Acceptance Towards COVID-19 Vaccination among the Lebanese Population: A Cross-Sectional Study

Introduction

The emergence of the SARS COV-2 (Covid-19) virus in Wuhan, China, has been posing major risks to human health and putting the entire world in jeopardy as it was classified by the World Health Organization (WHO) as a global pandemic on the 11th of March 2020 [1]. The ramifications of the pandemic on different economic sectors were catastrophic, the isolation and distancing regulations implemented paved the way towards an economic collapse [2]. This economic recession affecting most countries has been anticipated by the World Bank [3]. Such restrictions involved shutting down the frontiers and limiting the number of flights unless necessary [4]. In fact, according to The World Travel and Tourism Council, about 50 million jobs in the global travel sector might be at risk [5]. The lockdowns led to panic-buying and food stocking which caused a shortage of everyday products [6]. With millions of active cases and hundreds of thousands of deaths [7,8], research centers and pharmaceutical companies have been working at unprecedented rates to develop a vaccine to fight against this global pandemic [9].

According to the WHO, only two mRNA vaccines have been approved by the United States Food and Drug Administration (FDA); Pfizer-BioNTech Covid-19 Vaccine on the 11th of December 2020 and Moderna Covid-19 Vaccine on the 18th. Several companies developed vaccines based on different modes of action [10]. The Oxford-AstraZeneca vaccine is a double-stranded DNA vaccine that uses a modified version of a chimpanzee adenovirus that has been used in many countries such as the UK as an emergency vaccine in December 2020 [10]. Besides, China developed the Sino-pharm Covid-19 vaccine which is an Inactivated Coronavirus Vaccine where the virus is modified by a protein-denaturing treatment to make it noninfectious [11]. On the microscopical level, Lebanon is a third world country with an estimated population of 6,825,445 that has been plagued with political turbulence and economic crisis over the past year and a half [12], on the 21^st of February 2020, Lebanon witnessed its first Covid-19 case and since then around hundreds of thousands (387.000 confirmed cases on the fourth of March 2021) of cases have been recorded [13].

The government has been trying to implement various restrictions to limit the number of cases from curfews to complete lockdown, these Covid-19 related regulations had repercussions on employment since in June 2020, one out of three were unemployed and one out of 5 had their salary reduced [14]. Regardless, as the regulations and recommendations administered by the WHO and the ministry of public health did not achieve their target, the number of confirmed cases is still increasing in an alarming manner [15]. The hospitals’ Intensive Care Units (ICU) reached their maximum capacity and a shortage of medical supply needed has been witnessed. On the 28^th of January 2021, the minister of health, Dr. Hamad Hassan declared that the World Bank will be providing the government hospitals with 117 ICU beds for coronavirus patients [16]. Thus, it is being discussed that the vaccine is the sole method to limit the transmission and spread of the virus. The target of the ministry of health is to reach 70% of a vaccinated Lebanese population by the end of the year 2021-2022 by introducing the Pfizer-BioNTech and Oxford-AstraZeneca Covid-19 Vaccines while giving the priority to the elderly, the health workers, and susceptible patients [17]. However, concerns about the safety of the vaccine due to its fast development, short testing, its unknown long-term side effects, and the emergence of conspiracy theories and political underlying benefits have been raised. Misconceptions and misinterpretation about certain aspects of the pandemic have been circulating alarmingly. For instance, it is being discussed that the vaccine is being developed for monetary gains, while others believe that the purpose of the vaccine is to implant microchips into people’s bodies [18]. As a result, these factors have affected the Lebanese population’s acceptance and opinion regarding the proposed vaccines against the Covid-19. To date, this growing public health concern in Lebanon has received scant attention in the research literature. Therefore, this cross-sectional study examines the propensity to which the Lebanese population is willing to take the new covid-19 vaccine once available or not. Thus, the importance of this research is to study the possibility of reaching a 70% herd immunity by vaccination [19].

Aim of the Research

This research aims to study the acceptance of COVID-19 vaccination among the Lebanese population, moreover, it aims to study the general attitude and behavior during the pandemic.

Materials and Methods

Study design

A cross-sectional study was conducted to collect the data. the data were collected through the collaboration between ResAid Medical Research Organization (private research institute active in the Middle East countries) and the Lebanese American University (LAU). Due to the restrictions to conduct face-to-face research, an electronic questionnaire was used based on Google Forms, and the participant was asked to fill the questionnaire anonymously, and the questionnaire consisted of five sections:
a. Informed consent to participate in the research (first page)
b. Demographic variables (age, gender, educational level, socio economic status, etc.)
c. Willingness to take the vaccine (assessment of risk, 1-10 scale of acceptance, etc.)
d. Attitude and behavior during the pandemic (11 questions)
e. Measurements were taken during the pandemic (12 questions)
Participants were asked for their informed consent to participate in this research at the first page of the questionnaire, which included information about the research aims and objectives and the confidentiality of the information collected. Only participants who approved and provided informed consent were able to participate in the research. The questionnaire was distributed on social media platforms (Facebook, Instagram, WhatsApp, etc.) and using emails, one week after the announcement of the Lebanese governments that they are willing to bring the vaccination to the Lebanese population, and data were collected over 1 week (the second week of January 2021). The final sample size consisted of (1157) after excluding all participants under 18 years old, and the sample was balanced between the Lebanese governance. This sample is considered representative for the Lebanese population, as data collected from all age groups, and from all Lebanese governance, and from different socioeconomic status and educational level.

Statistical analysis

Data were collected using online questionnaire (google forms) which will eliminate the error in data entry (data automatically transferred to Excel file) and the missing data (as participants will be notified about questions they missed). The data then were analyzed using descriptive and inferential statistical methods using SPSS V.22 software, Pearson’s Correlation, T-test, ANOVA Test were used to analyze the data. multivariable regression model was done to test how the variables affect each other. Sample size was estimated using sample size calculator for cross-sectional studies, confidence interval was set at (5%), confidence level (5%), and the Lebanese population according to the latest statistics are (6.8m), and the results was that (384) sample were representative for the population. The final sample size was (1157) which increase the power of this study and reduced the confidence interval to (2.88).

Results

Sample analysis and demographic variables

The final sample size consisted of (1157) participants, age ranged between 18-79 and on average (33.3), and the sample balanced between males and females (41.4%, 57.9%) retrospectively. Sample were distributed across all the Lebanese governance, Beirut had the highest rate of the responses (33.1%), followed by mount Lebanon (30.6%). Financial status, education, parental education information was used to calculate the Socio- Economic Status index (SES), and most of the sample had moderate SES (42.1%), while (33.7%) had low SES, and (24.2%) had high SES. Most of the participants had health insurance (86.3%), and only (19.3%) of the participants were from the medical field. Table 1 represents the sample demographic variables.

Table 1: Sample analysis and demographic variables.

Behavior during the pandemic

Table 2 represents the sample behavior during the COVID-19 pandemic, among the participants (15.6%) are confirmed cases with COVID-19, however, over (95%) of the sample know someone who had coronavirus or symptoms related to the virus. Most of the sample (86.3%) think that the COVID-19 pandemic holds a major risk toward the society in Lebanon, and only (50.8%) think the pandemic holds a major risk on them. Moreover, (37.4%) of the sample answered that the main source of information regarding the pandemic is from health care workers, followed by common conversation and words of mouth (26.4%), and television (23%), while social media was the last source of information (4.6%). The decision of (65.6%) of the sample regarding the vaccination is affected by the source of the vaccine, and the most trusted vaccine among the Lebanese population was the German American vaccine (BioNTech- Pfizer) (73.4%), followed by the Chinese vaccine (10.5%), and the least trusted vaccine was the Russian vaccine (7.9%). Most of the sample will take the vaccine even if it is not free (51.9%), while (32.2%) will never take the vaccine even if it is free, and (15.8%) will only take a free vaccine.

Table 2: Clinical Characteristics.

Opinions toward the vaccination and measurements taken among the Lebanese population

Table 3 represents the Lebanese population’s opinion toward the vaccination, and the measurement taken by them. (77.1%) are worried about the side effects of the vaccine, and (65.7%) are not certain about its safety, and (64.8%) will take the vaccination if it is recommended by the doctors and the health specialist. On the other hand, the Lebanese population showed high responsibility following the restrictions and health measurements during the pandemic, as shown in Table 3, most questions are answered with “yes” from over (90%) of the sample, except for following a certain diet or taking supplements and vitamins (46.1%).

Table 3: Opinion toward the vaccination and measurements taken among the Lebanese population

The relation between the research variables

Inferential statistical analysis was used to test the relation between the different research variables. Pearson’s correlation test was used to identify the correlation between the age variable and the willingness to take the vaccine, and the result is represented in Table 4, there is a significant positive correlation between the age and the willingness to take the vaccine among the sample (sig=0.048, PC=0.042). Moreover, Pearson’s correlation showed a significant positive correlation between the socio-economic status and the willingness to take the vaccination, which means the higher the SES gets, the more willing the population becomes towards taking the vaccine (sig=0.003, PC=0.042). Multivariable regression analysis was run to test the effect of all variables on the willingness to receive the vaccine, the significant results are summarized from the most important factor to the least important factor in Figure 1-4. Free vaccine was the most important factor which affected the willingness to receive the vaccine (P=0.015). Followed by doctor’s recommendation (0.022), and the source of the vaccine (0.0239). The fear from corona virus also played a role in increasing the willingness to take the vaccination (0.0351), all other significant factors are represented in Figure 1.

Table 4: Correlation between age, SES and the willing to take the vaccination.

Figure 1: Represents the sample demographic variables.

Figure 2: Socio-economic status among the sample

Figure 3: Source of information regarding COVID-19.

Figure 4: Worries among the sample regarding the vaccine.

Discussion

The Covid-19 pandemic has reshaped our lives; therefore, it is considered that up till now, the vaccine is the best solution to eradicate the virus and stop its spread [20]. The Pfizer-BioNTech Covid-19 Vaccine arrived in Lebanon on the 14th of February and was distributed to hospitals and vaccination centers [21]. Thus, it was incumbent to conduct a study that aims to investigate the level of acceptance of the SARS COV-2 vaccine among the Lebanese population and the various factors that affect their decision. Hence, the importance of this study stems from the fact that it is among the first to discuss the acceptance in Lebanon, moreover, the big sample size that participated in this study can help to generalize the results of this study. Of our sample, over half of the population (58.8%) are willing to take the vaccine. This result is in direct contrast to the results of other studies since the acceptance observed in Lebanon is lower than the one in Iraq (77.6%), China (91.3%), Saudi Arabia (64.7%), and the United States of America (69%). However, a survey conducted in England revealed a lower tendency to take the vaccine (55.8%) [22-25]. Most of the sample stated that they know someone who caught the coronavirus, and as a result, it is concluded that the virus poses major risks to society.

The findings suggest that most of the participants who perceive the virus as a threat might be more inclined to protect themselves from the pandemic, this is consistent with the results of a longitudinal study concerning the first year of the H1N1 Pandemic which stated that the risk of infection is directly related to the acceptance of vaccination [26]. This goes in line with the previous result that stated that 58.8% of the sample is willing to take the vaccine. However, this acceptance is related to the source of the vaccine for over two-thirds of the sample. The majority prefer to take the German American vaccine (BioNTech-Pfizer) while the Chinese vaccine; Sinopharm was the second most trusted vaccine among the Lebanese population, and the Russian vaccine Sputnik V was the latest. This repartition might be due to the 95% efficacy of the Pfizer vaccine and its mode of action which could be reassuring [26]. The preference for the Pfizer vaccine is consistent with the results of a cross-sectional study conducted in Indonesia in July 2020 which shows that higher acceptance towards vaccination was associated with the choice of a 95% effective vaccine [22].

The acceptance toward the vaccine among the Lebanese population is affected by the fear of the unknown and un-welldocumented side effect of the vaccine and the uncertainty of its safety, similar results were found in other studies which concluded that the fast production of the vaccine resulted in worries among the people about the effectiveness and safety of the vaccine, and if the vaccine was free of charge increased the willingness to take the vaccination, moreover, it is important to document that about one-fifth of the Lebanese population are convinced that there is a hidden agenda behind the fast development of the vaccine, which raises again the conspiracy theory about the COVID-19 pandemic, this results can be directly related to psychological status [27], political trust, religious beliefs, and social status of the population [28]. Social determinants played a key role in the acceptance of the vaccine among the Lebanese population, gender, age, and higher socioeconomic status were significant factors affecting the willingness to take the vaccine, this can be explained as the following, COVID-19 pandemic affected seniors more than youth therefor, the older the person gets, the more willing to take the vaccine he/she becomes [29-31].

Furthermore, the socioeconomic status is higher when the education level is higher, and the higher education level can be a protective factor against the wrong information about the vaccination programs [32]. Similar results were found in many other studies, in Saudi Arabia, older age groups and education level were significantly associated with the vaccine acceptance, in other Arab community, males were more willing to accept the vaccine [33]. As stated earlier, the vaccination program is the only solution to pass the current pandemic and protect the communities around the world from a further speared of this virus and to protect the world economy from collapsing, therefore, the results of this study can be a cornerstone for the development and implications of the vaccination program in the Lebanese community, and it can give an in-depth overview for the groups that are least to accept the vaccine to start an awareness campaign aiming to raise the awareness toward COVID-19 vaccine. Further research might investigate the reason why the number of active Covid-19 cases keeps on increasing even if the participants are claiming to respect most of the safety measurements. Another further study could assess the updated data once people start getting the vaccine.

Conclusion

Within the limitations of this study, we can conclude that this study is the earliest attempt to assess the acceptance toward COVID-19 vaccination among the Lebanese population. The Lebanese population showed a moderately high acceptance rate for the vaccination, however, there is a notable percentage that needs to be directly addressed with any future awareness campaign which are the youth, and the people with low socioeconomic status. Most important factor affecting the acceptance level was the free vaccine, as the population are willing to take the vaccine if it was free.

Limitations of the Study

Due to the current pandemic situation, data were only collected in electronic form, which might be affected be selection bias, as most of the Lebanese population uses social media platform or emails are considered medium or high status on the socioeconomic scale, selection bias might be reduced when bigger sample size is collected which is the case of this study. Therefore, within these limitations, the results can draw an overview of the current situation with limited ability to generalize the results over all the Lebanese population, and further research should be done.

List of Abbreviation

COVID-19: Corona Virus Disease 2019

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the ethical committee at ResAid medical research organization, N. 116/s. All methods were performed in accordance with the relevant guidelines and regulations. Informed consents were collected from all the participants on the first page of the questionnaire along with detailed description of the research aims and methodology, and the confidentiality of the participant information.

Consent for Publication

Not applicable

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests

Funding

No sources of funding.

Authors’ Contributions

a. MBA: Supervised the research, wrote the manuscript, analyzed the data, finalized the research.
b. MA: Collected the data, helped writing the manuscript
c. EM: Collected the data, helped writing the manuscript
d. JK: Collected the data, helped writing the manuscript
e. MAA: Reviewed the manuscript, finalized the article.

Acknowledgments

We hereby thank everyone who helped to collect data for this research.

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