key: cord-0822269-oib3jjvl
authors: Simanjorang, Chandrayani; Pangandaheng, Nansy; Tinungki, Yeanneke; Medea, Gitalia Putri
title: The determinants of SARS-CoV-2 vaccine hesitancy in a rural area of an Indonesia-Philippines border island: A mixed-method study()
date: 2022-03-23
journal: Enferm Clin (Engl Ed)
DOI: 10.1016/j.enfcle.2022.03.002
sha: 3ec3826e1cf44bb7271f4c8f3942801299ccc7b7
doc_id: 822269
cord_uid: oib3jjvl

BACKGROUND: The SARS-CoV-2 vaccination program campaign has been underway in Indonesia for people aged ≥18 years. The program’s success can be hampered by vaccine hesitancy in communities. This study aims to elucidate the determinants of SARS-CoV-2 vaccine hesitancy in a rural area of the Indonesia-Philippines border island Sangihe. METHODS: A mixed-methods study was conducted; a quantitative part involving a cross-sectional survey was carried out among participantes aged ≥18 years to determine the prevalence and determinants of SARS-CoV-2 vaccine hesitancy. The qualitative part involved in-depth interviews to explore the perceptions towards the SARS-CoV-2 vaccine. RESULT: Among 557 participantes, the prevalence of vaccine hesitancy was 63.9% (95% CI: 59.8-67.9). In the adjusted analysis, three factors affected vaccine hesitancy: education (aOR: 0.40; 95% CI: 0.22-0.70), knowledge of the SARS-CoV-2 vaccine (aOR: 2.17; 95% CI: 1.41-3.34) and willingness to pay (aOR: 0.12; 95% CI: 0.07-0.20). The majority of reasons for refusing the vaccine included doubt regarding its safety and effectiveness, the fear of side effects, lack of information regarding the vaccine and local Christians’ religious beliefs. CONCLUSION: This study found that most adults in the area were hesitant about the SARS-CoV-2 vaccine. Lack of knowledge, a low level of education and misinformation were factors that greatly affected vaccination hesitancy. The government, by involving religious leaders, is expected to pay serious attention to the dissemination of accurate and convincing information to the public regarding the safety and importance of the SARS-CoV-2 vaccine.

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, is still a Public Health Emergency of International Concern (PHEIC). The Indonesian government has been attempting to control the spread of infection by providing vaccines. 1 The data as of July 5 th 2021 showed 3,197 M doses of COVID-19 vaccines have been administered across 215 countries (including Indonesia), areas, territories and economies. 2 In Indonesia, the goal is to vaccinate 181 million Indonesians to achieve herd immunity in populations 18 years and over. 3 The targeted immunization rate can be hampered by the presence of vaccine hesitancy among communities. Vaccine hesitancy is the delay in vaccine acceptance or refusal of vaccination despite the availability of vaccination services. 4 Vaccine hesitancy is a worldwide phenomenon. A cross-sectional study on COVID-19 vaccine hesitancy among caregivers from the USA, Canada, Israel, Spain, Japan and Switzerland showed its prevalence to be 35% (95% CI =32-37). 5 In concordance, the prevalence of Measles Rubella (MR) vaccine hesitancy varied from 14.1% in India to 33% in Indonesia. 6, 7 A recent study in urban area of Indonesia, also found a 35,2% of vaccine hesitancy. 8 However, the results of these studies cannot represent rural areas in Indonesia.

There has been limited research on the determinants and prevalence of vaccine hesitancy in rural areas using a mixed method. Sangihe Island is one of the outer islands of Indonesia, which is directly adjacent to the Philippines. As an island that constitutes mostly rural areas, it must be prioritised in handling the pandemic due to various limitations, including limited access to health services, limited information and a middle-average income (IDR 2.69 million per person per month). 9 Meanwhile, the number of COVID cases in North Sulawesi reached 15,670, of which 313 were in the Sangihe Island. 10 Therefore, this study aims to comprehensively determine the prevalence and determinants of the SARS-CoV-2 vaccine hesitancy. The results of this study can inform governments' and decision makers' policies regarding the SARS-CoV-2 infection vaccination program in Indonesia, which is an archipelagic country, and other countries in Southeast Asia that have the same characteristics.

This study uses a sequential explanatory mixed-method approach, which is a method that combines quantitative and qualitative data where the qualitative data aims to expand and deepen the results of the quantitative data. 11,12 Quantitative data were collected using cross-sectional data collection. Meanwhile, qualitative data were collected through in-depth interviews to explore information about people's perceptions of the SARS-CoV-2 vaccine.

The study was conducted on an Indonesian-Philippines border island called the Sangihe Island of North Sulawesi. Residents mostly live in rural areas. This island is a district with 15 sub-districts that has a population of approximately 130,000 people. There are two public hospitals, and the referral hospital is a provincial-level hospital 10 hours away by motorboat. At the time of the study, a vaccination program for health workers followed by educators and the general population was in progress.

Quantitative data collection targets were adult residents (aged ≥ 18 years) of Sangihe Island, and the samples were recruited from across the 15 sub-districts. Those who worked in health sectors were excluded from this study. Quantitative data collection was conducted from 16 February J o u r n a l P r e -p r o o f 2021 to 28 February 2021. The study was conducted after the Sinovac vaccine was available in Indonesia, which showed an efficacy of 65.3%. 13 The sample calculation used a sample size formula for estimating proportion, namely n= Z 1-α/2 P(1-P)/d, 2.14 where the P-value is the proportion of vaccine acceptance from previous studies in Indonesia, namely 64.8% (P = 0.65). The value of d (acceptable standard deviation) was 5% (d = 0.05), and a 95% confidence degree (Zα = 1.96) showed the total value of N = 350 samples. To adjust for the sampling method, a design effect of 1.5 was used, and the final sample size was 525. Snowball sampling was used for quantitative sampling. Priority for participation was given to the population in sub-districts geographically spread out and easy to reach.

In the qualitative phase, we interviewed at least 30 adult citizens from five sub-districts. The samples (participants) were selected using a purposive sampling technique. The research instrument was the researcher himself who used an interview guide. The questions in the interview guide aimed to find out the public's perceptions regarding the SARS-CoV-2 vaccine and the reasons why they accepted/rejected the vaccination. Qualitative data collection was conducted from 1 March 2021 to 14 March 2021.

To assess respondents' perceptions of the SARS-CoV-2 vaccine, respondents were asked questions about their willingness to be vaccinated. The answers 'hesitate/refuse' or 'accept' and the reason if the answer was 'hesitate/refuse' were gathered. Several explanatory variables were also collected through questionnaires. Specifically, these were socio-demographic variables, such as age, gender, education, occupation, religion, marital status, source of information on the vaccine, income, willingness to pay and economic status. Economic status was categorised as 'poor' for those living below the national poverty line, or around IDR 354,000 per person per month; as 'vulnerable' for those living above the poverty line but with a non-negligible risk of falling into poverty, or between IDR 354,000 and IDR 532,000 per person per month; as 'aspiring middle class' for those no longer living in poverty or vulnerability but who are not yet economically secure, or between IDR 532,000 and IDR 1.2 million per person per month and 'middle/upper class' for economically secure Indonesians with little chance of falling into poverty or vulnerability, or more than IDR 1.2 million per person per month.

Another variable is the knowledge variable related to the SARS-CoV-2 vaccine, which was assessed using 15 questions. Participants with 60% or more correct answers were categorised as having 'good knowledge', and participants with fewer than 60% correct answers were categorised as having 'poor knowledge'.

The quantitative research instrument used was a questionnaire taken from previous research and validated. 8 The enumerator distributed questionnaires to the first group of participants via social media, a WhatsApp group and email. Next, the first group was asked to distribute the link of questionnaires to the second group and so on. Once a participant opened the questionnaire link, they filled in the informed consent or willingness to become a participant. For people who did not have internet access, questionnaires were distributed in hardcopy, and the enumerator asked for the willingness of participants to continue to carry out their health protocols due to the pandemic.

Internal validity was maintained by enforcing good data management practices. Each participant had a unique ID to prevent double counting. It was unlikely that one participant filled out the questionnaire two times (offline and online) because the offline questionnaire was only for those who did not have internet access. Data collection was carried out using non-probability sampling so that it could not guarantee the representation of the entire population on one island (district).

However, the sample came from all existing sub-districts.

The qualitative research instrument was an interview guide for in-depth interviews. The questions in the guide aimed to find out people's perceptions regarding the SARS-CoV-2 vaccination. The research instrument was the researcher using interview guidelines.

The interviewer had a postgraduate degree with experience conducting qualitative research in the health sector. The interviewer was also a resident in the research community who understood the local language and customs. The interview began after obtaining approval by explaining the purpose and motive of the study. Each interview took at least 45 min-30 min for exploring the participants' perceptions of vaccination and 15 min for the introduction. The privacy of informants was maintained by conducting interviews in a special room without the presence of J o u r n a l P r e -p r o o f non-participants. All information provided by the informant was kept strictly confidential. All interview processes were recorded with the participants' consent. Field notes were taken during interviews. At the end of the interviews, a summary was presented to the participants for the validation of the data collected. Transcription was carried out using a verbatim format within 2 days of data collection to prevent information loss. The interviewer's relationship with the participants was equal.

Data analysis for the quantitative phase was conducted using a logistic regression model to clarify the determinants of SARS-CoV-2 vaccine hesitancy. The first step was to perform a bivariate (chi-squared) analysis to select a candidate as the independent variable. Associations between explanatory variables and vaccine hesitancy were analysed separately. In the second step, all variables with a p-value ≤ 0.25 (age group, education, occupation and marital status) in the first step were included in the adjusted analysis. The crude odds ratio (OR) and adjusted odds ratio (aOR) in the multivariate analysis were assessed at α = 0.05 with a 95% confidence interval (95% CI). All statistical analyses used SPSS software (25 th version, International Business Machines Corp., New York).

Data analysis for the qualitative phase was carried out using the Colaizzi method. We conducted triangulation to maintain the validity of the data. Triangulation was carried out by more than one researcher in analysing and collecting data to avoid researcher subjectivity. In addition, the researchers did member checking by validating the data from participants.

The protocol of this study was approved by the Health Research Ethics Committee of Manado Health Polytechnic, Ministry of Health (KEPK.01 / 02/008/2021). All participants were informed of the purpose of this study and were asked to provide their informed consent. All personal information was kept confidential and not reported in this paper.

J o u r n a l P r e -p r o o f A total of 584 people aged 18-89 years participated in this study; 19 respondents worked as health workers, and 8 respondents who did not complete the questionnaire were completely excluded from the research data. The total number of respondents included was 557 (95.3% response rate).

The prevalence of SARS-CoV-2 vaccine hesitancy was found to be 63.9% (95% CI: 59.8-67.9%). Table 1 shows the association between socio-demographic characteristics and vaccine hesitancy. In the first step (before the adjustment), there were three variables that were significantly related to vaccine hesitancy: education, knowledge towards the SARS-CoV-2 infection vaccination and willingness to pay. After the adjustment, the results showed that respondents with a diploma/university education were less likely to hesitate to get vaccinated compared to those with a primary/junior high school education (aOR: 0.40; 95% CI: 0.22-0.70).

Those who were senior high school graduates were less likely to be hesitant about the vaccine compared to those who were primary/junior school graduates (aOR: 0.32; 95% CI: 0.14-0.73).

Respondents who had poor knowledge of the SARS-CoV-2 vaccine were 2.17 times more hesitant to get the vaccine compared to those who had good knowledge of the vaccination (aOR:

2.17; 95% CI: 1.41-3.34). Those who had a willingness to pay were likely less hesitant to get the vaccine compared to those who were not willing to pay (aOR: 0.12; 95% CI: 0.07-0.20). Other variables were not significantly associated with vaccine hesitancy (Table 1) .

Of the total respondents who stated their hesitancy/refusal towards the SARS-CoV-2 vaccine (n = 356), the majority of the reasons given were 'not sure of safety' (36%) and 'fear of side effects' (27%; Figure 1 ).

In this study, 30 participants were interviewed, and data saturation occurred in all participants. Then, I heard the news on TV that the vaccine also has a chip…(the respondent chuckles)'. (P16) '…because the information concerning this vaccine circulating in the community is still lacking (I am not willing to be vaccinated), only when there is more information about the vaccine, then (I will consider that) it's safe to be vaccinated, and I will be willing (to get one; The respondent showed his confused facial expression) but I still have doubt (about the vaccination)....'

'The health workers said that the vaccination is good (for your health), but I don't want to be vaccinated because I'm still afraid of the syringe' (P17).

The prevalence of vaccine hesitancy against the SARS-CoV-2 vaccine was found to be 63.9% (95% CI: 59.8-67.9%). Previous studies demonstrated that vaccine hesitancy in urban areas in Indonesia was 35.2% 8 and was almost the same as other studies in Indonesia that used the 50% vaccine effectiveness scenario with a vaccine hesitancy of 33.0%. 7 Both studies were conducted at a time when the SARS-CoV-2 vaccine was still in the development stage. Vaccine hesitancy in general studies across various countries has been in the range of 12-18%. 15, 16, 17 Apart from the general population, SARS-CoV-2 vaccine hesitancy has also been found in health workers. 18, 19 The much higher prevalence of SARS-CoV-2 vaccine hesitancy in this study compared to previous studies is somewhat surprising. This is because this study was conducted at a time when the vaccination campaign was being carried out by the government, and the president, and other influencers subsequently, had already received the first injection of the vaccine, an event broadcast live on national TV. The differences are mainly due to the study population and a social context where participants' access to information was very limited. These findings are of serious concern, as the government is trying to ensure widespread SARS-CoV-2 vaccination in all regions of Indonesia. Another possibility is the efficacy of the SINOVAC vaccine (63%).

Previous research found that if the vaccine is 95% effective, 93.3% of participants would like to be vaccinated when the vaccine is provided for free by the government. However, this percentage decreases to 67.0% if vaccine efficacy is 50%.

A multivariate analysis (adjusted analysis) was performed to determine factors related to vaccine hesitancy. There are three factors associated with vaccine hesitancy, including the level of J o u r n a l P r e -p r o o f education, knowledge of the SARS-CoV-2 infection vaccination and willingness to pay. The higher the education, the less likely it is for vaccine refusal. These results are supported by the findings of other studies where education level is one of the factors related to vaccine hesitancy. 16, 20 This study proves that participants who do not have sufficient knowledge of the SARS-CoV-2 vaccination are twice as likely to refuse the vaccination compared to participants who have good knowledge, which is similar to the findings of other studies. 15, 21, 22 There is no study regarding knowledge of COVID-19 vaccination in the first month of vaccination for the general population (January to February 2021) in Indonesia. However, from a study in Malaysia conducted at the end of 2020, it was found that 62% of respondents had poor knowledge of the COVID-19

vaccine. 23 Access to information is very limited in rural areas, which causes people to not get comprehensive information regarding the SARS-CoV-2 vaccination. Therefore, the role of the local government in socialisation and education related to vaccination is very much needed. The increased knowledge is effective in increasing immunization coverage. 24 A previous study found that 21.6% of rural residents were willing to pay for the vaccination. The willingness to pay for the vaccination in that study was related to income. 25 This figure is not significantly different from the findings of this study, in which the proportion of rural residents willing to pay for the vaccination was 20.1% (Table 1) . In this study, the willingness to pay was one of the factors that influenced a person to accept or refuse the vaccination. This means that people who are not willing to pay for vaccines will tend to refuse vaccination. This may be related to the fact that the majority of participants in this study fell into the category of poor economic status. This is also supported by research that found that families with lower incomes are more likely to refuse vaccination. 14,26 Therefore, the Indonesian government's decision to provide the COVID-19 vaccination for free to all populations in Indonesia is very appropriate and should encourage a higher vaccination rate. 27 In this study, information on the reasons for receiving or refusing vaccination was extracted both qualitatively and quantitatively. Based on the quantitative results, the reasons for rejecting the vaccination from the largest to the smallest proportions included doubt of its safety, fear of side effects, doubt of its effectiveness, no trust in the vaccination, religious beliefs and comorbidities. The reason for vaccine refusal that cannot be revealed from the quantitative results is the factor of Christian religious belief. Some participants believed circulated rumours that there is a microchip in the vaccine that is a symbol of the Antichrist. In a previous study in Indonesia, measles vaccination was also associated with Muslim religious beliefs where the vaccination coverage for the Muslim population was lower due to the presence of haram in the vaccine. 28 However, the SARS-CoV-2 vaccine has been declared halal by the Indonesian Ulama Council, so it is not one of the reasons for vaccine rejection in this study. Rejection based on unfounded rumours about a microchip in the SARS-CoV-2 vaccine is not surprising. A theologian from Indonesia even conducted a study to refute this rumour. 29 In a previous study in Jordan, it was found that high vaccine hesitancy was associated with the belief of the conspiracy that the SARS-CoV-2 vaccination would implant a microchip into a person's body to control the person's movements. 30 Of course, further studies are needed to determine the relationship between local Christian religious beliefs and the hesitancy towards SARS-CoV-2 vaccination.

However, the findings of this study can become a serious concern for religious leaders, especially in Christian-majority areas such as the study area. Local governments can support Christian religious leaders to straighten out information related to rumours of microchips in the SARS-CoV-2 vaccination. The adopted sequential explanatory mixed methods are the strength of this study. This study provides more comprehensive data, as it explored reasons for doubt/refusal against vaccination to facilitate recommendations for targeted interventions to increase the rate of COVID-19

vaccination. The limitation of this study lies in the sampling method that used non-probability sampling, so there is the potential of sampling bias. 

The authors have declared that no competing interest exists.

The author(s) received no financial support for the research, authorship and/or publication of this article. 

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The authors thank all the participants involved in this study for their cooperation and support.

Main reason for vaccine hesitancy Principal motivo de indecisión ante la vacuna Majority participants were sure that the vaccination will increase the body immunity against COVID-19.Decrease the positive cases and death rate:Participants stated that the vaccination will decrease the positive cases and death rate caused by COVID-19.Appreciate the government's effort:Participants were willing to participate as a form of appreciation towards the government program.The vaccine was free:Participants were ready to get vaccination because they did not have to pay for it (free) Safe:Participants were sure that the vaccination was safe because many people have been vaccinated without any worrisome (side effects)Mejorar la resistencia corporal (inmunidad del cuerpo:La mayoría de participantes estaban seguros de que la vacuna incrementaría la inmunidad del cuero contra la COVID-19.Reducción de los casos positivos y de la tasa de fallecimientos:Los participantes afirmaron que la vacuna reduciría los casos positivos y la tasa de fallecimientos causados por la COVID-19.Aprecio del esfuerzo del gobierno:Los participantes estaban deseosos de participar como forma de aprecio del programa del gobierno.La vacuna era gratuita:Los participantes estaban dispuestos a ser vacunados porque no tenían que pagar (era gratuita)Seguridad:Los participantes estaban seguros de la seguridad de la vacuna porque muchas personas habían sido vacunadas sin problema alguno (efectos secundarios)

Participants said that they fear of side effects of Participants had concern about the safety of the vaccine since they had not received sufficient information about the vaccine. los efectos secundarios de la vacuna contra la COVID-19.Falta de información: Los participantes afirmaron que no habían recibido información relativa a la vacuna y a la importancia de la vacuna contra la COVID-19.Creencias religiosas cristianas:Los participantes creían los rumores sobre que la vacuna es el signo del fin de los tiempos, y símbolo del Anticristo (relacionado con el chip 666)Miedo a la inyección:Los participantes tenían fobia a las inyecciones.No confía en la seguridad de la vacuna:A los participantes les preocupaba la seguridad de la vacuna, ya que no habían recibido información suficiente sobre la misma.