Journal of Vaccines & Vaccination

Attitude and Perception of Young Adults Regarding Uptake of COVID-19 Vaccine in Nepal: A Cross-Sectional Study

Rajesh Kumar Yadav^1,2, Elina Khatri³, Sujan Babu Marahatta^2,4,5, Dipendra Kumar Yadav⁶, Yadu nath Baral⁷, Jiwan Kumar Poudyal⁸, Srijana Poudel⁷, Prabin Sharma⁹, Anupama Sharma⁵, Sujata Pokhrel¹⁰ and Sushila Baral^{2,9* 1}Department of Health Sciences, Kathmandu University, BNMT Nepal, Kathmandu, Nepal
²Department of Health Sciences, Health Research Together (HeaRT) Initiatives, Kathmandu, Nepal
³Department of Health Sciences, Nepal Health Research Council, Kathmandu, Nepal
⁴Department of Health Sciences, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
⁵Department of Health Science and Technology, Nepal Open University, Lalitpur, Nepal
⁶Department of Health Sciences, School of Health and Allied Sciences, Gandaki Province, Nepal
⁷Department of Health Sciences, National Academy of Medical Sciences, Kathmandu, Nepal
⁸Department of Public Health, Shree Medical and Technical College, Chitwan, Nepal
⁹Provincial Health Training Center, Gandaki Province, Nepal
¹⁰Department of Health Sciences, Kathmandu University, Health Section, Pokhara Metropolitan City, Gandaki Province, Nepal
^*Correspondence: Sushila Baral, Department of Health Sciences, Health Research Together (HeaRT) Initiatives, Provincial Health Training Center, Gandaki Province, Nepal, Email:

Received: 22-Jun-2021 Published: 13-Jul-2021, DOI: 10.35248/2157-7560.21.12.457

Introduction

A new corona virus strain SARS-COV-2 has emerged as a global challenge to human health and invading the world [1]. With this, most heated disputes happening around the world is use of vaccine to halt ongoing COVID-19 infection. Various sources of information are available, ranging from scientific logics to social media, all of which provide inconsistent information, causing public confusion [2]. COVID-19 vaccines are permitted by a number of nations after clearing various stages of studies and trials [3]. Nepal government has also begun to roll out the COVID-19 vaccine campaign on 27th January 2021, with some hopefulness as a part of resolving the pandemic [4]. Although government provides many vaccination services in Nepal, the new launch of the COVID-19 vaccine raises questions about the acceptance of vaccines within the country [5]. Vaccines is most effective strategy and important public health measures and a game changing tool but still many questions raises about the acceptance of vaccines within the country [5,6]. Equitable access to safe and effective vaccines is critical to ending the COVID-19 pandemic, so it is hugely encouraging to see so many vaccines proving and going into development [4].

Despite of the immense efforts made by different countries and developed a safe and effective vaccine; people are hesitant to accept the vaccine [7]. For the vaccine’s acceptance by the people, many influencing factors are playing role such as knowledge and perception on the perceived likelihood of the COVID-19 spread, perceived safety of vaccine, logistics, perceived efficacy of the vaccine and perceived risk etc. It is pivotal to understand the perception of young adult on acceptance of vaccines [8]. Most portion of the country is occupied by the young people; they are the future pillars so it is foremost important to know about their perception and attitude on COVID vaccine. Thus knowing their attitude, we can formulate programs and activities to motivate them for up taking vaccine. COVID-19 cases are at peak again in different countries of world including Nepal, it is vital that vaccination must be accelerated among all the age group. Information about the attitude and perception of young people towards COVID-19 vaccine must be understood. It also raised questions on the overall general public's knowledge, attitudes and perceptions about the vaccine as results of which the outcomes of a new study undertaken to understand the attitude and perception regarding COVID-19 vaccine among young people in Nepal. Therefore, this study aims to find out the attitude and perception regarding vaccine among young people in Nepal.

Methodology

Participants and procedures

The anonymous population based online survey was conducted among young adults aged above 18 to 40 years using cross-sectional study design. The web based study applying quantitative methods was conducted among the young adults from all seven provinces of Nepal. The online survey was conducted to enroll all the young adults using cluster sampling techniques. The participation was considered as voluntary based on their self-interest to fill up the online survey questionnaire.

The semi-structured questionnaire was designed based on extensive review and incorporated into the Google survey tool (KOBO toolbox) and a shareable link was generated. Then, the link was shared through various social media such as Facebook, Instagram, Twitter, Gmail and LinkedIn webpage site. Similarly, questionnaire was shared among contact lists of the investigators as well as research assistants. The online approach was used as an alternative to face-to-face data collection during pandemic situation.

Sampling procedures

The sample size was computed using single proportion based on Cochrane’s formula. Since there was no prior similar research study on knowledge, attitude and practice’s regarding COVID vaccine proportion, so it was assumed as 0.5. With 5% margin of error and 95% confidence interval. The sample size was computed as 390. This sample size was obtained proportionately based on total population in each province. Among all seven provinces, 64 participants were enrolled from province 1; 82 from province 2; 83 from Bagmati province, 34 from Gandaki province; 66 from Lumbini province; 24 from Karnali province and 37 from Sudurpaschim province. Those young adults aged 18 to 40 years and who were not vaccinated with COVID vaccine till now was included in the study. In the survey form, question was kept to screen the vaccinated and unvaccinated young adults.

Measures

The semi-structured questionnaire consisting socio-demographic characteristics, knowledge, attitude and perception related to COVID vaccine was used for data collection through self- administration. The questionnaire was developed based on extensive literature search and was then translated in national language (Nepali). The Google forms were created including all the questionnaire of the study. The online questionnaire was shared with participants through various websites. The validity of the tool was maintained by consulting with subject experts in each stage of research design and tools development. The final tool was then pretested among 10% (n=39) of participants using the survey tool through email and messenger. The social media was used to promote online survey by increasing the access of maximum number of participants.

Socio-demographic characteristics

The questions related to socio-demographic characteristics such as age, sex, marital status, educational status, family type, monthly family income and current residence were asked during the survey.

Knowledge, attitude and perceptions

All questions in this section were based on validated tools used in previous literature. The level of knowledge, attitudes, and perceptions was assessed based on total items of questions in the respective section. The score less than or equal to 10 was considered as unfavourable whereas above 11 was considered as favourable attitude. Likewise, score less than or equal to 5 was considered as unsatisfactory whereas score greater than 5 was considered as satisfactory.

Statistical analysis

Data collected was exported to excel format and cleaned for any inconsistency. Data was analyzed using SPSS V 16 software. The composite score was computed for knowledge, attitude and perceptions section for calculating actual score. The final score was interpreted based on the range.

Ethical considerations

The ethical approval for the study was obtained from Institutional Review Board (IRC) of Manmohan Memorial Institutes of Health Sciences (MMIHS). The informed consent was obtained from each participant prior data collection. The participation on the study was voluntary based on their self-interest. The rationale, expected benefits and possible harms regarding the study was explained to participants. The privacy and confidentiality of data was maintained to the extent possible.

Results

The mean age of the respondents was 24.70 ± 5.11 years, ranging from 19 to 40 years. More than one-third (37.9%) of the respondents were male. Majority (94.1%) of the respondents followed Hinduism. More than one-fourth (27.2%) of respondents were married. Majority (87.9%) of the respondents were staying with family during the lockdown. Around one-third (31%) of the respondents were enrolled in health insurance. Majority (79.2%) of the respondents had received all necessary vaccines in lifetime. Majority (90%) of the respondents had fear of COVID-19. More than one-tenth (14.1%) of respondents didn’t know about the COVID-19 vaccine. Majority (73.6%) of respondents know about effectiveness of COVID 19 vaccine (Table 1).

Table 1: Knowledge on COVID-19 vaccine.

Table 2 showed more than half (53.1%) of the respondents had favourable attitude towards COVID 19 vaccine. More than two- third (72.8%) of the respondents had favourable perception.

Table 2: Categorization of the variables.

In bivariate analysis, age, faculty of study, enrolled in Health insurance were found statistical associated with perception (p<0.05), as presented in Table 3. Fear from COVID-19 was significantly associated with perception on COVID vaccine. Participants who had got information through Internet were 1.71 times more likely to had favourable perception towards COVID vaccine. (p 0.018, OR 1.718, 95% CI 1.095-2.694) is illustrated in Table 4. Ethnicity, education was found statistical associated with attitude. With reference to respondents who had informal education, the odds were 3.16 times higher among the respondents who had formal education, as presented in Table 5. Know about COVID vaccine, effectiveness of COVID vaccine, know about allergic reaction were found statistical significant with attitude (p<0.05) (Table 6).

Table 3: Bivariate analysis of socio-economic variables and perception on COVID-19 vaccine.

Table 4: Bivariate analysis on COVID-19 related Information and perception on COVID-19 vaccine.

Table 5: Bivariate analysis on Sociodemographic variables and attitude on COVID-19 vaccine.

Table 6: Bivariate analysis on COVID-19 related Information and attitude on COVID-19 vaccine.

In multiple logistic regression analysis, faculty of study, enrolled in health insurance, fear from COVID-19, information through internet was found significantly associated with perception on COVID vaccines (p<0.05). Respondents who were enrolled in health insurance were 1.76 times more likely to had favourable perception compared to not enrolled participants (Table 7). Education status, vaccine increase allergic reaction were significantly associated with attitude towards COVID-19 vaccine (P<0.05). With reference to respondents who had informal education, the odds were 2.682 times higher among the respondents who had formal education, as presented in Table 8.

Table 7: Multiple logistic regression analysis with perception on COVID-19 vaccine.

Table 8: Multiple logistic analysis of different variables and attitude on COVID-19 vaccine.

Discussion

The findings reflect that a wide range of socio-demographic factors influence the attitudes and perceptions towards COVID-19 vaccine.

Attitude

Importantly, the finding from our study is similar with study from Bangladesh, Italy and China demonstrating that the over half of participants showed positive attitude towards COVID-19 vaccine [2,3,9]. Upper caste groups were 1.332 times more likely to possess favourable attitude on COVID-19 vaccine as compare d to other groups. In line with our finding, a study from UK also showed that distrustful attitudes towards vaccination were higher amongst individuals from ethnic minority backgrounds [10]. Compared to those with informal education, respondents having formal education were 2.682 times more likely to have favourable attitude towards COVID-19 vaccine which is related with finding from UK [10]. With support to this, a study from China also showed that majority of the college student were having favourable attitude and were willing to accept a COVID-19 vaccine in near future. More interestingly it showed that those studying health related course were more likely to own positive attitude towards COVID-19 vaccine [9]. On other hand, a study showed that although educational background had no influence on willingness to take the vaccine, those with a tertiary education were more likely to believe that the vaccine will protect the people who take it [11]. Further, in US studies people with a bachelor’s degree or higher were more likely to be willing to get vaccinated [12,13]. A scoping review revealed that educational status is significantly associated with attitude towards Covid-19 vaccine [14]. As review concludes that, as knowledge about COVID-19 vaccines is limited as illustrated in numerous studies [14], majority of the young people in our study also had inadequate knowledge about the COVID-19 vaccine. This inadequacy of information on COVID-19 vaccinations found in our study could be possibly due to limited government exposures to information or publicity on COVID-19 vaccinations since the vaccine rollout started. Respondents who are known about COVID-19 vaccine were 1.406 times more likely to have favourable attitude towards COVID-19 vaccine compared to those who do not know. Further, those who are known about effectiveness of COVID-19 vaccine are 1.565 times more likely to have favourable attitude towards COVID-19 vaccine as compared to those who don’t know. Regarding increase of allergic reaction by vaccine, as compared to those who replied no, respondents who replied with yes were 0.540 times more likely to have favourable attitude towards COVID-19 vaccine. In support to our findings, a study from UK showed that those who were having poor knowledge on Covid-19 had unfavourable attitude towards COVID-19 vaccine [10]. It’s well established that a lower level of education and knowledge of vaccinations is associated with vaccine hesitancy [15]. Good knowledge about COVID-19 and vaccination were also found to be significantly linked with positive attitude and vaccine acceptability in Bangladesh [16]. Additionally, a study from China showed that people who heard previously about COVID-19 vaccines believed that vaccines are safe and thought that vaccines can protect people from being infected with COVID-19 were having favourable attitude towards COVID-19 vaccine [9]. The rationale behind this might be that more knowledgeable people concerned about their health and well-being, through access to more information sources, and become more engaged in life events that might impact them, such as COVID-19 vaccinations [17].

Perception

Majority of the respondents have favourable perception towards COVID-19 vaccine in our study which is in line with the finding from Australia [18]. Vaccine hesitancy could be a risk to the accomplishment of COVID-19 vaccination programs. Findings of our study shows that, young people (18-30 years) as compared to adult (30-40 years) were 1.345 times more likely to have favourable perception towards COVID-19 vaccine. Similar findings was found in study done in UK which showed that young people (ages 18-29) were significantly less likely than older adults to possess negative attitudes towards COVID-19 vaccine [10]. Additionally, a scoping review also concluded that age is important factor determining person’s attitude towards COVID-19 vaccine [14].

Further, as compared to those from non-health science background, respondents belonging to health science background were 1.712 times more likely to have favourable perception towards COVID-19 vaccine. Similar findings was showed in study done in China which showed that those studying health-related courses were 1.581 more likely to have a positive attitude toward COVID-19 vaccines [9]. Further, this finding is similar to that of a study conducted at medical schools in the US [19]. Favourable perception towards COVID-19 vaccine among those studying health-related courses compared to those in other courses may be attributed to higher awareness of the importance of COVID-19 vaccines in disease prevention [20]. In addition, many students enrolled in health- related courses are required to visit medical institutions such as hospitals and primary care clinics on a regular basis. As a result, they believe their risk of infection is larger than that of other students, and that they have a greater need for immunization to protect their health. However, another study in Italy did not find any differences between healthcare and non-healthcare students [21]. Such discrepancy could be because of different study periods i.e. beginning or later part of COVID-19 pandemic.

In the present study, those enrolled in health insurance were found to be 1.767 times more likely to had favourable perception towards COVID-19 vaccine as compared to those not enrolled which corresponds with the findings of the study of Australia which showed those who held private health insurance had positive perception towards COVID-19 vaccine [18].

A key determining factor in people's decision to get vaccinated is the risk they relate with the disease which the vaccine protects [22,23]. In our study, those who had fear from COVID-19 had favourable perception towards COVID-19 vaccine as compared to those who do not fear with COVID-19. This means we can say that people having fear of contracting COVID-19 intent to get vaccinated if made available by government which corresponds with finding of study from US which showed that US respondents who rated the disease higher on a risk perception index more often reported that they would accept a COVID-19 vaccine [24]. Research also shows that individuals who perceive the risk of contracting a vaccine- preventable disease as low, consider the symptoms of the disease as mild, and worry little about the disease, report less intent to take the vaccines and more often remain unvaccinated [22,23,25-27].

Receiving misguided facts regarding the COVID-19 vaccine by the general public is probably going to come up with unfavourable perception and increase hesitancy among the public to be vaccinated [28]. In our study, comparing to those who do not get information about COVID-19 vaccine from internet, those who get it from internet were 1.665 times more likely to had favourable attitude towards COVID-19 vaccine. This could be related with the practice that most of the information nowadays regarding COVID-19 and COVID-19 vaccine are being sharable worldwide through internet.

Conclusion

The findings reflect favourable attitude among half of the respondents but more favourable perception towards vaccine among the young adult in Nepal. Vaccine safety and its efficacy should be disseminated through the public domain which is trustable to change the attitude of the young adult, information about the vaccines and its consequences should be clearly stated. Efforts must be made to restrain the spread of misinformation about the vaccine. Interventional educational campaign through internet regarding vaccine should be focused targeting non-health sciences background people to avoid low inoculation rates.

Acknowledgement

RKY, EK, DKY, SBM, JKP, SP and SB research conceptualization. RKY, EK, AS, SP, PS, YNB, SP, and SB: supervised the data collection and writing-original draft. RKY, AS, SB, YNB and SP: formal analysis. RKY, SBM, DKY, JKP, YNB and SP: writing review and editing. All authors read and approved the final manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

REFERENCES

1. WHO. The effects of virus variants on COVID-19 vaccines. 2021.
2. Biasio LR, Bonaccorsi G, Lorini C, Pecorelli S. Assessing COVID-19 vaccine literacy: A preliminary online survey. Hum Vaccin Immunother. 2021;17(5):1304-1312.
3. Islam MS, Siddique AB, Akter R, Tasnim R, Sujan MS, Ward PR et al. Knowledge, attitudes and perceptions towards COVID-19 vaccinations: a cross-sectional community survey in Bangladesh. medRxiv. 2021.
4. WHO. Nepal story on COVID-19 vaccine deployment: a good start. 2021.
5. Poudel A. Vaccine hesitancy poses challenge for Nepal’s campaign against Covid-19. Kathmandu Post. Health. 2021.
6. Islam MdS, Siddique AB, Akter R, Tasnim R, Sujan MS, Ward PR et al. Attitudes and perceptions towards COVID-19 vaccinations: a cross-sectional community survey in Bangladesh. medRxiv. 2021.
7. Harrison EA, Wu JW. Vaccine confidence in the time of COVID-19. Eur J Epidemiol. 2020;35(4):325-330.
8. Lazarus JV, Ratzan SC, Palayew A, Gostin LO, Larson HJ, Rabin K, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nat med. 2021;27(2):225-228.
9. Bai W, Cai H, Liu S, Liu H, Qi H, Chen X et al. Attitudes toward COVID-19 vaccines in Chinese college students. Int J Biol Sci. 2021;17(6):1469-1475.
10. Paul E, Steptoe A, Fancourt D. Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. Lancet Reg Health Eur. 2021;1:100012.
11. Cordina M, Lauri MA. Attitudes towards COVID-19 vaccination, vaccine hesitancy and intention to take the vaccine. Pharm Pract (Granada). 2021;19(1):2317.
12. Guidry JP, Laestadius LI, Vraga EK, Miller CA, Perrin PB, Burton CW et al. Willingness to get the COVID-19 vaccine with and without emergency use authorization. Am J Infect Control. 2021;49(2):137-142.
13. Szilagyi PG, Thomas K, Shah MD, Vizueta N, Cui Y , Vangala S et al. A. National trends in the US public’s likelihood of getting a COVID-19 vaccine—April 1 to December 8, 2020. JAMA. 2021;325(4):396-398.
14. Al-Jayyousi GF, Sherbash MA, Ali LA, El-Heneidy A, Alhussaini NW, Elhassan ME et al. Factors Influencing Public Attitudes towards COVID-19 Vaccination: A Scoping Review Informed by the Socio-Ecological Model. Vaccines. 2021;9(6):548.
15. Ferdinand KC, Nedunchezhian S, Reddy TK. The COVID-19 and Influenza “Twindemic”: barriers to Influenza vaccination and potential acceptance of SARS-CoV2 vaccination in African Americans. J Natl Med Assoc. 2020;112(6):681-687.
16. Mahmud S, Mohsin M, Khan IA, Mian AU, Zaman MA. Acceptance of COVID-19 vaccine and its determinants in Bangladesh. arXiv. 2021;2103:15206.
17. Mirowsky J, Ross CE. Education, personal control, lifestyle and health: A human capital hypothesis. Res Aging. 1998;20(4):415-449.
18. Seale H, Heywood AE, Leask J, Sheel M, Durrheim DN, Bolsewicz K et al. Examining Australian public perceptions and behaviors towards a future COVID-19 vaccine. BMC Infect Dis. 2021;21(1):1-9.
19. Lucia VC, Kelekar A, Afonso NM. COVID-19 vaccine hesitancy among medical students. J Public Health. 2020.
20. Albaqawi HM, Alquwez N, Balay-Odao E, Bajet JB, Alabdulaziz H, Alsolami F et al. Nursing students' perceptions, knowledge, and preventive behaviors toward COVID-19: A multi-university study. Front Public health. 2020;8:573390.
21. Barello S, Nania T, Dellafiore F, Graffigna G, Caruso R. ‘Vaccine hesitancy’among university students in Italy during the COVID-19 pandemic. Eur J Epidemiol. 2020;35(8):781-783.
22. Thomson A, Robinson K, Vallée-Tourangeau G. The 5As: A practical taxonomy for the determinants of vaccine uptake. Vaccine. 2016;34(8):1018-1024.
23. Betsch C, Schmid P, Heinemeier D, Korn L, Holtmann C, Böhm R. Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination. PloS One. 2018; 13(12): e0208601.
24. Malik AA, McFadden SM, Elharake J, Omer SB. Determinants of COVID-19 vaccine acceptance in the US. EClinicalMedicine. 2020; 26: 100495.
25. Schmid P, Rauber D, Betsch C, Lidolt G, Denker ML. Barriers of influenza vaccination intention and behavior–a systematic review of influenza vaccine hesitancy, 2005–2016. PloS One. 2017; 12(1): e0170550.
26. Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND. Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol. 2007;26(2):136-145.
27. Bish A, Yardley L, Nicoll A, Michie S. Factors associated with uptake of vaccination against pandemic influenza: a systematic review. Vaccine. 2011;29(38):6472-6484.
28. Su Z, Wen J, Abbas J, McDonnell D, Cheshmehzangi A, Li X. A race for a better understanding of COVID-19 vaccine non-adopters. Brain Behav Immun Health. 2020:100159.