A High Rate of COVID-19 Vaccine Hesitancy Among Arabs: Results of a Large-scale Survey

In this study, we present the results of the first large-scale multinational study (36,220 participants) that measures vaccine hesitancy among Arab-speaking subjects. Our analysis shows a significant rate of vaccine hesitancy among Arabs in and outside the Arab region (83% and 81%, respectively). The most cited reasons for hesitancy are concerns about side effects and distrust in healthcare policies, vaccine expedited production, published studies and vaccine producing companies. We also found that female participants, participants 30-59 year-old, those with no chronic diseases, those with lower-level of academic education, and those who do not know the type of vaccine authorized in their countries are more hesitant to receive COVID-19 vaccination. On the other hand, participants who regularly receive the influenza vaccine, health care workers, and those from countries with higher rates of COVID-19 infections showed more vaccination willingness. Interactive representation of our results is posted on our project website at https://mainapp.shinyapps.io/CVHAA.


Introduction 4
( Supplementary Fig 1). Yet, the Arab region is understudied, despite the geographical spread, the 75 number of residents, and the number of cases and deaths. So, a large-scale multinational study for 76 this area is necessary. 77 Our study aims to fill the gaps by investigating vaccine acceptance using a large-scale survey 78 targeting the relatively understudied Arab populations living in different countries around the 79 world following vaccine availability and administration. Secondly, to unveil the barriers leading to 80 vaccine hesitancy and their prevalence among the participants using an extensive updated list of 81 barriers against vaccine acceptance. Thirdly, the study compares the answers of the respondents 82 residing in and outside the Arab world to evaluate the effect of socioeconomic, cultural, health 83 policies and political differences on their reported attitudes and barriers to acceptance.

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The Survey of Arab COVID-19 Vaccine Acceptance (SACVA) is an open online survey that was 87 conducted using the online platform www.surveyplanet.com from 14-Jan 2021 to 29-Jan, 2021. 88 The sample population was a convenience sample targeted through a digital campaign using social

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The survey data was analyzed using R software-v.4.0.2. Descriptive statistics and analytical graphs 114 were used as needed. Participants were also subcategorized based on country of residence. Arab 115 countries with less than 100 participants (Somalia, Djibouti and Comoros) were grouped together 116 in one category and labeled "Other Arab countries". The non-Arab countries where the Arabic 117 speaking respondents were residing were classified into groups: European countries (n=30), North 118 American countries (n=3), Turkey and the rest of non-Arab countries as others (n=88). The 119 answers to the 14 th question, "Do you intend to take the vaccine?", were used as a dependent 120 variable and were analyzed using binary logistic regression. Two of the answer choices ("Yes", 121 "Depends on the type of vaccine") were used to define vaccine acceptance while the other three 122 ("No", "Not sure", "I will wait and see its effects on others" ) were labeled as "Vaccine Hesitancy".

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Responses to the question of the barriers to acceptance (Question 17) were compared for gender, 124 academic education and country of residence using Chi-Square. Our acquisition and analysis of the 125 results followed the guidelines of the CHERRIES checklist 22 . (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

COVID-19 Vaccination Hesitancy and related factors
158 When asked about their willingness to receive COVID-19 vaccine if the option is available to them; 159 4,548 (12.6%) of the respondents answered "Yes"; 1,615 (4.5%), answered "Depends on the type 160 of vaccine"; 7,552 (20.9%) answered "I will wait and see its effects on others"; 7,856 (21.7%) 161 answered "I am not sure"; and 14,649 (40.4%) chose "No". The first two choices were considered 162 acceptance to receive a vaccine while the last three were labelled as vaccine hesitancy (Fig 1). 163 Variations in responses were analyzed using different factors as covariates (Fig 2).  (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Figure 1
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Figure 2
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Figure 3
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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  There were 3,905 participants who chose acceptance but yet had one or more barrier(s) selected.

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Of the 29 barriers, the most common responses were "I am afraid side effects of the vaccine will  (Fig 4).  (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Fugure 4
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Figure 5
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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  Respondents who did not know the vaccine type available to them showed increased hesitancy.

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This may be attributed to the fact that some Arab countries were first to approve the Sinopharm (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.   about safety 5 .

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The three forms of distrust (in healthcare policies, in vaccine expedited production and in published 287 studies) were notably higher among respondents residing in the Arab countries than those living 288 outside the Arab world. The same applies to the belief that the vaccine has not been tested on a 289 large enough number of people, just tens or hundreds, which reflects less awareness of the vaccine 290 development process in the Arab countries and highlights the need to educate the general public 291 on the subject. Similarly, more residents of the Arab world believe that the vaccine is not necessary 292 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted March 10, 2021. ; https://doi.org/10.1101/2021.03.09.21252764 doi: medRxiv preprint anymore because most people in the participant's country "have already been infected" or because 293 the infection rate is decreasing. The infection rate is in fact decreasing (supplementary Fig 1, panel   294 A) but the public may need to be made aware that future outbreaks are still a possibility.

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With the high rate of distrust, any form of coercion to take the vaccine may have negative impacts. 296 Lazarus's et. al. large-scale study indicated that promoting voluntary acceptance is a better route 297 and that coercion should be avoided 6 . Similarly, a systematic review indicated that "mandates could 298 increase resistance" 5 . In our study, the majority of participants (59.5%) believed that vaccination of decreased efficacy of some vaccines 31,32 , this concern of efficacy is expected to increase among 306 the public.
do not seem to reflect the true nature of hesitancy and whether or not it changes its nature over 318 time.

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In 2015, the World Health Organization (WHO) Strategic Advisory Group of Experts on 320 Immunization defined vaccine hesitancy as a 'delay in acceptance or refusal of vaccination despite 321 the availability of vaccination services' 33 . We, therefore, question considering those who intend to 322 take the vaccine after a prolonged time of availability as "Accepting" since this may interfere with 323 the targeted achievement of collective immunity.

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In the present study, 20.8% of the participants chose (I will wait and see its effects on others)-  (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted March 10, 2021. ; https://doi.org/10.1101/2021.03.09.21252764 doi: medRxiv preprint high-risk groups such as people with chronic diseases are well-represented (n=5,839) or even over-368 represented (HCW, n=5,708). Our sample size was not pre-planned but was rather arbitrary 369 reflecting a convenience sample. We believe that the large number of participants and the 370 consistency of results in different countries that were geographically close and similar 371 socioeconomically confirm the reliability of our survey.

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(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.  (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted March 10, 2021.  (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.