Assessment of Attitudes and Intentions towards COVID-19 Vaccines and Associated Factors among General Populations of Pakistan: A Cross-Sectional Study

Objective: The goal of public health in combatting COVID-19 is to increase herd immunity. However, vaccine reluctance makes attaining herd immunity a worldwide challenge. This investigation aimed to identify negative and positive attitudes and intentions about COVID-19 vaccinations. Methods: A cross-sectional online survey was conducted once free COVID-19 vaccines became available in Pakistan in 2021. 4392 Pakistanis aged 18 and older were surveyed from seven administrative units between 1 July and 30 August 2021. Online structured questionnaires were utilized to collect data using a simple sampling procedure. The questionnaires were divided into three major sections: sociodemographic, health factors, and attitudes toward COVID-19. Results: The survey link was shared with approximately 4500 participants. 97.6%(4392) completed the survey once begun. Frequency, percentage and Chi-square tests were used to analyze statistical data. Most of the participants in the research were men (2703 (61.54%)), 3277 (74.61%) were aged 18–29 years, and 1824 (41.53%) were residents of the Khyber Pakhtunkhwa province. (18.69%) Respondents expressed COVID-19 vaccine hesitancy, whereas 36.66% of participants liked getting the Sinopharm and Sinovac vaccines and (35.84%) of participants preferred the Pfizer vaccine. A significant number of participants (38.05%) were concerned about the vaccine’s unexpected side effects Thus, it is essential to realize that many participants were concerned about the vaccine’s unexpected side effects. Conclusions: The overall high level of concern about the unforeseen side effects of COVID-19 vaccines, as well as widespread vaccine hesitancy among Pakistani populations and its predictors, should be taken into account if public health intervention campaigns in Pakistan are changing negative attitudes and improving compliance with regard to COVID-19 vaccines.

Vaccination has been necessary to minimize disease, disability, and mortality [6]. Vaccines are estimated to save the lives of four to five million people every year from deadly infections [5]. They were utilizing this advantage efficiently, resulting in countless outstanding achievements in the fight against influenza, polio, diphtheria, tetanus, hepatitis B, MMR (Mumps, Measles and Rubella) and pertussis. Yet, there is a vaccine coverage disparity among nations, including within countries [7]. Vaccine hesitancy was identified as one of the most significant threats to world health in 2019 by the World Health Organization (WHO) [8]. Vaccine hesitancy leads to measles, diphtheria, and pertussis epidemics due to incorrect vaccine safety concerns [6]. Religious and political leadership can influence vaccine rejection [9]. Because of religious convictions, Thailand, Vietnam and Mongolia have a significant aversion to vaccination [10]. Furthermore, unique ideas, such as whether active immunity from natural infection is preferable to vaccination or if a healthy lifestyle might inhibit disease development, play a role [11].
The immunization efforts of the Pakistani population are far from meeting the global vaccination targets. BCG (Bacillus Calmette Guerin) vaccination coverage is 80%, polio vaccination coverage is 60%, and measles vaccination coverage is 67% [12]. Vaccination product promotions tend to be influenced by political, religious, and commercial factors, as well as logistical challenges, inadequately trained health care professionals, a lack of parental awareness and education, as well as factors related to social norms, political systems, and the environment [12,13]. Previous vaccination campaigns had relied heavily on religious and political figures promoting conspiracy theories. These beliefs have also contributed to Pakistan's failure to eradicate polio [14]. Essential features for COVID-19 immunization uptake include government clearance of its safety and efficacy, employer endorsements, and expenditures [14]. Parents are also suspicious of the innovative COVID-19 vaccination [15]. The vaccine has been actively opposed by anti-vaccination groups, who attempt to deny the existence of COVID-19, in particular [16]. The COVID-19 vaccination program in Pakistan is managed by the National Command and Control Center (NCOC); frontline healthcare workers who are involved with the care and treatment of patients who have confirmed or suspected COVID-19 are the first to be vaccinated, followed by other healthcare workers and the general population [17].
The acceptance of the COVID-19 vaccine varies from country to country. Approximately half of Americans in the United States agree with vaccination [18]. In Indonesia, 93.3% support it [19], 62% approve of it in France, Denmark has an 80% support rate [17], and 59% of Italians [20], want to get vaccinated. When the COVID-19 vaccine becomes available in Pakistan, inaccurate narratives and religious conspiracy theories may influence people's decisions to take the vaccine [21,22]. In consideration of the COVID-19 pandemic, there is an immediate requirement for more current information on public attitudes toward COVID-19 vaccines and related variables to adapt suitable activities. The current study intends to assess the frequency of attitudes and intentions concerning COVID-19 vaccination and to identify drivers of unfavourable attitudes and intentions. Investigating determinants of intentions toward the COVID-19 vaccination might assist authorities and governments in identifying and implementing relevant actions to alleviate concerns and reluctance and boost trust in the vaccine.

Participants and Study Design
The online survey was developed from 1 July to 30 August 2021 via a link to Google Forms (https://docs.google.com/forms/, accessed on 1 September 2021, Survey, Supplementary file S1). The survey's data collection included the general population with only Vaccines 2022, 10, 1583 3 of 15 one age limit, participants had to be at least 18 years of age; there were no further exclusion criteria. The survey link was shared with approximately 4500 participants, and 97.6% of them (4392) completed the survey once begun. Pakistan's estimated population on 1 July 2021 was 225,199,937 according to the World Population Review [23]. The Raosoft sample size calculator was used to calculate the needed sample size [24]. A sample size of 385 was calculated. For the sample estimate, a 50% response distribution was assumed, a 5% margin of error was taken, and a 95% confidence level was used. Several channels were sent the poll URL after a call for participants. WeChat, LinkedIn, Facebook, Messenger, and Instagram were also used to increase general public interaction. The survey took about five minutes to complete. Core members could only access the repository data, ensuring privacy.

Variables and Questionnaire Instruments
A structured survey was prepared after reviewing the relevant scientific literature and available resources on COVID-19 [19,[25][26][27][28][29][30]. This survey was written in English, the preferred language of higher education and the national language of Pakistan. The utilized questionnaire consists of three parts: (1) sociodemographic information and (2) general public attitudes toward COVID-19 vaccinations, and (3) intentions for COVID-19 vaccinations.

Information about Socio-Demographics
Participants' gender, age, administrative unit, residence, marital status, chronic diseases, employment status, and education were collected under the "sociodemographic characteristics" section of the survey. The participants' educational level was classified as high school, college, graduate, or post-graduate. Occupations included full-time, part-time, unemployed, housewives, retired, and workers.

The Attitude towards COVID-19 Vaccines
The six questions in this section were about attitudes toward COVID-19 vaccines, such as "Have you had a flu vaccination?"; "Has any family member had COVID-19?"; and "Does the ministry of health provide adequate information about COVID-19 vaccines?"; Intentions to receive the COVID-19 vaccine; COVID-19 vaccine preferences; and "I do not believe the vaccine works".

The Intentions toward COVID-19 Vaccines
Fourteen questions were asked of the participants to assess their intentions toward the COVID-19 vaccinations, which are scored on a five-point Likert scale, such as strongly disagree, disagree, neutral, agree and highly agree.

Operational Definitions
Positive Value: Research participants answer positively to 50% or more of the attitude and opinion questions.
Negative Value: Less than 50% of attitude and intentions questions are answered by research participants.

Dependent Variable
Attitude and intentions of general Pakistani population toward COVID-19 vaccine acceptance.

Independent Variable
Sociodemographic features include gender, age, administrative units, residence, marital status, chronic disease, employment status, and education.

Statistical Analysis
To conduct a descriptive and statistical analysis of the responses obtained from Google Forms, the results were converted into Microsoft Excel format and then exported to IBM SPSSv20. Statistical Analyses were performed in Jupyter Notebook using Python 3 with Pandas, Matplotlib and stats libraries. The demographic characteristics of the research participants were displayed using descriptive medical statistics such as frequency and percentage. Chi-square tests examined the association between intentions and sociodemographic variables, which are also used in epidemiological, public health, and medical research. A p-value of 0.05 was used to determine statistical significance.

Consent to Participate
Our survey's first page consists of an informed consent page that describes the investigation of respondents. To continue the study, participants had to consent (or decline) participation, and there was no incentive for individuals to participate in this voluntary survey.

Ethical Approval
The Department of Microbiology approved the study Ethical Research Committee at University of Swabi in Pakistan (study registration no: 1(3)-Micro-8/UoS/2022/1674).

The Attitude towards COVID-19 Vaccines
Approximately 3102 participants (70.62%) had never taken the flu vaccination. At the same time, 37 Table 3, the row-wise percentage is calculated.   Table 3, the row-wise percentage is calculated.

The Intentions toward COVID-19 Vaccines
The most generally stated reason for vaccine acceptance was to defend oneself from obtaining the virus (1731 (39.41%)), followed by 1534 participants (34.92%) who feel sure that their family is safe after being vaccinated against COVID-19. 1654 (37.66%) participants agree that COVID-19 vaccines can end the pandemic. Half of the participants, 2250 (50.66%), believe that although most vaccinations seem to be safe, there may be issues that haven't yet been identified; COVID-19 vaccines might create unforeseen problems among different demographic groups according to 38.05% of respondents, and 1747 (39.78%) people were concerned about the unknown future effects of vaccinations. More than 1064 people (24.23%) disagreed that the government promotes vaccination for financial benefit instead of for people's health. In comparison, 1488 participants (33.88%) believed that COVID-19 vaccination schemes were a big con. Approximately 1384 (31.51%) participants were concerned about the rapidity with which the COVID vaccine is being produced, and 1044 (23.77%) had an early reaction to prior vaccinations and were worried about the reaction to COVID-19 vaccination. Just 490 participants (11.6%) said that they do not get vaccinated due to their fears about needles. Approximately 1698 participants (38.65%) indicated that natural immunity lasted longer than COVID-19 vaccination, 1140 participants (25.96%) agreed that natural exposure to the novel Coronavirus provides the safest and most effective protection, and 1288 participants (29.33%) believed that natural disease contact is a better method of preventing disease than vaccination (Tables 4 and 5, and Figure 4).

Discussion
Vaccination is one of the twenty-first century's most important public health breakthroughs. Vaccination fear represents one of the most critical public health challenges today. The significant degree of vaccination apprehension reveals that the obtainability of COVID-19 vaccines is not the source of concern.
Prior published studies indicated that proper public knowledge is a significant predictor of disease prevention and control. Compared to the more severe second wave, the Pakistani individuals and cancer patients surveyed during the first wave of COVID-19 infection were aware of COVID-19 prevention measures [31,32]. More than half of the participants (38.05%) expressed a high level of fear about the vaccine's unforeseen effects, which is consistent with a US study which revealed that the most common negative attitude toward COVID-19 vaccines was significant worry about its unforeseen effects [33]. Furthermore, according to Chinese research, 48% of participants postponed vaccination until vaccine effectiveness was proven [34]. Several scientists have expressed concern about the safety of vaccinations. The rapid production rate of vaccines and the doubts raised by some scientists and health experts may generate suspicion about the COVID-19 vaccine [35]. In the study, 39.78% of participants expressed concerns about possible adverse effects when the vaccine first became available. In a similar study, Pogue et al. found that 63% of participants were concerned about the side effects of COVID-19 vaccination [36].

Discussion
Vaccination is one of the twenty-first century's most important public health breakthroughs. Vaccination fear represents one of the most critical public health challenges today. The significant degree of vaccination apprehension reveals that the obtainability of COVID-19 vaccines is not the source of concern.
Prior published studies indicated that proper public knowledge is a significant predictor of disease prevention and control. Compared to the more severe second wave, the Pakistani individuals and cancer patients surveyed during the first wave of COVID-19 infection were aware of COVID-19 prevention measures [31,32]. More than half of the participants (38.05%) expressed a high level of fear about the vaccine's unforeseen effects, which is consistent with a US study which revealed that the most common negative attitude toward COVID-19 vaccines was significant worry about its unforeseen effects [33]. Furthermore, according to Chinese research, 48% of participants postponed vaccination until vaccine effectiveness was proven [34]. Several scientists have expressed concern about the safety of vaccinations. The rapid production rate of vaccines and the doubts raised by some scientists and health experts may generate suspicion about the COVID-19 vaccine [35]. In the study, 39.78% of participants expressed concerns about possible adverse effects when the vaccine first became available. In a similar study, Pogue et al. found that 63% of participants were concerned about the side effects of COVID-19 vaccination [36].
A 2021 study that looked at global trends in COVID-19 vaccination reluctance revealed that men, older people, and those who had previously had influenza vaccines were less prone to hesitancy, which confirmed our results [37]. They also observed that those who lived in cities and those in the upper or middle tiers considered affluent were less inclined to be fearful of vaccines. Regardless, our study found no evidence of a link between these factors [37]. Our results indicated that 76.37% of participants were highly likely to receive a COVID-19 vaccination, which was much lower than the reported rates in Brazil (89%), Italy (81%), and the United Kingdom (80%), but was higher than the reported rates in Canada (71%), the United States (57%), Turkey, and France (49% for both) [37]. The following elements were discovered to have a more extensive effect on vaccination ratios and might be utilized to develop public health strategies and communications to boost vaccination proportions. Knowing that the COVID-19 vaccine is both efficient and safe will increase a considerable percentage of the trial group to vaccinate. These two variables are part of the VCI and are currently investigated in a major worldwide investigation [38]. They are expected to have the greatest effect on COVID-19 vaccination acceptance. Instilling trust in vaccines and the companies that supply them will be critical if proper, honest reporting of the risks and benefits ratios is provided on social media and news platforms [39]. Although confidence in vaccine manufacturers has been recognized as a major factor in vaccination acceptance, this must be maintained by focusing on the stringent regulatory requirements that the companies must follow, which can be communicated through uniform and transparent healthcare communication. Participants' desire to vaccinate was also influenced by their belief that the COVID-19 vaccination would protect individuals surrounding them. Though vaccinated individuals can also transmit SARS-CoV-2, transmission is lowered, which ensures that friends and family are kept secure [40]. Even though confidence in vaccine companies has been established as a crucial determinant in vaccination acceptability [35], this has to be maintained by concentrating on the strict regulatory criteria that organizations must follow, which may be communicated through clear and uniform healthcare communication. Healthcare experts will use continuously updated connectivity to correct info on the COVID-19 vaccine. This will help battle non-evidence-based antivaccination propaganda by detailing benefits and concerns, assessing new data as it arises, and customizing it to people seeking treatment [41,42].
The public health authorities must offer precise, simple-to-understand data on the SARS-CoV-2 virus. Vaccinations to the public at large, such as those previously stated in the H1N1 pandemic [43]. This will help to reduce the confusion caused by disinformation in the media and on the internet. Moreover, we acknowledge Seale et al.'s recommendations [42], which include adjusting messaging and incorporating local leaders in communicating vaccination knowledge among minority ethnic groups, given the recognised effect of comparable social groups and community leaders. Participation and training are critical for healthcare staff, as they play a crucial role in demonstrating health-promoting behaviour for the public [44]. Several healthcare professionals in Australia have previously received the mandated influenza vaccine and compulsory COVID-19 vaccination for elderly care employees and healthcare staff in all regions and states [45].
Additionally, experience suggests that most people employed in other health institutions have been vaccinated, with just a tiny percentage refusing the COVID-19 vaccination since the required strategy was changed. Health providers' ideas and attitudes against COVID-19 vaccination may mirror similar community concerns reported in the UK, with reluctance being more common in non-white British healthcare professionals, female sex, and those of younger age [46]. Given the risks to patients and staff and the need for booster (or third dose) vaccines in the present outbreak, it is crucial to comprehend the legislation, information, attitudes, and opinions in influencing this behaviour.
In order to increase the number of COVID-19 vaccinations, it is important to reach people where they are with persuasive information from reliable sources. Optimizing or modifying the individual vaccination plan through the dynamic monitoring of vaccination efficacy is one potential solution. Volunteers and staff can go to areas where vaccination rates are low to answer people's questions about vaccinations and set up appointments for vaccinations for themselves and their loved ones. The elderly, those with disabilities, those who are confined to their homes, and residents of rural areas may be the most vulnerable groups in the community. For those who struggle to get to a vaccination site, at-home vaccinations might be a good option. In cooperation with nearby pharmacies, paramedics and healthcare professionals provide vaccinations door-to-door. Residents can fill-out an online form or make a phone request for at-home vaccinations. It is essential to use reliable channels of communication to inform communities about COVID-19 vaccines and vaccination locations. Gaining the confidence of their communities is essential for health departments if they want to see an increase in demand for COVID-19 vaccinations [47][48][49][50][51][52][53].
This research has certain limitations. It only included people who had access to the internet, eliminating the most marginalized communities. Among the respondents, only about 1% were older than 50 years of age, and about 40% were graduates. Furthermore, the data's cross-sectional character restricts our capability to make inferences regarding direct relationships. The sample, on the other hand, is representative of the Pakistani population, and the use of mixed approaches allowed for a better understanding of the results as well as the order of the ideas.

Conclusions
Despite the overall mortality, hospital readmissions, and death caused by COVID-19, the results of this study on vaccine hesitancy are noteworthy given the documented safety and efficacy of widely tested vaccinations to prevent these problems and the urgent need to accelerate immunization internationally, particularly in Pakistan. Vaccine intentions are influenced by vaccination efficacy, effectiveness, trust in corporations, and doctor advice. Further studies must be conducted on vaccination reluctance among specific groups, such as healthcare professionals and linguistically and culturally diverse individuals. COVID-19 vaccine uptake could be improved with this research, especially in Pakistan with the Delta variant. There is a high level of concern about unforeseen side effects of COVID-19 vaccines, as well as widespread hesitancy among Pakistani populations and its predictors when implementing public health intervention campaigns to change negative attitudes and improve uptake of COVID-19 vaccines. Informed Consent Statement: Our survey's first page consists of an informed consent page that describes the investigation of respondents. To continue the study, participants had to consent (or decline) to participate, and there was no incentive for individuals to participate in this voluntary survey. Data Availability Statement: On reasonable request, the corresponding author will provide the datasets used and analyzed in this study.