ANSWER
From early February 2021, the Bangladesh government will launch a nationwide vaccination campaign against SARS-CoV-2 infection. This study aimed to assess the acceptance of COVID-19 vaccines and investigate the factors that influence acceptance in Bangladesh. We conducted a web-based anonymous cross-sectional survey among the general Bangladeshi population from January 30 to February 6, 2021. There was a detailed consent section at the beginning of the survey that explained the study’s intent, the types of questions we would ask, the anonymity of the study, and the study’s voluntary nature. The survey was only completed when a respondent agreed and the respondents themselves responded. The multivariate logistic regression method was used to identify the factors influencing COVID-19 vaccination acceptance. This survey included 605 eligible respondents ranging in age from 18 to 100 (population size 1630046161 and required sample size 591). A large proportion of respondents (82%) are under the age of 50 and are male (62.15%). The majority of respondents (60.83%) live in cities. Sixty-one percent (370/605) of respondents were willing to accept/take the COVID-19 Vaccine. Only 35.14% of the accepted group said they would take the COVID-19 Vaccine immediately.
In comparison, 64.86% said they would wait until they had more information about the Vaccine’s efficacy and safety or until COVID-19 became more deadly in Bangladesh. Age, gender, location (urban/rural), level of education, income, perceived risk of being infected with COVID-19 in the future, perceived severity of infection, having previous vaccination experience after age 18, and having higher knowledge about COVID-19 and vaccination were all significantly associated with acceptance of COVID-19 vaccines, according to the regression results. According to the study, there is a high prevalence of COVID-19 vaccine refusal and hesitancy in Bangladesh. To reduce vaccine hesitancy and increase uptake, policymakers must devise a well-researched immunization strategy that eliminates vaccination barriers. False rumors and misconceptions about the COVID-19 vaccines must be dispelled (particularly on the internet), and people must be exposed to the actual scientific facts.
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Mahmud S, Mohsin M, Khan IA, Mian AU, and Zaman MA (2021) COVID-19 vaccine knowledge, beliefs, attitudes, perceived risk, and determinants of COVID-19 vaccine acceptance in Bangladesh. PLoS ONE 16(9): e0257096, doi:10.1371/journal.pone.0257096.
Kingston Rajiah, International Medical University, MALAYSIA, is the editor.
Accepted: August 23, 2021; Published: September 9, 2021; Date Received: April 12, 2021
Copyleft: 2021 Mahmud et al. This open-access article is distributed under the Creative Commons Attribution License, allowing unrestricted use, distribution, and reproduction in any medium as long as the original author and source are credited.
Data Availability: The data supporting the findings of this study are freely available via the Open Science Framework at https://doi.org/10.17605/OSF.IO/B38HY.
Funding: The authors did not receive any funding for this work.
Competing interests: The authors have stated that they have no competing interests.
Introduction
The COVID-19 (the disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCOV-2)) infection, declared a “pandemic” by the World Health Organization, has infected more than 111 million people and claimed more than 2.4 million innocent lives as of February 20, 2021 [1]. COVID-19’s emergence has devastated global healthcare systems, with repercussions in every aspect of human life as we know it. With no proven treatments or medicines, governments around the world imposed border closures, travel bans, and quarantines [2] to halt the virus spread which caused a massive economic downturn. The pandemic is still wreaking havoc on the world today.
Scientists and researchers worldwide have worked tirelessly to find a cure for the deadly disease. Vaccines are thought to be effective in developing a long-lasting immune system to combat infectious diseases. Vaccination prevents approximately 2-3 million deaths per year [3]. Many vaccines were developed during pandemics, such as the 1957, 1968, 1976, and 1977 outbreaks, the H5N1 outbreak (1997-1998) and the 2009 H1N1 outbreak [4]. In the case of the COVID-19 pandemic, approximately 100 vaccines are in pre-clinical/clinical trials, with some already approved for mass vaccination [5]. With the approval of COVID-19 vaccines, the pandemic is expected to be contained.
However, developing vaccines is not the only way to put an end to such a widespread and lethal virus. Vaccine hesitancy and adoption researchers warn policymakers and the scientific community that a successful vaccine is only the beginning. Based on previous experiences with pandemic vaccines and vaccine hesitancy, each country may require a well-researched strategy for rollout and adoption [6]. The most recent disease outbreak experience-the H1N1 outbreak in 2009-saw, poor immunization among adults, with one study finding that 26% of refusals were concerned about the safety and 17% did not believe in the Vaccine [7]. According to a recent study conducted in the United States, approximately 68% of all respondents are willing to vaccinate against COVID-19 despite concerns about side effects and efficacy [8]. In a comprehensive survey of 19 countries conducted in June 2020, 72% of respondents said they were either likely or very likely to take a vaccine, ranging from 89% in China to only 55% in Russia [9].
“Why are people unwilling to get vaccinated against a devastating disease?” asks one. Much research has been done on the factors that influence vaccine uptake. Previous research on seasonal and H1N1 influenza vaccinations found that vaccine attitudes and beliefs are related to vaccination intentions, which are good predictors of vaccination uptake [10, 11]. Higher vaccination intentions were associated with believing that the COVID-19 disease would last much longer. In comparison, lower vaccination intentions were associated with the belief that the dangers of COVID-19 had been exaggerated by the media [12]. Another study examined the links between vaccine intention and sociodemographic characteristics, concluding that lower vaccination intention was connected to younger age and Black and minority ethnicity [13]. However, vaccine intention and uptake factors might vary substantially by territory, culture, and socioeconomic conditions.
From the start of the pandemic, there has been widespread ignorance, rumors, and misinformation about COVID-19 among the general public in Bangladesh [14]. It is also anticipated that there will be significant misinformation and hesitancy in administering COVID-19 vaccines. Due to a lackluster response to online registration for COVID-19 vaccination, the Bangladesh government has revised its plan to inoculate 3.5 million instead of 6 million people in February 2021 [15]. It also reduced the general population’s age limit to 40 years from the previously stated 55 years. This demonstrates the people of Bangladesh’s aversion to receiving a COVID-19 vaccine. Bangladesh’s government has ordered and paid for at least 30 million doses of the Oxford-AstraZeneca vaccine, which will be delivered in installments throughout 2021, as well as another 68 million shots through the Covax initiative [16], which is led by the World Health Organization and Gavi, the Vaccine Alliance [15].
The Bangladesh government has done an outstanding job securing a sufficient vaccine supply. The challenge now is to get people to take the vaccines. This study aims to look into people’s knowledge, attitudes, and intentions toward COVID-19 vaccines, as well as the factors that influence COVID-19 vaccine acceptance in Bangladesh. We conducted an anonymous online survey between January 30 and February 6, 2021. The significance of conducting such a study in the context of Bangladesh cannot be overstated, as it will serve as a guide for the Bangladesh government in encouraging uptake among the general population.
Methods
Study participants and design
We conducted a cross-sectional, anonymous web-based survey between January 30 and February 6, 2021. An electronic questionnaire was used to conduct self-interviews with the participants. There was a detailed consent section at the beginning of the survey that explained the study’s intent, the types of questions we would ask, the anonymity of the study, and the study’s voluntary nature. The survey was only completed after a respondent agreed to the electronic informed consent and the respondents themselves responded. Following an eligibility check, they could participate in the survey if they consented. This survey was open to anyone over 18 who lived in Bangladesh. The questionnaire was created in English and translated into Bangla (see S1 Questionnaire). The respondents were informed that their participation was entirely voluntary, and they were asked to share the link with their contacts or acquaintances after completing the survey. The questionnaire was validated, and pilot tested before it was distributed online. There was no collection of sensitive or personal information.
The sample size
Because the purpose of this study is to examine the acceptability of the COVID-19 Vaccine among the general population in Bangladesh, and there has been no previous literature from Bangladesh that has examined the associated factors. We assumed that 50% of the general population is interested in the factor. And using an online sample size calculator [17, 18], we calculated a sample size of 591 based on a 65% percent response rate, 5% precision or margin of error, and 50% proportion with a 95% confidence interval for a total population size of 1630046161 [19].
Instruments
The researchers distributed and advertised the KoBoToolbox online survey link to the general public via Facebook, WhatsApp, and email. The questionnaire was divided into five sections: I Demographic information; (ii) Knowledge of COVID-19 and COVID-19 vaccination; (iii) Belief and attitude; (iv) Perceived barrier, likelihood, and severity; and (v) Vaccine acceptability. Previous research [20-22] was used to develop the questionnaire.
Background information on demographics.
At the beginning of the survey, we completed the eligibility check by asking two questions “How old are you (in years)?” and “Do you currently live in Bangladesh?”. This questionnaire section also includes personal information such as gender, religion, marital status, occupational status, monthly household income, and previous vaccination history.
Understanding of COVID-19 and COVID-19 vaccination.
Participants were asked a series of yes/no questions in this section to assess their knowledge of COVID-19 and COVID-19 vaccination. Such as “Is COVID-19 a lethal infectious disease?”, “Is COVID-19 deadlier for elderly people (60+ years)?”, “Do only elderly and sick people die of COVID-19?”, “Can COVID-19 not spread from one to another by contact?”, “Are hot and humid countries like Bangladesh safe from COVID-19?”, “Is it human-made and deliberately released?”, “Was the COVID-19 virus genetically engineered as part of a biological weapons program?”, “Is this a normal disease like cold/cough and fever? “Is there any effective medicine available for treating COVID-19/ coronavirus?”.
Attitude and belief.
In this section, we asked several questions with three options: “Agree,” “Neutral,” and “Disagree” to investigate participants’ beliefs and attitudes toward COVID-19 and COVID-19 vaccination. For example, attitudes toward COVID-19 and COVID-19 vaccination were examined by asking, “Vaccination is an effective way to prevent and control a disease,” “Young (less than 30) and children do not need any vaccination against COVID-19,” “We need to prioritize returning to our normal routines (opening schools, colleges, Office) as soon as possible while maintaining safety protocols,” and “It should be a crime if people know they have COVID-19 but do not isolate themselves.”
She perceived berried ness, likelihood, and severity.
We cover perceived likelihood by asking, “What do you think is the chance that you will get COVID-19 in the future?” with options “Low chance,” “Medium chance,” and “Higher chance.” The perceived severity was also addressed when the question “How severe do you think it would be if you got COVID-19?” was posed. With three options: “Not at all/low severity,” “Medium severity,” and “Higher severity.” The perceived barriers to COVID-19 and COVID-19 vaccination were examined by asking two questions: “If I decided to get the COVID-19 vaccine, would I have a difficult time finding a provider or clinic that could give me the vaccine.” “The COVID-19 vaccine may have side effects,” with three options “Agree,” “Neutral,” and “Disagree,” and “The COVID-19 vaccine may have side effects,” with three similar options.
Acceptability of vaccines.
The main finding of this study was vaccine acceptability. Firstly the participants who chose “Yes” to the question “Have you heard of any vaccine that is going to be inoculated in Bangladesh?” were asked, “Bangladesh Govt. is going to inoculate COVID-19 vaccine, will you take it?”. If the respondent chose “No,” we asked a multiple-choice question to determine the reasons for not accepting the covid-19 Vaccine. Otherwise, we asked, “When will you or your family members take the vaccine?” with the options “Will take as soon as possible,” “After 2-6 months if seems safe and effective”, “If COVID-19 becomes deadlier in Bangladesh,”, and “Not sure.” We also assessed people’s willingness to pay for COVID-19 vaccination by asking, “How much should a full dose of a vaccine cost?” with three choices: “should be free,” “1-1000”, and “1000+”. We also looked at vaccination priority groups by asking, “Considering the current scenarios, who do you think should receive the first shipment of a vaccine in Bangladesh?” with options such as “Healthcare workers/professionals,” “Elderly people (60+ years),” “People with underlying diseases,” “Politicians,” and “Others.”
Consent and ethical concerns
A voluntary online consent was obtained by sharing a consent form on the respondents’ timeline/inbox/WhatsApp, which included an outline of the research purpose and brief survey instructions.
Statistical investigation
The primary outcome of this study is the acceptance of the COVID-19 Vaccine. Based on their responses to the question, “Bangladesh Govt. is going to inoculate COVID-19 vaccine, will you take it?” we divided respondents into two groups (accept group and refuse group). Those who chose “will take as soon as possible” in response to the question “when will you or your family member take it?” were further classified as vaccine “immediate” recipients. Others who chose “After 2-6 months if seems safe and effective,” “If COVID-19 becomes deadlier in Bangladesh,” or “Not sure” were assigned to the vaccine delay group [23]. We calculated each participant’s knowledge score based on the number of valid/correct answers to the 12 questions in the subsection Knowledge about COVID-19 and COVID-19 vaccination. Knowledge levels range from 0 to 12.
We performed exploratory analysis/descriptive statistics (bivariate analysis, frequency analysis, means, graphs, and so on) to examine sociodemographic characteristics, perceived barriers, perceived likelihood, perceived severity, willingness to pay, beliefs, and attitudes toward COVID-19 and COVID-19 vaccination. The chi-square test was used to compare baseline data between two groups (accept and refuse group, immediate and delay group). Multivariate logistic regression was also used to identify the factors influencing decision-making for accepting the COVID-19 Vaccine in both groups (accept group and refuse group, immediate and delay group). The odds ratio (OR), 95% confidence interval (95% CI), and P-value were calculated using logistic regression. The factors were endorsed in the regression models that demonstrated a statistically significant correlation (at 10% significance) in the bivariate analysis.
Results
Six hundred forty-seven people clicked on the survey link. Among them, twenty-five people refused the survey, seventeen people could not complete it, and 605 returned the completed survey. Table 1 shows the characteristics of the participants. The sample broadly represents Bangladesh’s general population, as desired (90.25% Islam, 8.26% Hinduism, 0.83 Buddhism, and 0.66 Christianity [24]). Most respondents (82.78%) were under 50 and male (62.15%). More than half of those polled (60.83%) live in cities. A large proportion of respondents (45.45%) have a university degree, while 26.94% are honors students and 27.60% have passed HSC/Alim/Vocational degree/Nursing or less. A small percentage of participants (18.68%) had prior vaccination experience after 18.
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Table 1 shows the characteristics of the participants (n = 605).
https://doi.org/10.1371/journal.pone.0257096.t001
Overall, 61.16% (370/605) of respondents were classified as accepting, with 35.14% (130/307) willing to take it immediately and the remaining 47.84% (240/605) wanting to delay taking a COVID-19 vaccine (see Fig 1). Most of the participants (71.74%) expressed that the COVID-19 Vaccine should be free and the rest of the participants indicated they would like to pay out of pocket for a vaccine (25.29%) Tk 1–1000, and (2.98%) more than 1000. To inspect the reasons behind the unwillingness to accept the COVID-19 Vaccine, we asked a question with multiple selection options. Among 235 participants who showed unwillingness to accept the COVID-19 Vaccine, 78.52% were worried about the side effects or safety of the COVID-19 Vaccine, and 76.17% were doubtful about the efficacy of the COVID-19 Vaccine. Some of the respondents (42%) were also doubtful about the COVID-19 Vaccine since it is coming from India (Oxford-AstraZeneca vaccine produced by Serum Institute, India) (Oxford-AstraZeneca vaccine produced by Serum Institute, India). Almost 36% of respondents thought vaccination was unnecessary since COVID-19 is going away or they are young (See Fig 2). (See Fig 2).
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Fig 1. The acceptance of the COVID-19 Vaccine in Bangladesh.
https://doi.org/10.1371/journal.pone.0257096.g001
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Fig 2. Reasons behind the rejection of the COVID-19 Vaccine (n = 298).
https://doi.org/10.1371/journal.pone.0257096.g002
Participants were asked a series of yes/no questions to assess more general knowledge and belief about COVID-19 and COVID-19 Vaccination. The percentage of yes, no, and don’t know with the correct answer can be seen in Table 2. Many respondents (62.15%) think COVID-19 is a lethal infectious disease. Almost half (51.40%) of respondents provided a positive answer to the question “Is COVID-19 deadlier for elderly people (60+ years),” and 84.63% of respondents provided the correct answer to the question “Do only elderly and sick people die of COVID-19?”. Very few (30.51%) participants thought that COVID-19 is a normal disease like a cold/cough and fever. The survey results showed overall, 39.67% of respondents have good knowledge, 44.97% of respondents have medium knowledge, and 16.36% have limited knowledge about COVID-19 and COVID-19 vaccination (Fig 3). (Fig 3). Attitudes and beliefs towards vaccination, perceived barriers and perceived risks were also inspected in Table 2. According to a large proportion of respondents (74.71%), vaccination is an effective way to prevent and control disease, while 15.54% disagreed and 9.75% were neutral. A small percentage of 10.91% agreed with the statement “Young (less than 30) and children do not need any COVID-19 vaccination,” while 54.55% disagreed and 34.55% were neutral. The statement “The COVID-19 vaccines that are being inoculated worldwide are not effective and safe” received a large proportion of neutral responses (39.01%), while 37.85% agreed and 23.14% disagreed. A smaller proportion (28.10%) of respondents said it would be easy to find a provider or clinic to administer the Vaccine, while 42.31% disagreed. A small percentage of respondents (34.05%) said there is a low chance of getting COVID-19 in the future, while 40.17% said there is a medium chance, and 25.79% said there is a medium chance. Concerning perceived severity, 23.47% of respondents said they would have highly severe COVID-19 symptoms, 36.36% said medium, and 40.17% said low.
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Figure 3 depicts the distribution of participant knowledge (knowledge about COVID-19 and COVID-19 vaccination).
https://doi.org/10.1371/journal.pone.0257096.g003
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Table 2 shows descriptive statistics for items measuring COVID-19 knowledge, beliefs, attitudes, and COVID-19 vaccination (n = 605).
https://doi.org/10.1371/journal.pone.0257096.t002
Table 3 displays the results of multivariate logistic regressions. The parameter estimates of multivariate logistic regression indicate the odds of an event occurring in the concerned categories of the predictor variable versus the odds of an event occurring in the reference category of the same predictor variable. The odds of accepting the Vaccine are defined as the ratio of the chances of accepting the Vaccine to the chances of rejecting the vaccine [25]. The model was based on 605 complete data cases and found a link between willingness to be vaccinated (yes/no) and predictor variables. Another model, based on 370 cases (Vaccine accepted group), investigated the relationship between willingness to receive immediate vaccination and predictor variables. If a potential predictor showed a significant association (at a 10% significance level) with the corresponding response variable in Table 4, it was trained in the model. According to the findings, female respondents have a 62% lower chance of accepting the COVID-19 Vaccine than male respondents. Compared to respondents aged 18 to 29, respondents aged 30 to 50 and 51 to 70 had a 6.79 and 7.89 times higher (respectively) chance of accepting the COVID-19 Vaccine. The odds of accepting the COVID-19 Vaccine are 81% lower among respondents who live in rural areas than in urban areas. Participants with a university degree and hon’s (undergrad) running students were 21.38 times more likely to receive the COVID-19 Vaccine than those with a lower educational qualification (HSC/Alim/Vocational education/Nursing or less). Respondents with incomes of $30,000 to $39,999 had 4.35 times the odds of accepting the COVID19 Vaccine, 40,000-49,999 had 8.95 times the odds, 50,000-74,999 had 8.44 times the odds, and respondents with incomes of $75,000 or more had 6.31 times the odds. Respondents who had previous vaccination experience after the age of 18 had 4.79 times higher odds than respondents who had no vaccination experience after the age of 18. People who disagreed with the statement “the vaccines being inoculated globally are effective and safe” were 90% less likely to accept the COVID-19 Vaccine than those who agreed with it. Participants who believe they have a medium or high chance of being infected with COVID-19 in the future had 3.19 times and 8.68 times higher odds of taking the COVID-19 Vaccine, respectively than those who believe they have a low or no chance of being infected with COVID-19 in the future. Respondents who believed getting infected with COVID-19 would be highly severe had a 4.47 times higher chance of being in the Vaccine accept group than respondents who believed getting infected with COVID-19 would be mild. People with good knowledge of COVID-19 and COVID-19 vaccines were 22.23 times more likely to accept the COVID-19 Vaccine than people with poor knowledge of COVID-19 and COVID-19 vaccines.
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Table 3 shows the results of multivariate logistic regressions examining the associations between vaccination acceptance and immediate vaccination acceptance.
https://doi.org/10.1371/journal.pone.0257096.t003
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Table 4 shows the relationship between various factors, willingness to be vaccinated and willingness to receive immediate vaccination.
https://doi.org/10.1371/journal.pone.0257096.t004
Female respondents were 47% less likely than male respondents to accept vaccines immediately. Rural respondents were 2.03 times more likely than urban respondents to accept the COVID-19 vaccine immediately. When compared to Muslim participants, Hindu participants were 3.79 times more likely to take the COVID-19 Vaccine right away. Respondents who heard about any vaccine (s) approved globally for mass inoculation had an 84% lower chance of taking the COVID-19 Vaccine immediately than respondents who did not hear about any vaccine (s) that have been approved globally for mass vaccination. Compared to unmarried people, married people had nearly twice the odds of getting vaccinated immediately. Participants who disagreed with the statement “the vaccines that are being inoculated globally are effective and safe” were 68% less likely to accept the COVID-19 Vaccine right away than those who agreed.
QUESTION
How has COVID-19 affected your personal beliefs/values in your clinical practice? Include an example.
Submission Instructions:
Your initial post should be at least 600 words, formatted and cited in current APA style with support from at least 3 academic sources
Resources:
Ethics and personal safety on the frontlines of COVID-19 Download Ethics and personal safety on the frontlines of COVID-19
Weber, E. (2020). Ethics and personal safety on the frontlines of COVID-19. American Nurse Today, 15(6), 10–11.