Knowledge, Attitude, and Practice to COVID-19 and its Vaccines among the Lebanese Population: A Cross-sectional Study
1,3Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
2Department of Pediatric, Rafik Hariri University Hospital, Beirut, Lebanon
4Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
5Faculty of Medical Sciences, Beirut Arab University, Beirut, Lebanon
6The Heart Medical Centre, UAE
Corresponding Author: Aalaa Saleh, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon, Phone: +0096181363617, e-mail: firstname.lastname@example.org
Received on: 05 July 2020; Accepted on: 03 August 2020; Published on: 31 December 2022
Aims: Assess the knowledge, attitude, and practice (KAP) toward COVID-19 and its vaccines among the Lebanese population after the beginning of the vaccination campaign and identify the different factors affecting the acceptance of vaccination.
Patients and methods: The data was collected through hard copies, then it was filled in Google Form. The questionnaire included questions about sociodemographic data, dependent sources of information for COVID-19 and its vaccines, having past experience with COVID-19, and vaccination or willingness to take the vaccine at the nearest opportunity. Attitude against vaccination was assessed using a new KAP toward virus and vaccine scale consisting of 14 items.
Results: The average score of the attitude of 1,002 participants was 16.87 over 28. Accepting vaccination was significantly correlated with females, having past experience with COVID-19, being a healthcare worker, participants with a higher positive attitude, and participants following official resources like governmental resources and World Health Organization (WHO) or accredited international scientific institutions rather than social media.
Conclusion: The attitude toward COVID-19 and its vaccines is moderate in Lebanon, and extensive efforts are necessary for the further promotion of vaccines among the public. Social media has a high influence on the population’s attitude toward vaccination, and it should be monitored strictly.
Clinical significance: Social media and other factors influence on the decision on vaccination and public health.
How to cite this article: Saleh A, Awaida I, El Masri J, et al. Knowledge, Attitude, and Practice to COVID-19 and its Vaccines among the Lebanese Population: A Cross-sectional Study. Pediatr Inf Dis 2022;4(4):123-129.
Source of support: Nil
Conflict of interest: None
Keywords: COVID-19, COVID-19 vaccines, Health attitude to social media.
COVID-19 is a new highly infectious disease that can affect the upper and lower respiratory airway in different age groups throughout all seasons, which is caused by many different variants of coronaviruses. Coronaviruses are enveloped by positive-strand ribonucleic acid (RNA) virus. Sequencing of the full genome revealed that the coronavirus is a β-coronavirus, which is in the same subgenus as the severe acute respiratory syndrome virus.1 In consequence, The Coronavirus Study Group of the International Committee on Taxonomy of Viruses has proposed that this virus is designated as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).2 Unlike other RNA viruses, which have high mutation rates like human immunodeficiency virus, and influenza virus, SARS-COV2 undergoes only one–two mutations/month.3 The most significant mutations occur in the S protein, which increases the affinity of binding to angiotensin-converting enzyme 2 receptors and increases the amount of virus shed from the infected person, thus leading to a turning point in the context of a pandemic.4 According to the SARS-CoV-2 Interagency group (SIG), the variants of concern (VOC) nowadays are Δ (B.1.617.2 and AY lineages), and Omicron (B.1.1.529 and BA lineages).5 These VOC are variants that have evidence of an increase in transmissibility, more disease severity (for example, increased hospitalizations, or deaths), an important reduction in neutralization by antibodies generated during previous infection or vaccination, the decline in the efficacy of treatments or developed vaccines, and failure of detection by the diagnostic tests.
The first case of SARS-CoV-2 was detected in Wuhan, China on 31st December 2019, and then SARS-CoV-2 spread all over the world. According to the WHO dashboard, on 3rd March 2022, the number of total confirmed cases was 441,237,267, and the number of deaths was 5,996,417. On the level of Lebanon, the first confirmed case was on 3rd March 2020, and then the virus continued to spread so currently the total number of confirmed cases is 1,072,537, and the number of deaths is 10,115 according to the Ministry of Public Health.6
Due to the rapid transmission of SARS-CoV-2 infection worldwide, all the healthcare systems and governorates were alerted to find a vaccine to prevent the infection and reduce the economic and social burden. After many trials, there are currently 10 vaccines in phase IV, which are being monitored in the wider population after being approved. According to WHO, the vaccination campaign began on 14th December 2020 in the US, where in March 2021, about 9 billion doses of vaccine doses were administered. The impact of vaccine administration was immediate, where the overall attack rate reduced from 9 to 4.6%, as well as the adverse effect such as intensive care unit (ICU) administration, non-ICU administration, and death reduced by 63.5%.7 As for Lebanon, the vaccination campaign began on February 14, 2021, and the percentage of the Lebanese population who are fully vaccinated is about 30% in March 2022, in which vaccination is recommended for everyone starting at the age of 12 years. The approved vaccines by the Ministry of Public Health are Pfizer-BioNTech (BNT162b2), Moderna (Mrna-1273), Sinopharm (BBIBP-CorV), AstraZeneca-Oxford (Vaxzevria), Sputnik V (Gam-COVID-Vac). Due to the deterioration in the Lebanese economy and after Beirut Blast on 4th August 2020, Lebanon cannot bear another new epidemic wave, and cannot afford strict lockdown and sustain closure, so vaccination is the only way to reduce the number of deaths and prevent the burden up of the healthcare system.8
The attitude toward vaccination varied globally where among 26,852 participants all over the world, only 81.5% agreed to take the vaccine to protect the people from COVID-19.9 It is worth mentioning that the efficacy of the vaccine, location of vaccine development, and time spent on clinical trials affect the willingness on getting vaccinated.10 All these factors should be taken into consideration in the process of vaccination. According to our knowledge, our study was the first that assesses the KAP toward COVID-19 virus and its vaccines among the Lebanese populations and identifies the factors that affect the attitude toward vaccination, after the beginning of the vaccination campaign.
PATIENTS AND METHODS
This was a cross-sectional study conducted among 1002 Lebanese citizens aiming to assess their KAP toward vaccination against COVID-19. Data was collected via distributing the questionnaire via hard copies to the Lebanese population. After that, the data were entered into the Google Form, and the study was conducted between October and December 2021.
A total of 1,002 survey of hard copies of the questionnaire were randomly distributed in all Lebanese governorates, and all of them were collected back.
Lebanese population who are 18-year-old and above and who are capacitive.
Lebanese population who are living abroad. Uncompleted surveys were also eliminated.
Data Collection Tool
The questionnaire is formed of 24 question survey. The survey would take approximately 5 minutes to complete. The questionnaire contains questions about:
Sociodemographics data of the individual (e.g., sex, age, social status, number of children, educational level, and work area).
The dependent source of information about vaccines against COVID-19 (WHO or accredited international scientific institutions such as the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), or Ministry of Health and official media channels, or social media, or personal search on the internet).
Old experience with COVID-19 (if he or anyone he knows got infected by COVID-19).
Knowledge, attitude, and practice scale toward vaccine and vaccines scale after reviewing a large number of previously published surveys, the Director of Pediatric Infectious Diseases Services at The Heart Medical Center (UAE) developed a self-administered questionnaire of 14 items was used to assess the KAP toward coronavirus disease and COVID-19 vaccine. The scale was developed and used in the Arabic language.
Vaccinated or willing to take the vaccine.
Attitude against vaccination was assessed using a scale of 14 items following 3 points Likert scale between “0” and “2.” Attitude score was validated in our study population where the Cronbach’s alpha value was 0.724 and Kaiser-Meyer-Olkin (KMO) test and Bartlett’s test showed a KMO measure of sampling adequacy = 0.798 with p-value < 0.0001 of Bartlett’s test of sphericity. The statistical package for social sciences (IBM-version 25) was used for data analysis. Descriptive analysis was enrolled, and nominal variables were represented by frequencies and proportions, whereas continuous variables were represented by mean, median, standard deviation, minimum, and maximum. Bivariate analysis was enrolled to test the factors affecting the attitude toward vaccination against COVID-19. The tests used were the chi-squared test and the analysis of variance test. A binary logistic analysis was enrolled in order to predict factors affecting “receiving vaccination.” A p-value of <0.05 was used as the cutoff value for statistical significance.
The questionnaire is anonymous and confidential; we will not force any to participate in the study. Certainly, the confidentiality of the participants will be assured, since the digital signature is not applied in our country, the questionnaire did not include an informed consent section, but participants have the full right to refuse to participate or to withdraw at any time. The ethical approval was granted by the institutional review board at Sahel General Hospital. Confidentiality of the participants had been assured.
Participants were distributed between 513 (51.2%) females and 489 (48.8%) males. The study population was aged between 18 and 35 years (62.7%) and more than 35 years (37.3%). Out of 1,002 participants, 50.4% were single, 44.9% were married, 3.6% were divorced, and 1.1% were widowed. Among nonsingles, 87.5% had children. Concerning their educational level, 24.8% had less than a secondary degree, 19.7% had a secondary degree, 37.4% had a university diploma, 14.1% had a master or equivalent, and 4.1% had a doctorate or equivalent. Out of 1,002 participants, 19.1% were nonworkers, 7.6% were housewives, and 73.6% were working in different field sectors (Table 1).
|More than 55 years||60||6.0|
|Number of children||No children||62||12.5|
|More than three children||134||27.0|
|Educational level||Less than secondary degree||248||24.8|
|Master or equivalent||141||14.1|
|Doctorate or equivalent||41||4.1|
|Work status||Health field||185||18.5|
|The technical field (such as various branches of engineering, computer, programming, and artificial intelligence, etc.)||53||5.3|
|Literary field (such as poetry, journalism, writing, authorship, etc.)||16||1.6|
|Artistic field (such as singing, drawing, dancing, acting, etc.)||14||1.4|
|A field other than the one mentioned above||101||10.1|
Source of Information
Participants got information about vaccination against COVID-19 from social media (28.2%), approved government sources (such as the Ministry of Health and official media channels) (29.1%), the WHO, or accredited international scientific institutions such as the CDC, FDA (28.6%), and from the personal search on the internet (14%) (Fig. 1).
Attitudes toward Vaccination against COVID-19
Out of 1,002 participants, 787 (78.5%) had or knew someone who contracted COVID-19. Regarding the attitudes items, 41.1% agreed that COVID-19 virus is man-made and has been removed from the laboratory for political purposes, 32.6% agreed that COVID-19 virus will soon disappear, 57.9% agreed that immunity acquired from a natural infection is considered to be better and more sustainable than immunity acquired from a vaccine, 38.6% agreed that currently available COVID-19 vaccines are largely safe, 38.4% agreed that currently available COVID-19 vaccines are largely effective, 68.8% agreed that a commitment to physical distancing is one of the most important means to stop a pandemic, 67.9% agreed that wearing a mask in any public places is one of the most important means to stop the pandemic, 54.9% agreed that the use of the vaccine will significantly reduce the spread of the virus, 56.3% agreed that the use of the vaccine will significantly reduce the severity of infection and complications, and 50.7% agreed that the use of the vaccine will significantly reduce the risk of death. In addition, 53.5% were committed to all precautionary measures decided by the concerned authorities, 38.7% were using nutritional supplements such as vitamins, Magnesium, and oils regularly to strengthen my immunity, 40.3% stated that they could distinguish zero symptoms of COVID-19 infection without the need for laboratory tests, and 62.7% usually follow isolation if they have any respiratory symptoms such as a cough or a cold (Table 2).
|I have taken the vaccine, or I will take it at the earliest opportunity||p-value|
|No (N = 434)||Yes (N = 568)|
|Age||18–25 years||112 (27.8%)||291 (72.2%)||<0.001*|
|26–35 years||116 (51.6%)||109 (48.4%)|
|36–45 years||96 (55.8%)||76 (44.2%)|
|46–55 years||78 (54.9%)||64 (45.1%)|
|More than 55 years||32 (53.3%)||28 (46.7%)|
|Gender||Male||235 (48.1%)||254 (51.9%)||0.003*|
|Female||199 (38.8%)||314 (61.2%)|
|Marital status||Single||159 (31.5%)||346 (68.5%)||<0.001*|
|Married||249 (55.3%)||201 (44.7%)||<0.001*|
|Divorced||21 (58.3%)||15 (41.7%)||0.064|
|Widowed||5 (45.5%)||6 (54.5%)||0.885|
|Having children||No children||30 (48.4%)||32 (51.6%)||0.405|
|Yes||404 (43.0%)||536 (57.0%)|
|Number of children||No children||30 (48.4%)||32 (51.6%)||0.022|
|One child||34 (54.0%)||29 (46.0%)|
|Two children||88 (65.7%)||46 (34.3%)|
|Three children||47 (45.2%)||57 (54.8%)|
|More than three children||76 (56.7%)||58 (43.3%)|
|Educational level||Less than secondary degree||152 (61.3%)||96 (38.7%)||<0.001*|
|Secondary degree||106 (53.8%)||91 (46.2%)|
|University diploma||127 (33.9%)||248 (66.1%)|
|Master or equivalent||33 (23.4%)||108 (76.6%)|
|Doctorate or equivalent||16 (39.0%)||25 (61.0%)|
|Work status||Health field||24 (13.0%)||161 (87.0%)||<0.001*|
|Teaching field||87 (49.7%)||88 (50.3%)||0.060|
|Banking field||9 (36.0%)||16 (64.0%)||0.455|
|The technical field (such as various branches of engineering, computer, programming, and artificial intelligence, etc.)||16 (30.2%)||37 (69.8%)||0.048*|
|Commercial field||55 (60.4%)||36 (39.6%)||0.001*|
|Literary field (such as poetry, journalism, writing, authorship, etc.)||7 (43.8%)||9 (56.3%)||0.972|
|Artistic field (such as singing, drawing, dancing, acting, etc.)||8 (57.1%)||6 (42.9%)||0.293|
|Professional crafts||53 (70.7%)||22 (29.3%)||<0.001*|
|Housewife||38 (50.0%)||38 (50.0%)||0.221|
|A field other than the one mentioned above||58 (57.4%)||43 (42.6%)||0.003*|
|Unemployed||79 (41.4%)||112 (58.6%)||0.545|
|Source of information||Social media||159 (56.2%)||124 (43.8%)||<0.001*|
|Personal search on internet||75 (53.6%)||65 (46.4%)||<0.001*|
|Approved government sources (such as the Ministry of Health and official media channels)||118 (40.4%)||174 (59.6%)||0.008*|
|The WHO or accredited international scientific institutions such as the CDC, FDA||82 (28.6%)||205 (71.4%)||0.234|
Attitude toward vaccination against COVID-19 was assessed using a score of 14 items. Our findings showed that the study population moderate attitude toward vaccination against COVID-19, where the average attitude score was 16.87 ± 5.36 over 28, and the median score was 17 over 28 with a minimum of one and a maximum of 28 over 28 (Fig. 2).
Vaccination against COVID-19
Out of 1,002 participants, 568 (56.7%) took or will take the vaccine against COVID-19, whereas 434 (43.3%) did not receive the vaccine or will not take it.
Factors affecting Vaccination against COVID-19
Vaccination against COVID-19 was associated with age (p < 0.001), where the vaccination rate was shown to be higher in participants aged less than 25 years (72.2%) compared to other age categories. Vaccination against COVID-19 was associated with gender (p = 0.003), and the vaccination rate was shown higher in females (61.2%) compared to males (51.9%). Vaccination against COVID-19 was associated with the marital status being single (p < 0.001), where the rate was higher in singles (68.5%) compared to married (44.7%), divorced (41.7%), and widowed (54.5%). Vaccination against COVID-19 was associated with the educational level (p < 0.001) where the rate of vaccination was higher in participants having master’s degrees (76.6%) and university diploma (66.1%) compared to participants with low educational levels. Vaccination against COVID-19 was associated with the type of work, where the rate was higher in workers in the health field (p < 0.001) compared to others. Vaccination against COVID-19 was associated with the source of information (p < 0.05), and the rate was higher in participants following the WHO or accredited international scientific institutions such as the CDC and FDA (71.4%) compared to other participants following another source of information (Table 2).
Attitude toward vaccination was statistically associated with the decision of vaccination against COVID-19 (p < 0.001). The mean attitude score was higher in participants who received the vaccine (mean = 28.82 ± 4.25) compared to those who did not receive the vaccine (mean = 14.32 ± 5.58).
Binary logistic analysis showed that many factors were affecting the vaccination against COVID-19 noting gender (p = 0.001), experience with COVID-19 (p = 0.022), being single (p < 0.001), working in the healthcare field (p < 0.001), following sources other than social media (p = 0.036), and having positive attitude toward vaccination (p < 0.001) (Table 3).
|B||S.E.||Sig.||Exp (B)||95% CI for EXP(B)|
|Have you or someone you know contracted COVID-19?||0.404||0.177||0.022||1.498||1.060||2.119|
|Attitude toward vaccination||0.159||0.016||0.000||1.172||1.137||1.210|
|Dependent: Take/willing to take vaccine|
Odds ratio for vaccination increase 1.623 times [95% confidence interval (CI) (1.212–2.173)] in females, 1.498 times [95% CI (1.060–2.119)] when having an experience with COVID-19, 2.340 times [95% CI (1.739–3.150)] in singles, 2.958 times [95% CI (1.812–4.831)] in health care workers, and 1.172 times [95% CI (1.137–1.210)] in participants with positive attitudes against vaccination.
This cross-sectional study has aimed to assess the KAP of the Lebanese population toward the COVID-19 virus and its vaccines. KAP toward virus and vaccine scale was developed in Arabic language and validated to be used where the Cronbach alpha is 0.724. Thus, this scale could be used to assess KAP toward another virus and its vaccines. There are many predisposing factors affecting vaccination against COVID-19, including sociodemographic factors, previous experience with COVID-19, and the dependent source of information.
The average attitude of the selected population is 16.87 ± 5.36 over 28, the median score was 17 over 28 with a minimum of one and a maximum of 28 over 28. The median and average are approximately equal, which means our data were symmetrically distributed. Similar to our study, a study conducted by Mannan and Farhana in 2020 revealed that 65.5% of 26,852 participants strongly agreed that it is important to get the vaccine to protect from COVID-19.9
In this study, 56.7% of participants took or will take the vaccine more than 43.3% of participants didn’t take or are not willing to take the vaccine. This percentage is higher than a study done in 2020 before the beginning of the vaccination campaign where only 21.4% were willing to take the vaccines.11 We can hypothesize the change of willingness is caused by the enormous vaccination awareness campaigns that are going on now in Lebanon.
Regarding the factors that have an impact on vaccination, our findings showed that more acceptance of vaccination was noticed in participants <25 years (72.2%) compared to other age categories where the percentage of acceptance of vaccination is reduced to vary between 45.1% and 48.4%. These findings are similar to that in Jordan, where older individuals are less likely willing to take the vaccine.12 However, in the USA, willingness to take the vaccine was higher in participants who are 65 years and above compared with other age categories. This issue raises the importance of tackling more elderly people in developing countries during the vaccination campaign since they have the highest mortality and morbidity rate.14
The odds ratio for vaccination in females increases 1.623 times [95% CI (1.212–2.173)] as compared to males. This result is completely surprising because it is opposite to studies done in Jordan,12 USA,15 and UK.16 According to this data, we can hypothesize that Lebanese women become more confident regarding the vaccines and their effect on their health.
Our results showed that being single has significantly increased the odds ratio for acceptance by 2.340 times [95% CI (1.739–3.150)] as compared to married, widowed, and divorced, contrary to a study done in China.17 These results can be justified by the fact that singles have in general low responsibilities, whereas married have exaggerated hesitancy toward the efficacy of vaccines because any serious side effect could affect their families future.
Acceptance of vaccination against COVID-19 is significantly associated with the type of employment, where our study revealed that health care workers have an elevated odd ratio of 2.958 times [95% CI (1.812–4.831)]. This result is concordant with a study done in France where 75% of 2047 healthcare workers had the intention to get vaccinated against COVID-19.18 However, participants who are working in professional crafts have the lowest percentage of vaccination (29.3%). Thus, this population should be targeted in future vaccination awareness campaigns.
A total of 78.5% of the participants have previous experience with COVID-19, and these participants have a higher odds ratio for vaccination by 1.498 times [95% CI (1.060–2.119)]. This might be due to that person who have experience with COVID-19 are frightened of the risk of recurrent infection.
Binary logistic analysis showed that following source of information rather than social media has an influence on the acceptance of vaccination against COVID-19. This is correlated with a global study where participants depending on government sources were more likely to accept the vaccine.9 A randomized controlled trial revealed that exposure to misinformation against COVID-19 causes a decline in the intent of vaccination by 6.2% in UK, and 6.4% USA among those who stated previously that they would definitely accept the vaccine.15
Participants who are vaccinated or are willing to take the vaccine have an average attitude of 18.82 > participants who didn’t take the vaccine or are not willing to take the vaccine, which is 14.32. This is opposite to a previous study done in Lebanon in 2020 which shows no significant correlation between KAP toward COVID-19 and acceptance of the vaccine.11 Due to the enormous vaccination campaign associated with diminishing in the adverse effect,11 this leads to improvement in the attitude of people to vaccination against COVID-19.
Going deep into the components of our scale, 41.1% of participants think that COVID-19 is man-made and released from the laboratory for political purposes. This percentage could be correlated with the number of participants who refused to get vaccinated. Another study done in Jordan showed that 57% of participants believed that COVID-19 origin was related to biological warfare.19 Our findings could be justified that the people’s belief in the Middle East is influenced by the past events of biological wars in which thousands of people got affected by the release of pathogens in the Second World War.20
Our results showed that 56.2% of participants who depend on social media are not vaccinated or are not willing to take the vaccine. Our results are reassured by another study done in Saudi Arabia where 74.6% of participants agreed that the vaccines were misrepresented by social media.21 Thus, social media in Arabic countries has a significant impact on people’s decisions on vaccination.
This study was conducted, including some limitations. Many participants refused to participate in the study for unknown reasons, but we still believe that the study has managed to identify some gaps in the KAP of the participants regarding COVID-19 disease and vaccination. On the other hand, the strength of our study is the use of a new scale to assess the KAP toward COVID-19 and vaccines. Overall, the KAP toward COVID-19 and vaccines among Lebanese are moderate. The impact of social media on the acceptance of vaccines should not be misestimated in all vaccination campaigns, and more restrictions should be done on social media platforms.
Social media and other modifiable factors should be targeted due to their influence on the acceptance of vaccination, which is a public health issue. Improving the acceptance of vaccination should be addressed in by all committees because in the future and in case of the appearance of new diseases, vaccination will be the only solution to save humanity.
We want to acknowledge Mr. Bachir AtaAllah for his assistance.
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