Underlying Factors Associated with COVID-19 Vaccine Hesitancy and Refusal among the Iranian Population: A Qualitative Content Analysis

Document Type : Original Article

Authors

1 HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

2 Deputy for Health, Kerman University of Medical Sciences, Kerman, Iran

3 Sirjan School of Medical Sciences, Sirjan, Iran

4 Nursing Research Center, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran

10.34172/jhad.92192

Abstract

Background: COVID-19 vaccination is one of the most successful ways to control the ongoing pandemic and prevent severe diseases, hospitalization, and death. Current evidence suggests COVID-19 vaccine hesitancy (a delay in accepting or rejecting the vaccine despite the availability of vaccination services) is a barrier to successful vaccination programs worldwide. This study aimed to explore the underlying factors associated with COVID-19 vaccine hesitancy among the Iranian population.
Methods: This qualitative content analysis study was conducted using in-depth semi-structured interviews. A total of 32 Iranian participants with diverse ethnicity, language, age, and gender were selected through purposive sampling. Interviews were analyzed using Graneheim and Lundman’s qualitative content analysis method. MAXQDA software was used for data analysis.
Results: Three themes and eight subthemes emerged from the qualitative interviews. Individual underlying factors included knowledge, beliefs, and the fear of COVID-19 infection. Social factors included social media, the health system, and governance. Institutional factors included vaccine opponents and health experts that fueled COVID-19 vaccine hesitancy and refusal among the participants.
Conclusion: Poor knowledge, misbelief, and fear were the most commonly reported causes of vaccine hesitancy and refusal among Iranians. Therefore, targeted interventions are recommended to address misinformation among the Iranian population.

Keywords


  1. World Health Organization. WHO Coronavirus (COVID-19) Dashboard. 2022. Available from: https://covid19.who.int/. Accessed March 29, 2022.
  2. World Health Organization. COVID-19 Landscape of Novel Coronavirus Candidate Vaccine Development Worldwide. 2022. Available from: https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines. Accessed March 29, 2022.
  3. World Health Organization (WHO). Strategy to Achieve Global COVID-19 Vaccination by mid-2022. WHO; 2021.
  4. MacDonald NE. Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34):4161-4. doi: 1016/j.vaccine.2015.04.036.
  5. 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(1):29. doi: 1038/s41467-020-20226-9.
  6. Pomares TD, Buttenheim AM, Amin AB, Joyce CM, Porter RM, Bednarczyk RA, et al. Association of cognitive biases with human papillomavirus vaccine hesitancy: a cross-sectional study. Hum Vaccin Immunother. 2020;16(5):1018-23. doi: 1080/21645515.2019.1698243.
  7. Browne M, Thomson P, Rockloff MJ, Pennycook G. Going against the herd: psychological and cultural factors underlying the ‘vaccination confidence gap’. PLoS One. 2015;10(9):e0132562. doi: 1371/journal.pone.0132562.
  8. Sallam M. COVID-19 vaccine hesitancy worldwide: a concise systematic review of vaccine acceptance rates. Vaccines (Basel). 2021;9(2):160. doi: 3390/vaccines9020160.
  9. Ezati Rad R, Kahnouji K, Mohseni S, Shahabi N, Noruziyan F, Farshidi H, et al. Predicting the COVID-19 vaccine receive intention based on the theory of reasoned action in the south of Iran. BMC Public Health. 2022;22(1):229. doi: 1186/s12889-022-12517-1.
  10. Sun Y, Chen X, Cao M, Xiang T, Zhang J, Wang P, et al. Will healthcare workers accept a COVID-19 vaccine when it becomes available? A cross-sectional study in China. Front Public Health. 2021;9:664905. doi: 3389/fpubh.2021.664905.
  11. Pogue K, Jensen JL, Stancil CK, Ferguson DG, Hughes SJ, Mello EJ, et al. Influences on attitudes regarding potential COVID-19 vaccination in the United States. Vaccines (Basel). 2020;8(4):582. doi: 3390/vaccines8040582.
  12. Reiter PL, Pennell ML, Katz ML. Acceptability of a COVID-19 vaccine among adults in the United States: how many people would get vaccinated? Vaccine. 2020;38(42):6500-7. doi: 1016/j.vaccine.2020.08.043.
  13. 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):225-8. doi: 1038/s41591-020-1124-9.
  14. Salali GD, Uysal MS. COVID-19 vaccine hesitancy is associated with beliefs on the origin of the novel coronavirus in the UK and Turkey. Psychol Med. 2020:1-3. doi: 1017/s0033291720004067.
  15. Karafillakis E, Larson HJ. The benefit of the doubt or doubts over benefits? A systematic literature review of perceived risks of vaccines in European populations. Vaccine. 2017;35(37):4840-50. doi: 1016/j.vaccine.2017.07.061.
  16. Pelčić G, Karačić S, Mikirtichan GL, Kubar OI, Leavitt FJ, Cheng-Tek Tai M, et al. Religious exception for vaccination or religious excuses for avoiding vaccination. Croat Med J. 2016;57(5):516-21. doi: 3325/cmj.2016.57.516.
  17. Yaqub O, Castle-Clarke S, Sevdalis N, Chataway J. Attitudes to vaccination: a critical review. Soc Sci Med. 2014;112:1-11. doi: 1016/j.socscimed.2014.04.018.
  18. Jennings W, Stoker G, Bunting H, Valgarðsson VO, Gaskell J, Devine D, et al. Lack of trust, conspiracy beliefs, and social media use predict COVID-19 vaccine hesitancy. Vaccines (Basel). 2021;9(6):593. doi: 3390/vaccines9060593.
  19. Baig M, Jameel T, Alzahrani SH, Mirza AA, Gazzaz ZJ, Ahmad T, et al. Predictors of misconceptions, knowledge, attitudes, and practices of COVID-19 pandemic among a sample of Saudi population. PLoS One. 2020;15(12):e0243526. doi: 1371/journal.pone.0243526.
  20. 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. doi: 1371/journal.pone.0208601.
  21. World Health Organization. WHO Coronavirus (COVID-19) Dashboard, Islamic Republic of Iran Profile. 2022. Available from: https://covid19.who.int/region/emro/country/ir. Accessed March 29, 2022.
  22. Ministry of Health. National COVID-19 Vaccination Database. 2021. Available from: https://salamat.gov.ir. Accessed November 28, 2021.
  23. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-12. doi: 1016/j.nedt.2003.10.001.
  24. Amankwaa L. Creating protocols for trustworthiness in qualitative research. J Cult Divers. 2016;23(3):121-7.
  25. Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger J. Vaccine hesitancy: an overview. Hum Vaccin Immunother. 2013;9(8):1763-73. doi: 4161/hv.24657.
  26. Zhuang W, Zhang J, Wei P, Lan Z, Chen R, Zeng C, et al. Misconception contributed to COVID-19 vaccine hesitancy in patients with lung cancer or ground-glass opacity: a cross-sectional study of 324 Chinese patients. Hum Vaccin Immunother. 2021;17(12):5016-23. doi: 1080/21645515.2021.1992212.
  27. Kreps SE, Goldfarb JL, Brownstein JS, Kriner DL. The relationship between US adults’ misconceptions about COVID-19 vaccines and vaccination preferences. Vaccines (Basel). 2021;9(8):901. doi: 3390/vaccines9080901.
  28. Fisher KA, Bloomstone SJ, Walder J, Crawford S, Fouayzi H, Mazor KM. Attitudes toward a potential SARS-CoV-2 vaccine: a survey of US adults. Ann Intern Med. 2020;173(12):964-73. doi: 7326/m20-3569.
  29. Ward JK, Alleaume C, Peretti-Watel P. The French public’s attitudes to a future COVID-19 vaccine: the politicization of a public health issue. Soc Sci Med. 2020;265:113414. doi: 1016/j.socscimed.2020.113414.
  30. Wang J, Jing R, Lai X, Zhang H, Lyu Y, Knoll MD, et al. Acceptance of COVID-19 vaccination during the COVID-19 pandemic in China. Vaccines (Basel). 2020;8(3):482. doi: 3390/vaccines8030482.
  31. Goruntla N, Chintamani SH, Bhanu P, Samyuktha S, Veerabhadrappa KV, Bhupalam P, et al. Predictors of acceptance and willingness to pay for the COVID-19 vaccine in the general public of India: a health belief model approach. Asian Pac J Trop Med. 2021;14(4):165-75. doi: 4103/1995-7645.312512.
  32. Romer D, Jamieson KH. Conspiracy theories as barriers to controlling the spread of COVID-19 in the US. Soc Sci Med. 2020;263:113356. doi: 1016/j.socscimed.2020.113356.
  33. Allington D, McAndrew S, Moxham-Hall V, Duffy B. Coronavirus conspiracy suspicions, general vaccine attitudes, trust and coronavirus information source as predictors of vaccine hesitancy among UK residents during the COVID-19 pandemic. Psychol Med. 2023;53(1):236-47. doi: 1017/s0033291721001434.
  34. Lewandowsky S, Ecker UK, Seifert CM, Schwarz N, Cook J. Misinformation and its correction: continued influence and successful debiasing. Psychol Sci Public Interest. 2012;13(3):106-31. doi: 1177/1529100612451018.
  35. Uscinski JE, Klofstad C, Atkinson MD. What drives conspiratorial beliefs? The role of informational cues and predispositions. Polit Res Q. 2016;69(1):57-71. doi: 1177/1065912915621621.
  36. Evanega S, Lynas M, Adams J, Smolenyak K. Coronavirus misinformation: quantifying sources and themes in the COVID-19 ‘infodemic’. JMIR Preprints. 2020;19(10):2020.
  37. Himelein-Wachowiak M, Giorgi S, Devoto A, Rahman M, Ungar L, Schwartz HA, et al. Bots and misinformation spread on social media: implications for COVID-19. J Med Internet Res. 2021;23(5):e26933. doi: 2196/26933.
  38. Cuan-Baltazar JY, Muñoz-Perez MJ, Robledo-Vega C, Pérez-Zepeda MF, Soto-Vega E. Misinformation of COVID-19 on the internet: infodemiology study. JMIR Public Health Surveill. 2020;6(2):e18444. doi: 2196/18444.
  39. Ferreira Caceres MM, Sosa JP, Lawrence JA, Sestacovschi C, Tidd-Johnson A, Rasool MHU, et al. The impact of misinformation on the COVID-19 pandemic. AIMS Public Health. 2022;9(2):262-77. doi: 3934/publichealth.2022018.
  40. Lockyer B, Islam S, Rahman A, Dickerson J, Pickett K, Sheldon T, et al. Understanding COVID-19 misinformation and vaccine hesitancy in context: findings from a qualitative study involving citizens in Bradford, UK. Health Expect. 2021;24(4):1158-67. doi: 1111/hex.13240.
  41. Banerjee D, Rao TS. Psychology of misinformation and the media: insights from the COVID-19 pandemic. Indian J Soc Psychiatry. 2020;36(Suppl 1):S131-S7. doi: 4103/ijsp.ijsp_112_20.
  42. Erku DA, Belachew SA, Abrha S, Sinnollareddy M, Thomas J, Steadman KJ, et al. When fear and misinformation go viral: Pharmacists’ role in deterring medication misinformation during the ‘infodemic’ surrounding COVID-19. Res Social Adm Pharm. 2021;17(1):1954-63. doi: 1016/j.sapharm.2020.04.032.
  43. Rzymski P, Borkowski L, Drąg M, Flisiak R, Jemielity J, Krajewski J, et al. The strategies to support the COVID-19 vaccination with evidence-based communication and tackling misinformation. Vaccines (Basel). 2021;9(2):109. doi: 3390/vaccines9020109.
  44. Garrett L. COVID-19: the medium is the message. Lancet. 2020;395(10228):942-3. doi: 1016/s0140-6736(20)30600-0.
  45. Ahinkorah BO, Ameyaw EK, Hagan JE Jr, Seidu AA, Schack T. Rising above misinformation or fake news in Africa: another strategy to control COVID-19 spread. Front Commun. 2020;5:45. doi: 3389/fcomm.2020.00045.
  46. Jarrett C, Wilson R, O’Leary M, Eckersberger E, Larson HJ. Strategies for addressing vaccine hesitancy - a systematic review. Vaccine. 2015;33(34):4180-90. doi: 1016/j.vaccine.2015.04.040.
  47. Puri N, Coomes EA, Haghbayan H, Gunaratne K. Social media and vaccine hesitancy: new updates for the era of COVID-19 and globalized infectious diseases. Hum Vaccin Immunother. 2020;16(11):2586-93. doi: 1080/21645515.2020.1780846.
  48. Hays RD, Liu H, Kapteyn A. Use of Internet panels to conduct surveys. Behav Res Methods. 2015;47(3):685-90. doi: 3758/s13428-015-0617-9.
  49. Biddle N, Edwards B, Gray M, Sollis K. Change in vaccine willingness in Australia: August 2020 to January 2021. medRxiv [Preprint]. February 19, 2021. Available from: https://www.medrxiv.org/content/10.1101/2021.02.17.21251957v1.