key: cord-0710024-4o8yu0z9
authors: Saied, Shimaa M.; Saied, Eman M.; Kabbash, Ibrahim Ali; Abdo, Sanaa Abd El‐Fatah
title: Vaccine hesitancy: Beliefs and barriers associated with COVID‐19 vaccination among Egyptian medical students
date: 2021-03-25
journal: J Med Virol
DOI: 10.1002/jmv.26910
sha: 1cbd007178b32ba93511cc94b24054a8715fd60e
doc_id: 710024
cord_uid: 4o8yu0z9

BACKGROUND: Vaccine hesitancy poses serious challenges for achieving coverage for population immunity. It is necessary to achieve high COVID‐19 vaccination acceptance rates and medical students’ coverage as future health care providers. The study aimed to explore the level of COVID‐19 vaccine hesitancy and determine the factors and barriers that may affect vaccination decision‐making. METHODS: A cross‐sectional study was carried out among medical students in Tanta and Kafrelsheikh Universities, Egypt. Data collection was done via an online questionnaire during January 2021 from 2133 students. RESULTS: The majority of the participant students (90.5%) perceived the importance of the COVID‐19 vaccine, 46% had vaccination hesitancy, and an equal percentage (6%) either definitely accepted or refused the vaccine. Most of the students had concerns regarding the vaccine's adverse effects (96.8%) and ineffectiveness (93.2%). The most confirmed barriers of COVID‐19 vaccination were deficient data regarding the vaccine's adverse effects (potential 74.17% and unknown 56.31%) and insufficient information regarding the vaccine itself (72.76%). CONCLUSION: The government, health authority decision‐makers, medical experts, and universities in Egypt need to work together and make efforts to reduce hesitancy and raise awareness about vaccinations, consequently improving the acceptance of COVID‐19 vaccines.

coverage rate is an essential factor that decides successful vaccination.

Vaccine development was typically taking years. So, the public acceptance for a new vaccine of COVID-19 developed within a short period remains uncertain despite the availability. 6, 7 Lessons learned from the previous pandemics of influenza when the vaccine was introduced, and the acceptance rate was variably low in many countries urges proper understanding of the vaccine hesitancy problem. [8] [9] [10] [11] The concept of "vaccine hesitancy" means to delay accepting or refusing vaccination although the vaccination services are made available, that is, no demand for offered and available vaccines. It is a continuum between those who accept vaccines without a doubt to complete refusal without a doubt. 12 Vaccine hesitancy affects the hesitant individual and, consequently, the whole community as a high coverage rate is necessary to confer herd immunity needed to flatten the epidemic curve. 13, 14 Vaccine hesitancy is multidimensional and specific to one's environment, fluctuating by time, setting, and vaccines themselves. It is prompted by factors like complacency, convenience, and confidence.

Complacency means the low perception of disease risk; hence, vaccination seems unnecessary. Confidence denotes trust in vaccination safety, effectiveness, and competence of healthcare systems. Convenience involves availability, affordability, and delivery of vaccines in a comfy context. 15 Several determinants modify vaccination decisions and determine whether to refuse, delay, or accept some or all vaccines. These include contextual influences that arise from historical, socioeconomic, cultural, ecological, health system/institutional, and political factors. 12 Concerns about the efficacy or safety, the country of manufacture of the vaccine, the antivaccine movements, and the belief of rushed vaccine development and production, besides rumors and misinformation, were important COVID-19 vaccination hesitancy causes. 16 There are also individual and group influences that arise from the personal perception of the vaccine, beliefs, or attitudes toward vaccination, such as perceived efficacy or benefits of vaccines, safety concerns or side effects, and social/peer environment. Besides, specific issues directly related to the vaccine or vaccination like the introduction of a new vaccine or formulation or a new recommendation for a current vaccine, method of administration, development of the vaccination program, reliability and/or source of supply, schedule, cost, the strength of recommendations, knowledge base and/or attitude. Numerous vaccination studies have documented an association between some of these factors and the acceptance of the COVID-19 vaccine. [17] [18] [19] World Health Organization considers vaccine hesitancy as a significant threat to global health. Reported COVID-19 vaccine acceptance rates varied worldwide, 19 but a recent global report on COVID-19 vaccine acceptance illustrated that nearly 30% of the investigated participants would refuse or hesitate to take a COVID-19 vaccine when it is available. 20 The Middle East is among the regions with the lowest rates of vaccine acceptance globally. 19 As the vaccine development process progresses, it is crucial to boost the acceptance of the new vaccines. Developing effective COVID-19 vaccination strategies necessitate a proper understanding of the factors that would impact the decision of vaccination as these factors may change for individuals who accept and be determined to take the vaccine from those who do not. 21 The Egyptian Drug Authority (EDA) has approved the Sinopharm Chinese vaccine as the first primary one. In January, Egypt began its vaccination program, starting with medical teams in quarantine hospitals to be at the top of the vaccination priority categories, then medical teams, and set up a public immunization website for registration to start with high-risk groups. Late in January, Egypt obtained the second batch of AstraZeneca vaccine as part of the COVID-19

Vaccines Global Access (COVAX) Facility. 22 Most of the studies were conducted among healthcare providers or the general population, and limited literature has examined these factors in other risky groups of COVID-19. Young adults, specifically college students, are at risk of being infected with COVID-19 and transmitting the infection to others owing to the sense of invulnerability. 24 Experience with the ongoing pandemic has demonstrated medical students' ability to volunteer in health care assistant positions that can be of real help to healthcare systems during times of emergency. 25 A recent study was conducted to describe the existing profile of potential COVID-19 vaccine acceptance among Egyptian health care providers (medical students constituted 39.8% of participants), reported that 45.9% accept to receive the vaccine (only 13.5% totally accept the vaccine, and 32.4% were hesitant but somewhat agree) and 40.9% refused to take the vaccine. They concluded that the intention to accept COVID-19 vaccination among Egyptian health care workers (HCWs) is lower than in western countries but better than the African ones. Vaccine hesitancy in Egyptian HCWs could be a significant obstacle influencing the COVID-19 acceptance decision. 26 As medical students are likely to be exposed to COVID-19 patients, achieving high vaccination coverage rates for COVID-19 in this group is mandatory as soon as the vaccine is widely available as they can be used as vaccination role models for the public. They are the future health care providers and the notable influencers for people and their communities.

Besides, they will be responsible for making recommendations for vaccination and providing guidance to vaccine-positive patients. Given that limited research has addressed COVID-19 vaccine acceptance among medical students, the current study was formulated targeting medical students of Tanta and Kafrelsheikh Universities in Egypt to explore the level of COVID-19 vaccine hesitancy and to determine the factors and barriers that may affect their vaccination decision making.

A cross-sectional study was conducted during January 2021 in Tanta and Kafrelsheikh Universities, two central public universities in the Delta region that recruit students from lower Egyptian governorates. Our target population was medical students at both universities (a total of 27715 students). 27 distributed through faculties of Medicine, Pharmacy, Dentistry, Nursing, and Physiotherapy. The Egyptian medical educational system varies according to the college's type; the faculty of medicine consisted of 6 years of university education, followed by one year of internship, and was modified in 2019 to be five years, followed by two internships. Dentistry education consists of five years, followed by 1 year of internships which is the same in the pharmacy but without training.

The nursing and physiotherapy faculties comprised four years of education, followed by one year of internship. The students' groups are freshmen in 1st year, sophomores in 2nd year, juniors in 3rd and seniors in 4th, 5th, or 6th years-according to the college type-and graduates in the internship. 

The questionnaire was designed and pretested by the researchers after an extensive literature review. 24, [28] [29] [30] It addressed the following data: 

Data were extracted from the form to Excel sheet and statistically analyzed using IBM SPSS software version 26. Qualitative data were presented as frequencies and percentages, and a chi-square test was used for analysis. Quantitative variables were presented as mean and standard deviation, and ANOVA was used for analysis. Multivariate logistic regression was applied to predict factors affecting vaccine acceptance among respondents. The adopted significance level is p < .05.

Research ethical approval from the Tanta Faculty of Medicine Research Ethical Committee (REC) was obtained (code:34400/1/21).

An informative statement was added at the beginning of the anonymous online questionnaire, and the participants were provided with informed consent to be digitally signed before starting the survey.

Confidentiality and privacy of data were guaranteed during the study, and the collected personal information was stored in secure folders that could only be accessed by the researchers and protected from any unauthorized access.

The study included 2133 participants from five medical colleges in Tanta and Kafrelsheikh universities; their mean age was 20.24 ± 1. 

Near half (46%) of respondents showed hesitancy, and 6% either accepted the vaccine or refused it definitely ( Figure 1A ). Despite the reported hesitancy, most respondents (71%) intend to receive the vaccine but will postpone this for a while, and only 13% intend to receive it as soon as possible ( Figure 1B and newspapers were the least ( Figure 1D ). 

The preferred Pfizer-BionNTech one. Table 4 illustrates that being a pharmacy student, higher academic

year and graduates, average to very good self-perception of own health status, good self-rated COVID-19 knowledge level, and presence of confirmed COVID-19 infection in close social network were the significant predictors of COVID-19 vaccine acceptance among studied medical students (p < .05).

Vaccine hesitancy is a limiting step in global attempts to control the current pandemic with its adverse health and socioeconomic consequences. Understanding the student's attitude upon the COVID-19 vaccine and raising their acceptance is essential in planning an appropriate post-pandemic strategy. 31 In the present study, 35% of the students accepted the COVID-19 vaccination, 46% were hesitant, and 19% refused ( Figure 1A) . A lower percentage of hesitancy (32.4%) and a higher level of acceptance (45.9%) were reported among some Egyptian

HCWs. 26 The difference may be attributed to the higher age of health care staff (older participants seem to accept more) and the prevalence of co-morbidities or chronic diseases among them. Tam and on the other side, 13.9% of them reported no intention. However, the estimated intention to vaccinate is higher among medical students due to higher literacy on health-related issues. 33 Considerably high level (47.1%) of vaccine hesitancy was found among the senior students (Table 2 ). Seniors could help control the current pandemic in multiple ways and be prepared for future waves or peaks. Medical schools in some countries as the United States and England prepare students to help medical teams 34 efficiently, so they should be protected and vaccinated as vaccination of healthcare staff and students is a crucial measure in preventing health-related infections resulting from close interaction with high-risk patients. 29 The high level of vaccine hesitancy among the students was surprisingly associated with a similarly high level of perception of elevated risk of getting COVID-19 infection ( Figure 1C ). Similarly, Barello et al. 2020 concluded that the vaccination attitude is affected by students' In this study, most participants reported having concerns regarding vaccine effectiveness, safety, and adverse effects ( Table 2 & 3). Similar concerns were reported among Egyptian HCWs. 26 These findings may explain that although the students perceive the importance of the COVID-19 vaccine and agree to make the vaccination mandatory, they still have a significant hesitancy due to a lack of certainty on the safety of vaccinations and unknown potential adverse effects, in addition to misinformation from social media as a source of their knowledge. In This study, "Fear of being infected or infecting family with, especially parents" was highly reported among COVID-19 vaccination motivators (Table 3) . This finding is supported by Brewer et al. 38 who reported that anticipated regret for lack of action (i.e., not getting a vaccination and being infected and/or infecting loved ones)

is correlated with a higher likelihood of vaccination. However, a study on Saudi HCWs' willingness for COVID-19 vaccination concluded that the level of concern regarding contracting COVID-19

and infecting household members did not correlate significantly with their likelihood of being vaccinated. 39 In this study, the main vaccination barriers were insufficient information regarding the vaccine and its potential adverse effects, Gautam et al. 41 checked the responder's affordability and concluded that most responders wish a cheap or a free vaccine from the government. Vaccine cost and effectiveness appear as essential factors to accept vaccination. 42 A study on South Carolina college students reported vaccination costs as one factor that directly affects the students' vaccination behaviors. 23 Some of the vaccination barriers and beliefs in the present study were false and related to the students' misinformation as genetic effects, acquisition of COVID-19 from the vaccine, and nanochips' implantation (Tables 3 and 4) , and this could be attributed to lack of information concerning COVID-19 vaccination in their current curricula, so future inclusion of such topic into medical education could help them to evaluate the risks and benefits of vaccination. The World

Health Organization warned that the world is fighting another kind of epidemic called "infodemic" that rapidly spreads fake news, misleading information, and false scientific claims. 43 Lessons learned from past outbreaks of SARS, H1N1, and Ebola illustrated the essential role of health information in disease prevention and vaccine acceptance. 44 College students use various sources to know about COVID-19

vaccines, including health authorities, personal networks, and social media. 30 Hesitancy is exacerbated by social media, conspiracy theories, and misinformation. 45 The study participants' reported social media, scientific websites, then health care providers as the most extensive sources to obtain their COVID-19 and vaccine information ( Figure 1D ). Vaccination decision-making is often affected by social networks' impacts, including family members, colleagues, and healthcare professionals. 38 Harapan et al. 46 Most participants did not know the available types of COVID-19

vaccines, so they do not have a preferred one ( Figure 2 ). However, 46 .2% of Egyptian HCWs reported preferring (Pfizer-BioNTech) vaccine due to trust in this brand and the transparency of their vaccine details and information presented to the public. 26 The type of vaccine may affect the individual's attitudes toward vaccination, though Pogue et al. 51 found that the vaccine type did not make a difference to the respondents, as they detected no significant difference in comfort to vaccination.

This is the first study of vaccine hesitancy among university students-particularly medical students-in Egypt. This study highlighted the following:

▪ The COIVD-19 vaccine acceptance was only 35%, with considerably high hesitancy and refusal. Notably, the baseline acceptance for vaccination is not high enough in many countries, and the public confidence in vaccination is still weak.

▪ COIVD-19 vaccine acceptance's key barriers were concerns regarding safety, efficacy, and potential adverse effects, consistent with studies in other countries among different population groups. uncontrolled spread of fake news and misinformation, leading to infodemic.

Since 

The current study sample was from medical colleges in only two universities and done on only medically-oriented students, which may affect generalizability to other college populations elsewhere.

The online reaching of the participants within a short time. Respondents may also have been predominantly affected by media attention to the COVID-19 vaccine, as this topic has not been formally integrated into their curricula.

Authors declare no known competing conflicts of interest.

All authors contributed significantly to this study. Conceptualization and proposal writing was done by SS, IK, and SA. SS and ES supervised data collection. SS and SA managed the data and wrote the manuscript. All authors have read and approved the manuscript.

The peer review history for this article is available at https://publons. com/publon/10.1002/jmv.26910

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Shimaa M. Saied http://orcid.org/0000-0002-0189-1795

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Vaccine hesitancy: Beliefs and barriers associated with COVID-19 vaccination among Egyptian medical students