Chapter II

REVIEW OF RELATED LITERATURE

The researchers made a thorough exploration of the related literature which are

connected to the concerns of the study. This section presents various articles and texts

from books, journal, internet, and other information sources to provide to provide a vivid

picture about the topic investigated.

COVID-19

Several cases of pneumonia with unknown cause were reported in Wuhan, Hubei

Province, China, during the last week of December 2019, and the disease quickly spread

to other areas of China and the world. These patients presented to the hospital with a

fever and cough, as well as a history of interaction with the Huanan seafood market. On 7

January 2020, the Chinese Center for Disease Control and Prevention (CDC) found a

novel coronavirus in a throat swab sample of one patient, and the World Health

Organization (WHO) called the virus 2019-nCoV. The World Health Organization

declared the outbreak as public health Emergency of international concern (PHEIC) in

January 2020. The International Committee on Taxonomy of Viruses renamed the virus

as severe acute respiratory Syndrome coronavirus 2 (SARS-CoV-2) on 11 February 2020,

and the disease was named as coronavirus disease 2019 (COVID-19). (Samal, 2021)

COVID-19 is a disease produced by the SARS-CoV-2 virus that can cause a

respiratory tract infection, according to specialists. It can affect either your upper or

lower respiratory system (sinuses, nose, and throat) (windpipe and lungs).

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 When an infected person coughs, sneezes, speaks, sings, or breathes, the virus

spreads in small liquid particles from their mouth or nose. Larger respiratory droplets to

smaller aerosols are among the particles. If you are near someone who has COVID-19,

you can be infected by breathing in the virus, or by contacting a contaminated surface and

then touching your eyes, nose, or mouth. The virus is more easily spread indoors and in

crowded places.

SARS-CoV-2 is one of seven coronaviruses that can cause serious diseases such as

Middle East respiratory syndrome (MERS) and sudden acute respiratory syndrome

(SARS) (SARS). The other coronaviruses are responsible for the majority of the colds we

get during the year, but they aren’t a big threat to otherwise healthy people.

COVID-19 Vaccines

To put an end to the epidemic, a huge portion of the population must be immune to

the virus. A vaccination is the safest approach to accomplish this. Vaccines are a

technique that humanity has relied on to reduce the mortality toll from infectious diseases

in the past. Vaccines are antigens—dead or weakened viral molecules—that cause the

immune system’s protective white blood cells to produce antibodies that bind to the virus

and neutralize it.

Several research teams rose to the challenge and created vaccinations that protect

against SARS-CoV-2, the virus that causes COVID-19, in less than a year after the

epidemic began.

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 COVID-19 vaccines were developed rapidly, with all precautions taken to ensure

their safety and effectiveness. They were developed using decades-old science. COVID-

19 vaccinations aren’t being tested. They completed all of the required clinical trial

stages. These vaccines have undergone extensive testing and monitoring and have proven

to be both safe and effective. COVID-19 vaccinations have undergone and are still

undergoing the most extensive safety testing in US history.

COVID 19 vaccinations work well. They can help prevent you from getting and

transmitting the COVID-19 virus, as well as preventing you from becoming really ill

even if you do get COVID-19.

It’s possible that getting vaccinated will protect those around you as well. COVID-19

vaccinations are highly successful in preventing major coronavirus infections and

lowering the risk of hospitalization and death.

With the use of innovative technologies, scientific teams all over the world have

developed successful Covid-19 vaccines in incredibly short order. Pfizer and Moderna

are two of the newly produced covid-19 vaccines that showed astounding and essentially

similar levels of efficacy, at least in the early phases after immunization. (Balch,2021)

Pfizer and Moderna: The first two COVID-19 vaccines approved in the US use

messenger RNA (mRNA), a molecule that tells human cells to create a piece of the spike

protein that the coronavirus uses to bind to and infect human cells. The vaccine material

degrades quickly and never penetrates the nucleus of the cell, so it can’t change the

recipient’s DNA. The immune system responds to the presence of the harmless spike

proteins by producing antibodies and activating T-cells that initiate an immunological

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response. When the immune system is primed, it is ready to respond swiftly if the

coronavirus is detected in the body. (Balch,2021)

Vaccine Hesitancy

Vaccine hesitancy is a delay in acceptance, or refusal of vaccines despite the

availability of vaccine services. The term covers outright refusals to vaccinate, delaying

vaccines, accepting vaccines but remaining uncertain about their use, or using certain

vaccines but not others. “Anti-vaccinationism” refers to total opposition to vaccination; in

more recent years, anti-vaccinationists have been known as “anti-vaxxers” or “anti-vax”

(G. Hinsliff, 2020). Vaccine hesitancy is complex and context-specific, varying across

time, place and vaccines. It can influenced by factors such lack of proper scientifically-

based knowledge and understanding about how vaccines are made or how vaccines work,

complacency, convenience, or even fear of needles (Smith, 2015).

There is an overwhelming scientific consensus that vaccines are generally safe and

effective. Vaccine hesitancy often results in disease outbreaks and deaths from vaccine-

preventable diseases. Therefore, the World Health Organization characterizes vaccine

hesitancy as one of the top ten global health threats.

Hesitancy primarily results from public debates around the medical, ethical, and legal

issues related to vaccines. According to the study of Larson, H. J., Jarrett, C.,

Eckersberger, E., Smith, D. M., and Paterson, P. (2014) vaccine hesitancy stems from

multiple key factors including a person’s lack of confidence (mistrust of the vaccine

and/or healthcare provider), complacency (the person does not see a need for the vaccine

or does not see the value of the vaccine), and convenience (access to vaccines). It has

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existed since the invention of vaccination and pre-dates the coining of the terms

“vaccine” and “vaccination” by nearly eighty years. The specific hypotheses raised by

anti-vaccination advocates have been found to change over time (Gerber & Offit, 2009).

Determinants of vaccine hesitancy

Working Group developed a model of determinants of vaccine hesitancy, based on a

Systematic review of literature and interviews with immunization managers, which

categorized drivers into contextual influences, individual and group influences and

vaccine or vaccination specific Issues. The model of determinants was seen as a useful

tool to guide the selection of survey questions sensitive and specific to vaccine hesitancy

in order to provide information not only on the overall prevalence of vaccine hesitancy

but also its underlying determinants.

Contextual influences

Contextual influences are influences arising due to historic, socio-cultural,

environmental, health system institutional, economic or political factors.

Community leaders and influencers, including religious leaders in some settings,

celebrities in others, can all have a significant influence on vaccine acceptance or

hesitancy.

Negative historic influences such as the Trovan trial/ Wakefield MMR-autism scare

can undermine public trust and influence vaccine acceptance, especially when combined

with pressures of influential leader/media. Community experience isn’t necessarily

limited to vaccination but may affect it.

religious leaders prohibit vaccines, some cultures do not want men vaccinating children,

some cultures value boys over girls and fathers don’t allow children to be vaccinated.

Vaccine mandates can provoke vaccine hesitancy not necessarily because of safety or

other concerns, but due to resistance to the notion of forced vaccination.

A population can have general confidence in a vaccine and health service, and be

motivated to receive a vaccine but hesitate as the health center is too far away or access is

difficult.

Industry may be distrusted and influence vaccine hesitancy when perceived as driven

only by financial motives and not in public health interest; This can extend to distrust in

government when perceived that they are also being pushed by industry and not

transparent.

Individual and group influences

Individual and group influences are influences arising from personal perception of

the vaccine or influences of the social/peer environment.

Past negative or positive experience with a particular vaccination can influence

hesitancy or willingness to vaccinate. Knowledge of someone who suffered from a VPD

due to non- vaccination may enhance vaccine acceptance. Personal experience or

knowledge of someone who experienced an AEFI (adverse event following

immunization) can also influence hesitancy.

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 Vaccine hesitancy can result from 1) beliefs that vaccine preventable diseases (VPD)

are needed to build immunity (and that vaccines destroy important natural immunity) or

2) beliefs that other behaviors (breastfeeding, traditional/alternative medicine or

naturopathy) are as or more important than vaccination to maintain health and prevent

VPDs.

Decisions to vaccinate or not are influenced by a number of the factors addressed

here, including level of knowledge and awareness. Vaccine acceptance or hesitancy can

be affected by whether an individual or group has accurate knowledge, a lack of

awareness due to no information, or misperceptions due to misinformation. Accurate

knowledge alone is not enough to ensure vaccine acceptance, and misperceptions may

cause hesitancy, but still result in vaccine acceptance.

Trust or distrust in government or authorities in general, can affect trust in vaccines

and nd vaccination programmes delivered or mandated by the J government. Past

experiences that influence hesitancy can f includes system procedures that were too long

or complex, or personal interactions were difficult.

Vaccination-specific issues

Vaccine/Vaccination specific issues are directly related to vaccine or vaccination.

Scientific evidence of risk/benefit and history of safety issues can prompt individuals

to hesitate, even when safety issues have been darified and/or addressed e.g. suspension

of rotavirus vaccine due to intussusception; Guillain-Barre syndrome following swine flu

vaccine 1976) (1976) or narcolepsy (2011) following (A)H1N1 vaccination; milder, local

adverse events can also provoke hesitancy.

used/tested for long enough or feel that the new vaccine is not neededor d not needed, or

do not see the direct impact of the vaccine (e.g. HPV vaccine preventing cervical cancer).

Individuals may be more willing (i.e. not complacent) to accept a new vaccine if

perception of the VPD risk is high.

Mode of administration can influence vaccine hesitancy for different reasons. E.g.

oral or nasal administrations are more convenient and may be accepted by those who find

injections fearful or they do not have confidence in the health workers skills or devices

used.

Delivery mode can affect vaccine hesitancy in multiple ways. Some parents may not

have confidence in a vaccinator coming house-to-house; or a campaign approach driven

by the government. Alternatively if a health center is too far of the hours are

inconvenient.

Individuals may hesitate if they do not have confidence in the 5 system’s ability to

provide vaccine(s) or might not have confidence in the source of the supply h (e.g. if

produced in a culture the country/culture individual is suspicious ealth of); HCWs may

also be the hesitant to administer fent a vaccine (especially a new one) if they do not have

confidence that the supply will continue as it affects their clients trust in them. Caregivers

may not have confidence that a needed vaccine and/or health staff will be at the health

facility if they go there.

Although there may be an appreciation for the importance of preventing individual

vaccine preventable diseases, there may be reluctance to comply with the recommended

8
schedule (e.g. multiple vaccines or age of vaccination). Vaccination schedules have some

flexibility that may allow for slight adjustment to meet individual needs and preferences.

While this may alleviate hesitancy issues, accommodating individual demands are not

feasible at a population level.

An individual may have confidence in a vaccine’s safety and the system that delivers

it, be motivated to vaccinate, but not be able to afford the vaccine or the costs associated

with getting themselves and their child(ren) to the immunization point. Alternatively, the

value of the vaccine might be diminished if provided for free. Health care professionals

are important role models for their patients; if they hesitate for any reason (e.g. due to

lack cont of confidence in a vaccine’s safety or need) it can influence their clients’

willingness to vaccinate.

Research Hypothesis

H1. The leading determinants of COVID-19 vaccine hesitancy for the following

influences: (i) contextual influences: Religious and cultural influences, (ii) individual and

group influences: Vaccine safetyness, (iii) COVID-19 Vaccination- specefic issues:

Vaccine effectiveness.

Theoretical and Conceptual Framework

This study is supported by the theory of Soares, Rocha, Moniz, Gama, Laires, Pedro

and Nunes (Factors Associated with COVID-19 Vaccine Hesitancy), vaccine hesitancy

results from a complex decision-making process, influenced by a wide range of

contextual, individual and group, and vaccine-specific factors, including communication

and media, historical influences, religion/culture/gender/socioeconomic, politics,

9
geographic barriers, experience with vaccination, risk perception, and design of the

vaccination program. Their findings regarding factors associated with delaying or

refusing the COVID-19 vaccine are in agreement with previous studies that examined the

population in the first semester of 2020. The factors that they found to be associated with

higher odds of delay and refusal and in agreement with previous findings were not taking

the influenza vaccine in the previous season, low or nonexistent perceived risk of getting

COVID-19 and trust in the government. They also found that younger individuals had

higher odds of refusal and individuals with lower education levels were more likely not to

take the vaccine than individuals with a university degree. The authors also conclude that

lower trust in/poorer perception of the government and the measures they have

implemented, health service response, and information provided by health authorities

were associated with delaying or refusing COVID-19 vaccine.

Also, Jr., A. P., Bleza, D. G., Balibrea, D. M., & Equiza, C. (2021) conducted a

survey in Caloocan, Malabon, and Navotas, Philippines on the acceptability of

vaccination against COVID-19. The findings confirmed that several factors were found to

contribute to the unwillingness of some of the respondents to get a COVID-19 vaccine.

Vaccine safety and effectiveness was the most important factor that affects the

respondents’ intent to receive a COVID-19 vaccine

On the other hand, Syed Alwi et al (2021), conducted a survey on COVID-19

vaccine acceptance and comcern among Malaysian. They managed a 14 questions

covering sociodemographic characteristics, medical illnesses, source of information

regarding COVID-19, acceptance of COVID-19 vaccine and concerns regarding the

COVID-19 vaccine. In this study they indicate that the leading cause for hesitancy was
10
fear of the side effects of the vaccine, concerns about the safety, lack of information and

questions about the effectiveness of a new vaccines. Further analysis using the RII

supported that side effects, safety, lack of information and effectiveness were the crucial

concerns among respondents. The authors also conclude that the respondents’ main

source of information about COVID-19 was mainly from social media and mass media.

Figure 1. The Conceptual Framework of the Study

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Demographic profile Determinants of Covid- The leading
of the respondents: 19 vaccine hesitancy: determinants
of COVID-19
 Age  Contextual
Perceptions of vaccination
 Gender influences
hesitancy of
 Adress  Individual/group the respondents
influences the following
 Vaccine/vaccination influences.
specific issues,

Figure 1. The Conceptual Framework of the study

Definition of Terms

Contextual influences- Contextual influences are influences arising due to historic,

socio-cultural, environmental, health systeminstitutional, economic or political factors.

COVID-19. Coronavirus disease (COVID-19) is an infectious disease caused by the

SARS-CoV-2 virus. Most people who fall sick with COVID-19 will experience mild to

moderate symptoms and recover without special treatment. However, some will become

seriously ill and require medical attention.

Determinant- Determinant is a factor which decisively affects the nature or outcome

of something.

Hesitancy- Hesitancy is a lack of willingness or desire to do or accept something.

The quality or state of being hesitant.

Individual and group influences. Individual and group influences are influences

arising from personal perception of the vaccine or influences of the social/peer

environment..

Vaccination- specific issues- Vaccine/Vaccination specific issues are directly related

to vaccine or vaccination.
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 Vaccine. Vaccine is a biological preparation that provides active acquired immunity

to a particular infectious disease. A vaccine typically contains an agent that resembles a

disease-causing microorganism and is often made from weakened or killed forms of the

microbe, its toxins, or one of its surface proteins. The agent stimulates the body’s

immune system to recognize the agent as a threat, destroy it, and to further recognize and

destroy any of the microorganisms associated with that agent that it may encounter in the

future. (Melief, C. J., Hall, T. V., Arens, R., Ossendorp, F., & Burg, S. H., 2015)

Vaccine hesitancy. Vaccine hesitancy is a delay in acceptance, or refusal of vaccines

despite the availability of vaccine services. The term covers outright refusals to vaccinate,

delaying vaccines, accepting vaccines but remaining uncertain about their use, or using

certain vaccines but not others. (MJ Smith, 2015)

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