four motivational factors and the results have been depicted in (Table/Fig 9). Only yes responses (%) regarding motivational factors are mentioned in the Table. It has been seen that fear of COVID-19 infection significantly different (p-value <0.05) among different age groups (p-value=0.001), religions (p=0.030), occupations (p-value <0.001) and educations (p-value=0.002). There was statistically significant difference found in relation to fear of hospitalisation with gender (p-value=0.025), occupation (p-value <0.001) and education (p-value=0.021). COVID-19 vaccination due to self-motivation varied significantly in relation to participants’ age group (p-value <0.001), gender (p-value <0.001), religions (p-value=0.039), occupations (p-value <0.001), educations (p-value=0.002) and comorbidities (p-value=0.001) also. While considering availability of COVID-19 vaccine at free of cost, it is significantly different according to age group (p-value <0.001), gender (p-value=0.019), occupation (p-value=0.044) and education (p-value <0.001).
Other eight motivational factors also statistically tested against above mentioned background characteristics and the test results are mentioned in (Table/Fig 10). It has been found that motivation due to easy vaccine availability significantly vary according to occupation (p-value <0.001) and education (p-value=0.046). People with different age group (p-value<0.001), gender (p-value <0.001), religion (p-value=0.005), occupation (p-value<0.001) and education (p-value=0.019) significantly motivated for COVID-19 vaccination on family history of hospitalisation or death due to COVID-19. Influence of family or friends to get vaccinated found to be significantly different according to age (p-value<0.001), education (p-value<0.001) and co-morbidities (p-value=0.001). There was significant variation in age (p-value=0.012) and occupation (p-value<0.001) due to motivation by family physician’s advice. It has been found that fear of death varied significantly according to age group (p-value=0.026), gender (p-value=0.006), occupation (p-value=0.002) and presence of comorbidities (p-value=0.023). Participants with varied occupation (p-value<0.001) and education (p-value=0.010) significantly motivated due to trust on healthcare providers. Social media could motivate significantly for vaccination only due to presence of co-morbidities (p-value<0.001). No participants got significantly motivated by community health workers.
In this study about 16% of the participants suffered from past COVID-19 infections and majority (83.3%) of them took vaccines after 3 months of infections. Similarly a study performed in Czech Republic stated that 19.3% vaccinated individuals had been previously infected by COVID-19, but the median latency period between the recovery date and the first vaccine dose was 65 days (22).
In the present study, Covishield was taken by 75% of the people compared to 25% taken Covaxin. It may be due to more supply of this particular vaccine in West Bengal state of India. Comparison between proportion and distribution of post vaccination symptoms of the present study with the contrast studies are incorporated in (Table/Fig 11) (3),(19),(20),(21).
About 39.7% of the vaccinated beneficiaries developed PVS within 2 days of vaccination. Parallel findings were reported by Kamal D et al., (19). In the present study most (35.9%) of the participants suffered from PVS for 1-3 days and only 0.9% for more than 7 days. Almost similar findings suggested by Riad A et al., regarding the duration of side-effects (22).
After review of literature (19),(22),(23) the socio-demographic factors like age, gender, co-morbidities were found relevant with PVS, hence these factors were checked for significance level with PVS. Again no such references were found indicating PVS varied according to other socio-demographic variables like religion, occupation, education and type of family. In present study the onset of PVS among participants differ significantly (p-value <0.05) according to their age, gender, co-morbidities, interval between COVID-19 vaccination and past COVID-19 infection and type of COVID-19 vaccine. The onset of PVS in another study among healthcare workers was inversely correlated with the age group (r-value=-0.202; p-value=0.033), and directly correlated with the total number of non communicable diseases (r-value=0.018; p-value=0.914) (22).
Although, the biological mechanism for the higher incidence of PVS among female is not clear, it may be related to genes, hormones, environmental and immunologic factors (23). However, no peer reviewed published data has been found declaring the association of PVS with type of COVID-19 vaccine. This study could not find statistical significance according to age and co-morbidities with duration of PVS. But in another study, the duration of side-effects was significantly and directly correlated with age (r-value=0.097; p-value=0.006), the number of medical treatments (r-value=0.122; p-value<0.05) and the number of side-effects (r-value=0.256; p-value<0.001) (22).
Since, this study was a hospital based study among people attending to get vaccinated, vaccine acceptance was 100%. Higher and lower levels of acceptance were found across the different countries which have been tabulated in (Table/Fig 12) (24),(25),(26),(27),(28),(29),(30).
The most common motivational factors of vaccination in this study were fear of COVID-19 infection (61.2%), availability of vaccine at free of cost (34.2%), self-motivation (31.3%) and fear of hospitalisation (26.8%). World Health Organization (WHO) report has identified almost similar factors for COVID-19 immunisation (31). Another research by Kalam MA et al., also corroborated with this findings of the present study (32).
The present study found that motivational factors significantly vary (p-value <0.05) among different age, gender, religions, occupations, educations and persons with comorbidities. A study conducted by Jacob et al in India revealed that willingness for COVID-19 vaccination was strongly associated (p-value <0.01) with income, past COVID-19 infection, perceived risk of COVID-19 infection, trust in authority, cost of vaccine and safety of vaccine (33). The socio-demographic factors were also found significant for pandemic vaccine acceptability in Bangladesh (34), the US (35), and Japan (36).
The major strength of this study was, it reflected the vaccinated individuals with different socio-demographic variables in West Bengal, India. It also tried to explore the factors influencing onset and duration of post vaccination symptoms, which can help further to identify the priority groups needed special attention at vaccination centres and also to advise the vaccinated people beforehand to allay their fear of side-effects.
One of the few limitations of this study was being a hospital based study it included only the vaccinated individuals. Thus, the true proportion of vaccine acceptance could not be assessed. Another methodological limitation was use of online questionnaire, which may cause self-selection bias due to filling up only by the highly motivated participants. The self reporting of collected data may introduce information bias.
Most of the adverse events following COVID-19 immunisation were reported to be mild and self-limited and predominantly duration of symptom was shorter within 72 hours. This message should be percolated to reduce the worries about unforeseen side-effects of COVID-19 vaccine. While the higher motivational factors were found to be the fear of COVID-19 infection or self-motivation, messages from social media or community health workers were negligible. So, these modes of communications must be enhanced and directed to all community people to prevent spread of misinformation. Due to the hospital setting of the study the vaccine acceptance was full. But a community based study is highly recommended to explore the reasons of vaccine hesitancy; which ultimately improves the COVID-19 vaccination drives in India in large.
Authors would like to express our heartfelt gratitude to the hospital authorities for their kind support during the research work. Authors are thankful to the participants for their patience and co-operation to complete the online questionnaire.
Date of Submission: May 06, 2022
Date of Peer Review: Jun 18, 2022
Date of Acceptance: Aug 08, 2022
Date of Publishing: Oct 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. No
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• Plagiarism X-checker: May 11, 2022
• Manual Googling: Aug 02, 2022
• iThenticate Software: Aug 05, 2022 (9%)
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