COVID-19 vaccine hesitancy in Sri Lanka: A national level survey

Introduction

The coronavirus disease-2019 (COVID-19) is a pandemic that poses grave health and economical challenges. It has affected all aspects of life and has imposed enormous costs on individuals, communities, health-care systems, and nations.[1] The world became aware of the dreadful reality of the situation as soon as the World Health Organization proclaimed COVID-19 a pandemic on March 11, 2020.[2] COVID-19 still shows no signs of being contained, resulting in an increased number of human deaths, destroyed livelihoods, and significant economic losses for countries.[3]

In addition to basic preventative measures such as social distancing, wearing a face mask, and washing hands,[4] many countries have taken rigorous precautions such as compulsory community lockdown and border restrictions in an effort to reduce the virus spread while minimizing the pandemic. However, vaccination is the ultimate strategy to prevent this infection.[5] The COVID-19 vaccines provide disease protection by activating an immunological reaction to the SARS-CoV-2 virus.[6] Therefore, it provides immunity, which decreases the probability of getting the illness and its consequences[6] and the pandemic may be controlled through herd immunity.[7,8] In addition, it was identified that a significant proportion must be vaccinated to develop effective herd immunity to halt the transmission of the COVID-19 virus.[9] Thus, universal vaccination is increasingly becoming a crucial approach in the growing COVID-19 pandemic. However, hesitation for the vaccine by the general public has been noticed as a key impediment to the successful handling of the present epidemic.[10] Vaccine hesitation is described by the strategic advisory group of experts on immunization as a “delay in accepting or refusing immunization notwithstanding the availability of vaccination services.”[10] Vaccine hesitancy is a long-standing issue that poses a significant threat to world health, as seen by the resurgence of numerous infectious diseases, including measles and pertussis epidemics.[11,12] Conventionally, vaccination hesitancy is a widespread problem across the world with varying causes for the rejection of vaccine uptake.[13] The most prevalent reasons were anticipated risk versus advantage, religious views, and insufficient awareness and understanding.[13] Furthermore, as proven by the previous vaccination research, the willingness to get vaccinated is highly impacted, particularly by suspicion of health experts.[14,15] In addition, because of the disease’s novelty and worries about the safety of the vaccination and efficiency, a substantial number of the population have shown hesitate to get vaccinated against COVID-19.[16] The varied nature of vaccine hesitancy, including willingness to receive COVID-19 vaccinations, may hinder research into its worldwide impact. This implies that there are cognitive, psychologic, sociodemographic, and cultural aspects that contribute to vaccination hesitation. For instance, two recent reviews have discussed varying patterns of current COVID-19 vaccination acceptability in terms of proportion and associated factors such as gender, ethnicity, working status, education, age, religiosity, income, and working in health-care settings.[14,15] Following an evaluation of the extent and scale of this public health hazard, such variables must be examined to overcome COVID-19 vaccination hesitancy.[17] This can help in guiding interventional measures aimed at building and maintaining responses to tackle this threat.[18]

Sri Lanka is a low-to-middle income country with a population of more than 21 million people with diverse ethnic groups and different socioeconomic statuses. At present, the COVID-19 immunization program has been implemented in Sri Lanka and multiple types of vaccines were administrated.[19] The types of currently administered vaccines in Sri Lanka are CoviShield, Sinopharm, Sputnik-V, and Pfizer.[20] However, according to a small survey done in Sri Lanka, the majority of people were cautious about the brand of vaccine, its adverse reactions, allergy, and the period of immunity.[21] Therefore, the study was needed to collect reliable data on vaccination hesitancy when the vaccination is made accessible to the whole public. Considering a successful vaccination program, the government authorities must first accurately identify the target demographic factors and their nature in immunization concerns to develop effective intervention approaches such as implementing health education programs and then combat vaccine hesitancy accordingly. The purpose of this online survey was to investigate the prevalence of vaccine hesitancy and associated sociodemographic factors for vaccine hesitancy.

Materials and Methods

Results

At the end of the survey period, a total of 3714 replies were received. After excluding incomplete responses and trivial groups (1% categories), 3621 respondents of ≥16 years old were included in the analysis. The sociodemographic characteristics of the participants are shown in Table 1. The participants’ mean (SD) age was 32.98 (9.79) years, with the largest portion (24.6%) in the age range 26–30 years. About 60% of respondents were female. The current survey revealed from all 25 districts in Sri Lanka, with Colombo (38.0%, n = 1375), Gampaha (13.6%, n = 491), and Kandy (9.4%, n = 342) having the highest numbers. The majority (40.2 %, n = 1456) were in rural areas, with 32.6% (n = 1181) and 27.2% (n = 984) residing in municipal council and city regions, correspondingly. The study participants included people from all ethnic groups in Sri Lanka, with Sinhalese accounting for the majority portion (82.1 %, n = 2974). The majority of respondents held degree level (70.0%, n = 2533) or tertiary level (25.8%, n = 934) education. In terms of employment, 63.8% (n = 2311) were employed, 5.5% (n = 200) self-employed, 7.2% (n = 261) unemployed, and 16.6% (n = 602) were full time students. Nearly half of the participants (49%, n = 1785) had a gross monthly household income of far more than 100,000 LKR, while only 8.6% (n = 313) received an income less than monthly salary of 25,000 LKR.

Table 1 Demographic characteristics of the study population

In relation to the COVID-19 infection rate in this group, only 2.4% (n = 88) of those surveyed claimed to be infected with COVID-19. In addition, the majority of the respondents (65.3%, n = 2364) reported that they did not receive the vaccine. Among the vaccinated group (n = 1257), 54.0% got the first dose, while 47.9% received both doses. In relation to reasons for not having any dose of vaccine [Figure 1], the majority (75.7%, n = 1736) of them mentioned that they did not get the chance for vaccination, but expect to get the vaccine in the future and only 3.9% (n = 89) mentioned that they refused due to contraindication to the vaccine. However, over one-fifth of the study population (20.4%, n = 469) have mentioned that they were not willing to be vaccinated for other reasons.

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Figure 1

The reasons for not having COVID-19 vaccine

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Table 2 presents the distribution of the sociodemographic features by vaccine hesitancy due to acceptable reasons (unavailability of vaccine or contraindication to the vaccine) and other reasons. Across all the demographic variables, ethnicity and district indicated significant associations with vaccine hesitancy (hesitancy of accepting the vaccine due to other reasons) (P < 0.05). However, hesitancy of accepting the vaccine due to acceptable reason or other reason was not significantly associated with age, gender, area of residence, education level, employment status, and monthly family income.

Table 2 Distribution of the Socio-Demographic features by vaccine hesitancy

Table 3 shows the OR for the prevalence of vaccination hesitant by sociodemographic factors in both crude and adjusted regression analysis. According to the findings of the binary logistic regression analysis, age or gender had no significant impact on vaccination hesitancy in adjusted regression analysis. However, ages between 16 and 25 years were significantly less likely to hesitate vaccine compared to age >40 years (OR 0.66; 95% CI, 0.46–0.94; P = 0.022) in crude regression analysis. Respondents from other districts had significantly lower odds of vaccine hesitancy (OR 0.54; 95% CI, 0.41–0.71; P < 0.001) in comparison to Colombo in the adjusted model (multivariate analysis). In comparison to the municipal council area, people in rural areas were also more likely to be vaccination hesitant, only in the adjusted model (OR 1.34; 95% CI, 1.00–1.79; P = 0.05) which was almost significant, but not in the univariate analysis (OR 1.1; 95% CI, 0.86–1.40 P = 0.46). With regards to ethnicity, Indian Tamils (OR 2.22; 95% CI, 1.15–4.29; P = 0.018), Sri Lankan Tamils (OR 1.71; 95% CI, 1.18–2.49; P = 0.005) and Sri Lankan Moors (OR 1.91; 95% CI, 1.32–2.78; P = 0.001) had a significantly greater odds of vaccine hesitancy when compared to the Sinhalese in multivariate analysis. Moreover, all those categories had a significant greater odds of vaccine hesitancy compared to the Sinhalese in univariate analysis as well which was OR 1.46; 95% CI, 1.03–2.07; P = 0.033 in Sri Lankan Tamil, OR 2.44; 95% CI, 1.28–4.63; P = 0.007 in Indian Tamil, OR 1.83; 95% CI, 1.29–2.59; P = 0.001 in Sri Lankan moors. Any stratum of education and income level seems to have not significantly influenced the vaccine hesitancy both in univariate analysis and multivariate analysis. The employment status also had no influence on vaccine hesitancy in the adjusted model, but self-employed were significantly more likely to hesitate vaccine compared to the employed group (OR 1.57; 95% CI, 1.04–2.35; P = 0.03) in the crude regression analysis.

Table 3 The Odds Ratios (OR) for the likelihood of vaccine hesitancy by sociodemographic variables^a

Discussion

To the best of our knowledge, The current study is the first largest national-level online surveys conducted in Sri Lanka to investigate the prevalence of vaccination hesitancy and its relationship to socioeconomic factors. Survey participants were primarily young people under age of 35 used social networking sites more actively than the elder population. Furthermore, responders were mostly female and educated. During the survey period, the most of those who responded did not have the opportunity to be vaccinated but were expecting to acquire the vaccine when it becomes available. In Sri Lanka, 19/100 people have been vaccinated (received at least one dose) as of 1^st July 2021.[28] In other words, 13.62% of Sri Lankans have gotten at least one dose of any vaccination, while 5.3% have been fully vaccinated (received two doses).[28] Globally, over 3.16 billion immunization doses have been administered, equivalent to 41 doses for every 100 individuals.[28] However, there is already a significant disparity in immunization efforts in various nations, with some failing to record even a single dosage.[28] There is also a notable gap between regions. Africa has the lowest immunization rate of any region (3.8/100 people), while North America has the highest rate of vaccination (74/100 people).[28] Although high- and upper-middle-income nations accounted for 85% of all doses, in low-income nations, only 0.3% of dosages were delivered.[28] Although less-affluent nations are relying on COVAX, a vaccine-sharing agreement that intends to promptly supply two billion doses by the end of this year,[29] COVID-19 vaccination hesitancy was identified as a major obstacle worldwide in attempts to manage the present pandemic.[30] The most recent COVID-19 estimations indicated a range of 60–75 % vaccinated persons will be necessary for preventing the virus’s further replication and community spread.[31] Therefore, public acceptability of vaccination should be high for this endeavor to be successful.

From the present study, over 20% of the respondents stated hesitation regarding vaccination while nearly 80% of people could not have the vaccine due to acceptable reasons. Similarly, a survey from our neighboring country, India revealed a vaccine hesitancy rate of 25.5%.[32] In East and South-east Asian countries, the general public’s overall hesitancy rate was lower than in Sri Lanka. This includes two studies of the general people in China that revealed vaccination hesitancy rates of 8.7% and 16.5%,[33] with a further survey in South Korea reporting a rate of 20.2%.[32] In addition, other affluent countries such as Canada (20%), Denmark (20%), and the UK (as 17%; 21%; 10.9, and 28.3% with variability in different surveys) also reported lower vaccine hesitancy rates.[14] On the other hand, Middle East countries such as Jordan (71.6%) (34), Kuwait (76.4%),[34] and Saudi Arabia (35.3%)[35] have high rates of vaccine hesitancy.

Gender, income, level of education, and age appeared to have no significant effect on vaccination hesitancy based on the analysis in the present study. Association between vaccine hesitancy and gender is in conformity with the findings of a research done in Italy, which also had no significant association between gender and vaccine hesitancy,[36] otherwise, females had higher vaccine hesitancy than males in surveys done in many other countries such as the USA,[37] UK,[38] Turkey,[38] Italy,[39] Canada,[40] Japan,[40] and Switzerland.[40] Income had no association with the vaccine hesitancy in one survey done in the USA and Italy,[41] which was consistent with our result. However, other studies done in the USA, UK, Turkey, Italy, Canada, Japan showed that unemployed individuals as well as those with the lower incomes were more likely to be vaccination hesitant.[37-40] In addition, those studies have shown that individuals with a low level of education showed a greater prevalence of vaccination hesitancy.[37-40] The association of vaccine hesitancy and education level in our study is in accordance with the results observed in UK and Turkey,[38] which also showed no significant association. With regards to age, surveys done in the USA, UK, Turkey, Canada, Japan, and Switzerland have reported that the younger age group is linked with more vaccine hesitancy. In contrast, another study conducted in Italy discovered that people in the 40–50 years of age were more likely to hesitate vaccination than people in their 20–30 and >60 years of age.[39]

The district and area of residence have influenced the vaccine hesitancy in our study. Respondents from the Colombo district had significantly higher odds of vaccine-hesitant compared to “other” districts. One contributory reason for this might be that the vaccine was initially introduced to Colombo and when it came to the other districts; they already saw that it had been safely administered at Colombo and so it reduced their hesitancy due to concerns on safety. Moreover, people in rural areas also had substantially greater risk of vaccination hesitancy compared to people living in the municipal council areas. However, other surveys were done in countries with low- and middle-income (Brazil, Malaysia, Thailand, Bangladesh, and Africa) that has shown that residential setting (rural or sub-urban or urban) had no significant association with the vaccine hesitancy.[42] Although another study done in Bangladesh has revealed, the vaccine hesitancy is significant among rural residents compared to other living settings.[43]

Moreover, ethnicity has influenced the vaccine hesitancy reporting significantly lower odds in Sinhalese compared to both Tamil groups and Sri Lankan Moors, while Indian Tamils were more reluctant to be vaccinated among all ethnic groups. Similar to our finding, the vaccine hesitancy was significantly higher among the minor ethnic population in the USA[44] Great Britain.[45,46] Ethnic minorities indicated a higher vaccination hesitancy due to several reasons such as philosophical and religious issues, long history of distrust of the public medical services, and minority under-representation in health research and vaccination trials.[10] Our sample shows comparable proportions according to 2012 statistics,[47] demonstrating the country’s well-balanced distribution of ethnic groupings, the association of ethnicity toward vaccine hesitancy will be a remarkable finding. The same population recorded in this study was assessed for the usage of nutritional supplements to improve immunity and found that ethnicity had a significant relationship with the frequency of supplement intake.[48] There might be close relationships between significant disparities in this vaccine hesitancy and intake of immune-nutrients among these ethnic groups.

Conclusions

Vaccine hesitancy was considerably high in this survey population. Vaccine hesitancy was not related to age, gender, education level, or income. Sinhalese demonstrated significantly lower odds for vaccine hesitancy compared with other minority groups such as Sri Lankan Tamils, Indian Tamil, and Sri Lankan Moors, while Indian Tamil comprised significantly greater odds of vaccine hesitancy among other minority groups. Respondents from the rural area had increased odds of vaccine hesitancy compared with the municipal council area, and persons in the Colombo district were much more likely to be hesitant about getting the vaccination when compared to “other” districts. Our results emphasize the need of the Sri Lankan government taking appropriate efforts to establish a targeted COVID-19 vaccination campaign plan for rural and Colombo district residents. Attention should also be given to ethnic minority groups.

Author’s Declaration Statement