COVID‐19 vaccine hesitancy and attitudes in Qatar: A national cross‐sectional survey of a migrant‐majority population

Abstract Background Vaccine hesitancy is a global threat undermining control of preventable infections. Emerging evidence suggests that hesitancy to COVID‐19 vaccination varies globally. Qatar has a unique population with around 90% of the population being economic migrants, and the degree and determinants of hesitancy are not known. Methods This study was carried out to evaluate the degree of vaccine hesitancy and its socio‐demographic and attitudinal determinants across a representative sample. A national cross‐sectional study using validated hesitancy measurement tool was carried out from October 15, 2020, to November 15, 2020. A total of 7821 adults completed the survey. Relevant socio‐demographic data along with attitudes and beliefs around COVID‐19 vaccination were collected from the respondents. Results 20.2% of the respondents stated they would not take the vaccine and 19.8% reported being unsure about taking the prospective COVID‐19 vaccine. Citizens and females were more likely to be vaccine hesitators than immigrants and males, respectively. Concerns around the safety of COVID‐19 vaccine and its longer‐term side effects were the main concerns cited. Personal research around COVID‐19 and vaccine were by far the most preferred methods that would increase confidence in accepting the vaccine across all demographic groups. Conclusions This study reports an overall vaccine hesitancy of 20% toward the COVID‐19 vaccine and the influence of social media on attitudes toward vaccination which is in keeping with emerging evidence. This finding comes at a time that is close to the start of mass immunization and reports from a migrant‐majority population highlighting important socio‐demographic determinants around vaccine hesitancy.


COVID-19 was declared a global pandemic by the WHO in March
2020. 1 Toward the end of November 2020, the pandemic had spread to 215 countries and territories, infecting over 61 102 236 people, causing 1 433 132 deaths 2 and had an unprecedented negative impact on economic activity, education, travel, food production, and social activities. 3-6 Despite a global effort to evaluate treatments for COVID-19, no anti-viral agents have yet been identified as effective treatment. 7,8 Development of an effective vaccine to provide immunization was therefore identified early on as the main exit strategy from this global pandemic. 9 As a result, multiple vaccine development programs across the world have been working to develop an effective vaccine for COVID-19, and as of the end of November 2020, at least 55 vaccines were undergoing clinical trials on humans with at least 3 seeking approval for public use. 10 Vaccination requires inoculating a certain proportion of the atrisk population in order to achieve immunity of the whole population. 11 Despite being acknowledged as one of the most successful public health measures, many individuals choose not to be vaccinated citing concerns around safety and questioning the necessity of immunization, and there is evidence that vaccine refusal and hesitancy by individuals across the world have been increasing. 12,13 This hesitancy has been recognized as one of the top ten global health threats by the WHO. 14 The WHO set up the Strategic Advisory Group of Experts (SAGE) to address the global challenge of vaccine hesitancy and refusal.
Studies by SAGE and other research groups have identified a number of reasons that may contribute to vaccine hesitancy; and although these reasons may vary across different countries, vaccine hesitancy is recognized as a growing concern. 15,16 Reports are emerging from several countries across the world, exploring attitudes to the prospective COVID-19 vaccine. [17][18][19][20][21][22] The results from these studies show high levels of vaccine hesitancy to COVID-19 vaccination, ranging from 20% to 40% of the surveyed populations. Most of the published studies are based in developed economies with majority native/local populations.
Qatar is a hub of international travel and massive economic development and incidentally has had one of the highest COVID-19 infection rates in the world. 23,24 Therefore, like other countries, vaccination will play a major role in managing the effects of this pandemic in this nation. Qatar has a unique population, in that the over 90% of the residents are economic immigrants from other countries. 25 The concerns and priorities of this migrant-majority population, who do not live with their wider families or elderly relatives and are keen to return back to economic activity, are likely to differ. We anticipated that the motivations for accepting vaccines will therefore be different in Qatar compared to the native majority populations studied to date. Additionally, there are no studies on COVID-19 vaccine hesitancy from Qatar and the wider MENA region, with similar demographic characteristics, to our knowledge. Therefore, it is important to explore attitudes toward vaccination and the degree and nature of potential vaccine refusal. We carried out a national cross-sectional survey of adults in the State of Qatar to measure attitudes toward COVID-19 vaccination using a validated vaccine hesitancy tool and to study socio-demographic and personality characteristics associated with vaccine hesitancy. In this article, we present a subset of the findings of the wider study focusing on the degree of COVID-19 vaccine hesitancy and its sociodemographic correlates.

| Study design
We conducted a national cross-sectional survey in Qatar between October 15 and November 15, 2020 using an online survey. The link to the survey was advertised through online local newspapers, and across the social media platforms of the Hamad Medical Corporation, which is the state funded major healthcare provider for the country.
The advertisements were accompanied by short videos in English and Arabic explaining the rationale and nature for the survey. The survey was available in both English and Arabic languages.

| Participants
All 2.3 million adult residents of Qatar 25 were eligible for the study and were invited to participate in the survey.

| Study materials
A validated vaccine hesitancy measurement tool-The Vaccine Attitudes Examination Scale (VAX) 26 -was used as part of a composite questionnaire to assess the vaccine attitudes, awareness, and hesitancy among the study participants. This tool was translated into Arabic, and validation of the translated version was carried out using the guideline published by Sousa et al. 27 The survey also collected relevant demographic and contextual information of the participants.
Details of study materials are given in the Appendix.

| Outcome measures
The selection of study tools (VAX) and the design of the composite questionnaire were guided by the SAGE group recommendations in assessing vaccine hesitancy. These included: Contextual factors like ethnic origin, gender, socioeconomic status, educational level, impact of media, individual's perception of the pharmaceutical industry among others.
Individual and group influences like previous vaccination experience, beliefs and attitudes to vaccination in general and knowledge and awareness of the COVID-19 pandemic and vaccines, trust in health systems, and perception of risk and benefits of vaccines.
Vaccine specific issues like risks of new vaccine, risk to children and older adults, and role of healthcare professionals.

| Ethical approval
The study was granted ethical approval by the Medical

| Analysis
We analyzed the data using descriptive statistics and multivariable logistic regression using Stata 12. 28

| RE SULTS
We received 7859 responses to the survey; of these, 38 were under the age of 18 and were excluded from the analysis, leaving 7821 adult respondents. 66% of the respondents were in the working age group being between 26 and 45 years in age. 59.4% of the respondents were male, and 82.5% were married. 19.8% were healthcare workers; the remainder were from the general public.
87.5% of respondents had completed childhood vaccinations, and 46.6% had received the influenza vaccine at least once in the last three years. 3.6% of respondents reported that they had had COVID-19, and another 9.8% reported that a family member had had COVID-19. (see Table 1).

| Intention to accept vaccine
In response to the question "Will you take the COVID-19 vaccine when it becomes available?" 44.7% and 15.8% responded that they would "definitely" or "probably" accept the vaccine, respectively.
19.8% were unsure, 8.7% responded that they would "probably not" accept the vaccine, and 11.5% reported they would "definitely not" take the vaccine.
Very similar proportions were observed in response to a question on whether they would recommend the vaccine to elderly family members or relatives with chronic conditions, or whether they would get their children vaccinated for COVID-19 (see Table 2).
For those wishing to travel, 25.6% responded that they would preferentially accept the State required (at that time) 2-week quarantine on return, rather than accept the vaccine.

| Main worries and attitudes around COVID-19 infection and its vaccine
The biggest worries reported were of family members getting infected (53%) or personally getting infected (37.6%) (see Table 3).
Beliefs toward COVID-19 infection, vaccination and immunity were further explored through a 5-point Likert scale (see Table 4). We categorized those who reported were "definitely" or "probably" not going accept a COVID-19 vaccine as vaccine hesitators, and investigated variables associated with vaccine hesitancy. We first investigated univariate associations, and then carried out multivariable logistic regression and included all variables that were significant at P < .2 level of significance. We found that those who were significantly more likely to be vaccine hesitators were older, native Qataris, self-employed or retired, single, and female (Table 5). Non-locals of working age were significantly more likely to accept the vaccine in contrast with the nationals in the same age group. In fact, the overall vaccine hesitancy among the local Qataris of working age was 42.57% compared to 16.71% for the immigrant population (Table 6).
Those who had a flu vaccine in the last 3 years, took regular medication were significantly less likely to be vaccine hesitators (see Table 5).
We then carried out logistic regression to model opinions associated with vaccine hesitancy and controlled for the above variables.
We found that vaccine hesitancy was significantly associated with the belief that there has been insufficient testing of COVID-19 vaccines (OR = 1.7, P < .001), the view that authorities are motivated by financial gain rather than health of people (OR 1.14, P = .03) and that natural exposure to germs and viruses gives the safest protection (OR 1.22, P < .01) (see Table 5).
Finally, we investigated variables that would give respondents more confidence in accepting the COVID-19 vaccine (Table 7). Of those who were unsure and showed vaccine hesitancy, 36.1% and 43.4% respectively reported that their own understanding of the disease and vaccine was the main reason that would make them more confident to accept the vaccine. The figures for healthcare workers for the same variables were 37.7% and 49.7%, respectively.
The "other" category contained free-text responses, of which 172 (2.2%) of the respondents stated that they would not take it under any circumstance. In the published studies described above, a more or less consistent theme of concerns around the safety of the vaccine itself is emerging as the most prominent. This concern cuts across demographic variables and countries. These concerns range from possible unexplored side effects of the vaccine, beliefs about the disease itself, public perception of vaccine trials being rushed through, pharmaceutical companies profiteering from the vaccine and preferred reliance on natural immunity. 17,18,21,22 These findings were mirrored in our survey and concerns around vaccine safety and longer-term side effects were significantly associated with vaccine hesitancy.

| D ISCUSS I ON
The theme of concerns around vaccine safety was also significantly associated with vaccine hesitancy in healthcare workers themselves in this study population. Although concerning, it has been noted previously that while healthcare providers should be the ones that instill confidence in immunization programs, a paradoxical increase in vaccine hesitancy has been noticed in healthcare workers themselves for vaccination programs in the past. 30 These concerns need to be taken together with our finding that nearly two thirds of those surveyed in our study reported that they Further, algorithms within social media platforms allow users to follow content that agrees with their views and reject contrasting views leading to development of distinct communities that subscribe to specific opinions and ideologies. 34 This has been shown to be associated with increasing negative attitudes to the COVID-19 and the vaccination. 32,34,35 Our research further underlines the importance of developing trust in the safety of this vaccine. States and healthcare authorities need to recognize the power and influence of social media and devise innovative awareness and information dissemination strategies to increase vaccine uptake. Our study identifies the specific subgroups that these campaigns should be focused upon and the content of such campaigns. Belief that being exposed to diseases naturally is safer for the immune system than vaccination Overall, the high degrees of hesitancy demonstrated should be of major public health concern when considering the minimum required proportion of the population needed vaccinate in order to achieve herd immunity. The frontrunners among the COVID-19

TA B L E 3 Worries around COVID-19 infection and its vaccine
vaccines in production are reporting efficiencies ranging between 70% and 80%, and with the reported R 0 from pooled studies for COVID-19 being 2.5 to 3.5, the percentage of the population that needs to be vaccinated to achieve herd immunity is between 70% and 90% 38 underlining the magnitude of the task.
Moreover, it is known that vaccine uptake may be actually lower than the stated intent 39 so the expected impact of vaccine hesitancy on an immunization program may be far worse than anticipated.
Therefore, possible determinants of vaccine hesitancy in this region require in-depth exploration.

| Strengths
We surveyed a large nationally representative sample which allows a degree of generalizability of the results. Moreover, this study was conducted in a demographically distinct part of the world with a migrant-majority population. Our study was conducted at the time when the front runners for COVID-19 vaccine were publishing efficiency results and states across the world were discussing mass immunization strategies. A validated vaccine hesitancy tool was used, and outcome measures were based on internationally established vaccine hesitancy parameters.

| Limitations
Our sample was somewhat self-selecting as the study was available only in two languages which although widely spoken throughout the state of Qatar still excludes some non-speaking residents.
Additionally, Internet access was required to participate. This survey was conducted before the actual vaccination programs were rolled out and the hesitancy rates and attitudes are likely to vary as the situation evolves.

| CON CLUS ION
Vaccine hesitancy has obvious repercussions for the success of planned immunization initiatives and has been recognized as a threat to universal immunization programs and across the globe. 13 In fact, WHO estimates that around 1 in 5 children do not receive routine lifesaving immunizations and as a result an estimated 1.5 million children still die each year of diseases that could be prevented by vaccines that already exist due to vaccine hesitancy. 13 We found that a significant proportion of the respondents in Qatar showed vaccine hesitancy to the COVID-19 vaccine, and although the vaccine hesitancy was lower in economic immigrants, the hesitancy attitudes were almost always driven by concern around the vaccine safety. The reliance on personal research to seek information underlines the role of social media in playing a significant part in influencing people's attitudes toward vaccine uptake. States and healthcare authorities need to recognize the massive trust deficit around the vaccine and use the popular media used by people to share credible and reliable information. TA B L E 7 Variables that would give more confidence in accepting the vaccine among hesitators and non-hesitators

CO N FLI C T O F I NTE R E S T
None.

AUTH O R CO NTR I B UTI O N S
Majid Alabdulla and Shuja Reagu are joint first authors of this work. Writing-review & editing (equal).

PATI E NT A N D PU B LI C I N VO LV E M E NT S TATE M E NT
There was no Patient or Public involvement in the design or recruitment of this study.

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/irv.12847.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request and pending additional ethical approval.