INTRODUCTION:

In December 2019, an unknown respiratory illness known as coronavirus emerged in Wuhan city, China. It quickly became a major outbreak in various cities across China and expand globally¹

Healthcare providers faced one of their biggest challenges in 2019 with the Coronavirus (COVID-19) outbreak. It has been predicted that vaccination programs might control the pandemic if more than 67% of the population becomes immune due to vaccination or infection ². A novel coronavirus that causes COVID-19 outbreak was identified ¹. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) emerged in late 2019, spreading to trigger a global pandemic in 2020. It is linked to the SARS-CoV and Middle Eastern Respiratory Coronavirus (MERS-CoV) that occurred in the 2000s in East Asia and the Middle East ³. SARS-CoV2 is one of these zoonotic viruses that may originate in bats and were not previously identified in humans ⁴. Primarily, the majority of cases at the epicentre of the outbreak in Wuhan, Hubei Province, China, involved live animals and seafood, suggesting animal-to-human transmission⁵. On December 31, 2019, The World Health Organization (WHO) stated that several pneumonia cases had been found in Wuhan City, Hubei Province, China. Chinese authorities identified the causative virus of the disease on January 7⁶.

During the COVID-19 pandemic, Health Care Workers (HCWs) face the highest risk of infection and mortality ⁷. Healthcare workers have shown professional dedication from the onset of the COVID-19 epidemic despite fears of spreading the virus to patients or their families⁸. Dentistry and related residencies are the very acutely affected sectors. Due to their unique exposure to aerosols and oral secretions, which increase the likelihood of viral exposure and transmission, in which dental practitioners face increased occupational dangers⁹. They seem more likely to transmit viral infections to others, including coworkers, hospital attendees and family members. Vaccination is a practical approach to preventing infection and reducing the mortality of many infectious diseases¹⁰. Since December 2020, several vaccines have been authorised in the European Union (E.U.). Furthermore, COVID-19 vaccine hesitancy appears as a significant obstacle in the pandemic control efforts, considering the increasing evidence of its pervasive nature across different regions, countries, and societies ^11,12. Vaccine hesitancy, delay in vaccine acceptance or refusal despite its availability, has been considered by the WHO as one of the highest ten global health threats in 2019 ¹³. Numerous studies have been accomplished to determine the acceptability rate of the COVID-19 vaccine among dental professionals and dentistry students. Still, the results have been equivocal, ranging from 56 % to 86 % ¹⁴. Social media platforms are crucial in communicating health-related information, including pro- and anti-vaccination messages, which can affect public opinion about vaccines, their effectiveness, and safety ¹⁵.

Until the paper was written, no research had been published on accepting the COVID-19 vaccine among Basrah's dental students. The current study sought to investigate COVID-19 vaccine acceptability and identify the factors and barriers influencing vaccination decision-making among Basrah's dental students.

METHODOLOGY:

Study design and study participants

This descriptive, cross-sectional study was conducted on March 15, 2021, among dental students in the College of Dentistry/ University of Basrah to assess dental students' acceptance of COVID-19 vaccination.

In this study, a Google Form was designed and distributed via Email to the targeted population; before enrolment in the study, The purposes of this survey were explained to the target group, and participants were invited to sign an online informed consent form. The questionnaire was automatically closed if they did not sign the consent.

The questionnaire was constructed and pre-tested on a small group (no.=10); then, it was distributed by Email; Email addresses were gathered from the College of Dentistry/ University of Basrah's databank. On March 15, 2021, questionnaires were sent to all dental students (DS) registered in the databank. Data collection ceased ten days after the questionnaires were submitted (March 25, 2021). Around ten minutes were allocated for completing the questionnaire.

Study population (Inclusion /Exclusion criteria):

Inclusion criteria: The current study involved male and female dental students in the College of the Dentistry/ University of Basrah (17 years old and above). Regarding internet access, the participant students used a computer and a smartphone to log in to the questionnaire. The exclusion criteria include students under 17 years of age or those outside the field of dentistry.

Questionnaire and Data Collection

After reviewing references ¹⁶, the questionnaire was built in English and translated into Arabic. Following that, it was translated back into English to make it compatible. The researchers examined the survey in both languages before presenting it via the Google platform. Before releasing the foundation, experts' opinions on the text's significance, understandability, and clarity were considered.

The questionnaire comprised two sections. The 1st section assessed sociodemographic information, which contained questions of different criteria such as: (Name, Age, Gender, Academic stage, history of any chronic disease, smoking, or if they have been sick with COVID-19), While the second part covered the acceptance rate of COVID-19 vaccines.

A single item was considered to assess the willingness of dental students to receive the vaccine by asking them: "If you have the choice, do you take the vaccine against the Coronavirus voluntarily and without any external pressure". The dichotomised response to the COVID-19 vaccination will be (2=accept; 1=hesitant, 0=refused). This variable was represented as COVID-19 vaccine acceptance. They also asked about the sources of their information about the COVID-19 vaccine‎ with multiple choice answers such as (a. Websites, b. social media, c. Tv, d. Family and friends, e. government health institutions, f. WHO, g. Posters and educational lectures).

Participants who responded "hesitant" or "refused" were then asked for the leading cause for their refusal or hesitation to take the vaccine due to different reasons such as (Fear of the vaccine's side effects, Loss of trust in manufacturers, rumours that the vaccine may cause infertility, fear of needle injection, or fear of rapid vaccine production?)".

Data analysis

All collected data were enlisted in an Excel sheet; then, data were coded and entered into the SPSS software, version 24, for analysis. Descriptive statistics were given as frequency and percentage with bar charts for qualitative data to summarise variables in addition to characterising the features of the sample. Pearson Chai square and Fisher Exact tests were used to evaluating the qualitative variables' associations. Statistical significance was defined as a p-value of (< 0.05).

RESULTS:

A total of 1,085 dental students were invited to participate in this survey, and only 880 (81%) of them completed it.

Acceptance of COVID_ 19 vaccines:

Concerning acceptance, about 70% of DS confirmed that they would take the vaccine voluntarily without any hesitation/apprehension. While 16 % of DS were reluctant to take the vaccine, and 14 % generally refused the vaccine. It was noticed that the median age was 20 years old (18-26 years), the respondents were mainly females (70.5 %), and the highest proportion came from the pre-clinical stage (76.2 %); most of the respondents reported nonsmokers and did not have any chronic disease (Table 1).

Concerning factors influencing COVID‐19 vaccine acceptance among dental students: Vaccine acceptance among DS differed by sociodemographic characteristics. Males (192/260; 73.8 %) appear to be more accepted to be vaccinated than females, but such a difference was not statistically significant. On the other hand, DS at the clinical stage (162/209; 77.5%) represents the most respondents who were most likely to receive a COVID-19 vaccine which was statistically significant (P =0.002). However, other factors showed no statistically significant difference occur between the groups of students accepting, hesitating, or refusing the COVID-19 vaccine.

Most respondents reported no chronic disease (93%) with an acceptance rate of about 70% compared to students with chronic illness, but such differences were statistically insignificant. Almost half of DSs (55.8%) were not infected with COVID‐19, and only 36.5% had confirmed infection, with no statistically significant differences regarding accepting, hesitating, or refusing the vaccine (Table 1).

Table 1: Factors influencing COVID-19 Vaccine Acceptance, Hesitancy and Refusal among dental students.

Sociodemographic characteristics		Overall Respondents (n.= 880,100%)		COVID-19 Vaccine Acceptance (n.=618, 70%)		COVID-19 Vaccine Hesitancy (n.= 140, 16 %)		COVID-19 Vaccine Refusal (n.=122, 14%)		P value
Sociodemographic characteristics		n	%	n	%	n	%	n	%	P value
Gender:	Male	260	29.5 %	192	73.8 %	38	14.6 %	30	11.5 %	0.291
Gender:	Female	620	70.5 %	426	68.7 %	102	16.5 %	92	14.8 %	0.291
Academic stage:	Pre-clinical stage	671	76.2 %	456	68 %	122	18.2 %	93	13.9 %	0.002 *
Academic stage:	Clinical stage	209	23,8 %	162	77.5 %	18	8.6 %	29	13.9 %	0.002 *
Smoker:	No	844	95.9 %	592	70.1 %	136	16.1 %	116	13.7 %	0.693
Smoker:	Yes	36	4.1 %	26	72.2 %	4	11.1 %	6	16.7 %	0.693
Chronic disease:	No	818	93 %	574	70.2 %	132	16.1%	112	13.7 %	0.750
Chronic disease:	Yes	62	7 %	44	71 %	8	12.9 %	10	16.1%	0.750
Have been sick with COVID-19	No	491	55.8%	342	69.7 %	83	16.9 %	66	13.4 %	0.142
	Yes	321	36.5%	235	73.2%	46	14.3 %	40	12.5 %
	I don't know	68	7.7%	41	60.3 %	140	15.9 %	16	23.5 %

Chi-square test, ∗ statistically significant < 0.005

Reported barriers against COVID-19 vaccine acceptability among dental student.

Regarding barriers against COVID-19 vaccine acceptability among DS who were unwilling to be vaccinated, 107 of 262 responders (40.8%) agree that the reason behind the unwillingness to receive the vaccine was fear of the possible adverse effects of the vaccine. In comparison, fifty-six (21.4%) of them mentioned the loss of trust in manufacturers as the leading cause of unacceptable COVID-19 vaccine. On the other hand, about 17.2 % of this group believed that the fear of rumours that the vaccine may cause infertility. Others stated barriers against COVID‐19 vaccination were fear of needle injection (n=23, 8.8%). However, fear of rapid vaccine production was (n= 31, 11.8%). On the other hand, only two variables show a significant difference between males and females regarding the reasons behind being not vaccinated (Table 2). While fear of needle injection and fear of rumours that the vaccine may cause infertility with p-value about (p-value = 0,048, 0,013) respectively.

Table 2. Reasons for COVID-19 Vaccine Unwillness across sociodemographic Characteristics (n= 262):

Sociodemographic characteristics		Unwilling to accept a COVID-19 vaccine n = 262	Fear of potential side effects n= 107 (40.8%)	Loss of trust in manufacturers n= 56 (21.4%)	Fear of needle injection n= 23 (8.8%)	Fear of rapid vaccine production n= 31 (11.8%)	Fear of rumours that the vaccine may cause infertility = 45 (17.2%)
^$ Gender:	Male	68, (26.2%)	26, (38.2 %)	18, (26.5%)	2, (2.9%)	12, (17.6%)	5, (7.4%)
^$ Gender:	Female	194, (31.3%)	81, (41.8%)	38, (19.6%)	21, (10.8%)	19, (9.8%)	40, (20.6%)
P value		0.146	0.612	0.234	0.048	0.084	0.013
^$Academic stage:	Pre-clinical	215, (32%)	90, (41.9%)	48, (22.3%)	19,(8.8%)	22,(10.2%)	35, (16.3%)
^$Academic stage:	Clinical	47, (22.5%)	17, (36.2%)	8, (17%)	4, (8.5%)	9, (19.1%)	10, (21.3%)
P value		0.008	0.472	0.422	1.000	0.130	0.522
^# Smoker:	No	252, (29.9%)	105, (41.7%)	54, (21.4%)	22,(8.7%)	29, (11.5%)	42, (16.7%)
^# Smoker:	Yes	10, (27.8%)	2, (20%)	2, (20%)	1, (10%)	2, (20%)	3, (30%)
P value		0.789	0.207	1.000	1.000	0.336	0.363
^#Chronic disease:	No	244, (29.8%)	101, (41.4%)	54, (22.1%)	23,(8.4%)	27, (11.1%)	40, (16.4%)
^#Chronic disease:	Yes	18, (29%)	6, (33.3%)	2, (11.1%)	0, (0%)	4, (22.2%)	5, (27.8%)
P value		0.895	0.502	0.378	0.382	0.244	0.207
Have been sick with COVID-19	No	148, (30.2%)	56, (37.8%)	36, (24.3%)	11, (7.4%)	20, (13.5 %)	26, (17.6%)
	Yes	87, (27%)	39, (44.8%)	15, (17.2%)	10,(11.5%)	8, (9.2%)	14, (16.1%)
	I don't know	27, (39.7%)	12, (44.4%)	5, (18.5%)	2, (7.4%)	3, (11.1%)	5, (18.5%)
P value		0.110	0.530	0.410	0.549	0.608	0.941

*unwilling to be vaccinated = (definitely refuse + hesitancy), ^$= Chi sequer test, # = FischerExact Test, statistically significant < 0.005

Sources of information and Organisation Confidence in COVID-19 vaccine.

Social Media (n= 552: 62.7%), family and friends (n=549: 62.4%), Government Health Institutions (n=375: 42.6%) and the WHO (n=363: 41.2%) were chosen by DS as the most reliable sources for COVID-19 vaccine information. Additionally, DS reported the greatest confidence in the Website (n= 273: 31%), TV (n= 222: 25.2%), Posters and educational lectures in their college (n= 118: 13.4%) as shown in (Figure 1).

Across DS who would accept the COVID-19 vaccine (n =618, 70%) reported family and friends (64.4 %), social media (61 %), the WHO (47%), Government Health Institutions (46 %) and websites (32 %) as the most reliable sources for COVID-19 vaccine information. While DS who were hesitant regarding the COVID-19 vaccine (n = 140, 16 %) reported family and friends (67.9%), social media (66 %), Government Health Institutions (38 %), the WHO (36%), the TV (30%) and Website (26%), as the most trusted sources of information. On the other hand, DSs who were refused the COVID-19 vaccine (n=122, 14%) have been reported on social media (67%), family and friends (45.9 %), Websites (32%), Government Health Institutions (30 %), TV (25%) and the WHO (20%) as the most trusted sources of information.

Figure 1: Sources of information and Organisation Confidence in COVID-19 vaccine among DS.

DISCUSSION:

Healthcare professionals (HCPs) are expected to have high vaccine acceptance rates because of their nature of work and knowledge of vaccine effectiveness. Clarity has been absent in the willingness of dental students worldwide to take the vaccine, as it varies over time and across different scenarios ¹⁷. Global lockdowns were implemented; however, such a procedure could not stop the pathogen's spread. During the pandemic, many SARS-CoV-2 strains have been identified, particularly those of the Delta and Omicron variants, which spread more quickly than the original SARS-CoV-2 strain and increased the number of COVID-19 cases¹⁸. However, vaccination programs only work if they are widely accepted and have high levels of coverage sufficient to meet herd immunity, which is believed to be between 55% and 82% ¹⁹.

We conducted our survey during the overlapping second and third waves, parallel with the FDA's approval of the first COVID-19 vaccines. Concerning acceptance, this study confirmed that about 70% of DS would take the vaccine voluntarily, without any hesitation/ apprehension, similar to other studies in China²⁰, France, and in French-speaking regions of Belgium and Canada²¹, which also demonstrated an equivalent level of acceptance as 72.4% 78.5%, and 76.4%, respectively. Only 36 % of participants were willing to take the vaccination as soon as it became available²². However, other studies demonstrate a higher acceptance rate of about 90% of medical students in India²³. In general, university students were shown to have a wide range of hesitancy regarding COVID-19 vaccines across several studies that sampled them, from Iraq (70.4%)²⁴and Egypt (46%)²⁵

Regarding factors associated with COVID‐19 vaccine acceptance among dental students: this study shows that vaccine acceptance, hesitancy or refusal differed by several sociodemographic characteristics. Although prior research suggested that gender is a predictor factor of vaccination acceptability, this study showed no reported no statistically significant association between males and females (P>0.05). This result may be due to the vast majority of the samples (70.5%) being females; hence no significant association has been established. It would be helpful to figure out the discrepancy between females and males regarding this vaccine. In this aspect, the present study outcome is consistent with another survey of American dental students and Italian dentists, where there was no significant association in the acceptance rate between males and females ²⁶. This study also found that DS at a clinical stage was more likely to accept a COVID-19 vaccine than those in a pre-clinical stage, with a statistically significant difference (P = 0.002). One possible explanation might be the perceived risk of contracting the infection through direct involvement with COVID‐19 patients during their training. There has been a substantial impact of the current pandemic on the dental profession. Dental students are often exposed to high levels of aerosols, droplets, and oral fluids throughout their clinical years as they work closely with patients. As a result, there may be additional hazards of viral transmission between infected patients and the dental team and vis versa, as well as spread to other patients if proper precautions are not taken to prevent infection ²⁷. According to previous reports, dentists are more at risk to infected with SARS-CoV-2 than other occupations ²⁸. Additionally, such difference can be clarified by the fact that DS at the clinical stage may have increased awareness since COVID-19 is a highly contagious disease that can lead to serious illness and even death.

The study also demonstrated that being infected by COVID-19 has no impact on DS's decision regarding getting the vaccine. However, another study proposed the positive influence of the previous infection with COVID-19 on their decision¹⁴. In a different light, the other study showed that infection was associated with a decreased willingness to vaccinate²⁹ as they may falsely believe they were protected from COVID-19 by natural immunity. This also highlights the lack of data on innate immunity and the importance of vaccination.

Despite the high acceptance rate, barriers still prevent people from moving from intention to acceptance. In this study, the main barriers expressed by DS comments were concerns about the vaccine's potential side effects (40.8%). Similar worries have been found in COVID-19 vaccination hesitancy studies conducted globally among HCWs and the general public¹⁶. In contrast, others stated that the loss of trust in manufacturers and fear of rapid vaccine production considered as causative factors for their vaccine unacceptability.

In comparison, about 17.2 % of DS mentioned the fear of rumours that the vaccine may cause infertility as the leading cause, with a significant difference between males and females. An explanation for this observation could be that the absence of data on the effects of a COVID-19 vaccination on the hazards of pregnancy or infertility may be to blame for the gender gap.

Also, the study reported a significant difference between males and females (p-value = 0,048) regarding fear of needle injection as a causative factor for their vaccine unacceptability. Such a finding aligned with another study in the U.S. that listed fear of needles and safety concerns as significant apparent barriers³⁰. A study performed in China recorded safety, efficacy, and cost concerns as the main barriers³¹. While Luma, Haven et al. 2022 An Iraqi/Kurdish cohort of 1704 HCWs, reported fear of side effects and lack of confidence in using the vaccine were the most common perceived barriers³². The COVID-19 vaccination programs can only be successful if there is a widespread conviction that the provided vaccines are safe and efficient, given the low public confidence in vaccination³³. The importance of transparency and addressing worries about the quickness and safety of vaccine development were emphasised by Lucia et al.³⁴. Social media and mass media have a massive effect on how young people think and feel about health-related issues, such as getting vaccinations ³⁵. Our study demonstrates that social media (n= 552: 62.7%) were chosen by DS as the most reliable sources for COVID-19 vaccine information. Hence, Social media has played a pivotal role during the present pandemic. This highlights the importance of public health officials disseminating information through multiple media channels to increase the likelihood of reaching vaccine-hesitant individuals. In conclusion, vaccination is seen as the most effective measure to control the COVID-19 pandemic. In this study, it was found that dental students in Basrah were well-being to receive COVID-19 vaccination. Such a level of acceptance among dental students is expected to positively influence public acceptance and awareness ³⁶.

The study suggests that to prepare students to effectively volunteer during the pandemic and thereby contribute to the nation's health system and educate their families and friends, government health institutions should implement appropriate teaching programs via TV programs, educational lectures, and any other urgently required measures.

ACKNOWLEDGMENTS:

We appreciate all the work that has been conducted by students regarding the survey completion

CONFLICT OF INTEREST:

The authors declare that there is no conflict of interest.

AUTHORS’CONTRIBUTION:

This review was carried out in collaboration with all the authors, and they have fully contributed to the literature review planned, preparation, and editing of the manuscript.

ETHICS STATEMENT:

This article does not contain any studies with human participants or animals performed by any of the authors.

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Received on 08.12.2022 Modified on 13.02.2023

Research J. Pharm. and Tech 2023; 16(8):3608-3614.

DOI: 10.52711/0974-360X.2023.00595