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INTRODUCTION
The COVID-19 pandemic has led to changes affecting the healthcare systems and the approach to the infectious diseases worldwide: it has been argued that is the current emergency will impact on health provision in general in the long-term 1.
Quarantines and social isolation have been adopted in order to prevent the increase of cases of COVID-19 globally 2. These measures can generate consequences at the social level and intense psychological stress that can influence people's attitudes and behaviors 3 in the search for "normalcy". And, in fact, it is in the development of vaccines that the hope of regaining some level of "normalcy" lies 4. However, with the enforcement of even more restrictive measures by local governments, an increasing amount of general distrust in the population towards their governments and official reports of pandemic have been registered and fake news and disinformation have been spread by social media, “opinionists” or politicians also including the efficacy and safety of vaccines 5,6. These aspects may lead to different responses in the population and impact on its attitudes regarding the COVID-19 vaccination 7. Healthcare providers and governmental public health officials should properly address any fear and concern in the general population in order to contrast the disinformation with related psychosocial stress and improve the adherence to the COVID-19 vaccination 8.
The aim of this study was to describe attitudes towards the COVID-19 vaccine in the Paraguayan population, exploring factors that could be addressed to support the SARS-CoV-2 vaccination campaign.
MATERIALS AND METHODS
Participants
This was a cross-sectional and descriptive study. Participants were recruited through an Internet-based survey, spread through social media, during the month of March 2021. All participants received complete information about the aim of the study, privacy and data-processing. No payment has been foreseen for completing the survey. Subjects were older than 18 years and voluntarily accepted to participate in the study.
The Internet-based survey approach was employed in compliance with the rules of social distancing adopted in the country. Nevertheless, it has been demonstrated that this approach may provide similar findings to those reported through “in person” sampling 9,10.
The sample size was calculated using the Epidat epidemiological package. With a targeted population of 5 174 980 Paraguayans ≥ 18 years, we used a margin of error of 2,1%, a confidence level of 95%, an expected response distribution of 50%, giving a minimum sample size of 2177 11. Finally, the sample consisted of 2297 respondents, which was found to be suitable for similar research done in Europe and Asia 12,13.
In this research, all measures, conditions, data exclusions, and procedure for the determination of the sample size, have been reported.
Measures
We adapted and translated into Spanish the questionnaire previously used by Yoda and Katsuyama in Japan 13.
We collected the following information:
Sociodemographic data: gender, age, employment status, area of residence, education level.
COVID-19 status: explored through the question - have you been diagnosed with COVID-19 previously? (Answers: Yes or No)
Flu Vaccination: explored through the question- did you get vaccinated against the Influenza virus in the last year? (Answers: Yes or No)
Attitude for COVID-19 vaccine: explored through the question- are you willing to get vaccinated against COVID-19? (Answers: Yes, No or Unsure).
Reasons for the previous answer: multiple answers (see figures 1 and 2).
Statistical analysis
Data were processed with the statistical package RStudio, version 1.2.5033. Descriptive analysis has been performed: categorical variables were presented as frequencies and percentages, and the numerical variables with measures of central tendency and dispersion. Chi-squared test was used to evaluate categorical variables. Statistical significance was established for a value of p <0.05. Willingness to be vaccinated against COVID-19 was also explored through an OR analysis between selected variables.
Ethical considerations
The study was approved by the Department of Psychiatry of the National University of Asunción, School of Medical Sciences (Paraguay). Data were treated with confidentiality, equality, and justice, respecting the Helsinki principles. Implied consent was used rather than formal written consent to maintain the anonymity of participants. The participants clicked on the item reporting “I agree” before starting the survey to indicate their own consent.
RESULTS
Of the 2,297 participants, 67.9% (n=1,559) were women, their age was between 18 and 89 years, with a mean age of 34.85 ± 13 and a median of 32 years, IQR=18. Of the participants, 49.9% (n=1,147) were employed, 89.1% (n=2,046) reported a university education, and 96.6% (n=2218) were from urban areas. These data are shown in detail in Table 1.
Overall, 81.8% (n=1,879) of participants stated that they were willing to be vaccinated against COVID-19 if a vaccine was available. Of the participants, 11.5% (n=269) stated that they were not sure to be inclined to get vaccinated as well as 6.7% (n=154) stated that they were not into getting vaccinated. As shown in Table 2, we found considerable differences in the attitudes towards the vaccine across age groups, employment status and area of residency.
We asked participants who were willing to get vaccinated about their main reasons for this. Almost all the participants reported they thought that vaccination would have been effective and safe for themselves (n=1400, 73.65%) and for relatives (n=978, 51.45%). 23 respondents (1.21%) reported the thought that after the vaccination they would have not had to engage in preventive measures such as social distancing, respiratory masks and others. The remaining reasons are shown in Figure 1.
Figure 1. Participants’ reasons for getting vaccinated against the COVID-19 (n=1901; multiple answers)
We also asked participants who were unsure (Figure 2) or refused (Figure 3) of being vaccinated about their main reasons for this. Nearly a half of them reported to be concerned about the potential adverse events related to the vaccine.
Figure 2. Reasons for being unsure about being vaccinated against COVID-19 (n=436, multiple answers)
Table 3 shows that 17.2% have been previously diagnosed with COVID-19 and that 45.1% received the influenza vaccine. A significant relationship has been found between having applied the influenza vaccine and the intention to be vaccinated against the COVID-19 (p <0.0001).
Performing an OR analysis (excluding those who were unsure and those who did not remember to get vaccinated against influenza), we obtained 3.09 (95% CI 2.1-4.5) which meant that those who received the influenza vaccine have been 3-times more willing to be vaccinated against the COVID-19 (Table 3).
DISCUSSION
Our study found an overall positive attitude, with more than 80% of the participants expressing willingness to be vaccinated against COVID-19. These results are similar to those reported in China 14,15, Indonesia 16, the United States 17, Australia 18, and Latin America and the Caribbean 19,20. This percentage is somewhat higher than those reported in Italy 21 and in other reports from United States 22. The estimated national rate of immunization, either by vaccination or via prior infection, is more than 82% according to a recent study 23. These results are auspicious and imply that a large part of Paraguayan population should join the vaccination campaign.
There were significant associations between the willingness to be vaccinated and some factors such as being a student, prior influenza vaccination, and those who received the influenza vaccine were 3-times more willing to be vaccinated against the COVID-19. This evidence was reported in a study from China confirming the association between willingness to vaccine and age (between 30 and 49) or university and college education 14. Similarly, predictors for willingness to COVID-19 vaccine in an American study were education, having health insurance, positive attitudes towards the vaccines, high perceived susceptibility to COVID-19 and high perceived benefits of the vaccine 24,25.
An important percentage of subjects were willing to be vaccinated in order to protect themselves and their relatives. Similar attitudes were found among caregivers of children admitted in emergency departments, which also were interested in testing the vaccine before the current clinical use 26.
Reasons motivating the refusal of getting vaccinated included potential side effects. Some strategies to address hesitancy at the individual level are currently based on evidence-based information about COVID-19, on promoting altruism and prosocial behaviors, addressing any misperception on vaccination campaign 7.
Although our study found a high percentage of people willing to be vaccinated against COVID-19, a non-negligible percentage (almost 20%) were unsure or unwilling to do so. In that sense, improving vaccine acceptance requires a deeper understanding of the issues underlying reluctance to vaccinate 27. Our study can serve as a starting point to explore these issues in Paraguay.
Limitations of this study may include the higher rate of women among participants, the high level of education (mostly university education) and residence in urban areas: this may be related to a selection bias since people with higher education and living in an urban setting may be more accessible. Another limitation may include the lack of open questions regarding the reasons of being willing to be vaccinated as well unwilling: this may have biased the responses of some participants possibly reporting additional personal reasons.
In conclusion, the percentage of participants inclined to be vaccinated against the COVID-19 is similar to that of those expecting a proper immunization from the vaccine; some demographical factors associated to this attitude (age, employment, area of residence) were similar to those reported in studies on general population from different other countries. Government and health agencies should make an effort to provide accurate information that responds to people's concerns about vaccination, at any level of society.
Authors' contribution statement:
Julio César Torales, Carlos Ríos-González, Marcelo Gerardo O’Higgins, José Almirón-Santacruz, Derlis Duarte-Zoilán, Noelia Ruiz-Díaz, Iván Barrios: conception and design of the study, analysis and interpretation of the results and conclusions, critical revision of the manuscript, final approval of the manuscript. José Nicolás Ayala Servín, Oscar García Franco, Gladys Estigarribia Sanabria, Gabriela Sanabria Báez, Patricia Ríos Mujica, Jorge Villalba-Arias, João Mauricio Castaldelli-Maia, Antonio Ventriglio: collection/obtaining data/results, drafting, final approval of the manuscript.
