Introduction

The ongoing 2019 coronavirus disease (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has put a considerable burden of morbidity, mortality, political, financial and social dysfunction worldwide. ¹ The mortality of the COVID 19 disease is higher among vulnerable groups, including the elderly, and the individuals with comorbidities such as diabetes, malignancies, cardiovascular disease, chronic obstructive pulmonary disease and chronic kidney disease. ^{2, 3} To date, there is no curative treatment for COVID 19, although some drugs are being approved and used to manage COVID-19 patients. ^{4, 5, 6} Therefore, COVID 19 vaccines consist of one of the most promising and effective strategies to control and mitigate the COVID 19 crisis. ⁷

Vaccines have proven to be one of the most effective ways to prevent and control infectious diseases over the last 200 years. They have a tremendous potential in saving lives and preventing hospitalization and long-term complications of several infections from poliomyelitis to influenza and beyond. High immunization rates and population — wide compliance to vaccination strategies are prerequisites for the containment, and in some cases the extinction, of particular communicable diseases. ⁸ With the COVID-19 pandemic being expected to impose a considerable burden during the next months, governments are bracing for quick vaccine roll out, in order to build immunity at national and international level. So, it is necessary to investigate the populations’ perceptions towards vaccine acceptance. ^{7, 8}

Evidence suggests that vaccine-hesitancy is related with negative past experiences with vaccination, fear of injections, mistrust of modern/western medicine, traditional and religious practices/beliefs, lack of access to healthcare services and credible information sources. Also, the lack of trust on the COVID-19 vaccines may be attributed to accelerated procedures of drug discovery, approval and production. The use of novel biotechnology such as m RNA, the timeline of clinical trials and the speed of the authorization procedures have created an iota of suspicion, enlarged by misinformation in social and mainstream media.

In India, the low level of understanding of vaccines science and the misinterpretation of medical concepts and terminology in local languages are likely to fuel incorrect beliefs on vaccine effectiveness and duration, leading to future distrust of vaccines and providers, contributing to reduced acceptance rates. ⁹ Previous studies identified the need for further community education and transparency on vaccines to reduce hesitancy, encouraging and educating influencers such as elders and religious leaders in improving the acceptance of vaccines. ^{8, 9} Hence, it is crucial to evaluate the acceptance of the upcoming COVID 19 vaccines among the general population for framing the programs and strategies towards effective vaccination delivery by the governments.

Nevertheless, the general public's vaccine demand and attitudes towards vaccination in the low- and middle-income countries (LMICs) are not well-studied. There could exist different considerations and discrepancies among the population of LMICs compared to high-income countries. ^{10, 11} Hence, vaccines can replenish hope and become game-changers in the struggle against COVID-19, as long as their acceptance rate grows. ¹²

In this study, the authors attempt to evaluate the acceptance of the COVID-19 vaccine among the general population of South India. To the authors’ knowledge, there is no study conducted on COVID-19 vaccine acceptance in this region to date. The implications of this study could be important and can guide the government in formulating better approaches for implementing mass vaccination programs and vaccination drives for COVID-19 in South India.

Materials and Methods

Study design: An Observational Cross-sectional study by means of an online questionnaire.

Study Target Population: Adult residents of South India of states Andhra Pradesh, Telangana, Tamilnadu, Kerala, Karnataka, Pondicherry.

Sampling method: Random sampling method

Study tool : Self-administered pre-tested questionnaire (10 item questionnaire) 

Inclusion Criteria: All Residents of South India aged 18 and above who are willing to participate in this study.

Exclusion Criteria:  Health care workers/students, North India Residents, people aged below 18 and people who are unwilling to participate in this study.

Study Period: December 2020 and January 2021 (2 months)

The questionnaire was provided in English and consent of participation was obtained at the beginning of the questionnaire following a thorough explanation of the design, the purpose of the study and the action taken by the researchers to protect confidentiality. The initial questions focused on socio-demographic and background information, (age, gender, state, educational status, occupation) followed by questions regarding the views of the participants on vaccines and their acceptance. The study was conducted through an online survey with Google questionnaire forms. Google form containing questionnaire was circulated among the family groups, general groups of south Indian states in WhatsApp, Instagram, Facebook. The title, objectives, voluntary participation and confidentiality declaration about their information was attached to the survey form. This study was approved by the Prathima Institute of Medical Sciences (Ref no — IEC/PIMS/2020-003-01112020).

Statistical Analysis

Data were entered into Excel spreadsheets 2019, and statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) version 24.0 (SPSS, Inc., Chicago, IL, USA) and was presented by using mean and standard deviation. Data was presented by using frequency and percentage. Descriptive statistics were used, and the Chi-square test was used to determine the role of socio-demographic characteristics on questions. The statistical significance level was set at p < 0.05 (two-sided). 

Result

A total of 686 people have participated in this study, and the mean age was 30.40 + 10.55 (mean + SD). 51.6% of the study participants were male, and 67.2% (most of the study participants) belong to the age group 18-30. 51.4% were from Telugu states (Andhra and Telangana),17.6% were from Karnataka, and 16.9% were from Tamil Nadu. 25.8% of the study participants were graduates, and 36.9% were still students. 56.8% belonged to the middle class, and 68.2% of study participants were unmarried. The socio-demographic characteristics of study participants (n=686) were described in Table 1.

Among the study participants, 27% were family members of healthcare workers/student. 30.9% of participants were already infected with COVID-19 before filling this study form. In 25.8% of the participants, any one of their family members has infected with COVID-19. 89.9 of the respondents don't have any comorbidities. Study participants' background and clinical profile (n=686) were described in Table 2.

Only 27.1% responded 'yes' for participating in a vaccine trial, while 42% responded 'maybe' for the same. 44.4% 'agreed' and 37.6% felt 'neutral' about COVID-19 vaccines protection against SARS-CoV-2 infection. For the question, COVID-19 vaccines are safe and effective — 36.6% 'agreed' and 46% felt 'neutral'. 75.5 % responded 'yes' for concern on side effects due to vaccine. 76.2% responded 'yes', and 20.7% responded 'may be' for accepting COVID-19 vaccine if it is successfully developed and approved for listing in the future. 58.75% responded 'no' for the cost of the vaccine affects the decision to take the vaccine, 69% preferred 'routine' administration for COVID-19, while 31% prefer 'emergency' administration only. 50.1% were likely to take the COVID19 vaccine 'as soon as possible' once available. 28.6% responded to prefer 'imported vaccine' and 54.2% responded as 'both are acceptable'. 75% responded that they would feel 'more confident' against COVID-19 if the vaccine was available for the public. Study participants’ responses to questions regarding vaccine acceptance (n=686) are described in detail in Table 3.

For the question regarding accepting vaccine if the COVID-19 vaccine is successfully developed and approved in relation to occupation, there was a statistically significant difference with p< 0.001 Table 4.

For the question, which type of COVID-19 vaccine you would prefer in relation to economic status, there was a statistically significant difference with a p=0.002 Table 4 was obtained. For the question, which type of immunization do you prefer for COVID-19 in relation to occupation, a P-value of 0.052 was obtained, which was not statistically significant.

Discussion

To the authors’ knowledge, this research project was one of the foremost studies conducted on vaccine acceptance in India. Being an observational cross-sectional online study, it explored the potential acceptance of COVID-19 vaccines among 686 voluntary study participants across the south Indian states. A relatively high tendency towards accepting the vaccine was observed among upper and lower-middle classes in our study. An important point to note is that 75.5 % of the respondents have concerns about the side effects due to the vaccine. An inclination for a routine vaccine against COVID 19 is seen, with 69% of the population choosing routine vaccination against emergency only vaccination 31% (213). The above data support the population's belief that the COVID 19 pandemic will not be ending soon in the near future.

Although vaccine acceptance is a cornerstone of mass vaccination, a small number of relevant studies have been reported worldwide so far. The authors compared the results with existing studies on acceptance of the COVID-19 vaccine. In an online cross-sectional study by Harapan H et al. regarding COVID-19 vaccine acceptance in Indonesia, 1359 have participated. ¹³ Ninety-three (93.3%) of study participants would like to be vaccinated for a 95% effective vaccine. Still, this acceptance rate decreased to 67.0% for a vaccine with 50% effectiveness in that study. In contrast, 76.2% responded as 'yes' in our study, and 20.7% responded as 'may be' for accept vaccination if the COVID-19 vaccine is successfully developed and approved for listing in the future. ¹³ In a web-based cross-sectional study by Al-Mohaithef M et al. in Saudi Arabia, 992 people have participated in that study; 64.7% said 'Yes' to uptake the COVID-19 vaccine, which was less than our study. ¹⁴ In a study in China with 2058 study participants, 91.3% responded 'yes' to receive the vaccine, which was higher than our study. However, 49.4% preferred to take routine immunization, which was lower than our study (69%). ¹⁵ In a study in the United States by Malik A et al., involving 672 participants, 67% said 'Yes' to take COVID-19 vaccine, indicating a lower level of acceptance than in our study. ¹⁶ A study by Murphy J et al. analyzed the psychological characteristics of COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom (UK). 2025 individuals from UK and 1041 from Ireland have participated in the study. Out of them, 69 % of the UK and 65% of the Irish participants accepted to take the vaccine. This finding was consistent with our study. ¹⁷ In our study, there was more preference for imported vaccines over the home-manufactured vaccines, indicating lack of trust in the protocols in place that were followed to release the vaccine samples out to the general public. Compared to various international agencies’ approaches of revealing all the data and research papers regarding trials of their respective vaccine candidate, the Indian approach disclosed less information fueling distrust in COVID-19 vaccines among the general public. Identifying pharmaceutical companies for the restricted use of vaccines under the current pandemic has caused an increase in skepticism in the vaccine's effectiveness. Policymakers, governments and healthcare professionals could use this data to better address a vaccine candidate and create proper communication channels for the general public. Knowledge, attitude and practices towards COVID-19 and vaccines will also play a key role in making decisions regarding vaccine acceptance. ¹⁸ However, the rate of acceptance of vaccines has increased in the current studies when we compare with vaccination of past outbreaks of influenza. ¹⁹ The reasons could be increased awareness among the general public, advances in technology, and governments' steps to bring trust in vaccines among the people. ¹⁹ A communication strategy should be adopted for further phases of the ongoing vaccination to address misinformation and distrust campaigns better. The fact is that one's decision to get vaccinated is multi factorial and is subject to changes over time.

Limitations of the study:

The major limitation of this study is it was only conducted in English, as the target population is the general adult residents of South India. There are decent chances of the selection bias and representativity of the survey to the general population, whom may not have internet access and cannot understand English may not be able to participate in this survey. People aged 65+ years are underrepresented in the study. Due to the online nature of the survey, it could only reach people who have access to internet and electronic devices. This population group consists (mainly) of young people (reflected by the mean age, 30.4 years), literate, socioeconomically advantaged and mostly urban residents.

Conclusion:

The acceptance of the COVID-19 vaccine is expected to be influenced at a large scale in the coming months. Higher acceptance will depend on emerging data regarding the efficacy and safety of vaccines. Given that many countries have provided vaccines to front line workers and vulnerable populations, data on the potential adverse events must be collected and analyzed on case-by-case basis. Public health authorities and policymakers need to frame systematic interventions and awareness campaigns to improve the acceptance of COVID-19 vaccines and reduce the vaccine hesitancy levels. These campaigns and interventions ought to focus on reviving the trust in the vaccination procedures and outcomes, offering transparent information regarding the vaccines' efficacy and safety.

Sources of Support: Nil

Conflict of Interest: None Declared