The relationship of Covid-19 vaccine attitude with life satisfaction, religious attitude and Covid-19 avoidance in Turkey

ABSTRACT

The aim of this study was to determine the relationship between the attitudes toward the Covid-19 vaccine and life satisfaction, religious attitude, and the avoidance attitudes from Covid-19. This cross-sectional study was conducted online between 24 December 2020 and 06 January 2021 among adults age 18 years and older. Total 1033 people participated in the study. The data were collected using the Attitudes Toward Covid-19 Vaccine, Avoiding Attitudes from COVID-19, Religious Attitude Scale and Contentment with Life Assessment Scale. According to the “agree” and “strongly agree” responses of participants to the positive attitude items; the participants responded to the question “Who would you like to be vaccinated?” as follows: everyone (31.3%); family members (31.8%); and themselves (28.1%). The rates of those who responded to these items as “indecisive” were 44.5–48.2%. While there was no significant relationship between the COVID-19 vaccine attitude with the avoidance attitude from COVID-19 and the religious attitude; life satisfaction was found to be significant. It was observed that factors such as increasing fear of COVID-19 contagion, being male, increased life satisfaction, other relatives infected with Covid-19, increasing perceived health status, increased age, and not being a worker-tradesman increase the probability of having a positive attitude toward COVID-19 vaccine. It was observed that about one-third of the participants think the COVID-19 vaccine is protective and supports its administration, that almost half of them were undecided on these issues. Thus, it can be said that society needs accurate information about vaccination.

KEYWORDS:

• Covid-19 vaccines
• avoidance
• life satisfaction
• religious beliefs
• attitude

1. Introductıon

Epidemic diseases are one of the major disasters affecting people’s physical, psychological health and social life negatively throughout history.¹ The coronavirus epidemic, which first appeared in Wuhan, China and spread rapidly all over the world, significantly affected the lives of individuals, societies and the economy.² The coronavirus is a known large family of viruses and it is known that there are species causing various diseases such as MERS-CoV and SARS-CoV.³ The Covid-19 pandemic caused significant changes in many aspects ranging from social life and psychological problems to economic problems.

Life satisfaction can be defined as emotional responses to life consisting of work, leisure time and other non-work time.⁴ Life satisfaction is a set of processes related to individuals’ own life patterns and standards. Life satisfaction of individuals can be affected by many things. Individuals have harbored feelings such as positive/negative, happiness and unhappiness in every stage of their lives. As a result of the situations they encounter, their satisfaction or dissatisfaction with life may change.⁵

Attitude; It is possible to define it as a preliminary tendency that cannot be directly observed and guides our choices and decisions for action.⁶ Religious attitude is a way of directing one’s religious feelings, knowledge, thoughts and behaviors consistently. People display their attitudes according to certain beliefs in the face of some events they encounter. Beliefs emerge as effective in perceiving, recognizing and questioning the event.⁷

Vaccine refusal is sometimes linked to philosophical beliefs or moral beliefs about health and immunity. For example, in vaccination, vaccines are opposed because “natural” drugs are preferred instead of “artificial” drugs. Refusal of vaccines has also been associated with strong religious beliefs. Vaccines are necessary and important drugs to protect the health and for well-being of individuals and societies. The primary purpose of vaccination is to protect the general health status of the individual, and to prevent death, disability and illnesses. Vaccination is an effective, safe and inexpensive method used in the prevention of life-threatening infectious diseases.^8,9 Positive attitude toward vaccination is important in controlling infectious diseases. Vaccine rejection is a situation that started to appear especially toward the middle of the 19th century and has been affected by many different reasons and has continued until today. Vaccine hesitancy has been due to the complex interaction of different social, cultural, political and personal factors, possible attitudes about vaccination include doubts and hesitations about vaccination, delaying and/or rejection of the vaccine in the vaccination program.^10,11 Vaccinated individuals slow down the transmission of vaccine-preventable diseases, resulting in indirect protection or herd immunity for the general population, thereby reducing the risk of infection among susceptible populations.¹²

Indecision about vaccination reduces vaccine applicability. This situation has negative effects in increasing the risk of vaccine-preventable disease outbreaks and epidemics.¹³ The effect of political and socio-cultural context, the role of the media and communication, the role of public health and vaccination policies, the role of healthcare professionals, the individual decision-making process, individuals’ knowledge of vaccination, past experiences with vaccination services, perception of the importance of vaccination in health protection opinions are widespread among the possible reasons for vaccination hesitation. It is widely believed that factors such as risk perception, moral and religious beliefs have an effect.¹⁴

This study was conducted to evaluate the attitude toward the Covid-19 vaccine and avoidance of Covid-19; Observing the effect of socio-demographic factors, religious attitude and life satisfaction on them will be beneficial for other studies on this subject. As a result of the literature review, no study was found in which these four factors were examined together.

2. Materıal and methods

2.1. Type of research

A cross-sectional study was conducted using on line Google forms.

2.2. Population and sample

The research was conducted among adults over the age of 18 between 24th December 2020 and 06th January 2021. No sample selection was made for the research. In the research conducted by Salali & Uysal in Turkey, it has been observed that 67% of adults sure about getting themselves or their children vaccinated.¹⁵ In calculating the minimum sample size, when the rate of willingness to have vaccination 0.67, ɑ error 0.05, the effect size 0.10, and the level of power (1-β error) 0.95 are taken as basis, minimum sample size was calculated as n = 327. Total 1033 people participated in the study.

2.3. Collection of data

The data included the socio-demographic data form prepared by the researcher (13 questions), the Attitudes Toward the COVID-19 Vaccine (ATV-COVID19) (9 items), the Avoidance Attitudes from COVID-19 (AA-COVID19) (10 items), Contentment with Life Assessment Scale (CLAS) (5 items) and Ok-Religious Attitude Scale (Islam) (ORASI) (8 items). The link of the survey forms was shared on social media platforms such as whatsapp, twitter, facebook, instagram and also posted in e-mail groups. In addition, other people were asked to share this link in their own groups.

2.3.1. Attitudes toward the COVID-19 Vaccine

The ATV-COVID19 scale consists of 9 questions and has two sub-dimensions, positive and negative. Statements in the scale are evaluated as “Strongly disagree (1)”, “Disagree (2)”, “Undecided (3)”, “Agree (4)”, “Strongly agree (5)”. Items in negative attitude sub-dimensions are scored inversely. A value between 1–5 is obtained by dividing the total score obtained by adding the item scores in the scale sub-dimension to the number of items in that sub-dimension. High scores from the positive attitude sub-dimension indicate that the attitude toward vaccination is positive. The items in the negative attitude sub-dimension are calculated after reversing, and the higher scores in this sub-dimension indicate that the negative attitude toward vaccination is less. Inverse substances 1 → 5; 2 → 4; 3 → 3; 4 → 2; It is coded as 5 → 1. ATV-COVID19 total internal consistency Cronbach alpha coefficient was 0.898, this coefficient was determined as 0.935 for the positive attitude sub-dimension and 0.785 for the negative attitude dimension.¹⁶

2.3.2. Avoidance attitudes from COVID-19

The (AA-COVID19) scale consists of 10 items. The scale is a five-point Likert scale. Expressions in the scale; It is evaluated as I definitely do not (1), I do not (2), I am undecided (3), I do (4) and I definitely do (5). It has two sub-dimensions: cognitive avoidance and behavioral avoidance. There is no reverse item in the scale. A value between 1–5 is obtained by dividing the total score obtained by adding the item scores in the scale sub-dimension to the number of items in that sub-dimension. High scores from sub-dimensions show that avoidance in the relevant area is high. The scale total internal consistency Cronbach alpha coefficient was 0.810, this coefficient was 0.891 for the cognitive avoidance sub-dimension and 0.890 for the negative attitude dimension.¹⁶

2.3.3. Contentment with life assessment scale

Developed by Lavallee et al., (2007) the CLAS was adapted into Turkish by Akın and Yalnız (2015). The Turkish adaptation study was carried out with 295 university students, and the item-total correlation coefficients of the scale range from 0.31 to 0.61. Cronbach’s alpha internal consistency reliability coefficient of the scale was calculated as 0.73. So it can be said that the scale is eligible and reliable as a measuring tool. In addition, it consists of 5 items and there is no reverse item in its scoring.¹⁷ In this study, the internal consistency Cronbach alpha coefficient was determined to be 0.882.

2.3.4. Ok-religious attitude scale (Islam) (ORASI)

The Ok-Religious Attitude Scale (Islam) (ORASI) has been developed by Ok in the light of Islamic religion and consists of four content dimensions. The ORASI evaluates the relationship between the cognition, feelings, behavior, and relation (God) dimensions of religious attitude that were highlighted in social psychology. The ‘cognition’ dimension measures how a person’s general view of religion is, while the ‘feelings’ dimension measures how much a person is affected by the emotional aspect of religion and the ‘behavior’ dimension to what extent a person’s behavior is guided by religious values. The relation (God) dimension measures the perception of an individual to what extent he/she feels that God is very close to him/her and God helps him/her. The scale consists of eight items (two for each dimension). Responses to items of this Likert-type scale were rated on a five-point scale ranging from agree: “Not at all (1)”, “A little (2)”, “Half the time (3)”, “Mainly (4)”, and “Completely (5)”. The two items in the scale stating that there is no need for religion were reverse coded. It was determined that the scale, along with its sub-dimensions, exhibit satisfactory internal consistency (Cronbach alpha scores, 0.75–0.87) and it was valid and reliable.¹⁸ In this study, the Cronbach alpha internal consistency coefficient of the scale was found as 0.899.

2.4. Data evaluation

The data was analyzed in IBM SPSS Statistics Standard Concurrent User V 25, Authorization Code: e31d836848b0a60e5756. The Covid-19 attitude scale shows normal distribution. Chi-square, independent sample t test, one way ANOVA, correlation and regression tests were used to analyze the data. The variables found important at p < .1 level in linear regression (LR) analysis, univariate tests and correlation analysis were included in the model and analyzed by bacward method. The variables deemed important at the end of the analysis are shown in the tables. ATV-COVID19 and AA-COVID19 scores were taken as dependent variables on LR analysis. Cognitive and behavioral avoidance from Covid-19, life satisfaction and religious attitude scale scores and demographic characteristics of individuals were taken as independent variables. Variables that are categorical from personal characteristics are taken as dummy variables in the model.

2.5. Ethical permission

The approval of the ethics committee of the study was obtained with the decision of the Yozgat Bozok University Ethics Committee dated 23.12.2020 and numbered 17/21. In addition, permission was obtained by registering to the database of the Ministry of Health, General Directorate of Public Health. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Before starting the survey, those who consented to participate in the survey online were allowed to complete the questionnaire.

2.6. The limitation of the research

In order to participate in the study, people must be literate, have access to the internet and have the ability to fill in online questionnaires, and those who do not meet these conditions could not participate in the study.

3. Results

The study included 1033 people, aged 18–78 years, and mean age was 26.58 ± 9.95. Of the participants, 72.1% were female, 71.6% were single, 81.8% were university graduates, 38.6% had a monthly family income of 5,000 TL and above, 64.4% did not work in any job, 83.1% had a good health. Participants in the study, 33.0% of those stated that they had a healthcare professional in their family or close relatives, 56.3% were afraid that Covid-19 would be transmitted to them and their close relatives, and 70.4% had sufficient information about Covid-19. Eighty-seven point seven percent had caught Covid-19 around him, 29.5% had himself or his family members caught this disease, 28.1% of them stated that around him people, and 9.4% of his family or close relatives died due to Covid-19 (Table 1).

Table 1. Covid-19 vaccine attitude scores’ mean and standard devision according to the various characteristics

			Positive attitude		Negative attitude *
Socio-demographic characteristics	Count	Col. %	Mean	SD	Mean	SD
Gender				P < .001		P < .001
Male	288	27.9	3.21	1.07	3.20	0.75
Female	745	72.1	2.94	0.97	3.03	0.70
Marriage status				P > .05		P > .05
Married	293	28.4	3.10	1.01	3.07	0.73
Single	740	71.6	2.98	1.00	3.08	0.72
Having their children vaccinated				P > .05		P < .05
I have never done	38	11.9	2.93	0.92	2.95	0.81
Missing vaccinations	9	2.8	2.75	0.92	3.73	1.01
I had it done regularly	271	85.2	3.20	1.02	3.06	0.69
Level of education				P > .05		P > .05^b
Primary school	16	1.5	2.84	1.04	3.05	0.66
Middle School	33	3.2	3.05	1.08	2.84	0.60
High school	139	13.5	3.01	0.98	3.06	0.80
Associate degree	262	25.4	3.02	0.99	3.05	0.66
License	583	56.4	3.02	1.02	3.10	0.73
Family monthly income				P < .01		P < .01
2,500 TL or lower	209	20.2	2.83	1.00	2.97	0.76
2,500–3,499	247	23.9	3.01	0.86	3.04	0.62
3,500–4,999	178	17.2	3.06	1.00	3.18	0.74
5,000–6,999	180	17.4	3.07	1.11	3.05	0.74
7,000–9,999	122	11.8	2.93	1.04	3.04	0.73
10,000 and higher	97	9.4	3.35	1.02	3.30	0.74
Working status				P < .05		P > .05
Not working	665	64.4	2.98	0.98	3.05	0.73
Worker-tradesman	137	13.3	2.96	1.04	3.08	0.67
Officer	231	22.4	3.16	1.03	3.15	0.72
Health level perception				P < .05		P < .05
Middle	175	16.9	2.89	1.07	3.05	0.79
Good	690	66.8	3.01	0.94	3.06	0.69
Very good	168	16.3	3.19	1.15	3.17	0.78
Number of people in the house				P < .05		P < .05
1–2 people	110	10.6	3.08	1.06	3.05	0.74
3 people	219	21.2	3.18	1.00	3.21	0.68
4 people	289	28.0	2.90	0.95	3.03	0.71
5 people	219	21.2	3.06	0.99	3.04	0.72
≥ 6 people	196	19.0	2.93	1.05	3.04	0.75
Health worker in the family				P > .05		P > .05
No	692	67.0	3.01	1.02	3.08	0.73
Yes	341	33.0	3.04	0.97	3.07	0.70
			Positive attitude		Negative attitude *
Covid-19 related responses	Count	Col. %	Mean	SD	Mean	SD
Fear of Covid-19 transmission				P < .001		P < .001
None/A little	182	17.6	2.83	1.13	2.85	0.83
Moderately	270	26.1	2.91	0.99	3.11	0.71
Much	254	24.6	3.20	0.91	3.18	0.68
Too much	327	31.7	3.06	0.98	3.09	0.67
Covid-19 knowledge level				p > .05		p > .05
None/A little	54	5.2	2.82	0.95	3.02	0.59
Middle	252	24.4	3.01	0.91	3.13	0.66
Enough	588	56.9	3.01	1.01	3.05	0.71
Very enough	139	13.5	3.12	1.15	3.13	0.88
Infected Covid-19 in people around				p > .05		p > .05
Yes it’s okay	906	87.7	3.02	1.00	3.08	0.71
No it isn’t	127	12.3	3.03	1.02	3.07	0.77
Infected himself/family members				p > .05		p > .05
No	728	70.5	3.05	0.99	3.09	0.70
Yes	305	29.5	2.94	1.05	3.05	0.76
Infected other relatives				P < .05		p > .05
No	509	49.3	2.97	1.02	3.07	0.74
Yes	524	50.7	3.11	0.97	3.10	0.69
Infected neighbors				p > .05		p > .05
No	741	71.7	3.02	1.01	3.08	0.73
Yes	292	28.3	3.02	0.95	3.07	0.69
Death due to Covid-19 people around				p > .05		p > .05
Yes	290	28.1	2.98	0.97	3.08	0.73
No	743	71.9	3.03	1.02	3.07	0.72
Family members who died				p > .05		p > .05
No	936	90.5	3.02	1.00	3.08	0.71
Yes	97	9.4	2.97	1.01	3.07	0.84
			Positive attitude		Negative attitude *
Covid-19 related responses	Count	Col. %	Mean	SD	Mean	SD
Death from neighbors				p > .05		p > .05
No	866	83.8	3.02	1.01	3.07	0.72
Yes	167	16.2	2.98	0.99	3.10	0.71
Death from friends				p > .05		p > .05
No	995	96.3	3.02	1.01	3.08	0.73
Yes	38	3.7	3.07	0.86	2.99	0.51
Total	1033	100.0	3.02	1.00	3.08	0.72

* Higher score less negative attitude. Parametric tests: Independent Sample t test, One way Anova F test.

When the answers of “I agree” and “I strongly agree” to the questions of ATV-COVID19 positive attitude sub-dimension of the participants were examined; 31.3% stated that everyone, 31.8% wanted their family members to have the vaccine, 28.1% wanted to have this vaccine for themselves, 24.0% trusted the statements made about the vaccine. Those who gave undecided answers to these questions were 44.5%, 48.2% and 45.9%, respectively. When the questions of ATV-COVID19 negative attitude sub-dimension are examined; 18.5% stated that the vaccine could cause the transmission of the disease, 19.5% of the vaccine would not have a protective effect, 13.0% stated that the vaccine was dangerous, 41.0% stated that the effectiveness of the vaccine was not sufficiently tested, and 30.4% could overcome the epidemic without vaccination (Table 2).

Table 2. Responses to the Covid-19 vaccine attitude scale questions

Positive attitude	I strongly disagree	I do not agree	I am indecisive	I agree	Absolutely I agree
I want my family to have the vaccine to be developed/developed for this disease.	113 (10.9)	94 (9.1)	498 (48.2)	199 (19.3)	129 (12.5)
I want to have the vaccine to be developed/developed for this disease as much as possible.	130 (12.6)	139 (13.5)	474 (45.9)	169 (16.4)	121 (11.7)
I think everybody should have the vaccine to be developed/developed for this disease.	108 (10.5)	141 (13.6)	460 (44.5)	208 (20.1)	116 (11.2)
I trust to explanations made for the vaccine to be developed/developed	152 (14.7)	166 (16.1)	467 (45.2)	186 (18.0)	62 (6.0)
Negative attitude
The vaccine to be developed/developed may cause spread of the disease.	85 (8.2)	266 (25.8)	491 (47.5)	150 (14.5)	41 (4.0)
I think the vaccine to be developed/developed will not/does not have a protective effect.	86 (8.3)	230 (22.3)	515 (49.9)	148 (14.3)	54 (5.2)
The vaccine to be developed/developed is dangerous.	100 (9.7)	267 (25.8)	532 (51.5)	95 (9.2)	39 (3.8)
I think the effectiveness of the vaccine to be developed/developed will not be/has not been tested adequately	47 (4.5)	158 (15.3)	404 (39.1)	281 (27.2)	143 (13.8)
I think I may survive the epidemic without a vaccine	128 (12.4)	200 (19.4)	391 (37.9)	239 (23.1)	75 (7.3)

The mean item scores of “Positive Attitude” (3.02 ± 1.00) and “Negative Attitude” (3.08 ± 0.72) (higher scores indicate fewer negative attitudes) subscales of the ATV-COVID19 scale were found to be similar and consistent. According to the correlation analysis, there is a very weak positive relationship between the positive attitude sub-dimension of ATV-COVID19 and life satisfaction (r = 0.103) and age (r = 0.083). No relationship was found between ATV-COVID19 sub-dimensions and AA-COVID19 cognitive avoidance and behavioral avoidance sub-dimensions and religious attitude (Table 3).

Table 3. Arithmetic mean, standard deviation and correlation of scales

	Mean	SD	Vaccine positive attitude	Vaccine negative attitude	Covid Cognitive avoidance	Covid Behavioral avoidance	Life satisfaction	Religious attitude
Vaccine positive attitude	3.02	1.00	1
Vaccine negative attitude	3.08	0.72	0.646**	1
Covid-19 Cognitive avoidance	2.45	0.97	−0.010	−0.056	1
Covid-19 Behavioral avoidance	3.74	1.15	0.014	0.019	0.064*	1
Life satisfaction	19.17	7.16	0.103**	0.065*	0.017	0.002	1
Religious Attitude	31.93	6.96	0.007	−0.031	−0.002	−0.056	0.203**	1
Age	26.58	9.95	0.083**	0.046	−0.006	−0.091**	0.229**	0.034

**. Correlation is significant at the 0.01 level (2-tailed).

*. Correlation is significant at the 0.05 level (2-tailed).

The scores of ATV-COVID19 sub-dimensions, which were found significant according to independent variables in univariate analyzes and correlated in correlation were examined with multivariate LR analysis. In LR analysis, in order of priorities of showing positive attitudes toward the Covid-19 vaccine, the factors such as increasing fear of COVID-19 contagion (β = 0.134), male gender (β = 0.132), increased life satisfaction (β = 0.080), relatives other than family members caught Covid-19 (β = 0.077), good levels of perceived health status (β = 0.075), increasing age (β = 0.068), and not being among the worker-tradesman profession (β = −0.063) were found to be statistically significant, while family income level and number of persons per household were found to be insignificant. In order of priorities of showing more negative attitudes (lower score indicate higher negative attitude) toward the Covid-19 vaccine; Decreasing fear of Covid-19 contagion (β = 0.124), female gender (β = −0.112) and decreasing family income (β = 0.077) were found to be statistically significant, while age, life satisfaction, employment status, perceived health status and number of persons per household were found to be insignificant (Table 4).

Table 4. Analysis of factors affecting attitude toward Covid-19 vaccine by linear regression

		Unstandardized Coefficients	95,0% Confidence Interval for B		Standardized Coefficients
		B	Lower Bound	Upper Bound	β	t	p
	Vaccine positive attitude^a
	(Constant)	1.862	1.335	2.389		6.933	0.000
	Life satisfaction	0.011	0.002	0.020	0.080	2.497	0.013
	Age	0.007	0.000	0.013	0.068	2.092	0.037
	Gender = Female	−0.296	−0.438	−0.155	−0.132	−4.105	0.000
	Employment status = Worker-tradesman	−0.186	−0.369	−0.003	−0.063	−1.990	0.047
	General health status perception	0.122	0.020	0.225	0.075	2.354	0.019
	Fear of Covid-19 transmission	0.117	0.064	0.170	0.134	4.333	0.000
	Other relatives Covid-19 = Yes	0.155	0.034	0.275	0.077	2.512	0.012
	Vaccine Negative Attitude (Lower score indicate higher negative attitude)^b
	(Constant)	2.813	2.633	2.993		30.628	0.000
	Gender = Female	−0.180	−0.278	−0.081	−0.112	−3.577	0.000
	Family income level	0.035	0.007	0.062	0.077	2.497	0.013
	Fear of Covid-19 transmission	0.078	0.040	0.116	0.124	4.016	0.000
	Vaccine Attitude Total
	(Constant)	23.563	21.602	25.524		23.578	0.000
	Gender = Female	−2.218	−3.151	−1.286	−0.144	−4.669	0.000
	Life satisfaction	0.098	0.040	0.156	0.101	3.315	0.001
	Fear of Covid-19 transmission	0.855	0.490	1.221	0.142	4.595	0.000
	Other relatives Covid-19 = Yes	0.924	0.096	1.752	0.067	2.190	0.029

^aIndependent variables: Life satisfaction, age, gender, family monthly income, working status, perception of health status, number of people in the house, fear of Covid-19 transmission, Covid-19 infected to other relatives.

^bIndependent variables: Life satisfaction, age, gender, family monthly income, perception of health status, number of people in the house, fear of Covid-19 transmission,

While the item mean score of the cognitive avoidance subscale (2.45 ± 0.97) of the AA-COVID19 scale was found to be moderate, the item mean score of the behavioral avoidance attitude (3.74 ± 1.15) was quite higher. According to the correlation analysis, no significant relationship was found between the cognitive and behavioral avoidance attitude sub-dimensions of the AA-COVID19 with life satisfaction, and religious attitude (Table 3).

Analyzing AA-COVID-19 subscale scores with multivariate LR analysis; The cognitive avoidance attitude from the Covid-19 increases with decreasing self-knowledge level regarding the Covid-19 (β = −0.106) and increasing family income levels (β = 0.085). Cognitive avoidance was not related to age, gender, educational level, employment status, perceived health status, number of persons per household, fear of being infected with Covid-19, infection of Covid-19 to themselves/their family members, deaths of their relatives due to Covid-19, and presence of healthcare workers in their family. Again, in order of priorities of behavioral avoidance from the Covid-19; it was determined that behavioral avoidance increased with increasing educational level (β = 0.217), female gender (β = 0.115), increasing family income levels (β = 0.083) and increasing fear of Covid-19 contagion (β = 0.082), while behavioral avoidance decreases with being a worker-tradesman (β = −0.108), being a civil servant (β = −0.080) and increasing number of persons per household (Table 5).

Table 5. Analysis of factors affecting Covid-19 avoidance attitude by linear regression

	Unstandardized Coefficients	95.0% Confidence Interval for B		Standardized Coefficients
Cognitive Avoidance	B	Lower Bound	Upper Bound	β	t	p
(Constant)	2.802	2.493	3.111		17.791	0.000
Family income level	0.052	0.015	0.089	0.085	2.744	0.006
Covid-19 knowledge level	−0.135	−0.212	−0.057	−0.106	−3.415	0.001
Behavioral Avoidance
(Constant)	2.222	1.747	2.697		9.183	0.000
Gender = Female	0.295	0.139	0.452	0.115	3.695	0.000
Level of education	0.269	0.194	0.345	0.217	6.990	0.000
Family income level	0.060	0.011	0.109	0.083	2.385	0.017
Employment status = Worker-tradesman	−0.366	−0.583	−0.150	−0.108	−3.323	0.001
Employment status = Officer	−0.221	−0.415	−0.027	−0.080	−2.230	0.026
How many people in the house	−0.057	−0.107	−0.008	−0.071	−2.259	0.024
Fear of Covid-19 transmission	0.082	0.024	0.141	0.082	2.758	0.006

Independent variables: Age, gender, education level, family income level, working status, perception of health status, number of people living at home, fear of Covid-19 transmission, Covid-19 knowledge level perception, Covid-19 transmission to oneself/family members, death of relatives from Covid-19, health worker presence amıng family members.

4. Discussion

In this study, the relationship between positive and negative attitude toward Covid-19 vaccine and avoidance of Covid-19, life satisfaction and religious attitude was examined. No study has been found that examines the Covid 19 vaccine attitude and these three factors together.

Approximately 1/3 of the participants in the study stated that everyone (31.3%) and their family members (31.8%) should get the Covid-19 vaccine, 28.1% of them will get the vaccine, while 24.1%, 20.0% and 26.1% respectively has expressed an opinion that it should not be done. It was observed that 45.9% of the individuals were undecided about vaccination (Table 2). In the study of Lindholt et al.¹⁹ conducted in 8 countries, the desire to be vaccinated in Denmark (79%), the United Kingdom (65%), Italy (54%), Germany (54%), Sweden (50%) and US (48%) are much higher than our findings (28.1–31.8%). Guidry et al.²⁰ reported that while 30.7% of the participants stated that they were definitely willing to be vaccinated, 11.9% of them stated that they would not be vaccinated. Salali (from U.K.) and Uysal (from Turkey) in their studies, the vaccine instability in Turkey 31%, in United Kingdom is 14%, and vaccine rejection rate is 3% in both countries., Vaccine instability (45.9%) and rejection rates (26.1%) in our study were considerably higher than the rates in their study (Table 2).¹⁵

In a study, it has been reported that mass-type immunity can be achieved if 55% of the population for the infectious contagion coefficient R0 = 2.2 and 82% for R0 = 5.7 are immunized through exposure or vaccination.²¹ In studies conducted in China, the vast majority (87.2–91.3%) of the participants stated that they wanted to get the Covid-19 vaccine.^22,23 As seen in the literature, in studies conducted in China and developed countries, it has been observed that the desire for vaccination is higher than our study findings. Vaccine acceptance and rejection rates differ widely in studies conducted in other countries. The reason for the low desire to have Covid-19 vaccine in our study is thought to be due to the low confidence (24%) in the explanations about the vaccine and the high vaccine instability (45.9%) (Table 2). In a study conducted in elderly and with chronic respiratory diseases, it was found that the vaccine was new and the results were not known enough, causing concern against the vaccine.¹³ Participants who rely on national health authorities were found to be more willing to cope with the Covid-19 vaccine than those who did not. In addition to the lack of trust, it was found that for the study participants, the vaccine attitude was affected in situations such as conspiracy theories, lack of knowledge, anxiety and unwillingness.¹⁹ It can be said that as the sense of trust increases, the positive attitude toward the vaccine may increase. It has been determined that informing the public by the health system is an important basic determinant of vaccine attitude and behavior.²⁴ The level of knowledge affects the desire for vaccination. The human mind is oriented toward choosing the most risky situation in the face of uncertainty.²⁵ Therefore, when a person encounters an unknown situation, they can choose to do the most risky. Faced with uncertainty about the vaccine, the human mind may either refuse to be vaccinated or remain undecided.²⁶ As seen in the studies, the public should be adequately informed about the Covid-19 vaccine by the health authorities. Otherwise, the vaccination attitude may be adversely affected.

It has been determined that negative attitude toward Covid-19 vaccine is seen at lower rates than positive attitude. Thirteen percent of the participants stated that the vaccine is dangerous, 18.5% of the vaccine may cause the disease to be transmitted, 19.5% of the vaccine will not have a protective effect, 49.9% is undecided about the protection of the vaccine, 41.0% of the vaccine efficacy is not adequately tested (Table 2). Akarsu et al.²⁷ in his study, among the vaccine instability and rejection reasons, 7.2% of the participants think that the vaccine may cause Covid 19 infection, and 8.2% of it that its protective effect will not be sufficient. When looking at other studies examining the reasons for negative attitude toward vaccination, Biasio et al. (2020) in his study, the majority of the participants stated that the Covid-19 vaccine is unsafe (83%) and there is no need for vaccination because there is natural immunity (84%).²⁸ In another study, among the reasons for not wanting to be vaccinated, concerns about vaccine safety were reported as the most common (45.4%), and the vaccine needed more tests as other reasons.²⁹ Leng et al.³⁰ in his study in China, reported that 81.9% of the participants in the study thought that the vaccine was safe. Khubchandani et al.³¹ reported in the study they conducted in the U.S. that 78% of the participants trusted the Covid 19 vaccine and were highly likely to get it. Guidry et al.²⁰ 30.7% of the participants stated that they trust the vaccine. In the same study, it was reported that having a bachelor’s degree or higher education level and being male affected the attitude toward vaccination more. When the literature was reviewed, it was found that the confidence in vaccination in our study was lower compared to other studies. It is thought that the low trust in vaccines may be due to the lack of information on vaccines, the presence of information confusion on the media and social platforms regarding vaccination opposition, and the high vaccine instability due to all these.

According to the linear regression analysis, the probability of having a positive attitude toward Covid-19 vaccine was higher in those with high fear of Covid-19 contamination, being male, those who were satisfied with their life, those who perceived their health status as good, those who were older, and those who were not worker-tradesmen (Table 4). In the study conducted by Akarsu et al.²⁷ it was in line with our study and it was found that male had more positive views on vaccination than female. In a study conducted on vaccination attitudes, it was found that income level, education and satisfaction with health insurance were related to vaccination attitude, while age, gender and ethnic status had no effect.²⁹ Li et al. (2020)³² found that married participants (30.0%) intend to be vaccinated at a higher rate than singles (24.3%); However, this relationship was found to be insignificant in multivariate analysis. Participants who perceived their general health conditions very well had the highest rate of desire to be vaccinated (34.8%). Among the participants, the self-employed and service sector employees have a significantly higher desire for vaccination. These study findings support our findings. In the literature, there are studies related to increasing age and increasing vaccination attitude.^33,34 In another study, positive beliefs about vaccination were found to be significantly associated with higher education, not with age.²⁸ In our study, while there was a positive relationship between the increase in age and the attitude to vaccination, education level was not found to be significant. Bell et al.³⁵ found that male, those aged 25 and under, and married people show more positive attitudes toward the Covid-19 vaccine. According to the logistic regression analysis in the study conducted by J. Wang et al. (2020),²² it has been shown that being a male, being married, having a high perception of infection risk, having had an influenza vaccine before, believing the effectiveness of the Covid-19 vaccine, or valuing doctor’s recommendations may increase the likelihood of accepting the Covid-19 vaccine. Similarly as in other studies, in our study, those being male show more positive attitudes toward the vaccine. When asked about the Covid-19 vaccine, more females were indecisive (47.0–51.5%) than males (38.2–41.7%). Therefore, female may have shown less positive attitude toward Covid-19 vaccine than male. Salali and Uysal (2020) observed that those with high anxiety were found to have a higher acceptance of the Covid-19 vaccine. Similarly, in our study, those with a high fear of Covid-19 transmission show more positive attitudes toward the vaccine.

The probability of having a negative attitude toward Covid-19 vaccine was found to be higher in those with low fear of Covid-19 transmission, female and those with low family income (Table 4). Murphy et al.³⁶ in their study on the hesitation and resistance against Covid 19 vaccine in Ireland, the rate of those who are hesitant about vaccination was found to be higher in the 35–44 age group, female and those with low income.

No relationship was found between the religious attitude of the participants and both the positive or negative attitude of the Covid-19 vaccine (Table 3). WHO reported that religion, culture, gender and socio-economic factors are important among contextual factors affecting immunization.⁸ When the studies in the literature are examined, it has been found that there are studies showing that religiosity is related to the attitude to instillation. It has been found that an Orthodox Protestant minority in the Netherlands has religious objections to vaccination and 40% of them have never been vaccinated. As Orthodox Protestant parents’ reasons for not being vaccinated; It has been determined that inoculation is primarily a prevention of divine will and that God will not allow disease to occur in the human body, and that they use religious arguments, and it is based on the belief that trust in divine will is necessary.^37,38 In a study conducted in Malaysia, where Muslims are the majority, 13.5% of mothers answered “I agree” to the question “childhood vaccine is banned in religion”. As a justification, they stated that they believed that the vaccine should be halal and therefore its use should be prohibited.³⁹ In another study, arguments supporting vaccination were put forward based on the Bible, and it was reported that the vaccine was thought to be a gift of God.⁴⁰

The mean of AA-COVID 19 cognitive avoidance items (2.45) is similar to the average value (2.5), and the mean of behavioral avoidance items (3.74) is much higher than the average. No significant relationship was found between cognitive and behavioral avoidance attitude with life satisfaction and religious attitude (Table 3). When the studies in the literature are examined, there are also studies showing that religiosity is related to Covid-19 avoidance. Religiosity and Covid-19 anxiety were found to be significantly associated with social distance.⁴¹ In our study, no relationship was found between Covid-19 avoidance attitude and life satisfaction (Table 3). Contrary to our study, there are studies showing that the increase in sensitivity to social risks causes a decrease in life satisfaction. It is suggested that increasing the positive emotions of people will be useful in the effective fight against Covid-19, and policy makers should provide this situation.³² Increasing positive emotions is only possible by increasing life satisfaction.

According to the multivariate LR analysis, the possibility of cognitive avoidance from Covid-19 is higher in those with high level of Covid-19 self-knowledge and family income, while other variables were not found to be statistically significant. The probability of behavioral avoidance increases with increased educational level, female gender, increasing family income level, and increasing fear of COVID-19 contagion, while the probability of behavioral avoidance decreases with being a worker-tradesman, being a civil servant, and increased number of persons per household (Table 5). In support of our study, there are studies showing that as the level of knowledge decreases, the cognitive avoidance adaptation of Covid-19 decreases.⁴² In the study conducted by Li et al. (2020), a result was obtained in the direction of our study. It has been determined that the increase in the income level of individuals and the fear of Covid-19 transmission are associated with more frequent participation in most (at least three) preventive health behaviors.³² In situations where individuals are more vulnerable to infection, the cost of being socially assertive is relatively higher. Therefore, when people feel they are relatively vulnerable to infections, they naturally tend to reduce social initiative.⁴³

4.1. Conclusion and recommendations

The attitude toward COVID-19 vaccine were not related to avoidance from the Covid-19 and religious attitude. As the life satisfaction increases, positive attitude toward the COVID-19 vaccine increases, too. It was determined that about one-third of the participants think that the Covid-19 vaccine is protective and support its administration, while almost half of them were undecided about these issues, and one-fourth trust to explanations made for the vaccine.

It would be important to monitor changes in people’s vaccine acceptability, while the vaccine development process continues. The importance of accessing the right resources on different platforms should be emphasized by considering the fear and rejection reasons of people who experience vaccine hesitation or rejection. Arrangements should be made to develop necessary strategies and to raise awareness about the importance of vaccination.

Disclosure of potential conflicts of interest

The authors declare that they have no competing interests. The authors alone are responsible for the content and writing of the paper.

Availability of data and materials

The study data are stored. The data may be provided if desired. The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

MK. The research’s planning, implementation, statistical analysis, writing and reviewing, NUO. The research implementation, conducting surveys, conducting ethical permits, writing and reviewing, GU. Conducting surveys, conducting ethical permits, writing and reviewing.

Ethics approval

This research was conducted in accordance with the rules and ethical codes specified in the Declaration of Helsinki (all revisions including 2013).

Consent to participate

The participants were informed about the research and consents were obtained. Before starting the survey, those who approved to participate in the survey online were allowed to complete the questionnaire.

Consent for publication

In the research, people’s images, private data, etc. not collected.

Additional information

Funding

No financial support was received from any person or institution for the research.