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Coronavirus

Hesitancy toward vaccination against COVID-19: A scoping review of prevalence and associated factors in the Arab world

Zufishan Alama Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab EmiratesView further author information
,
Salma Mohameda Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab EmiratesView further author information
,
Javaid Naumana Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates;b Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway;c Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, College of Applied Health Sciences, University of Illinois, Chicago, IL, USAView further author information
,
Rami H. Al-Rifaia Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab EmiratesView further author information
,
Luai A. Ahmeda Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates;d Zayed Centre for Health Sciences, United Arab Emirates University, Al Ain, United Arab EmiratesView further author information
&
Iffat Elbarazia Institute of Public Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab EmiratesCorrespondence[email protected]
ORCID Iconhttps://orcid.org/0000-0001-7151-2175View further author information
ORCID Icon
Article: 2245720 | Received 19 Apr 2023, Accepted 04 Aug 2023, Published online: 18 Aug 2023

ABSTRACT

Despite widespread availability of vaccines against SARS-CoV-2 virus, the cause of Coronavirus Disease 2019 (COVID-19), its uptake in many Arab countries is relatively low. This literature review aimed to scope evidence on COVID-19 vaccine hesitancy (VH) in the Arab world. A total of 134 articles reporting prevalence of COVID-19 VH and associated factors, conducted in any of the 22 Arab League countries, were reviewed. COVID-19 VH prevalence ranged from 5.4% to 83.0%. Female gender, young age, low education level and lack of previous influenza vaccine uptake were most commonly reported to be associated with COVID-19 VH. The most-reported personal concerns contributing toward VH were related to the rapid development, safety and side effects of vaccine, as well as an overall lack of trust in government policies toward pandemic control and widespread conspiracy theories. Tailored interventions to enable the distribution of trusted information and enhance public acceptance of immunization are warranted.

Introduction

During December 2019, several cases of acute pneumonia of unknown etiology were diagnosed in Wuhan-China, with spread and severity so substantial that it rapidly drew global attention. Consequently, the new virus genome sequence was identified as severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), causing the ongoing COVID-19 pandemic.Citation1 The pandemic has infected over 758 million confirmed cases worldwide and caused over 6.86 million deaths as of February 2023.Citation2

As different measures were taken to curb the worst effect of virus, pharmaceutical industries were also urged to develop vaccines immediately to limit the escalating infection rates.Citation3 The new awaited vaccines were predicted to reduce incidence, virulence, and morbidity. However, despite the eager anticipation of vaccine availability worldwide, the urgency of the development, coupled with the unknown side effects, triggered vaccine hesitancy, refusal, and antivaccine movements.Citation4 According to WHO, vaccine hesitancy (VH) is defined as a “delay in the acceptance or refusal of vaccination despite the availability of vaccination services.”Citation4 Even long before the COVID-19 pandemic, vaccine hesitancy has hindered the global effort to control outbreaks affecting thousands of vulnerable individuals to the extent that the World Health Organization (WHO) considers it as one of the top public health challenges, that needs to be tackled, along with poverty and HIV.Citation5 The scope of vaccine acceptance ranges from accepting the vaccine without any doubts to rejecting it altogether. Accepting and taking some, refusing others, and delaying vaccination are all counted toward VH.Citation6

With a total population of over 440 million, the Arab world comprises 22 countries extending from the Arabian Sea in the east to the Atlantic Ocean in the west.Citation7 Despite the significant disparities in cultural, environmental, and socio-economic determinants of health in the Arab world, it has been affected by the COVID-19 in a way similar to that of the rest of the world. The pandemic has infected over 14.1 million individuals and caused around 173.3 thousand deaths as of February 2023 in the Arab world.Citation8 Several types of vaccines have been introduced in the region to control the pandemic (refer to Table S1 for vaccines used in each country), including RNA-based vaccines such as Pfizer-BioNTech and Moderna, non replicated viral vector vaccines such as Oxford-AstraZeneca, Jcovden, CanSino, Sputnik V and Sputnik Light, whole inactivated virus-based vaccines such as Sinopharm, Sinovac, Covaxin and Valneva and protein subunit based vaccines such as Recombinant-SARSCoV-2 Vaccine.Citation9 The expedited production and approval processes, along with wide variations in the vaccine brands, have led to an increase in uncertainty regarding effectiveness of the vaccines. In addition, the distribution of vaccines in the Arab world faced some initial challenges, especially with supply, accessibility, and storage, that were overcome to ensure availability for all individuals.Citation10

Despite the wide availability and accessibility of vaccines in most of the countries in the Arab world, VH was very common, particularly in the initial phases of vaccination campaigns.Citation11,Citation12 Early cross-sectional surveys showed variable attitudes toward COVID-19 vaccination ranging from high acceptance rates in some countries to increased hesitancy rates in others.Citation10,Citation12 Sociodemographic factors that could have contributed to VH and personal views that might influence vaccination decisions were investigated.Citation11 Several reviews have been carried out within the last three years summarizing the COVID-19 vaccination uptake and affecting factors in several regions of the world.Citation13,Citation14 However with the emergence of more studies in relation to this topic, targeting different populations and using different models, there is a consistent need to review the findings of these papers to provide policy makers with latest evidence on best vaccination programs and approaches. This scoping review summarizes evidence from the published literature investigating prevalence of the hesitancy toward vaccination against COVID-19 and/or factors associated with the hesitancy in the Arab world. The review also explores the most common personal perspectives acting as barriers, leading to hesitancy against vaccination to COVID-19 in this region.

Materials and methods

Search strategy

This review was conducted and is reported in accordance to the guidelines set by Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).Citation15 Refer to Table S2 for PRISMA-ScR checklist. The protocol for the review was registered with Open Science Framework (OSF; Digital Object Identifier https://doi.org/10.17605/OSF.IO/K83ZX). Review was performed following five key steps of Arksey O’Malley framework.Citation16 PubMed, Scopus, and Embase databases were searched between October 2021 and February 2023, for articles with studies based on cross-sectional design, reporting prevalence of hesitancy against vaccination to COVID-19. A search strategy using appropriate combination of key words and MESH terms, developed by the authors and reviewed by expert librarian was used. Search terms related to COVID-19, vaccine, and vaccine hesitancy, in addition to the list of the 22 Arab countries (Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates (UAE), and Yemen) were included. Refer to Table S3 for the search strategy used in the PubMed. Study search was conducted by two independent reviewers (SM, ZA).

Eligibility criteria

Articles were included if they were based on a study with cross-sectional design, with a primary aim to investigate the prevalence of COVID-19 vaccination; and/or factors associated with vaccine hesitancy, in any of 22 Arab countries, regardless of the studied population (refer to Table S4 for the eligibility criteria). Articles published in Arabic or English language were considered eligible. Mixed method studies were included if the quantitative component in the study was based on a cross sectional design. Articles based on studies in non-Arabic countries, with other than cross-sectional study designs, and those addressing VH for non-COVID-19 viruses were excluded. Only articles reporting VH and associated factors and attitudes among adults were included, with those addressing parents’ views regarding VH among children excluded. Articles were eligible if they were published from October 2021, as the vaccine was widely available for the majority of the populations by that time. Original peer-reviewed articles were included whereas conference proceedings and abstracts with incomplete data were excluded.

Study selection and data extraction

After removal of duplicate records, titles and abstracts of the retrieved articles were screened for their full or potential eligibility. Full texts of the eligible articles were screened and assessed for inclusion against the pre-set inclusion criteria. Title/abstract screening and full-text screening were carried out by two reviewers (SM, ZA) independently and any conflicts were resolved by mutual discussion or involvement of the third reviewer (IE). The bibliography of the included articles was also hand-searched for any additional eligible studies that might have been missed in the database search.

From the articles that were deemed eligible for inclusion, data were extracted using a predetermined extraction tool. The extraction tool included fields on the basic characteristics of studies as well as methodological aspects, such as author and year of publication, study setting, type of population, sample size, and mode of data collection. Study outcomes in terms of calculated or calculable data on the prevalence of and factors associated with hesitancy against COVID-19 vaccination as well as personal beliefs leading to VH acting as barriers for vaccine uptake were also extracted. Only data on factors found to be statistically significant as reported in the studies, based on regression modeling were included. Data on the outcomes were then summarized narratively.

Results

Study selection

A total of 622 articles were identified from the database search, including PubMed (260), Embase (200) and Scopus (162) (). After removal of duplicates and screening the records for title/abstract and full text, 156 articles remained. 22 records were excluded via full-text screening due to irrelevant outcomes i.e., parents’ hesitancy toward vaccination of children (6), irrelevant populations such as Arab immigrants in non-Arabic countries (3), wrong vaccine types such as that for Influenza (5), irrelevant geographical locations (2), wrong study design i.e., qualitative (3) and nonavailability of full text (3). Resultingly, 134 articles met the inclusion criteria and were included in the review.

Figure 1. PRISMA flow chart illustrating study selection.

Figure 1. PRISMA flow chart illustrating study selection.

Characteristics of the included studies

Characteristics of the included studies are summarized in , with detail of individual studies provided in . Overall most of the studies (132) were cross-sectional, with two of mixed method design.Citation77,Citation87 Of the included articles, 123 addressed hesitancy against primary COVID-19 vaccination whereas 10 addressed against that of booster vaccination and one addressed both.Citation106 Studies were conducted in 18 (81.8%) out of the 22 Arab countries. The majority of the included studies were conducted in Saudi Arabia (29.8%), followed by Egypt and Jordan (11.9% each), multiple countries (11.1%), Lebanon (5.2%), Iraq, Qatar and UAE (4.5% each), Kuwait (3.7%), Palestine (3.0%), Sudan (2.2% each), Algeria and Oman (1.5% each), Morocco, Somalia, Syria, Yemen, Tunisia and Libya (0.7% each), ().

Figure 2. Distribution of the number of the included studies by country.

Figure 2. Distribution of the number of the included studies by country.

Table 1. Summary of the included studies based on characteristics.

Table 2. Summary of 124 articles with studies reporting hesitancy against primary COVID-19 vaccination.

Table 3. Summary of 11 articles with studies reporting hesitancy against COVID-19 booster vaccination.

Number of participants in the included studies ranged from 111–36,220.Citation35,Citation81 The general public was the most commonly addressed population (76 studies), followed by healthcare workers (HCWs) including physicians, nurses and dentists (32 studies), university students (14 studies) and pregnant/lactating women (14 studies). Other populations subgroups addressed in the studies included patients with cancer and chronic illnesses, refugees, older adults, dental patients and air travelers. Participants suffering from chronic diseases included those with diabetes, rhematic disease, HIV and on hemodialysis.Citation61,Citation119,Citation129,Citation139

For data collection, the majority of the studies used online surveys (122), whereas few used printed questionnaires (14). Telephone calls and in-person interviews were also used for data collection sparingly.Citation35,Citation36,Citation47,Citation111 Most of the questionaries used in the survey were self-developed by the researchers or based on those used in previous studies. However, few studies developed their questionnaires on validated existing tools such as the WHO-SAGE survey tool,Citation72–77 the GRA Vax scaleCitation21,Citation22 and the 5C scale.Citation31,Citation85 Few included studies also used Health Belief Model (HBM) to guide data collection.Citation24,Citation67,Citation93,Citation127

Prevalence of hesitancy toward vaccination against COVID-19

Study-based prevalence of hesitancy against primary COVID-19 vaccination is described in whereas that against booster vaccination in . COVID-19 VH varied considerably across the 130 articles reporting VH, included in this review. Hesitancy levels ranged from as high as 83.0% in a large multinational survey of 22 Arab countriesCitation82 to just 5.4% among the general population in Saudi Arabia.Citation130 Some articles included studies focused on the attitude toward vaccination and did not report data about the hesitancy ratesCitation26,Citation56,Citation57,Citation85 (). Reported VH ranged between 12%-83% for general population, 14%-79% for HCWs, 20.1%-49.1% for pregnant and lactating mothers, 13%-65.1% for students, 10.4%-75.6% for refugees, 45% for cancer patients and 37–63.8% for patients suffering from chronic diseases. When summarized on the basis of geographical location, VH prevalence was found to be 5.4%-63.8% (Saudi Arabia), 12%-79% (Egypt), 10.4%-80.1% (Jordan), 16.7%-74.3% (Kuwait), 13%-78.9% (Lebanon), 27.9%-62.2% (Palestine), 26%-57.3% (Qatar), 31.8%-57% (UAE), 57%-60.1% (Oman), 31.4%-44.2% (Sudan), 38.3%-49.9% (Yemen), 20.4% (Libya), 34.7% (Tunisia), 36%(Morocco), 47% (Algeria) and 24.5%-83% (multiregional). VH was found to be 9.6%-83% in articles published in 2021, 5.4%-81.0% in articles in 2022 and 20%-38.3% in articles in 2023. 11 articles including studies that measured COVID-19 booster vaccine hesitancy found it to be 21.8% − 55.4%.Citation106–141–Citation150

Factors associated with hesitancy and acceptance toward vaccination against COVID-19

The factors most commonly reported to be associated with hesitancy toward vaccination against COVID-19 in the majority of the studies were female gender, young age, rural background, low level of educational attainment, low-income level, lack of previous Influenza vaccine uptake, lack of acquaintance with someone having suffered from COVID-19 infection, low COVID-19 vaccine knowledge, less fear and worry of contracting the infection and low risk perception. Other less commonly reported associated factors leading to low VH, identified from the studies, included healthcare sector-related profession, preexisting chronic disease, positive attitude toward general vaccination, COVID-19 vaccine access and price and migrant status. For healthcare workers, years of experience, practice setting, previous provision of care for COVD-19 patient and mode of contact (direct versus indirect) with patients were found to be associated with VH in the included studies. For pregnant and lactating women, pregnant or breastfeeding status, knowledge of other pregnant and breastfeeding women being infected with COVID-19 or having had the vaccine and recommendation by obstetrician/gynecologist were important predictors for VH.

Few articles based on studies assessing hesitancy via HBM showed that it was consistently associated with constructs including preventive measures, perceived benefit, perceived barriers, cues to action and subjective norms. Studies also reported that attitudinal scores and protective measure adherence scores were also associated with COVID-19 VH.Citation25,Citation42,Citation71,Citation77 In terms of personal perspectives leading to COVID-19 VH, the worry regarding vaccine side effects, insufficient time for vaccine testing, belief in natural immunity, belief that symptomatic cases are the only infection carriers, mistrust in government authorities, healthcare system and pharmaceutical companies, concerns on vaccine safety and effectiveness, experience of contracting infection after previous vaccine, belief in origin of the pandemic, conspiracy theories related to COVID-19 vaccine development, belief in community responsibility and vaccine compulsion for all citizens, were identified from the included studies. For communication and sources of information, studies reported that participants relying on a trusted source of information were less vaccine hesitant compared to those dependant on social media for updated information regarding the vaccines. Acquiring online information through nonscientific resources was found to reduce the acceptability of the vaccine.Citation64,Citation90

Discussion

This review documented a wide variation (5.4% − 83%) of COVID-19 vaccine hesitancy among countries of the Arab world. Variations were obvious in studies conducted in different countries as well as among the studies conducted in the same country. Hesitancy for booster dose was found to be comparatively less (21.8% − 55.4%). The most commonly reported factors associated with hesitancy included female gender, younger age, previous influenza vaccine uptake, and low education and income level. The most-reported personal concerns were related to the rapid development, safety, and long-term side effects of the vaccine. Moreover, overall lack of trust in government policies toward pandemic control, widespread conspiracy theories about vaccines, and different misconceptions increased the probability of COVID-19 vaccine hesitancy among population in these countries.

With the emergence of COVID-19 virus and infections, vaccine hesitancy became a hot research topic that has been studied extensively all around the globe. Vaccine acceptance ranges from as high as 90% in China to just 55% in Russia, while countries like the USA and Canada reported acceptance rates of 69% and 76.5%, respectively.Citation151 Similar considerable disparity in vaccine acceptance rates in the Arab world was reported in our article. The willingness to receive the vaccine was higher in studies from Saudi Arabia and Kuwait compared to other Arab countries.Citation34,Citation63 The regional and worldwide variations could be attributed to the countries’ differences in the effectiveness of the health systems in dealing with the pandemic, severity of the infection, the number of cases, and the mortality rates across the countries.Citation10 On the other hand, political instability, unfavorable legislation, and financial issues as well as educational status of the people may adversely affect people’s opinions regarding vaccination as evident from differences in VH prevalence between Arabic and Western countries.Citation11,Citation12 Other reasons may include conspiracy theories rooted in religious concerns and misinformation disseminated through various media platforms.Citation14,Citation152 Variations in vaccine hesitancy were also evident from studies within the same country. For example, studies in Egypt reported hesitancy rates ranging from 12%Citation21 to 79%Citation18 depending on the studied area, such as urban or rural background, and the studied population (general population vs university students).

Interestingly, the high levels of vaccine hesitancy were not reflected in the vaccination rates. For instance, in the UAE, despite relatively high hesitancy rates (31.8% −75.6%), the vaccination rates are very high.Citation72 This could be related to the carefully planned and implemented effective policies that ensured vaccination of all community members.Citation153 The reviewed studies listed various factors that influence vaccine hesitancy among the studied populations. It was found that younger age, female gender or low levels of education are associated with high hesitancy levels, while previous intake of Influenza vaccine was perceived to increase the motivation to accept COVID-19 vaccination. Other reasons for the increased uptake of COVID-19 vaccines such as working in healthcare related profession, preexisting chronic diseases, good knowledge of COVID-19 disease and immigrant status, were also reported in a previous review on global hesitancy.Citation151

Previous studies have found a clear association between the female gender and hesitancy. It is suggested that the influence of gender on the decision is most probably related to high anxiety levels in females in general and fear of needles in particular.Citation157 Moreover, pregnancy and breastfeeding are sensitive health matters that require careful considerations and decisions for vaccine uptake in this population. The higher vaccine hesitancy rates in younger individuals may be related to the focus of the vaccination campaign on the elderly, providing false assurance for the younger generation that they are immune to the disease.Citation62 Previous Influenza vaccination uptake was found to be associated with increased COVID-19 vaccine acceptance in this review, as reported in another study conducted in the UK.Citation154 A recent review summarizing the coverage of Influenza vaccine in sixteen countries of WHO Eastern Mediterranean region informed that the vaccine was available free of charge to general public or at risk groups in most (81%) of these countries. However, the availability depended upon the resources and socioeconomic status of the country.Citation155

A commonly stated concern related to the vaccines was emergency authorizations of vaccines which may have triggered questions about the unknown long-term side effects. Other worries were related to mistrust in the governments in general, especially after the chaotic situation that challenged the health systems and exposed all the deficiencies in emergency planning. Some surveys reported that people believe in conspiracy theories related to vaccines’ efficacy and safety, production sites of the vaccines, and the uncertainties around the origin of the disease.Citation29,Citation81 Moreover, self-perception of poor health triggered hesitancyCitation25,Citation114 in contrast to people with chronic illness (hypertension, diabetes, etc.) who were more willing to get vaccinated.Citation51,Citation58,Citation123

Many countries in the Arab region have encountered enormous disasters and tragedies including wars, political conflicts, and natural disasters. COVID-19 pandemic has further deteriorated the conditions of poverty and accessibility to medical treatment as well as vaccination services.Citation156 However, in a study that examined older Syrian refugees living in Lebanon, it was found that the intention to receive the COVID-19 vaccine is higher among those living inside refugee camps compared to those living outside the tented settlement. The study also argued that the vaccination and educational campaigns are overlooking many of those who are not registered informal refugee camps.Citation35

Despite the inclusion of many high-quality studies in this review, there were some limitations, inconsistencies were noted with the definition and scope of hesitancy, classifying hesitancy and refusal separately in many studies conducted in the Arab world, as the standard definition developed by WHO for hesitancy was not followed. However, in this review, we have reported hesitancy as defined by WHO and prevalence might not be very precise given the large variation in the reported data. Another limitation is that most of the surveys conducted in the studies included in this review were carried out online, which is justifiable given the social distancing measures. However, this means that a large number of individuals from the Arab population were underrepresented such as those who do not have internet access, those from the low socio-economic strata especially people with low levels of education and older adults. Future studies are warranted to investigate the prevalence of COVID-19 vaccine hesitancy and associated factors in all subgroups of the population. Critical appraisal of the included studies, as well as meta-analysis to measure strength of association between VH and its predictors was not conducted. It would have added further to the evidence, yet with the coverage of extensive number of studies and given objective of the review, it was not feasible. Additionally, the review did not address parents’ attitudes toward vaccination in the children. These limitations could potentially be addressed in future reviews.

Conclusion

In summary this review provided an overview of evidence on COVID-19 VH levels in the countries of Arab world and most commonly reported factors associated with it. Results suggested varied COVID-19 VH prevalence across different Arab countries. Most common factors associated with COVID-19 VH as reported in the studies included female gender, young age, low educational level and lack of previous vaccination against Influenza. Strategies for proper information dissemination and clarification of misconceptions regarding the vaccine are required. This will lead to improvement in vaccination uptake, thus preventing mortality and morbidity from the infection when acquired, in the future.

CRediT authorship contribution statement

ZA: Literature search, data extraction, data analysis, initial manuscript drafting, revision of manuscript; SM: Literature search, data extraction, data analysis, initial manuscript drafting; JN: Critical review; R Al-R: Critical review, LA: Critical review; IE: Concepualisation, Supervision, Critical review.

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Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary data

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2023.2245720.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

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