Determinants of COVID-19 Vaccine Hesitancy: A Cross-Sectional Study in Three Communities in the United States and Lebanon

1. Introduction

Vaccination has been extremely important to control COVID-19 infection since immunization is one of the most effective and affordable health strategies to prevent infectious diseases. Despite the record time in which the various COVID-19 vaccines were developed and the clinical trials were conducted [1,2], the vaccine rollout was not always as swift. Efforts to achieve widespread vaccination were stalled by several social, economic, and political factors [3,4,5], and one of the most notable obstacles was reluctance to receive the vaccine [6]. Several studies have looked at COVID-19 vaccine acceptance rates and have found that the numbers vary greatly by geographical region and population type [7]. In a global survey [8], the percentage of adults willing to receive the COVID-19 vaccine was higher in low- and middle-income countries (average of 80.3%) compared to the United States (64.6%) and Russia (30.4%). Among low- and middle-income countries, the lowest acceptance rates were observed in Burkina Faso and Pakistan (66.5%), while the highest were in Nepal (96.6%) and Mozambique (89.1%).

A number of studies have looked at the factors contributing to vaccine acceptance [9,10,11]. Higher perceptions of COVID-19 severity, increased likelihood of being infected, positive perceptions of protective behaviors against COVID-19 in the community, and self-engagement in protective behaviors against COVID-19, are all factors that influenced vaccination receptivity positively [12]. Married status, male sex, receiving the seasonal influenza vaccination, and valuing a physician’s recommendations were additional factors contributing positively to vaccine acceptance [13]. Race and a rising perception of the vaccine's risks were factors that made people less eager to get immunized [12].

While reports on vaccine uptake from the United States are abundant, data from Lebanon are much scarcer. To our knowledge, there are no studies that examine the awareness, perceptions, and attitudes towards the COVID-19 vaccines among adults in Lebanon. The aim of this study is to compare the determinants of COVID-19 vaccination in the United States and Lebanon. Identifying factors associated with vaccination hesitancy will help in addressing the challenges of vaccine uptake and would inform vaccination campaigns at the local and international levels.

2. Materials and Methods

Study design and setting: We conducted a cross-sectional survey between March 2021 and June 2021 in three major urban areas in the United States and Lebanon served by university medical centers: Case Western Reserve University in Cleveland, OH, Spectrum Health at Michigan State University College of Human Medicine in Grand Rapids, MI, and the American University of Beirut Medical Center in Beirut, Lebanon. In the United States, the survey was disseminated electronically via ResearchMatch.org, a disease-neutral, web-based recruitment registry while in Lebanon, surveys were sent using LimeSurvey. The catchment population included members of the general public, healthcare workers, and university students.

Survey: The survey included socio-demographic data, health-related characteristics, knowledge questions about COVID-19 infection and vaccine, as well as perceptions and attitudes towards COVID-19 infection and vaccine. To assess COVID-19 knowledge, a 10-item True-False questionnaire was included in the survey. Questions were prepared based on publicly available information available on the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) websites. A knowledge score was calculated for each respondent based on the number of questions answered correctly. For the primary endpoint variable pertaining to vaccination intent, respondents to the question “I am willing to take the COVID-19 vaccine” could select only one of four possible options: (1) definitely yes (2) undecided/likely (3) undecided/unlikely (4) definitely no. Vaccine hesitancy was defined as any answer other than “definitely yes”.

Statistical analysis: Survey data analysis was performed using IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL, USA). For categorical variables, the Chi-square test was used to compare the baseline characteristics, knowledge, perceptions, and attitudes in the US and Lebanese cohorts. For the continuous variable of knowledge score, the independent samples t-test was used to compare the means in the two groups. In each cohort, multivariable backward logistic regression was used to calculate adjusted odds ratios (aOR) and their 95% confidence intervals (CI) in the evaluation of independent associations between the different variables and vaccine hesitancy. Variables were included in the logistic regression model if the p-value on bivariable analysis was ≤ 0.20.3.

4. Discussion

Administering a cross sectional survey to over 7,000 individuals across three communities in two countries has allowed us to identify the major determinants of vaccination uptake and vaccination refusal during the peak months of the COVID-19 pandemic. During the timeframe of this study (April 2021 – June 2021), a gradually rising proportion of the population in both countries had access to COVID-19 vaccines, yet a significant fraction seemed reluctant to receive the vaccine. Therefore, estimating vaccine hesitancy and its underpinnings is important in informing future vaccination campaigns.

Reports from the United States place the vaccine acceptance rate between 60% and 75% [8,12,14]. In Lebanon on the other hand, where the studies are fewer, the numbers are much more varied, ranging from a low of 21.4% to as high as 87% [15,16]. We found a high acceptance rate of 87.8%, which was similar in both groups. However, vaccine rejection was more prevalent among US participants (4.6% vs. 1.2%), with the Lebanese participants being more on the undecided side.

Misinformation regarding COVID-19 vaccines is rampant. In a national study in the United States, people who doubted the safety of the COVID-19 vaccine thought that it will be used to control people, to track their locations, or to change human DNA [17]. In our study, most respondents in both cohorts had similar misinformation, with only around 7-13% having correct knowledge about the vaccine. Knowledge, or lack of it, is an important, albeit non-sufficient factor that determines an individual’s perception of risk. This is particularly important when there is conflicting information available. Based on the ambiguity aversion theory, a person who receives conflicting information is unable to assign risk appropriately. In addition, a “known”, even if it carries a higher risk, is better perceived than an “unknown” which is safer [18]. This emphasizes the importance of combatting misinformation and providing people with venues through which they could acquire appropriate and accurate knowledge.

When asked about attitudes and perception about COVID-19 infection and vaccine, most study subjects believed in the benefit of routine vaccinations and in the effectiveness of vaccines in controlling transmissible diseases. This COVID-19 vaccination concerns are particular to this vaccine and are not related to an anti-vaccine sentiment. The fact that a significant proportion of subjects believed that the COVID-19 vaccine development was rushed serves as a further confirmation that people are uniquely concerned about this vaccine. It is an incontrovertible fact that the COVID-19 vaccines were the fastest vaccines ever to be developed; some people may therefore assume that safety was overlooked in favor of efficacy [10]. In one study, vaccination acceptance was more likely if the amount of time spent in clinical trials increased [19]. Since there is considerable mistrust in the pharmaceutical industry [20,21], it becomes incumbent upon the healthcare providers to explain the science to the general public and to assuage undue concerns about safety. Indeed, most respondents in our study stated that they would get the COVID-19 vaccine if their healthcare provider recommended it. Another aspect that complicates the perception of the general public is the use of social media. We found that a large proportion of our study subjects (more in the US cohort than the Lebanese cohort) obtained their health information from social media. In a recent narrative review, COVID-19 vaccine hesitancy correlated positively with reliance on social media as a source of information [22]. Given its powerful influence, it is therefore important to use social media as a means of disseminating reliable scientific information in lieu of its use to propagate conspiracy theories.

The independent determinants of vaccine hesitancy were more extensive in the US cohort, mainly because of the larger sample size, but all of the variables in the Lebanese regression model also featured in the US model and in the same order of importance. The 3C model of vaccine hesitancy was first introduced in 2015 where Confidence, Complacency, and Convenience are used to classify the underpinnings of vaccine hesitancy [23]. Looking at our results, the variable having the strongest association with hesitancy (COVID-19 vaccine being more dangerous than the infection) falls within the Complacency category. Therein is a perception that the vaccine is not needed, i.e. that the risk posed by the infection does not justify the potential risk incurred by the vaccine. Another variable from the US regression model (COVID-19 infection does not worry me) is also in the same category. In the study by Kricorian et al., 20% of Americans questioning the safety of the vaccine thought that the pandemic is being exaggerated, and 14% thought that the vaccine is not needed [17]. In another report from the United States, the perception of high risk of acquiring the infection, high severity of the infection, and high effectiveness of the vaccine were all predictive of vaccine acceptance [12]. This is also consistent with data published from Lebanon [24,25]. The remaining important variables in our models (healthcare provider advice, rushed vaccine development, laboratory origin of the virus) all relate to Confidence, which refers to the trust in the healthcare system and its agents. Numerous studies have established that mistrust in health systems is a powerful deterrent to vaccination [6,26,27]. In a Turkish study looking at the psychological factors affecting COVID-19 vaccine hesitancy, participants who believed in conspiracy theories were less likely to accept vaccination [28]. In addition, a recent large survey from the United States reported that individuals who rejected the vaccine often attributed their decision to categorical beliefes against vaccination (termed “dissent”) or to cynicism towards the government or medical establishment (termed “distrust”) [29]. Interestingly, being a healthcare worker does not necessarily correlate with increased trust in the health system. Studies have revealed that healthcare workers who were not willing to get vaccinated believed in the rushed vaccine development [30] and questioned the reliability of the vaccine manufacturers as well as the novelty of the vaccines [31]. Despite an apparent lack of trust in the system, our study suggests that the participants have a high level of trust in their healthcare providers, seeing that a positive vaccine recommendation would increase the willingness to receive the vaccine, whereas a negative recommendation would have the opposite effect. This is consistent with the literature, where a positive and trusting relationship with healthcare providers was shown to boost vaccine acceptance [32,33]. As for Convenience, the third element of the 3C model which refers to difficulties in obtaining the vaccine, our survey did not address vaccine access issues, which prevents us from making any conclusions regarding their effect.

The main limitation of our study is that it used a convenience sample, indicating that it might not be totally representative of the American and Lebanese societal behavior. However, this is, to our knowledge, one of only a few studies that directly compared a population from a developed country to that from a developing country using the same instrument.

5. Conclusions

We found a relatively low vaccine hesitancy rate among US and Lebanese respondents. A number of determinants of hesitancy were identified, the most important of which are perception of high risk from the vaccine and negative vaccine recommendation by healthcare workers, whereas a positive recommendation by healthcare workers was associated with decreased hesitancy. Despite the obvious sociobehavioral differences between the US and Lebanese cohorts, the factors associated with hesitancy were similar for the most part in the two populations. The identified determinants could serve to inform vaccination programs in order to curb vaccination hesitancy.