Status and perception toward the COVID‐19 vaccine: A cross‐sectional online survey among adult population of Bangladesh

Abstract Introduction COVID‐19 has become a global public health concern. Safe and effective vaccines are required to control the pandemic. However, positive perception toward the vaccine is also necessary for a successful vaccination effort. Objective A rapid online survey was conducted to evaluate the status and perception toward the newly administered COVID‐19 vaccine among the adult population (18 years and above) of Bangladesh. Methods A total of 850 adult people participated. χ 2 or Fisher's exact test was performed to determine the association between the first dose of vaccination and sociodemographic information. Logistic regression analyses were carried out to examine the predictors of knowledge, attitude, and hesitation toward the vaccine. Results Exactly 24.12% of the study population received their first dose of COVID‐19 vaccine, whereas 30.23% expressed hesitation about pursuing the vaccine. Older age groups (>70%), married people (49.62%), capital Dhaka city outsiders (32.76%), and high‐income groups (>50%) received the vaccine much higher than their counter group. Age, marital status, educational attainment, monthly income, and prior COVID‐19 positive status were all significantly associated with the knowledge regarding the vaccine. Only age (>55 years age group = aOR: 4.10; 95% CI: 1.30, 14.31) and level of knowledge (poor knowledge = aOR: 0.17; 95% CI: 0.12, 0.23) were significant determinants of attitudes. In case of hesitation, age group and monthly income were found as significant determinants. Fear of adverse consequences (86.67%) was the most common reason for hesitation, followed by insufficient information (73.85%). Conclusion This study sought to determine the status and perception of the newly administered COVID‐19 vaccine to aid in the current inoculation campaign's effectiveness. Collaboration between academics, government officials, and communities is essential in developing a successful COVID‐19 vaccination program for the entire population. The authority should develop effective strategies to ensure the implementation of its policy of widespread COVID‐19 vaccination coverage.

population. The authority should develop effective strategies to ensure the implementation of its policy of widespread COVID-19 vaccination coverage. cases worldwide, with over 2.86 million deaths. 5 The situation has deteriorated significantly across the Americas, Europe, and Southeast Asia. India, Pakistan, and Bangladesh were the South-Asian region's worst-affected countries. 5 Bangladesh reported the first COVID-19 case on March 8, 2020. 6 Afterward, the country observed a public holiday from March 26, 2020 7 to reduce the outbreak. All educational institutions and offices were closed, but subsequently the offices reopened. The country has been battling this long-term pandemic for years, notably in the socioeconomic and educational sectors. [8][9][10][11][12] Maintaining social distance, wearing masks, and washing hands regularly proved challenging for the Bangladeshi people because of the highly crowded region, a large number of unconscious individuals, and a lack of knowledge about how to appropriately treat this pandemic. 9,10 Additionally, many individuals in the country were required to work outside to earn a living. 13 Throughout the pandemic period, the capital Dhaka city became a hotspot and one of the worst-affected COVID-19 regions in the country. 9,11 In these circumstances, authorities faced impediments in promoting healthy behavior among the public. 14,15 People have been anticipating the development of an efficient COVID-19 vaccine to avert the pandemic. Several vaccines have already been rollout. 16 However, the success of the vaccination campaign is contingent on both its effectiveness and community acceptability. 17 A positive impression of the vaccine is necessary to contain the outbreak. 18 On January 27, 2021, the government of Bangladesh began administering the Oxford AstraZeneca vaccine Covidshield to the general population, and other vaccines like Moderna, Pfizer, and SinoPharma have also been launched (free of charge). 19,20 However, as is the case in many other countries, the government initially concentrated vaccination efforts on relatively particular categories of people (frontline medical personnel, government employees, private officials working on pandemic issues, and people of 40 years and over), with the entire population expected to be eligible for vaccination later. 20

| Survey instrument and data collection
Literature reviews 9,21,27,28 were carried out to prepare the draft questionnaire (both in English and local Bengali language) in Google form.
A pilot survey was conducted among some university students.
Experts' opinion and cultural appropriateness were also considered.
After the modifications, a final questionnaire was prepared. It had five major sections: general information contained sociodemographic information and previous COVID-19 experience; knowledge section; attitude section; practice section; and hesitation section. The selfadministered online questionnaire was designed in such a way that respondents could receive different questions depending on their responses. If respondents reported receiving their first dose of the COVID-19 vaccine, they were directed practices section toward COVID-19 (to evaluate their preventive practices even after the first dose). However, when respondents indicated they had not yet received the vaccine, they were directed to an alternative question concerning their hesitations about the vaccine. If they reported hesitation, they were then directed to the final hesitation part. This part contained factors that could lead to hesitancy toward the vaccine.
The final four sections (knowledge, attitude, practices, and hesitation) contained a total of 30 components. All the components were scored on 0 to 1 scale (correct/agree/hesitation = 1, neutral = 0.5, and wrong/do not know/disagree/no hesitation = 0). We believe that treating "do not know" as a 0 score was justifiable for our study. 29 The knowledge section had 09 components with "true," "false," and "I do not know" responses. This section contained the vaccine's effectiveness, health behavior required to maintain even after the first dose were ineligibility to pursue the vaccine, lack of confidence in the vaccine's ability to combat COVID-19, lack of enough information, fear of side effects, cost, religious view, and other reasons. Additionally, we evaluated Cronbach's Alpha for reliability to assess the KAP section's internal consistency. Exactly 0.86, 0.80, and 0.73 were calculated for the knowledge, attitude, and practice section, respectively. The accepted value is >0.60. 30,31 A group of university students from the Bangladesh University of Professionals and the University of Dhaka, Bangladesh, were recruited for data collection. The selection was based on their research experience. They administered the study link from March 12 to April 2, 2021, through Facebook, email, WhatsApp, Imo, and Google classroom. The link was distributed to respondents who were easily accessible and competent in accessing the online survey. Thus, this study followed a non-probability sampling technique. Even though an online-based survey may not require a prior sample size, this perception-based study estimated the sample size of 384 respondents (95% confidence interval [CI]) following Morgan's table. 32 Approximately 980 respondents were approached. We received enormous responses where a total of 850 respondents participated. Thus, the overall response rate for the survey was 86.73%. Data were carefully monitored and double-checked after each day of the data collection.

| Data management and analysis
The collected data were transferred to Microsoft Excel in Office 365 (Redmond, Washington, USA). 33 Afterward, data management and statistical analyses were performed in Python (version 2.7; Beaverton, OR 97008, USA) and "R" programming language (version 3.6.3; Vienna, Austria). 34,35 Descriptive statistics such as the frequency and percentages were calculated. The associations of sociodemographic information with the vaccination status were examined through χ 2 or Fisher's exact test, where appropriate. Post hoc analysis was carried out using the "rcompanion" package 36 with the false discovery rate (fdr) method to compute the adjusted P value.
Overall scores (for the knowledge and attitude) were calculated by summing each section's component scores. Then, "Good" and "Poor" levels in the overall knowledge and attitude section were determined based on the 80% cutoff scores. Previous public healthrelated research employed a cutoff score of 80% for good knowledge and attitude level. [37][38][39] For the current study, 80% score in the overall knowledge section (overall score = 9) was calculated as 7.2. Seven and more than that was treated as "Good" knowledge level. A similar method was applied for the attitude section. Covariates were determined through χ 2 or Fisher's exact test. Univariate and multivariate logistic regression analyses were performed to determine the predictors of knowledge and attitude, where odds ratios (ORs), adjusted odds ratios (aORs), and 95% CI were estimated. Only the significant variables in the univariate analysis were considered in multivariate analysis. The logistic regression analyses were carried out to examine the predictors of hesitation toward the vaccine. Ninety-five percent CI was considered for all statistical analyses. Table 1 presents that 24.12% were vaccinated (first dose) in our study population. Age group, marital status, current accommodation, educational attainment, present occupation, monthly income, and previous COVID-19 positive was significantly associated with the vaccination status. Post hoc analysis revealed that respondents aged 46 to 55 and over 55 were significantly more vaccinated than younger respondents.

| RESULTS
Individuals from Dhaka city were significantly less vaccinated (19.57%) than the Dhaka city outsiders (32.76%). University students were significantly less vaccinated (2.81%) than the business, employed, and unemployed individuals. Similarly, higher-income respondents (30 000 BDT to 50 000 BDT) reported significantly more vaccinations (more than 50%) than lower-income or "no income" respondents. Respondents who previously tested COVID-19 positive vaccinated at a significantly higher proportion (34.80%) than those who did not (20.22%).
The further results ( of the respondents believed that the vaccine could create infertility and long-term physical problems. More than 65% of them agreed to pursue the vaccine for themselves and their family members. Table 3 reports that the respondents were following the good practices after their first dose of the vaccine.  • Poor 0.17 (0.12, 0.23)*** 0.17 (0.12, 23)*** Abbreviation: aOR, adjusted odds ratio; BDT, Bangladeshi Taka; OR, odds ratio. *P < .05; **P < .01; ***P < .001.

| DISCUSSION
COVID-19 has developed into a global health threat, and the world is awaiting an effective vaccine to avert this situation. [40][41][42] International communities have considered vaccines as a means of ensuring public safety. 43 However, a lack of knowledge, a negative attitude, and increased hesitancy may cause the vaccination to be delayed. WHO has labeled vaccine hesitancy as one of the top 10 global health threats in 2019. 44 Concerns about the vaccine's efficacy and safety against new COVID-19 variants have also grown. 45,46 We found that the older age group in Bangladesh were vaccinated more than the younger age group. This result is consistent with the government's strategy, under which only people aged 40 and over were eligible for the vaccine. 47 Frontline health workers and other high-risk government and private sector employees have received the vaccine before reaching this age limit. Additionally, the government announced the commencement of a vaccination campaign for university students and staff. 48 The primary objective of this campaign was to reopen educa-

| CONCLUSIONS
COVID-19 has become a long-term burden for many countries. Along with the non-therapeutic treatments such as the following health behavior, a long-awaited effective vaccine can demolish this burden.
However, positive perceptions without hesitation regarding the vaccine can only make the whole process successful. This study revealed the requirement of an extensive campaign to motivate the Bangladeshi people toward the vaccine. More people should be covered without considering the sociodemographic information to ensure herd immunity. A holistic approach is required where people from multisectoral fields should be incorporated.

ACKNOWLEDGMENT
The authors would like to mention the author's university students for their fabulous effort to complete this study. The authors would also like to appreciate the experts (including six anonymous reviewers for their extensive review) who supported throughout the study.

CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.