Predictors of unwillingness or inaccessibility to receive the COVID-19 vaccination among persons with disabilities in Bangladesh

Introduction

Bangladesh was targeted to cover 119,221,953 vaccine administrations for COVID-19, and the Directorate General of Health Services (DGHS) reports the achievement of 82.95 % at the first dose, and 72.94 % at the second dose. Nearly 36% of the population received the third dose of the COVID-19 vaccine.¹ Since the global vaccine campaign, the World Health Organization has urged special consideration for persons with disabilities (PWDs) as a priority. According to the Bangladesh Bureau of Statistics (BBS), 7% of the population in Bangladesh is living with some form of disability. There are a scarcity of data about the rate of vaccine administration to PWDs in Bangladesh. Though the percentage of registered individuals for COVID-19 vaccination is approximately 94%, a population-based study reported that one-third of Bangladeshi adults had vaccine hesitancy²; these were mostly men from low-income families who were unsure regarding the effects of the COVID-19 vaccine. The unwillingness to receiving vaccines was 27.4%,³ near the hesitancy margin of 33%.² This unwillingness was found to be associated with a semi-urban dwelling, low income, and a lower educated population. No data related to the unwillingness towards COVID-19 vaccine was found in PWDs in Bangladesh; however, one study reported that 42.7% of parents of children with a neuro-developmental disability express hesitancy towards receiving the vaccine for their children.⁴

Unwillingness can be defined as not receiving any doses of vaccine despite there being ability to access and scope for vaccination, or not responding to the call for vaccination⁵, while hesitancy is doubtfulness of receiving vaccine.² In the UK, 4% of the population was hesitant or uncertain, and another 4% were unwilling to receive the COVID-19 booster dose.⁵ The former study⁴ states that people might have poor compliance with guidelines to vaccination; this was particularly seen in vulnerable communities who were unwilling to receive the COVID-19 vaccination. The WHO and UNICEF policy brief states that PWDs are a part of the vulnerable community that needs to be protected through effective public vaccine campaigns. A study in the United States revealed that 25% of PWDs aged 18–65 years expressed hesitancy to receive COVID-19 vaccination.⁶ This hesitancy was associated with female sex, race, and education regarding the vaccine. In Bangladesh, PWDs had good knowledge, a positive attitude, and good behavioral practices in battling the COVID-19 pandemic.⁷ The majority of the PWDs followed health advisories during their in-patient and out-patient rehabilitation, hence it is assumed that they had access to information regarding the COVID-19 vaccination. Furthermore, the existing significant barriers for PWDs in Bangladesh to access healthcare, reliable information, long-term rehabilitation, social care, and support in livelihood⁸ were made worse by the COVID-19 pandemic. Challenges faced by PWDs during the pandemic included mobility issues, physical functioning, communication barriers, an inadequate workforce, and a lack of inclusive programs in health and rehabilitation in Bangladesh.⁹ There are a lack of relevant data in Southeast Asia on vaccine hesitancy or unwillingness for COVID-19 vaccination for persons with disabilities, but the study in the UK⁵, USA⁶, and Bangladeshi parents of neuro-developmental disability (NDD) children⁷ indicate there might be a significant number of PWDs in Bangladesh hesitant and unwilling to receive the COVID-19 vaccine. Besides, the parallel barriers to healthcare accessibility by PWDs in Bangladesh^8,9 may contribute to the unwillingness or inaccessibility to receiving COVID-19 vaccines.

Hence the objectives of the study were to find out (1) the COVID-19 vaccination rate of persons with disabilities (PWDs) in Bangladesh, (2) the rate of unwillingness and inaccessibility to vaccination for them, and (3) predict the possible reasons for unwillingness or inaccessibility.

Methods

Results

Vaccination status of persons with disabilities

A total of 241 persons with disabilities responded to our invitation, giving a response rate of 69%. A total of 186 (77.2%) PWDs had received one or more doses of COVID-19 vaccines of three doses supplied, and 55 (22.8%) were unwilling to go for a vaccination. Among the vaccine receivers, 186 (77.2%) received the first dose, 168 (69.7%) received both first and second doses, and six (2.5%) received all three doses, up until May 2022. Stroke survivors had the highest median days since receiving first and second doses (257, 192) than spinal cord injury survivors (170, 131) and others (169, 132). Figure 1 shows the median days of receiving shots among the vaccinated PWDs.

Figure 1. Median days since vaccination among the persons with disabilities (PWDs).

Relationship among variables

A significant relationship (p<.05) was found between socio-demographic variables and vaccine status for age (P<.05), education (p<.01), area of origin (p<.01), disability status (p<.001), and mobility status (p<.001) (Table 1). However, the knowledge score and knowledge category regarding the COVID vaccine were also related to the status of the vaccine (p<.05). Figure 2 shows that the median knowledge score made a difference in vaccine acceptance or unwillingness to accept the vaccine. Attitudes towards COVID vaccine and belief also were related to vaccine acceptance or rejection (p<.05).

Figure 2. Knowledge score distribution according to vaccine status.

Discussion

A 77.2% acceptance rate and 22.8% unwillingness rate towards COVID-19 vaccines for PWDs in Bangladesh was seen. All participants had high accessibility of vaccine-related invitations, information, and booth availability for the PWDs. The vaccination booth operators were also cooperative and accessible to the PWDs. The predictive factors of unwillingness were spinal cord injury type of disability, people coming to the rehabilitation center from rural areas, poor knowledge of COVID-19 vaccination, and dependency on mobility.

The Centre for the Rehabilitation of the Paralysed (CRP) is the only comprehensive rehabilitation center providing both in-patient and out-patient specialized rehabilitation for spinal cord injury in Bangladesh. In 2021, the center served 279 spinal cord injury in-patients for a median length of 131 days, more than 3000 musculoskeletal and neurological cases, including stroke and amputee in-patients, for a median of 21 days, more than 1000 child in-patients with a disability for a median 14 days, and covered nearly 50000 out-patient PWDs through its 12 clinical service centers. As the population was drawn from the CRP, the study had respondents with spinal cord injury as the majority (62.7%), followed by stroke, amputees, and other forms of physical disability (Table 1). The age category was eligible from 12 years, keeping the ongoing vaccine campaigns (12 years and above) as of February 2022¹⁰, but the majority of respondents were youths and young adults aged between 18 and 80 years. Males were the major respondents, and only six people tested COVID positive; the profile matches CRP’s patient demographics as there was only 300 RT-PCR tests performed at CRP in the year 2021. As the majority were spinal cord injury and stroke patients, the main method of mobility (67.2%) was either wheelchairs or assistive walking devices. A study on spinal cord injury at CRP¹¹ suggests that the tetraplegia and paraplegia ratio of spinal cord injury was 0.7: 1; 67% of the discharged spinal cord injury patients used a wheelchair for mobility, with 85% of them originating from rural areas of Bangladesh. All the predictive factors except knowledge were associated with the disease burden or mobility issues of spinal cord injury (Table 2).

One study³ examined the unwillingness of receiving COVID-19 vaccination in Bangladesh for the general population. The study found a 27.4% unwilling rate, close to our study (22.8%). The study indicated that youths and young adults (18–25 years), education category, residence category, and non-adherence to the COVID-19 test were associated with unwillingness. Our study found a significant relationship between vaccine status and age category, education, and area of origin. Another study on the parents of NDD children in Bangladesh⁴ had similar association of vaccine hesitancy in age groups and areas of origin, but the study concluded that parents without an RT-PCR test or vaccination were significantly hesitant about receiving a vaccine for their children with disabilities. Studies on PWDs in the USA⁶ associated vaccine hesitancy with young age, demographic factors, and education; they also had factors associated with types of disability and the female sex. Our study could not find any relationship between vaccination status and sex category, but it found a relationship between vaccination status and disability and mobility status (Table 2). Our study findings are related to the existing national data of Bangladeshi people^6,7 and the PWDs data of the USA⁶. The novelty of our study was to examine the “knowledge of the COVID-19 vaccine” as a predictive factor.

We examined the knowledge of COVID-19 vaccination with 10 questionnaire items prepared following the previously published studies^12,13, with categorical answers “yes”, “no” or “don’t know”. The right answers scored as 1, wrong answers or “don’t know” were scored as 0. Our study had a mean score in vaccine-related knowledge of 5.97±2.314, as in category 16.6% had poor knowledge of vaccine (0–3 score), and 47.3% had excellent knowledge (7–10 score). Knowledge score was related to vaccination status (p<.05) (Table 1), and median scores were significantly different for PWDs with acceptance or unwillingness (Figure 2). The previous study suggests the level of knowledge of vaccines and sources of knowledge were factors that were indicative of the willingness to accept the vaccine.¹² In addition, beliefs about the COVID-19 vaccine are another factor in the Southeast Asia region.¹³ We found 89.2% had a positive attitude toward COVID-19 vaccination, but only 41.1% believed that the vaccine could benefit PWDs. In regression analysis, we found poor knowledge of the COVID vaccine to be predictive of the unwillingness to be vaccinated; but we did not find any associations with attitude or belief. For persons with disabilities, accessibility and availability of the COVID-19 vaccine might be a factor in receiving the vaccine, but we found accessible information about the vaccine among the respondents. The respondents were invited and aware of the vaccine campaigns near them, and the camps were accessible to them.

A total of 83% of the vaccinated individuals received the vaccine with the support of their family members, 10% were supported by a disabled people’s organization, and 7% went alone to receive the vaccine shot. In addition, 48% of the vaccinated people stated there was a separate booth for PWDs, while others said they were given special considerations. One study reveals¹⁴ that vaccination unwillingness could be predicted by the likelihood of risk, susceptibility, and severity of the disease. The respondents of our study had stable medical conditions with a variety of co-morbidities such as hypertension 38.9%, diabetes (26.9%), lung disease (22.4%), genito-urinary problems (24.6%), and heart disease (7.8%); none of these were linked to unwillingness or acceptance except hypertension (p<.05). Matched with knowledge level and rural origin, the unwilling respondents might have had no concern about their risk estimation of being out of the vaccination campaign; however, this was not evidenced by statistical calculation except support in mobility issues.

The strength of this unique study was to determine the predictive factors of the unwillingness for COVID-19 vaccination in persons with disabilities, who are vulnerable to the sequelae of COVID-19. Besides, the study examined two more important factors alongside the previous studies: knowledge, and accessibility to vaccines. The study had some limitations: respondents were clustered in an organization that was related to the rehabilitation of physical disabilities, hence other forms of disability were not accurately reflected in the study. We had a satisfactory response rate (69%) but were unable to fulfil the targeted sample size. Future studies adding the spectrum of disabilities, a larger sample size, and examining the impact of vaccination with post-COVID sequelae are recommended.

Conclusion

The study found that more than one-fifth of the persons with disabilities aged between 12 and 80 years were unwilling to receive the COVID-19 vaccination despite the accessibility of information and availability of the COVID-19 vaccine. The unwillingness was predictive of knowledge level, disability category, demography of origin, and mobility issues.

Ethical approval

Ethical approval was obtained from the Institutional Review Board (CRP/BHPI/IRB/02/2022/561) on February 1, 2022.

Consent

Written informed consent was obtained from the respondents. Participants were assured about the confidentiality of data and their rights to withdraw their participation at any point in the study.

Author contributions

MZH, MAH, KMAH, VR contributed to conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, supervision, validation, visualization, writing—original draft preparation, writing—review and editing; MYAA, MHR, RA, SA, SJ, IKJ contributed to data curation, funding acquisition, methodology, validation, visualization, writing—original draft preparation, writing—review and editing.