|Year : 2021 | Volume
| Issue : 1 | Page : 28-35
Attitude towards COVID-19 vaccine among the general public in south India: A cross sectional study
Ganga Raju Godasi1, Raj Kiran Donthu2, Abdul Salaam Mohammed2, Ravi Sankar Pasam3, Sri Lakshmi Tiruveedhula4
1 Associate Professor, Department of Psychiatry, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India
2 Assistant Professor, Department of Psychiatry, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India
3 Professor and Head, Department of Psychiatry, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India
4 Post Graduate, Department of Respiratory Medicine, NRI Institute of Medical Sciences, Visakhapatnam, Andhra Pradesh, India
|Date of Submission||19-Mar-2021|
|Date of Acceptance||20-Apr-2021|
|Date of Web Publication||01-Jun-2021|
Dr. Raj Kiran Donthu
Department of Psychiatry, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram - 533 201, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Coronavirus disease-19 (COVID-19) is a novel infection that sets off a pandemic in a short period. Research has been going on to develop safe and effective vaccines and around 150 are in the process of development. In India, two vaccines have been given emergency approval. There has been a rise in hesitancy toward vaccination not only in India but also worldwide.
Materials and Methodology: The study included 697 participants who were not vaccinated. The study questionnaire was administered through online Google Forms and included informed consent, sociodemographic details, questions related to COVID-19 infection and vaccine, and vaccine attitude examination (VAX) scale.
Results: Among the 697 participants, 216 (31%) were not willing to get vaccinated. Those with prevailing mental (P = 0.011) or physical health (P < 0.001) problems were of negative opinion toward vaccination because of unforeseen complications. Participants with lower education (P = 0.041), skilled to semi-skilled job (P = 0.028), and joint family (P = 0.006) opined that vaccination was more of commercial profiteering for manufacturing companies. Participants who were married (P = 0.010) and living in a joint family (P = 0.009) setting were more inclined toward a preference for natural immunity.
Conclusion: The study highlights that 69% of participants were willing to take the COVID-19 vaccine. Various measures can be taken by different stakeholders to improve the positive attitude. As medical professions, we can improve the positive attitude by actively taking the vaccine and educating the local people about the benefits.
Keywords: Coronavirus disease-19 vaccines, coronavirus disease-19, vaccines
|How to cite this article:|
Godasi GR, Donthu RK, Mohammed AS, Pasam RS, Tiruveedhula SL. Attitude towards COVID-19 vaccine among the general public in south India: A cross sectional study. Arch Ment Health 2021;22:28-35
|How to cite this URL:|
Godasi GR, Donthu RK, Mohammed AS, Pasam RS, Tiruveedhula SL. Attitude towards COVID-19 vaccine among the general public in south India: A cross sectional study. Arch Ment Health [serial online] 2021 [cited 2021 Jun 19];22:28-35. Available from: https://www.amhonline.org/text.asp?2021/22/1/28/317419
| Introduction|| |
Coronavirus disease-19 (COVID-19) is caused by a novel coronavirus that originated in Wuhan city of China in late 2019. Due to its widespread nature, the World Health Organization declared it a pandemic on March 11, 2020. The disease infected nearly 10 million people and caused 21 lakh deaths worldwide, with the United States of America having the highest infected cases followed by India. India had reported more than 1 million cases and more than 1.73 lakh deaths.
While the pandemic was still ongoing, scientists and organizations worldwide were working to develop safe and effective vaccines to control the infection. More than one hundred fifty candidate vaccines are under development as of this date. Meanwhile in India, two vaccines have been given emergency approval by the Government of India for use. They were “Covishield” which was developed by Oxford-AstraZeneca and “Covaxin” developed by Bharat Biotech. India started vaccinating the health-care workers on January 15 and as of March 15, 2021, nearly 30 million have been vaccinated with at least one dose.
The Government of India announced that it is committed to vaccinating every citizen and is taking the necessary steps to achieve the mammoth task. Amidst all of this, there is a rise in anti-vaccine sentiments. This is not a new phenomenon and there have been such protests in the past, but recently over the COVID-19 vaccine, there has been such vaccine hesitancy even in countries such as Japan and Brazil. In India, there were reports of hesitancy to take vaccines among frontline health workers.
The vaccine role out for the general public has begun since few days and there have already been newspaper reports and social media posts that people are hesitant to take the vaccine., Various reasons were quoted for the anti-vaccine sentiments; some of them were concerning vaccine safety and efficacy, nontransparency of the vaccine clinical trials, sporadic reports of mortality following vaccine administration, and poor understanding of the basic disease pathophysiology.
To the best of our knowledge, currently, there is a lack of scientific literature addressing whether anti-vaccine sentiments for the COVID-19 vaccine exist in our setting. We naturally expect people to be open to the vaccine when the government is forthcoming about the safety and efficacy. The study is an attempt to study the willingness of the general public to take COVID-19 vaccine.
| Materials and Methodology|| |
- To study the general public's willingness to take the COVID-19 vaccine and their attitude toward vaccination
- To study the reasons for people not taking the COVID-19 vaccine.
Setting and design
The study was started after reviewing and obtaining permission from the ethics committee. It was a cross-sectional study conducted with the help of an online questionnaire. The questions were designed as per the study aims; it included an informed consent sheet, sociodemographic details, questions related to vaccine hesitancy or reluctance and reasons for the same, and a vaccine attitude examination (VAX) scale. Google Online Forms were created and used for the dissemination of the questionnaire. A link was created which was then shared with friends, relatives colleagues, and other contacts. They were then requested to share with their contacts; snowballing techniques were used for sample collection.
The informed consent sheet included all the details of the study, including the contacts of the investigators in case of any clarification. After the individual had accepted the consent for the study, the study-related questionnaire was opened.
Sociodemographic details included basic details such as age, gender, religion, place of stay, education, and occupation. It also included questions on knowledge about COVID-19 disease and the COVID-19 vaccine. If the participant had already been vaccinated, then they were only asked “whether they would recommend others to take the vaccine”?
VAX scale: This is a 12 item scale created by Martin and Petrie in 2017. This scale helps in identifying the vaccination resistance. The scale assesses the attitude of participants in general to a vaccine, rather than being specific to COVID-19. It has four domains, which help in a nuanced understanding of the nature of the views. The domains are mistrust of vaccine benefit, worries about unforeseen future effects, concerns about commercial profiteering, and preference for natural immunity. Each question is scored on a 6-point Likert scale as; “1” for strongly agree to “6” for strongly disagree. A higher score indicates higher negative attitudes in the domain. Each domain is grouped into high, intermediate, and high levels of negative attitudes toward vaccines. Permission to use the scale has been obtained from the primary author, Ms. Leslie R Martin through e-mail.
The data were obtained in a comma-separated values format from the Google Online Forms. The data were initially cleaned for any missing or ill-fitting data. A total of 1212 responses were received: 459 have already received the vaccine and 753 have not received between the 1st week of February to the 1st week of March 2021. Among 753, 56 responses had missing data and were hence excluded. Finally, 697 were included for the analysis. The data were analyzed using R language with R studio integrated development environment. In R language, the packages used for analysis were “summarytools,” “dplyr,” and “ggplot2.” Descriptive analysis was done to get percentages, means, and standard deviations. Inferential analysis was done using the Student t-test and analysis of variance.
| Results|| |
Sociodemographic details [Table 1]: Nearly 60% of the participants belong to the age group of 20–35 years. There was a nearly equal number of males and females. Hindus constitute 85% of the sample. Twenty-seven percent of the participants identified themselves as not having religious beliefs. Seventy-two percent of the sample hail from an urban background, 40% of the participants were married, the majority (57%) of the sample had under graduation as highest educational qualification, and 44% of the sample were unemployed (which included students, retired personnel, and house makers). Sixty-four percent of the participants live in a nuclear family type of setting. Persons reporting to have mental and physical illness were found to be 3.6% and 9.8%, respectively. The details of the mental and physical illness were not recorded. The majority (78%) of the participants belonged to Telugu speaking that is Telangana and Andhra Pradesh, followed by 15% from Karnataka and the rest from Kerala and Tamil Nadu.
Questions related to COVID-19 disease and vaccine [Table 2]: We included questions related to both COVID-19 disease and vaccine. For those who were vaccinated, we asked them whether they would recommend others to get vaccinated. Among the 459 vaccinated participants, only 6% were not willing to recommend others to get vaccinated. Details of their choice were not explored.
|Table 2: Questions related to coronavirus disease-2019 disease and vaccine|
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Among the 697 nonvaccinated participants; two-third (67%) were willing to get vaccinated and 1.3% were not sure. Thirty-six percent have received some of the other vaccines (like tetanus toxin, hepatitis, or flu) in the recent past; only 3% refused to take the vaccine in the recent past; 93% reported having adequate knowledge regarding COVID-19 infection; 15% were infected by COVID-19; 81% of the study population felt that health-care personnel handled the pandemic well; and 98% adhered to the COVID-19 precautionary guidelines imposed by the central government.
Distribution of the sample in the VAX domains [Table 3]: Among the different VAX domains, the high negative attitudes were reported due to worries over unforeseen future consequences (51%) followed by a preference for natural immunity (37%). In the other domains, the high negative attitudes were due to 9% in mistrust of vaccine benefit and 22% in concerns about commercial profiteering with vaccine administration.
|Table 3: Vaccine attitude examination-2019 domains distribution of negative attitudes|
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Comparison of sociodemographic details with VAX scale domains [Table 4]: There was no significant association between the demographic details with the mistrust of vaccine benefit. There was a significant association between the presence of any mental or physical illness with the worries over unforeseen future effects of the vaccine. Those participants with the presence of mental (mean = 4.80, P = 0.011) or physical illness (mean = 4.61, P < 0.001) have significant negative attitudes toward unforeseen future effects of the vaccine. There was a significant association between educational status, occupation, and family type with the concern about commercial profiteering of vaccines. Those participants who were educated only up to high school education (mean = 4.53, P = 0.041); working as a skilled laborer (mean = 4.04, P = 0.028); or staying in a joint family (mean = 3.62, P = 0.006) have reported higher negative attitudes than others. There was a significant association between marital status and family type with the preference for natural immunity. Married participants (mean = 3.91, P = 0.010) and those staying in a joint family type (mean = 4.03, P = 0.009) of setting have higher negative scores.
|Table 4: Comparison of sociodemographic variables with vaccine attitude examination scale|
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Comparison of COVID-19 related questions to VAX scale domains [Table 5]: There was a significant association between those not willing to take COVID-19 vaccine with mistrust of vaccine benefit (mean = 3.37, P < 0.001), worries about unforeseen effects (mean = 4.50, P < 0.001), and preference for natural immunity (mean = 4.05, P = 0.009). There was also a significant association between those participants who have not received any recent vaccine with the worries about unforeseen effects (mean = 4.33, P = 0.024) and concern about commercial profiteering (mean = 3.50, P = 0.017).
|Table 5: Comparison of coronavirus disease-2019-related questions to vaccine attitude examination scale|
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| Discussion|| |
The vaccine race has led to the development of many effective and safe candidates in a short period. In the past, vaccine development used to be a laborious process taking many years of hard work, but with the advancement in genomics and structural biology, scientists were able to develop a vaccine in a short period. India is playing a strategic role in mass production and at the same time supplying them to the other nations. Along with the diplomatic distribution to other nations, there is an equal effort going on to vaccinate all the citizens. The vaccine rollout has been going in a phased manner, initially involving the frontline warriors and then slowly inoculating the general public.
Studies on COVID-19 vaccine acceptance have reported various rates of willingness to take the vaccine: an online survey in a French representative population reported 74%, an United States household-based survey reported 89%, a nationwide survey in New Zealand reported 87%, a cross-sectional study in the United Kingdom reported 86%, and an online survey in Australia reported 95%. We find the same to be 69% in the current study. Probably, the acceptance rates are lower in the current study. Various reasons have been cited for unwillingness to take vaccine which includes concerns over the safety and efficacy of the vaccine, anti-vaccine attitudes, requiring additional information, mistrust of the vaccine manufacturers, and lack of transparency in vaccine trials. In the current study, the most common reasons were “side effects or adverse events due to vaccine” (32%), “wait for others to get vaccinated then take a decision” (12%), “prevailing health issues” (9%), and “vaccine is not required” (9%). Some of the participants have also reported that they have achieved natural immunity as they have not been infected or they might have been infected with subclinical infection and thus possess the disease-specific antibodies.
Unwillingness to get a vaccine may play a hindrance in controlling the ongoing COVID-19 pandemic. These sentiments started surfacing in social media and then in the news media platforms from the initial days of the COVID-19 vaccine development itself. Historically seeing, this is not a new phenomenon to observe. In the past, many protests were carried out against vaccination in many countries. There were many reasons quoted for these anti-vaccine sentiments. People have been misled by the beliefs that vaccines are not safe or vaccines are a way for the pharmaceutical companies to make huge profits etc. Studies conducted in the western population during the initial days of the pandemic have reflected these negative sentiments toward the COVID-19 vaccine as well.
Studies,, have found negative attitudes to be prevalent among elderly people (aged above 65 years), lower socioeconomic status, lower education, larger family size, people belonging to minor ethnicity, poor compliance with government-imposed COVID-19 precautions, who had a poor understanding about the disease, and history of not receiving earlier influenza vaccine. Female gender has not been consistently associated with negative attitudes, but there were concerned about unforeseen effects and preference for natural immunity.
Those with physical or mental illness were more concerned about the unforeseen future effects of the vaccine. Among the most common reason for rejecting vaccination; side effects stand the first. Hence, those with preexisting physical or mental illness will probably have more negative attitudes because of their already compromised health status. Furthermore, the media reports of anecdotal cases and highlighting them may have contributed to this finding.
Although in the current study not many have reported that pharmaceutical companies responsible for manufacturing the COVID-19 vaccine make a lot of profits as the reason for not taking vaccine, these beliefs were more among individuals with lower education, skilled to semi-skilled laborers, and those living in a joint family type of setting. This is similar to the results of a study conducted in the United Kingdom and Ireland, those who were resistant to receive vaccines had lower levels of trust toward scientists, health-care professionals, and also had higher levels of paranoia and conspiracy. Similar to the study Fisher et al., the individuals from a higher family size or joint family held negative attitudes. We feel that in a joint family as the majority of family decisions are taken by the elder member of the family, they might influence the younger members' views. In previous studies, elder members held negative attitudes toward vaccination, probably this might get imposed on the whole family members.
In previous studies,,, female gender held the belief that natural immunity is better than the one which is created by vaccine. In the current study, married individuals and joint family type of setting held these beliefs. It may be because these individuals were more worried about the children and elders in the family so may not be willing to take the risks associated with the vaccine and hence the guarded stance. They might have beliefs that naturally occurring immunity is better as it develops without any human intervention. In the starting days of the pandemic, there were theories that herd immunity which develops as the pandemic progresses will try to arrest the disease process, but that did not show any positive results. We are still not in a position to say whether natural immunity for COVID-19 infection exists and if it exists, how long will it be active in an individual.
Various initiatives can be taken to increase the positivity toward the vaccination. We feel that even though the Government is playing an active role in immunizing the citizens, it cannot be done without adequate transparency on scientific trials. Further, it could take up initiatives such as mass educational campaigns endorsed by vaccine trial data; free and fair reporting of the side effects/adverse effects; and maintaining the free press policy backed with adequate scientific evidence. Initiatives can also be taken by various stakeholders such as Non-Government Organizations to improve the awareness among the public. As medical professionals, we can improve a positive image by actively taking the vaccine and educating the local masses about the benefits of the same.
The sample size is small, a bigger sample might have yielded results that could be generalized. We restricted the sample to the southern states of India; hence, the study does not represent the views from other zones of India. Due to COVID-19 precautionary measures, we had to use an online method to collect the sample, this might have some influence on the authenticity of the data collected.
| Conclusion|| |
The current study highlights that 69% of the participants in South India were willing to take the current COVID-19 vaccine. This can be considered as a positive sign in ending the ongoing COVID-19 pandemic. Among those not willing to take the vaccine, side effects or adverse events due to vaccine were the most common cited reasons. Commercial profiteering by the pharmaceutical companies has been a concern for not getting vaccinated among participants with lower education, skilled to semi-skilled jobs, and those staying in joint family settings. Preference for natural immunity to develop rather than immunity induced by the vaccine has been a concern among participants who were married and living in a joint family setting.
We acknowledge the help extended by Ms. Leslie R Martin for permitting us to use their VAX scale in our study. We also acknowledge the help provided by Dr. Vungarala Aaritha and Dr. Vundi Charitha in coding the data for statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaur SP, Gupta V. COVID-19 vaccine: A comprehensive status report. Virus Res 2020;288:198114.
Dror AA, Eisenbach N, Taiber S, Morozov NG, Mizrachi M, Zigron A, et al.
Vaccine hesitancy: The next challenge in the fight against COVID-19. Eur J Epidemiol 2020;35:775-9.
Martin LR, Petrie KJ. Understanding the dimensions of anti-vaccination attitudes: The vaccination attitudes examination (VAX) scale. Ann Behav Med 2017;51:652-60.
R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2020. Available from: http://www.R-project.org
. [Last accessed on 2021 Mar 01].
RStudio Team. RStudio: Integrated Development for R. RStudio, PBC, Boston, MA. 2020. assessed at http://www.rstudio.com/
. [Last accessed on 2021 Mar 01].
Wickham H. ggplot2: Elegant Graphics for Data Analysis. New York: Springer-Verlag; 2016. Available from: https://ggplot2.tidyverse.org
. [Last accessed on 2021 Mar 01].
Lurie N, Saville M, Hatchett R, Halton J. Developing Covid-19 vaccines at pandemic speed. N Engl J Med 2020;382:1969-73.
The COCONEL Group. A future vaccination campaign against COVID-19 at risk of vaccine hesitancy and politicisation (comment). Lancet Infect Dis 2020;20:769-80.
Fisher KA, Bloomstone SJ, Walder J, Crawford S, Fouayzi H, Mazor KM. Attitudes toward a potential SARS-CoV-2 vaccine: A survey of U.S. adults. Ann Intern Med 2020;173:964-73.
Menon V. and Thaker J. Aotearoa New Zealand Public Attitudes to COVID-19 Vaccine. Wellington, New Zealand: Massey University. 2020.
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 2020;1:100012.
Dodd RH, Cvejic E, Bonner C, Pickles K, McCaffery KJ, Sydney Health Literacy Lab COVID-19 Group. Willingness to vaccinate against COVID-19 in Australia. Lancet Infect Dis 2021;21:318-9.
Murphy J, Vallières F, Bentall RP, Shevlin M, McBride O, Hartman TK, et al.
Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom. Nat Commun 2021;12:29.
Vignesh R, Shankar EM, Velu V, Thyagarajan SP. Is herd immunity against SARS-CoV-2 a silver lining? Front Immunol 2020;11:586781.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]