|Year : 2022 | Volume
| Issue : 2 | Page : 180-187
A study to access the prevalence and drivers of COVID-19 vaccine hesitancy in Indian population including health care professional and dental students – A cross-sectional survey
Manisha Saxena1, Neel Kant Patil1, Mohit Sareen1, Manoj Meena1, Nitesh Tyagi2, Mridula Tak3
1 Department of Oral Medicine and Radiology, Rajasthan Dental College and Hospital, Jaipur, India
2 MDS in Oral Medicine and Radiology, Consultant in Private Practice, Jaipur, India
3 Department of Public Health Dentistry, Paciffic Dental College, Debari, Udaipur, Rajasthan, India
|Date of Submission||13-Aug-2021|
|Date of Decision||28-May-2022|
|Date of Acceptance||29-May-2022|
|Date of Web Publication||22-Jun-2022|
K-404, ARG City, Jaipur Road, Ajmer, Rajasthan
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The acceptance and availability of effective vaccines are crucial for the success of vaccination programs. Medical doctors and students are the epitome of shaping the public interest in vaccines. Aim: To evaluate the general public's attitudes, including dental students and health care professionals, at the national level towards COVID-19 vaccines and explore the potential drivers for students' acceptance levels. Methods: A national-level cross-sectional study was carried out in May-June 2021 using an online questionnaire. The sample was categorized based on age, gender, academic level, and location. The dependent variable was the willingness to take the COVID-19 vaccine. The independent variables included demographic characteristics, COVID-19-related experience, and the drivers of the COVID-19 vaccine-related attitude suggested by the WHO SAGE. Results: The number of people who answered the questionnaire was 1271. The males accounted for 38.9%, and females were 61.1%. The age group, 18-45 years with 14.7%, has the highest percentage of people who have not taken vaccination. In context to gender, 13.5% of males and 13.1% of females have not taken vaccination. The percentage of vaccination hesitancy is highest in rural areas with 19.5%. The health care professionals were vaccinated with the highest percentage of 89.8%. Conclusion: The vaccination acceptance level of the population for COVID-19 vaccines was good, approximately 63%, and their worrisome level of vaccine hesitancy 27% was governed by demographic, social, and economic factors. The media and social media, public figures, insufficient knowledge about vaccines, and mistrust of governments and the pharmaceutical industry were major hurdles to vaccination.
Keywords: COVID-19 vaccines, dental students, drivers, rural, vaccination hesitancy
|How to cite this article:|
Saxena M, Patil NK, Sareen M, Meena M, Tyagi N, Tak M. A study to access the prevalence and drivers of COVID-19 vaccine hesitancy in Indian population including health care professional and dental students – A cross-sectional survey. J Indian Acad Oral Med Radiol 2022;34:180-7
|How to cite this URL:|
Saxena M, Patil NK, Sareen M, Meena M, Tyagi N, Tak M. A study to access the prevalence and drivers of COVID-19 vaccine hesitancy in Indian population including health care professional and dental students – A cross-sectional survey. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2022 Jul 1];34:180-7. Available from: https://www.jiaomr.in/text.asp?2022/34/2/180/347918
| Introduction|| |
Hastening mass vaccination is the blueprint for incapacitating the COVID-19 pandemic. India has amalgamated with other nations in mass vaccination against the COVID-19. Dental surgeons being part of the medical profession across the country, are also being vaccinated. The vaccination among Indian dentists has declined despite its spread across the world. The cynical reaction by the Indian general public, including the medical fraternity, towards vaccination, has an important concern.
As of 26 July 2021, India had suffered 420,000 officially reported deaths in India.
Out of more than 44.1 crores of vaccine doses, 26.39% of the Indian population have received single-dose, and 7.21% have received both doses.
Covaxin, technically called BBV152, is a whole inactivated virus, a product of Bharat Biotech got approval for emergency use by India's Central Drugs and Standards Committee (CDSCO) on 3 January 2021.
Drug Controller General of India (DCGI) has approved Covishield from Serum Institute of India for emergency use on 19 January.
As described by WHO, vaccine hesitancy is a “delay in acceptance or refusal of safe vaccines despite availability of vaccine services.” A 3C model has been proposed to understand the VH, including complacency, convenience, confidence, and sociodemographic contexts.
Vaccine hesitancy has been there since Jenner's smallpox vaccination. Recently, the Andrew Wakefield scandal created the anti-vaccination sentiment by proving the association between the MMR vaccine and led to reduced vaccine uptake in the United States. In India, 5 lakh children die every year due to vaccine-preventable diseases, and another 89 lakhs remain at risk due to partial or no immunization. Therefore, vaccine hesitancy associated with COVID 19 vaccines is not new.
Dental students constitute small percentage of healthcare community. The clinical postings begins early and they are also vaccinated for various diseases. This makes them role model for their patients and increases their capacity to modify behavior of patient.
The primary objective of this study was to evaluate the prevalence of COVID-19 vaccination hesitancy (VH) among the general public, including dental students, on a national level. The secondary objectives were to investigate the potential drivers for dental students' VH and evaluate their impact on students' acceptance of the COVID-19 vaccine.
| Materials and Methods|| |
A cross-sectional online survey-based study was carried out between 30 May and 30 June 2021 at the national level during the disastrous second wave of Covid-19. The study consists of a self-designed and structured online self-administered questionnaire (SAQ) of multiple-choice items developed on Google forms.
The sample size estimation was based on findings of a previous study; 95% confidence level and 80% power of study sample size were calculated using Cochran's formula of estimation of proportion.
The sample was classified according to gender, age, academic level, and location. Age groups were divided into three groups 18-45 years, 46-60, and above 60 years. The vaccination drive has started in India in different phases according to the same age criteria. The sample was also stratified according to academic level as dental students (UG and PG), healthcare professionals, and non-medical groups. The participating States were also categorized into four groups according to the latest ranking of the RBI (the fiscal year 2021) rural, semi-urban, urban, and metropolitan. Rural: Population less than 10,000, Semi-Urban: 10,000 and above and less than 1 lakh, Urban: 1 lakh and above and less than 10 lakhs, Metropolitan: 10 lakh and above.
The inclusion criteria consist of all individuals above 18 years who can understand and fill their responses in Google forms. The digital informed consent was taken before filling in the questionnaire. The forms were made available using various methods like uniform resource locator (URL) of the questionnaire, including social media platforms (Facebook) and instant messaging groups (WhatsApp). The confidentiality of data was maintained.
A total of 1314 students' response was collected in this survey, of which 43 forms were improperly filled. Therefore their response was not counted.
The SAQ included 30 multiple-choice items that required 7–9 minutes to be completed. It was divided into four categories: (a) demographic data, which covers gender, age, academic level, state, and location, the criteria used for location are based on RBI policy of rural, semi-urban, urban, and metropolitan-based on population residing in a particular area; (b) COVID-19-related experience, including the previous infection, providing care to a COVID-19 patient, having a COVID-19 patient within the social circle, and having a deceased COVID-19 patient within the social circle and none; (c) Covid-19 vaccination update and willingness to take the COVID-19 vaccine determined by a 5-point Likert scale; and (d) the drivers of COVID-19 vaccine-related attitude.
The items of the fourth category were taken from the authenticated SAGE criteria by the WHO, that consist of contextual influences, individual influences and vaccine related issues.
The study protocol was carried out after obtaining permission from the Ethics Committee.
Ethical guidelines of the Helsinki Declaration were followed.
The study was conducted after receiving approval from the ethical committee and letter-number RDCH/GEN/2021/0582.
All the statistical tests were performed by the Statistical Package for the Social Sciences (SPSS) version 27 IBM Corp USA. Primarily, descriptive analysis was done for the demographic variables, COVID-19-related experience, willingness to take the COVID-19 vaccine, and the drivers of COVID-19 vaccine-related attitude represented by frequencies, percentages, cumulative percentages, means, and standard deviations.
Inferential statistics were performed to understand the COVID-19 vaccine acceptance level and demographic variables using the Chi-square test and Mann–Whitney U-test.
| Results|| |
The current study included 1271 participants of which 776 were females, while males were 495. Considering UG dental and PG dental students together constitute almost 48% of total responses.
The detail and percentage are mentioned in [Table 1]. Age and gender wise distribution is shown in [Figure 1].
|Figure 1: (a) Pie diagram showing age wise distribution of participants. (b) Gender wise distribution|
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|Table 1: Demographic characteristics of the participating candidates across the country in June 2021|
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COVID-19 related experience
About 286 (22.5%) participants divulged that they had been previously infected by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The people from metropolitan areas were infected more with 24.9% than rural areas with 20.8%. This difference is statistically significant with a P value of 0.001 as shown in [Table 2].
In terms of gender comparison, females (23.5%) were infected more than males (21%) counterpart by COVID 19. Females were significantly more infected by COVID 19 than their male peers, 23.5% vs. 21%, respectively. Moreover, 8% of females versus 7.7% of males provided care to Covid-19 patients. Similarly, more females knew deceased COVID-19 patients, 3.4% vs. 2.4%.
Covid-19 vaccination update
The highest acceptance of the COVID 19 vaccine was seen in the age group above 60 years with 94.8%. The country started the second phase of the vaccination drive on March 1, which included vaccination for everyone above 60 years of age and over 45 years with comorbidities. The vaccination hesitancy was highest in 18-45 years at 14.7% in rural areas with 19.5% and in the non-medical group at 19%.
The vaccination update of different categories has been shown in [Figure 2]. State wise COVID 19 vaccination update is shown in [Figure 3].
|Figure 2: Column chart of Vaccination update (a) Age wise. (b) Gender wise. (c) Location wise. (d) Academic level related|
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|Figure 3: Composite bar graph depicting state wise Covid-19 vaccination acceptance|
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COVID-19 vaccine related attitudes
Attitude towards the Covid-19 vaccine is based on the Likert scale; 4% totally disagreed to take vaccine, 5% disagreed, 6% were hesitant to take vaccine, 22% agreed and 63% totally agreed to get vaccination as shown in [Table 3].
|Table 3: Attitudes towards the COVID-19 vaccine stratified by academic level|
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The urban population is more hesitant to take vaccines than its metropolitan peers, 61% versus 30%.
Female participants have shown higher vaccine acceptance than their male counterparts, 64% vs. 62%.
The age-wise 18-45 group has shown the highest acceptance with 64%.
The academic level UG dental (67%) is on the top in accepting Covid-19 vaccines, followed by HCP (65%), PG dental (60%), and the last are a non-medical group (57%).
Drivers of COVID-19 vaccine-related attitude
The UG dental students were significantly (P < 0.01) influenced by the Celebrity and political leaders influence the news they read in media and social media compared to their PG students' peers, 58.9% vs. 56.3%, respectively as shown in [Table 4].
Any previous ill effect has prevented PG students from getting vaccines.
Health care professionals know more people (P <.01) with religious or cultural reasons that have prevented them from getting the vaccine. The reason could be that they are more in touch with patients regarding queries about vaccination than peer groups.
HCP were more confident in trusting the government's decisions and ready to travel longer to get vaccines.
The trust in the motives of pharmaceutical industries is highest among UG dental students, which is statistically significant with a P < 0.01.
Individual group influences
PG dental students are more aware of someone who had a serious reaction to the vaccine.
Most of HCP are confident about the seriousness of vaccine-preventable disease versus 59.1% of UG dental students (P < 0.01)
The HPV vaccine is known to PG dental students.
Vaccine specific issues
HCP are more inclined to new company introduced vaccines, shown interest in trying a new mode of vaccination.
PG dental students have a higher level of belief that the benefits of COVID-19 vaccines exceed their reported side effects.
Females have more influence on social media as an information source than their male counterparts, 58.5% vs. 50.9% (P < 0.01).
Social pressure is more on females 13.4% vs. 9.3% (P < 0.01), and they have higher confidence in pharmaceutical companies (53.9% vs. 43.7%)
Males know a higher percentage of people (P < 0.01) who have not taken a vaccine due to religious or cultural causes, 75.4% vs. 69.3%.
Males had higher levels of confidence in government (75.4% vs. 69.3%), thought that COVID-19 benefits outweigh its reported side effects (67.7% vs. 64.2%), and inclination to take newly introduced vaccines (26.5% vs. 9.8%) with P value < 0.01.
| Discussion|| |
India launched the world's largest COVID-19 vaccination program on January 16, 2021, to vaccinate its 900 million eligible population in different phases. An estimated 30 million healthcare and frontline workers were to be vaccinated in phase 1.
Data from our survey at the national level showed that 27% of dental students were hesitant about taking COVID-19 vaccines. The vaccination acceptance rate was 63% approximately. A recent report by Chowdhury et al. estimated that almost a third (29%–39%) of Indians were vaccine-hesitant in early 2021. A study by Umakanthan et al. from January to June 2021 disclosed that VH was 36% due to religious and populistic attitudes towards vaccination. Verger et al. (2021) reported that 28.39% of healthcare workers in France and French-speaking parts of Belgium and Canada were hesitant about COVID-19 vaccines.
Khubchandani et al. showed COVID-19 VH in Americans to be 26.3%, African-Americans have 41.6%, and Hispanics showed it as 30%. A study done by S Chandani et al. showed that females and urban dwellers are more vaccine-hesitant. In the present study, few males participated in our survey, which could be the reason for showing males as VH. This rate of COVID-19 vaccine hesitancy is highly concerning given the threat of emerging variants worldwide and a healthcare system in India that can be quickly overwhelmed with future outbreaks. At the same time, our data collected is very small, given that the sample predominantly consisted of college-educated and urban individuals. A significant proportion of the Indian population is rural, without formal education, and affected by a greater digital divide. This would mean that the actual rate of vaccine hesitancy could be much higher.
Malik Sallam et al. carried out survey studies in 33 countries. They concluded that among adults representing the general public, the lowest COVID-19 vaccine acceptance rates were found in Kuwait (24%), Jordan (28%), Italy (54%), Russia (55%), and Poland (56%), US (57%). In a maximum number of surveys, the acceptance of COVID-19 vaccination disclosed a level of around 70%, consistent with the present study. Low rates of COVID-19 vaccine acceptance were reported in the Middle East, Russia, Africa, and several European countries.
Male sex was associated with significantly higher rates of COVID-19 vaccine acceptance as males can perceive Covid-19 danger and are more inclined to the vaccine.
Bartosz Szmyd et al. conducted a study on medical students in Poland and concluded that 92% of medical students showed interest in vaccination which is in line with the current study. The anxiety associated with SARS-CoV-2 infection was the probability of communicating the disease to elderly relatives.
Jeffrey V. Lazarus et al. conducted a survey in 19 countries covering about 55% of the global population and concluded that young people 18–24 were hesitant to take a vaccine compared to higher age; the same trend is followed in our study. The gender difference was small, and higher levels of education have shown good vaccine acceptance.
Alwi S et al. surveyed Malaysians found the over all acceptance was high (83.3%). Social media (97.4%) was the primary source of information regarding COVID 19 which was consistent with our study.
Causes of VH
The rapid development of vaccines in a short time, low confidence in the safety and efficacy of the new vaccines, fear of side effects, reports about thrombosis and infertility and death after taking the vaccine, combined with the difficulty of registration/booking slots, low-risk perception from COVID-19 and the absence of incentives for rural and urban poor, etc., are fuelling high vaccine hesitancy.
This is the first study to assess the prevalence and drivers of COVID-19 VH among dental students in India using the SAGE criteria by WHO.
The first limitation of this study is its sample which is not equally distributed across gender and location. The second limitation is the imbalanced representation of economic levels, and this occurred mainly due to the disproportionate geographic representation.
The findings of this nationwide study call for further implementation of infectious diseases epidemiology education and vaccination trends within the undergraduate dental curriculum.
| Conclusion|| |
The overall acceptance level of dental students (63%) for COVID-19 vaccines in India was good. The worrisome level of VH (27%) is governed by the economic context where dental students live and study. The female gender is associated with an increased level of vaccine acceptance. The media and social media, public figures, insufficient knowledge about vaccines and their safety, and mistrust of governments and the pharmaceutical industry were barriers to vaccination.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]