Fears and misconceptions toward COVID‐19 vaccination among Syrian population: A cross‐sectional study

Abstract Background and Aims Despite the significant milestone of vaccine discovery, the spread of misinformation and pseudoscientific claims has resulted in an increasing number of people refusing vaccination in Syria. In this study, we aimed to explore fears and misconceptions towards COVID‐19 vaccines among the Syrian population. Methods We conducted a nationwide cross‐sectional study between January and May 2022, using a convenience sample of 10,006 participants aged at least 18 years and living in Syria. We administered a validated online/paper questionnaire and conducted face‐to‐face interviews. We used SPSS software (version 26) for statistical analysis, assessing our data using frequency and χ 2 tests, with p < 0.05 considered statistically significant. Results The majority of the participants were female 6048 (60.4%), university degree holders 7304 (73%), and from urban areas 8015 (80.1%). Approximately half of the participants 5021 (50.2%) belonged to the medical sector (49% had concerns about the vaccine). Females, university degree holders, and participants with a history of symptomatic COVID‐19 were more likely to have fears about the vaccines. The main concerns about the vaccines were the rapid development, fears of blood clots, and common side effects. The prevalence of some misconceptions was relatively high, such as the belief that the vaccine is an experiment or a secret plan to reduce the population. Reliable sources are crucial to fight misleading information on social media. Conclusion COVID‐19 vaccine is key to controlling the spread, but acceptance rate is critical. High variability in vaccine acceptance and high vaccine hesitancy can affect the efforts to terminate the COVID‐19 pandemic. Addressing the barriers associated with the acceptance of COVID‐19 vaccination will be the cornerstone to achieving maximum vaccination coverage. It is important to consider the reasons for refusing the COVID‐19 vaccine when interpreting the results of any study on vaccine attitudes among the Syrian population.

Although vaccine discovery was one of humanity's greatest milestones, we stand today against pseudoscience and misinformation's plead for irrational side effects and its ineffectiveness against diseases, which in turn has led many children and adults not to take their required vaccines, these concerns are rising even in the vaccinated. 3,4 Long before the SARS-COV2 pandemic, the number of people refusing vaccination was increasing and although vaccines like any other medical drug are associated with several side effects, they are considered a normal reaction of the vaccines and not necessarily a negative reason to halt its administration, except for specific cases with known allergies to vaccine's components or have impaired immunity. Vaccine acceptance could be improved through social guidance campaigns as humanity is currently going through an "infodemic" which may be responsible for increased morbidity and mortality of several infectious diseases. Social media has been responsible for aggravating many existing fears of vaccines and helped "anti-vax" campaigns reach out to a large percentage of the population and provide convincing claims against vaccines and their efficacy. 4,5 Since the first COVID-19 vaccine by Pfizer dose that was Yasmin and colleagues found that 87.8% of the study cohort indicated a willingness to get vaccinated, with certain factors, such as younger age and lower attained education, being associated independently with vaccination hesitancy. 6 In Japan, Machida et al. 7 have found that individuals with any social capital are more likely to receive a COVID-19 vaccination than those with none, suggesting that social capital may be a factor that can reduce vaccine hesitancy during a pandemic. Gautier et al. 8 have found high rates of vaccine hesitation in health sciences students, which in turn may raise concerns about vaccine acceptance among healthcare practitioners and its influence on the population's acceptance.
In Syria, Shibani et al. 9 found that both fears of side effects and mistrust in the rapid development of vaccines would steer the efforts away from eliminating the pandemic. However, at the same time of the study, new campaigns were launched to raise awareness in the population and the results of these campaigns were yet to be discovered. In addition, The Shibani and colleagues study's objectives were regarding vaccines in general. Since a lot of vaccines with different mechanisms of action were released to the public afterwards, there was an increasing need to know which type of vaccine Syrians would prefer and how this would later affect vaccination rates. Swed et al. 10 have suggested that in addition to the aforementioned factors rural areas may have the highest rate of vaccine hesitancy due to factors like high rates of poverty and poor infrastructure. To our knowledge, no study was conducted to investigate the vaccination rates in these areas.
According to Mohammad et al. 11 the reasons for this low rate of vaccination are delayed vaccine availability in Syria and low acceptance of COVID-19 vaccines among the Syrian population.
The objective of this nationwide study is to provide insights into the factors that contribute to vaccine hesitancy, identify the most common fears and misconceptions, and inform public health strategies to improve vaccine uptake and address vaccine-related concerns in Syria. of error of 1%, and considering the population of Syria in 2022 is 18,563,379 people. 12 The sample size was calculated with https:// www.checkmarket.com/sample-size-calculator/. The inclusion criteria were individuals who were at least 18-year-old, voluntarily agreed to participate in this study, and living in Syria. Paper questionnaire and a face-to-face interview aimed to reduce the sampling error, increase the study power, and ensure that the questionnaire will reach all individuals such as the elderly, people with no internet connection, and people who do not have mobile phones and social media.
The questionnaire was created by the authors after an extensive review of the literature, designed via Google form, and disseminated the electronic link through social media networks (Facebook, WhatsApp, Telegram, Instagram, and Twitter). The paper questionnaire was distributed in all suitable places (hospitals, private clinics, pharmacies, markets, and university housing).
The data was collected by 58 collaborators from different cities in Syria, each collaborator had to collect approximately 150-200 answers. Thirty collaborators collected data through an online questionnaire with 20 face-to-face interviews. Seventeen collaborators collected data through both electronic and paper questionnaires.
Ten collaborators collected data through only a printed questionnaire. The collaborators were trained to conduct the data collection process to ensure accuracy and validity. To ensure the accuracy and validity of the data collection process, the first author trained each of the collaborators on the study objectives and procedures, reviewed the questionnaire and its variables with them, and provided guidance on how to approach participants and collect the data. The collaborators were also trained on how to handle illiterate participants and avoid duplication of participants by asking if they had already participated in the survey.
To collect the data, a set of questions were constructed. The questionnaire was first pre-tested, revised, and finalized based on a pilot sample (n = 30) to assess the questionnaire's clarity. All questions were simple, and clear with multiple response options and were written in the Arabic language as it is the native language of the Syrian population. Informed consent included "Yes or No" question was obtained at the beginning of the questionnaire to ensure the approval of participant, the survey was voluntary and anonymous, response to all questions was not mandatory and and participants were allowed to withdraw from the survey at any time.
No personal identifications were obtained, and all data maintained confidential without posing any threat according to the Syrian culture and traditions. Time for the questionnaire completion was approximately 12 ± 5 min.
To make sure that our sample is representative and not biased, we used multiple strategies to reach a diverse group of participants.
We used a probability-based approach to select participants from both urban and rural areas across various governorates. Additionally, we used a convenient sampling method to reach individuals who may be harder to access through traditional means, such as the elderly or disabled. We also utilized the snowball sampling method to increase the size and diversity of our sample.

| Data management and statistical analysis
The Data Collection Group manually entered the information obtained through paper questionnaires and face-to-face interviews into an online Google Form that was used for collecting data online.
Subsequently, the data was extracted directly from the Google Form and transferred to an Excel spreadsheet. Finally, the raw data in the Excel sheet was transformed into a format that could be used with statistical software.
All analyses were performed using SPSS Inc software version 26 on Microsoft Windows and reported as frequencies and percentages (for categorical variables). Analysis groups were defined as: gender, age, place of residence, education, field of study, and so forth.
There were no missing data in the final data set used for analysis. KLIB ET AL.

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A two-sided χ 2 test was applied to assess relationships between categorical sociodemographic variables and responses to the question (Do you have fears about the COVID-19 vaccine?). Figure 1 discusses how data was handled. Figure 2 and tables were used to display the main results. p < 0.05 were considered statistically significant.

| RESULTS
Out of 10,766 participants, 10,006 have completed the survey. Table 1 shows the demographical characteristics of the study population which was divided into two groups based on the question having health insurance, and this group had fewer concerns compared to those who did not have health insurance χ 2 (1, N = 10006) = 12.7, p < 0.001) ( Table 1).
We recorded 5811 participants who still have fears and anxieties about the COVID-19 vaccine, and our data proved that this group had a significant difference compared to the another group in the following results (Table 1) Which vaccines do you trust? and Which vaccines do you have low confidence in? As a result, AstraZeneca is the most trusted vaccine (43.5%) compared to Sinopharm/Sinovac, which has the lowest confidence (32.9%) among our study population (Table 2).
We divided our population's fears into five subgroups ( Table 3).
The majority of fears belonged to the "Side Effects" subgroup as well the "Effectiveness." The main concerns on COVID-19 vaccines were the rapid development of vaccines (41.8%), fears of blood clots (39.5%), the fears of common side effects (36.9%), and allergic reactions (27.5%).
It is worth noting that (20.8%) of the participants who belonged to the medical sector had major concerns about blood clotting (Table 4) even though the real number of such incidents is quite low.
These results alongside the high prevalence of some misconceptions already stated above can be linked to the widespread misleading sources of information especially social media which is more accessible to the public and affect the general opinion on a large scale. Table 5 shows that the majority of people with fears about COVID-19 vaccines tend to have mild to extreme concerns about the obligation of vaccination. However, less than 25% chose points 1 or 2 on the Likert scale.

| DISCUSSION
The study revealed that more than half of the population surveyed The aim of this study was to investigate the reasons behind vaccine hesitancy among Syrians. Of the 10,006 participants, approximately half (n = 5511, 50.1%) did not take the COVID-19 vaccine, and more than half of them were hesitant or not willing to take the vaccine in the future. This low rate of vaccine acceptance can be attributed to pre-existing fears related to the COVID-19 vaccine, which were reported in 58.07% of participants. This is consistent with a study of Arabs in and outside the Arab region, 13 21 We found a significant difference between fears about the COVID-19 vaccine and the different age groups, low rates of vaccine acceptance were observed in young age groups (18)(19)(20)(21)(22)(23)(24). This  information can be obtained from the corresponding author upon reasonable request.

ETHICS STATEMENT
The study was approved by the University of Aleppo, Faculty of Medicine, and performed as per Helsinki Declaration principles.
Ethical approval was obtained from the Institutional Review Board

TRANSPARENCY STATEMENT
The lead author Mohamad Klib affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.