The Likelihood of the Saudi Population to Accept Covid-19 Vaccine

Background: The global spread of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has threatened public health systems and aggravated international economic situations. The study investigated the different factors affecting the feasibility of Saudi intention to take Covid-19 Vaccines. A Cross-sectional study based on an online questionnaire from February 2021 to April 2021. Results: Most respondents would wear a face mask during all activities with a positive attitude toward using hand sanitizers to prevent COVID-19. Most respondents (88.8%) still needed to be vaccinated, and less than half of them stated that they have a family member or a close relative who got immunized (43.4%), the acceptance of vaccination if the vaccine is generally available was 64.4%. More than half of the respondents agreed about the vaccine’s safety while 34.8% stated having fears about the vaccine. Conclusion: The participants have proper information about the Covid-19 pandemic, preventive measures, and the role of vaccines in preventing the spread of the disease with a high acceptance rate of vaccines and low levels of fear regarding the side effects of the vaccines.


INTRODUCTION
Coronaviruses (CoV) are a vast family of viruses that cause common colds and more serious infections such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV) (COVID- 19). Novel coronaviruses were discovered in China on December 31, 2019, and the WHO Regional Office was told of pneumonia cases of unknown origin in Wuhan City, Hubei Province of China. However, in March 2020, the WHO declared the outbreak of COVID-19 a pandemic [1].
COVID-19 showed signs and indications from two days to fourteen days after divulgence. The common signs and indications were incorporated fever, tiredness, and shortness of breath which may exaggerate into pneumonia in some severe cases. Also, people with immunodeficiency, the elderly and people with chronic disorders such as asthma, heart disease, and lung infection may suffer from severe complications [2]. On the other side, this infection can spread primarily when an infected person is in direct contact with another person through coughing, sneezing, laughing, singing, or breathing profoundly or by indirect contact with surfaces in the immediate atmosphere or with items used by the infected person. It spread rapidly around the world since last December affecting 217 countries and territories worldwide. The number of confirmed global cases has now reached 53,146,272 cases, and 352,160 confirmed cases in KSA, as well as global death cases have reached 1,300,762 cases and 5,605 cases in KSA. These numbers were taken on November 13, 2022, and may be increased [3][4][5].
The purpose of the COVID-19 vaccination is to create an immune response that will prevent infection. There was an extensive knowledge base regarding the structure and role of coronaviruses before the COVID-19 pandemic, allowing for the rapid development of several vaccine technologies in early 2020. The genetic sequence data of SARS-CoV-2 was exchanged via GISAID on January 10, 2020, and on March 19, 2020, the global pharmaceutical sector made a substantial commitment to solving COVID-19. Results from Phase III studies of COVID-19 vaccines have shown the efficacy of up to 95% in preventing symptomatic COVID-19 infections [4,6].
As of April 2021, at least one national regulatory authority had approved 13 vaccines for use in the general public: two RNA vaccines, five conventional inactivated vaccines, four viral vector vaccines, and two protein subunit vaccines [6]. By December 2020, nations had pre-ordered over ten billion vaccine doses, with 14% of the world's population in high-income countries [8].
The Kingdom had a pioneering and crucial role in limiting the COVID-19 epidemic. Due to the lack of a vaccine or treatment that alters the virus's transmission, Saudi Arabia has imposed tight restrictions on all residents and visitors since the WHO declared a pandemic. The Saudi government moved well to manage the virus. The first intervention was the March 4, 2020 suspension of visits to the Holy Mosque in Saudi Arabia. Due to an increase in COVID-19 cases, the government banned Inlet inhabitants from entering Makkah and Al Medina on February 27, 2020. Most of these instances included travel to Iran. KSA takes severe measures to prevent the spread of illness, including the MOH's use of hotline 937 for any suspected disease or inquiry [9].
Saudi researchers studied COVID-19's diagnosis, treatment, and prevention. Their study was published in highly regarded publications globally, making KSA one of the top nations for viral research and the first Arab country [10,11].
During COVID-19, a healthy diet was essential. What a person eats and drinks affects his body's ability to fight illnesses and recuperate [12]. COVID-19 infection cannot be avoided or treated with foods or dietary supplements. Healthier diets should improve immunity mechanisms to keep it short; there is currently little evidence that COVID-19 can be transmitted by contact with food or food packaging [13]. COVID-19 is widely believed to be spread from person to person. However, care should still be taken when handling food to avoid any food-borne pathogens by following proper hygiene habits. Simply obey the five keys to healthy food from WHO, keep clean, distinguish raw and prepared, prepare thoroughly, keep food at safe temperatures and use clean water and raw materials [1]. This study aimed to measure the feasibility of the different groups of citizens in KSA taking the Covid-19 vaccine.

Research Design
A qualitative, prospective, cross-sectional noninterventional questionnaire-based study was performed from February 9, 2021 to April 9, 2021.

Population and Study Sample
The study included citizens and residents of the western region of the Kingdom of Saudi Arabia during the COVID-19 pandemic. The inclusion criteria were educated individuals aged 18 and over including women, men, healthy subjects, and others suffering from chronic diseases. A sample size of 384 participants was sufficient to identify a single proportion with a margin of error of 5 percentage points and a 95% confidence interval [14].

Tools
This study included a self-administrated questionnaire sheet. The preliminary questionnaire was written in both Arabic and English. It included questions about the participant's demographic information, familiarity with COVID-19, and willingness to receive the COVID-19 vaccine in the future. To ensure that it can be completed quickly and with slight confusion, we kept the questionnaire to a minimum of questions. Experts from our hospital medical board reviewed the questionnaire for both content and clarity. There were preliminary tests of the questionnaire by a pilot study among 20 subjects then adjusted according to their responses The Participants completed the survey on their own time.

Data Analysis Strategies
The data and values were processed for descriptive analysis through ANOVA using the IBM SPSS software program (24.0). The continuous variables were processed for statistical analysis through Chi-square test (Twotailed) to obtain the results' significance.

Demographic and Baseline Attributes
The demographic characteristics of the respondents include different qualities such as age, gender, region, income, occupation, and education are presented in Table 1. There were 1467 participants, including 656 males and 811 females. So, the overall frequency of females was higher compared to males. Also, the age distribution of the participants showed that 420 participants (15-25 years), 982 participants (26-60 years), and 65 participants were older than 60 years. The study included participants from 16 different nationalities 1339 were Saudi, 14 were Egyptian, and the rest were from various races.
As for the educational status, most of the participants were well-educated as 206 were diploma holders, 814 were university bachelors, and 137 had postgraduate degrees. Also, 541 participants were unemployed, 374 were health workers, and 506 were non-health workers.

Face Masks and Sanitizers to Prevent Covid 19
Most participants (86%) think that face masks prevent COVID-19 infection spread, while 10.8% responded neutral, and the remaining disagreed (3.1%). About 66.9% of participants agreed they could do all daily activities with a face mask. Data related to the views that wearing a face mask when it was not mandatory showed that 67.4% of participants agreed with this logic. As for hand sanitizers, 82.6% of participants agreed about using hand sanitizers to prevent Covid-19, 11.6% responded neutral, and the remaining (17.2%) disagreed. The general practice score was Excellent among most participants (Table 3).

Attitude toward Covid 19 Vaccination
During the research period, most respondents (88.8%) still needed to be vaccinated, and less than half of them stated that they had a family member or a close relative who got vaccinated (43.4%). As for their acceptance of vaccination, if the vaccine is generally available, about 64.4% agreed the same idea concluding that more than half of them tend to have the vaccine. On the other hand, 34.8% agreed about having fears of the vaccine. Also, 51.5% agreed about the vaccine's safety, while 41.2% were neutral. Most participants had positive attitudes toward the efficiency of the vaccine against Covid-19 and the need to have the vaccine even if they have been diagnosed with Covid-19. The overall attitude score was positive among more than half of the respondents (55.9%) and neutral among 32.9% (Table 4). Tables 5 and 6, the higher attitude and practice scores were significantly associated with female gender, Saudi nationality, younger age, higher educational status, and being a health care worker.

DISCUSSION
Vaccination is widely regarded as one of the 21st century's most significant contributions to public health. Its acceptance rate varies according to geographical location, historical period, socioeconomic status, racial background, and cultural setting [1,2]. This study is one of the minor studies conducted in Saudi Arabia to study the acceptance of the COVID-19 vaccine administration.
In the current study, most participants preferred Pfizer, followed by AstraZeneca, Sinopharm, and Sputnik. The remaining participants responded mix-up of all mentioned vaccines without any unique or individual one. The characteristics of COVID-19 pose several risks for vaccine-based elimination strategies, including the dwindling nature of both natural and vaccine-mediated immunity, the capability for vaccinated individuals to transmit the infection, the age-dependence of disease severity and (potentially) vaccinemediated immunity [3][4][5]. Numerous cases of reinfection with COVID-19 have been established using direct molecular techniques. Participants' preference for the type of vaccine may be associated with the global and local vaccination reports as in mid-December 2020, KSA authorized the Pfizer-BioNTech vaccine. Five hundred thousand dosages were provided in December and given by January 2021. Then, the Oxford-AstraZeneca vaccine was authorized for use in KSA in February 2021. Due to the vaccine's flexible storage and handling, it may be sent to all parts of the Kingdom and held in central warehouses before distribution thus, it may be the first two considerations for the Saudi population to administrate [6].
As for the preventive measures, most respondents would wear a face mask to prevent COVID-19 spread and tend to wear it during all activities. Also, the majority have positive attitudes toward using hand sanitizers to prevent COVID-19. The high level of acceptance to the preventive measures indicated proper knowledge among Saudi subjects. WHO and CDC stated that covid-19 patients or caregivers are the only ones who should wear face masks [5,7]. The government, at all levels, has made significant efforts, including public awareness initiatives. Through its website, national television, and other forms of social media, the Saudi Arabian Ministry of Health (MOH) has launched a comprehensive public education campaign. The Ministry of Health has released a COVID-19 reference book with information and safety tips in over ten languages. The MOH also interacts with the general public and the press through social media. There has been a significant expansion of these initial activities to involve the public in preventative and control measures and efforts to counter rumors and disinformation. The Kingdom of Saudi Arabia (KSA) is in a rare situation but successfully contained two epidemics caused by linked viruses [8][9][10]. Thanks mainly to this novel experience, the government has been able to swiftly respond to and take precautions against the spread of COVID-19.
However, most respondents (88.8%) were not vaccinated yet, and less than half of them stated that they have a family member or a close relative who got immunized (43.4%), the acceptance of vaccination if the vaccine is generally available was 64.4%. Those results are in accord with those found in both the United States (80%) and China (72.5%) [11,12]. A Saudi study showed that about 64.7% were enthusiastic about getting the COVID-19 vaccination [13]. Our findings on the willingness to get the COVID-19 vaccine were more positive on a regional scale when compared to those obtained in Qatar (60.5%) [14], Kuwait (53.1%) [15], Jordan (34.9%) [16], and Egypt (6.0%) [17] which showed lower acceptance rates.
More than half of the respondents agreed about the vaccine's safety, while 34.8% stated having fears about the vaccine. Lower levels of hesitancy due to worries about the vaccine were found in a Saudi study conducted among university students as only 6.1% refused to have the COVID-19 vaccination [18]. Vaccine safety and efficacy worries and worries about possible adverse effects were the most critical factors in vaccine rejection [19]. Researchers discovered that those who thought vaccinations posed health hazards were less likely to be vaccinated [15,20]. Another Saudi Arabian research found that concerns about the vaccine's effectiveness and safety were significant factors in people's reluctance to get the shot [21]. Long-term adverse effects were a concern, although the CDC in the United States stated there was little risk of them happening. Adverse reactions to vaccines manifest themselves within the first six weeks after vaccination, thus the FDA required follow-up checks on all people who received the COVID-19 vaccination for at least two months following the last dosage [5].
A chi-square test and logistic regression analysis showed that higher vaccine acceptance attitude scores were significantly associated with female gender, Saudi nationality, younger age, higher educational status, and being a health care worker. This result aligns with numerous other types of research [13,15,18,20] that found statistical correlations between demographic variables, including gender, age, and marital status, with the acceptance of the COVID-19 vaccination.
This study has some limitations as it is crosssectional research reflecting the community's reaction during the study period. We asked respondents whether they would get COVID-19 vaccine if it became accessible. When the vaccination is available, the goal may change as participants' intentions change through time and circumstance. Second, a web-based selfadministered survey was used instead of a faceto-face interview which may cause bias in their replies. Third, the research did not examine COVID-19 vaccination acceptance or hesitation reasons. During the study time (lockdown due to , an online questionnaire was the only way to obtain participant data.
Despite the constraints mentioned earlier, this research has a representative sample size throughout the county. It demonstrates the population's desire to get the COVID-19 vaccination.

CONCLUSION
The current research provides crucial new information on the viability of administering the Covid-19 vaccine to various populations in the Kingdom of Saudi Arabia. Vaccine development, production, and distribution provide hope for controlling the global COVID-19 outbreak. A few common misunderstandings about how COVID-19 is spreading needed to be cleared up. Health education and novel measures should be implemented to ensure that vaccination is accessible to control Covid-19.

CONSENT
All individuals gave informed permission before participation.

ETHICAL APPROVAL
This study was approved by the hospital committee as it was done during our regular conferences during the era of Covid-19. Also, the study followed the Helsinki Declaration and Saudi CDC research rules.