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Review

Aljoharah Algabbani,¹ Othman AlOmeir² and Fahad Algabbani³

¹King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (Correspondence to Aljoharah Algabbani: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). ²Pharmacy Practice Department, College of Pharmacy, Shaqra University, AlDawadmi, Saudi Arabia. ³Prince Sultan Military Medical City, Riyadh, Saudi Arabia.

Abstract

Background: Vaccination has a tremendous impact on health at the regional and global levels, however, the tendency for people to hesitate on vaccination has been increasing in the past few decades.

Aims: We assessed vaccine hesitancy and its determinants in the Gulf Cooperation Council countries.

Methods: We conducted a literature review to assess peer-reviewed articles published up to March 2021 on vaccine hesitancy in the Gulf Cooperation Council countries using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach. A search was conducted via PubMed and 29 articles were identified. After the removal of duplicates and irrelevant articles, 14 studies remained relevant and were used for the review.

Results: Vaccine hesitancy in the Gulf Cooperation Council countries ranged from 11% to 71%. Differences in rates were noted for vaccine type, with COVID-19 vaccine having the highest reported hesitancy (70.6%). The likelihood of accepting vaccination was associated with previous individual acceptance of vaccine, specifically the seasonal influenza vaccine. The most common determinants of vaccine hesitancy were distrust in vaccine safety and concerns about side-effects. Healthcare workers were among the main sources of information and recommendations about vaccination, but 17–68% of them were vaccine-hesitant. The majority of the healthcare workers had never received any training on addressing vaccine hesitancy among patients.

Conclusions: Vaccine hesitancy is prevalent among the publics and healthcare workers in the Gulf Cooperation Council countries. There is a need to continually monitor perceptions and knowledge about vaccines and vaccination in these countries to better inform interventions to improve vaccine uptake in the sub-region.

Keywords: Vaccine confidence, vaccination strategy, immunization, vaccine refusal, vaccine acceptance, immunization, trust

Citation: Algabbani A, AlOmeir O, Algabbani F. Vaccine hesitancy in the Gulf Cooperation Council countries. East Mediterr Health J. 2023;29(5):402–411. https://doi.org/10.26719/emhj.23.064 Received: 07/12/21; accepted: 21/11/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). 

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Introduction

Infectious diseases affect more than one billion people each year, causing severe complications and leading to 17 million deaths annually (1). Effective vaccines are available for many preventable infections that cause serious, and sometimes fatal, complications such as meningococcal, pertussis, pneumococcal and diphtheria. Vaccines prevent over 3 million deaths each year and an additional 1.5 million deaths could be saved by increasing global vaccination coverage (2). The World Health Organization (WHO) and regulatory bodies around the world are working to ensure the safety of vaccines and to monitor any adverse events reported from all vaccines approved for use.

Despite the regulatory monitoring of vaccine safety and evidence that vaccines work and saves lives, critics of vaccines exist in local and global communities. The link between the measles, mumps and rubella vaccine and autism based on a fraudulent retracted study conducted in 1998 is still raising fears among the public as the false information is still circulating on social media (3). There are debates on vaccine safety and relevance based on nonevidence or inaccurate information on traditional and social media (4). These debates raise and reinforce concerns among the public, and even among healthcare workers, about how vaccines work, including its safety, efficacy, effectiveness and relevance (5).

Lack of confidence in vaccine has a significant impact on its acceptance by the public and reduces vaccination coverage at the community level, a phenomenon driving vaccine hesitancy. Vaccine hesitancy is defined as a “delay in acceptance or refusal of vaccination despite availability of vaccination services” (6). Lack of confidence is a major factor influencing vaccine hesitancy (7) and a major cause of low vaccination rates in the community.

Vaccination has a tremendous impact on national, regional and global health. In the past few decades, the tendency among community members to hesitate or delay vaccination has been increasing as emerging diseases spread and new vaccines are developed. As access increases and information (which sometimes is misleading or inaccurate) becomes viral through social media, people increase in knowledge and become more skeptical about new vaccines (8,9).

Misleading information spreads virally among different age groups over social media in the Gulf Cooperation Council countries (GCC) countries, especially whenever there is news of a new vaccine or an emerging disease, as in the case of human papillomavirus (HPV), H1N1 and lately COVID-19 (8). To address this issue, we need to assess vaccine hesitancy among communities and understand why they feel hesitant towards vaccines. This can help health authorities boost vaccine acceptance and limit the spread of a disease by increasing herd immunity (10). Our review assessed and explored vaccine hesitancy and its determinants in the Gulf Cooperation Council countries.

Methods

Data collection strategy

This review was conducted to assess vaccine hesitancy and its concomitant factors in the Gulf Cooperation Council countries: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates. A review of peer-reviewed original research articles on vaccine hesitancy in the GCC countries published from 2009 until March 2021 was conducted using PubMed, Web of Science and Embase search engines. The key terms used during the search were “(Saudi or Kuwait or Qatar or Oman or Bahrain or “United Arab Emirates”) AND (“vaccine delay” or “vaccine refusal” or “vaccine confidence” or “vaccine hesitancy” or “vaccine acceptance”)”.

Study eligibility criteria

Inclusion criteria were: studies conducted in the GCC countries; epidemiology of vaccine hesitancy and confidence and their associated factors; and published in the English language in peer-reviewed journals. Literature review, systematic review and preprint papers were excluded.

Study selection and data analysis

From the peer-reviewed literature, 29 articles were initially identified (Figure 1), out of which 14 were excluded. After reviewing the retrieved articles, 15 articles met the search criteria. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach (PRISMA) was used to review existing studies (Figure 1).

Data were collected, synthesized and summarized using the narrative approach based on vaccine type and population studies. Collected data were categorized based on an overview of the study, including study year, study setting, population, study design, data collection tools used and main findings in regard to vaccine hesitancy, acceptance, confidence and their determinates. The overall prevalence of vaccine hesitancy was reported as a range of percentages (highest–lowest).

Results

Overview

A total of 29 articles were identified from the original search in PubMed. Articles on irrelevant topics or different populations were excluded. One study met the inclusion criteria but was excluded because it was in preprint form. Only 14 studies were included in the study after the removal of duplicates and irrelevant articles.

The majority of studies included in this review were cross-sectional studies (12); there was 1 qualitative study and 1 cohort study. The studies were categorized into 2: studies where the target population was the public

(Table 1) and studies where the target population was healthcare workers (HCWs) (Table 2).

Four main vaccines were targeted: influenza, COVID-19, H1N1 and HPV. Some studies focused on childhood vaccination and parents’ hesitancy. The studies covered in this review were published during 2009–2021. Sample size ranged between 33 and 7821 participants. The majority of the studies were conducted in Riyadh, Saudi Arabia, but others were conducted in other GCC countries, such as Kuwait, Oman, Qatar and the United Arab Emirates. No studies conducted in Bahrain were identified in the search.

The tools used to construct the assessment of vaccine hesitancy and associated factors were the Vaccine Attitudes Examination Scale, the Strategic Advisory Group of Experts on Immunization Vaccine Hesitancy survey, the Vaccine Conspiracy Belief Scale and the Parent Attitudes about Childhood Vaccines survey.

Vaccine hesitancy prevalence ranged between 11% and 71%. Differences in rates were noticed for population and vaccine type. Hesitancy to receive the recommended vaccines was present among both the public and HCWs.

Childhood vaccination

In a cross-sectional study (2017–2018) conducted among parents in Saudi Arabia, 36% of children were not fully vaccinated in accordance with the vaccination schedule. Incomplete vaccination status of children and vaccination hesitancy among parents were associated with negative beliefs about vaccine effectiveness and the importance of vaccination. Parents with a higher education level were more hesitant to get their children vaccinated (P < 0.001) (11). In another Saudi Arabian study, 11% of parents were hesitant to get their children vaccinated, but in this case there was no significant association between education level and vaccine hesitancy (12). A study conducted in the United Arab Emirates found that 12% of parents were hesitant to get their children vaccinated, and the most common concern reported was vaccine side-effects (13).

Novel viruses – COVID-19 vaccine

A survey to assess acceptability of the COVID-19 vaccine across Saudi Arabia found that 65% were willing to get vaccinated against COVID-19, with a relatively higher prevalence among those with a higher education level (69%) (14). A national survey conducted in Qatar found 20% of participants were not willing to be vaccinated against COVID-19 and 20% were unsure. The most common concerns for COVID-19 vaccine refusal were the safety of vaccines and their long-term side-effects (15). In a 2020 cross-sectional study in a number of countries [Jordan, (n = 2173, 64%), Kuwait (n = 771, 23%) and Saudi Arabia (n = 154, 5%)], acceptability rates were 29% for the COVID-19 vaccine and 30% for the influenza vaccine. Higher scores were recorded on the Vaccine Conspiracy Belief Scale for female participants, those with lower education levels and those relying on social media as their main source of information (16).

Human papillomavirus vaccine

We identified 2 studies conducted among female students to assess HPV vaccine acceptability. Both were conducted in Riyadh, Saudi Arabia. The first (2013–2014) found only 11% of the participants were aware of HPV vaccines and 96% had a poor knowledge level, which was associated with years of education (P < 0.01) and specialization (P < 0.001) (17). The most common reason for HPV vaccine hesitancy was concern about its side-effects (52%) and the majority (65%) reported that they trusted vaccination recommendations from their family physician. The second study (2020) found that 31% of the participants were aware of HPV vaccines, and the reason for HPV vaccine hesitancy was concern about its side-effects (70%) and fear of injections (55%) (18). Almost 85% of participants had poor knowledge about the vaccine, which was statistically significantly associated with years of education, specialization and age. Students whose parents were health professionals had a higher level of knowledge (P < 0.01).

Influenza A virus subtype (H1N1)

A prospective cohort study (2009) conducted during the Hajj season in Saudi Arabia found that almost 47% of participants were willing to be vaccinated against H1N1. Vaccination acceptance was greater among non-HCWs (71%) than among HCWs (35%). The most common reason for H1N1 vaccine refusal was the belief that the disease was not fatal (25.4%) (19). A cross-sectional study conducted at Aramco Medical Services Organization, Saudi Arabia, found that the vast majority (94%) were aware of the H1N1 influenza situation and 69% of participants felt susceptible to H1N1 (20). Only 31% were willing to get vaccinated against H1N1 and vaccine acceptance was significantly associated with profession (other than physician and nurse) [odds ratio (OR) = 3.4, 95% CI: 1.45–8.07] and influenza vaccine acceptance (OR = 7.9, 95% CI: 3.5-17.6); 11% of the participants believed that the H1N1 vaccine caused infertility and 18% believed that the vaccine caused Guillain–Barré syndrome (20).

Influenza

In a cross-sectional survey conducted in Riyadh among patients and healthcare workers, the most common reason for influenza vaccine refusal was doubt about its efficacy and effectiveness; there was no statistically significant association between education level and vaccine uptake (21). The majority reported high confidence in the information received on vaccines from the Ministry of Health and HCWs. In a qualitative study conducted in the United Arab Emirates among HCWs, the majority expressed hesitancy to receive the mandatory influenza vaccination. Misinformation on vaccines on social media was of major concern to HCWs: most reported that they had never received training on how to address their patients’ concerns regarding vaccine hesitancy (22). In a cross-sectional study conducted among HCWs in Oman, influenza vaccine uptake was 60%, with the most common reason for vaccine hesitancy being the side-effects. The mean knowledge score was higher among those who had received the influenza vaccine [7.2, standard deviation (SD) 2.14] than among those who had not (6.3, SD 2.2). The odds of having the vaccination were higher among those who believed in mandatory influenza vaccination (OR = 2, 95% CI: 1.2–3.0) (23). There was no significant association between education level and influenza vaccine uptake in a study conducted among HCWs in Saudi Arabia (24). The most common reason for influenza vaccine uptake was self and family protection and the most common reason for refusal was the perception that they did not need the vaccine or were not susceptible to the dusease.

Discussion

In this study, we determined that there was a proportion (11–71%) of the population of the GCC countries who were vaccine-hesitant. Differences in hesitancy rates were noted in relation to population and vaccine type. The highest hesitancy (70.6%) toward the COVID-19 vaccine was among the public (16). Hesitancy to receive the recommended vaccines ranged between 11% and 71% among the public, and between 17% and 68% among HCWs. The likelihood of accepting to be vaccinated was associated with individual previous acceptance of vaccine, specifically seasonal influenza vaccine (OR = 2, P < 0.01). This association has been observed in a national survey conducted in the United States of America (25).

A number of sociodemographic determinants of vaccine hesitancy were found among the majority of the populations studied. Age was sometimes strongly associated with vaccine hesitancy (26), but in other research age was associated with willingness to be vaccinated (14,18). Some studies found an association between vaccine hesitancy and education while others found no significant association (12,21). Among those with a higher level of education, vaccine hesitancy was greater (18). Parents with higher education levels were more hesitant to get their children vaccinated (P < 0.001) (11). Some studies, however, found the opposite association: vaccine hesitancy increased among those having a lower level of education (14,16). The complexity of the determinants of vaccine hesitancy, including education level, has been noted in other systematic reviews (9,27).

The willingness of individuals to be vaccinated was associated with their beliefs and information received on vaccine safety, effectiveness and importance. The main reported sources of information were the ministries of health and HCWs. Sources of misinformation on vaccines were mainly social media. The most common reported determinants of vaccine hesitancy were distrust in vaccine safety and concerns about side-effects. Beliefs about vaccine association with health conditions (e.g. infertility and Guillain–Barré syndrome) were noted among the public and HCW populations. A systematic review conducted to assess vaccine hesitancy at the global level found that beliefs about vaccines were complex, but they had a powerful impact on vaccine hesitancy (28). Hesitancy to be vaccinated can be explained by the beliefs among individuals on such things as hidden agendas and negative perceptions about vaccine safety and effectiveness.

HCWs have a role in addressing vaccine hesitancy amont the public We found that they were among the main sources of information and recommendation about vaccination and the majority had high confidence in the information given by HCWs because they are considered to be knowledgeable about the risks and benefits of vaccines (29). Previous research has found that many HCWs were themselves vaccine-hesitant and 43% were not recommending vaccines to their patients (29). We found that vaccine hesitancy was prevalent among HCWs (range 17–68%), and that a proportion did not recommend vaccination to their patients. Many HCWs had never received any training on how to address vaccine hesitancy among their patients (22).

This review of literature indicates that relatively little research has been conducted on vaccine hesitancy in the GCC countries. Most research was conducted in Saudi Arabia, and mostly targeted HCWs and parents. The vaccines that were most often assessed for public hesitancy were the COVID-19, influenza and HPV vaccines. The majority (if not all) of the studies on vaccine hesitancy in the GCC countries were published in the past 10 years. This highlights how important this issue has become as a research interest in the last decade in the countries of this region.

Misinformation among the public contributes to a lack of trust in the healthcare system, pharmaceutical companies and political institutions. Rebuilding public trust and vaccine confidence will require mobilizing the community and engaging different sectors to solve this health problem. Vaccines are among the major public health successes in recent history. To maintain this success, confidence in vaccines and trust in the decisions of health authorities should be strong among the majority of community members.

Vaccine hesitancy is prevalent among the public and HCWs in the GCC countries. Determinants of vaccine hesitancy vary by population and vaccine type. Due to the complexity of vaccine hesitancy, there is no single approach to meet it (7). Understanding the concerns of the population and increasing their confidence in vaccines and trust in health authorities will help address this issue. As the governments of the GCC countries aim to improve vaccination coverage among their populations, they need to tackle the issue of vaccine hesitancy. These countries are facing a rising burden of vaccine hesitancy with rapid changes in public beliefs on vaccine safety and efficacy. Concerns about vaccine safety were associated with misinformation from personal beliefs and misinformation from media sources. Vaccine hesitancy should be continually monitored to understand the beliefs and knowledge about vaccination among the public, address the implications of hesitancy and motivate the population towards improving vaccine uptake to realize the vaccination goals.

This review had certain strengths and limitations. Variation in vaccine hesitancy rates in the studies we reviewed may be attributed to the different sensitivities of the tools used in assessing vaccine hesitancy among the different populations. Some of the studies used assessment tools that had not been tested for validity and reliability.

Review retrieval was limited to the PubMed search engine. Although PubMed is one of the largest databases of medical research, we cannot claim that we reviewed all the relevant articles related to vaccine hesitancy in the GCC countries.

As discussed previously, vaccine hesitancy is am emerging concept, not yet frequently used at either the regional or the global level, and this presented challenges in identifying validated tools and studies that assessed the phenomenon. Therefore, only 14 studies – the majority of them small-scale cross-sectional studies – were included in this review. Despite the nature of the studies conducted and the low number of studies on vaccine hesitancy in GCC countries, this review provides a comprehensive assessment of currently available studies on the status of vaccine hesitancy in these countries, thus, it provides a foundation for future research in the region on the subject matter.

Funding: None.

Competing interests: None declared.

La réticence face à la vaccination dans les pays membres du Conseil de coopération du Golfe

Résumé

Contexte : La vaccination a un impact considérable sur la santé aux niveaux régional et mondial, mais la tendance à l'hésitation en matière de vaccination s'est accrue au cours des dernières décennies.

Objectifs : Nous avons évalué la réticence face à la vaccination et ses déterminants dans les pays membres du Conseil de coopération du Golfe.

Méthodes : Nous avons procédé à un examen de la littérature afin d'évaluer les articles publiés jusqu'en

mars 2021 et revus par des pairs sur la réticence face à la vaccination dans les pays membres du Conseil de coopération du Golfe à l'aide de l'approche des éléments de notification préférés pour les revues systématiques et les méta-analyses (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Une recherche a été menée via PubMed et 29 articles ont été identifiés. Après élimination des doublons et des articles inappropriés, 14 études sont restées pertinentes et ont été utilisées dans le cadre de l'examen.

Résultats : Dans les pays membres du Conseil de coopération du Golfe, le taux de réticence vaccinale se situait entre 11 % et 71 %. Des différences de taux ont été observées pour le type de vaccin, le vaccin contre la COVID-19 ayant le plus grand nombre d'hésitations signalées (70,6 %). La probabilité d'accepter la vaccination était associée à une acceptation individuelle antérieure du vaccin, en particulier du vaccin contre la grippe saisonnière. Les principaux déterminants de la réticence à se faire vacciner étaient la méfiance à l'égard de l'innocuité des vaccins et les inquiétudes concernant ses effets secondaires. Les agents de santé faisaient partie des principales sources d'information et de recommandations sur la vaccination, mais 17 % à 68 % d'entre eux étaient réticents face à la vaccination. La majorité des agents de santé n'avaient jamais reçu de formation sur la manière de prendre en compte la réticence des patients face à la vaccination.

Conclusions : La réticence face à la vaccination est très répandue au sein de la population et parmi les agents de santé des pays membres du Conseil de coopération du Golfe. Il est nécessaire de surveiller en permanence les perceptions et les connaissances relatives aux vaccins et à la vaccination dans ces pays afin de mieux éclairer les interventions qui visent à améliorer l'adoption des vaccins dans la sous-région.

التردد في أخذ اللقاحات في بلدان مجلس التعاون الخليجي

الجوهره القباني، عثمان العمير، فهد القباني

الخلاصة

الخلفية: ‏للتلقيح تأثير هائل على الصحة على المستويَيْن الإقليمي والعالمي، ومع ذلك ازداد ميل الناس إلى التردد في أخذ اللقاحات في العقود القليلة الماضية‎.

الأهداف: هدفت هذه الدراسة إلى تقييم التردد في أخذ اللقاحات ومحدداته في بلدان مجلس التعاون الخليجي.

طرق البحث: أجرينا استعراضًا للمواد المنشورة لتقييم المقالات التي استعرضها الأقران والمنشورة حتى مارس/ آذار 2021 بشأن التردد في أخذ اللقاحات في بلدان مجلس التعاون الخليجي، باستخدام نهج PRISMA. وبالبحث في موقع PubMed وجدنا 29 مقالة. وبعد إزالة المواد المكررة وغير ذات الصلة، تبقَّت 14 دراسة ذات صلة واستُخدمت في الاستعراض.

النتائج: تراوحت نسبة التردد في أخذ اللقاحات في بلدان مجلس التعاون الخليجي بين 11% و71%. ولوحظت اختلافات في النسب ترجع إلى نوع اللقاح، إذ كان أعلى معدل للتردد يرتبط بلقاح كوفيد-19 (70.6%). وكان احتمال تقبُّل التلقيح مرتبطًا بالتقبُّل الشخصي السابق للتلقيح، بالتحديد لقاح الإنفلونزا الموسمية. وكانت أكثر محددات التردد في أخذ اللقاحات شيوعًا هي عدم الثقة في مأمونية اللقاحات والمخاوف بشأن آثارها الجانبية. وكان العاملون في مجال الرعاية الصحية من بين المصادر الرئيسية للمعلومات والتوصيات بشأن التلقيح، ولكن ما نسبته 17-68% منهم كانوا مترددين في أخذ اللقاحات. ولم يتلقَّ أغلب العاملين في مجال الرعاية الصحية أي تدريب على التصدي للتردد في أخذ اللقاحات في أوساط المرضى.

الاستنتاجات: التردد في أخذ اللقاحات منتشر بين عامة الناس والعاملين في الرعاية الصحية في بلدان مجلس التعاون الخليجي. وثمة حاجة ماسة إلى مواصلة رصد المعتقدات والمعلومات المتعلقة باللقاحات والتلقيح في هذه البلدان من أجل توجيه التدخلات بشكل أفضل لتحسين الإقبال على اللقاحات في هذا الإقليم الفرعي.

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