Systematic review of COVID-19 vaccine acceptance and hesitancy: global perspectives and implications.

Muhammad Mohsin khan; Noman Shah; Mhran Daie

doi:10.12688/f1000research.148376.2

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Systematic Review

Revised

Systematic review of COVID-19 vaccine acceptance and hesitancy: global perspectives and implications.

[version 2; peer review: 1 approved with reservations, 1 not approved]

Muhammad Mohsin khan ¹, Noman Shah¹, Mhran Daie¹

PUBLISHED 23 Aug 2024

Author details Author details

¹ Neurosurgery, Hamad Medical Corporation, Doha, Doha, Qatar

Muhammad Mohsin khan
Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation

Noman Shah
Roles: Validation, Writing – Review & Editing

Mhran Daie
Roles: Investigation, Visualization

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Global Public Health gateway.

Abstract

The acceptance rate towards COVID-19 vaccination among the global population could be higher due to the need for more education or awareness of prevention strategies to control the COVID-19 outbreak. Thus, there is a dire need to reduce the population’s reluctance towards COVID-19 vaccination across the globe, which will ultimately lead to the implementation of prevention and control strategies against the COVID-19 virus and improving health outcomes across the globe. The following study intends to conduct a systematic review of the literature to evaluate the relationship between COVID-19 vaccination and the current trends related to COVID-19 vaccination faced by the global population. The methodology employed in this study primarily focused on assessing secondary data by conducting a systematic literature review. Internet and electronic databases were used to select research articles to obtain secondary sources. Six articles were selected from ScienceDirect and Google Scholar for a systematic literature review. The keywords used for the selection of articles were “COVID-19,” “Global trends,” Reluctance, “and “vaccination.” The selected articles that were most suitable for the topic consisted of global trends related to COVID-19 vaccination. Six articles relevant to the topic were selected and reviewed. The selected articles showed data collection results from different research journals. The findings of the six research articles depicted common themes, such as each vaccine having a different level of access attitude towards the regional existence, which primarily depends on the variability to determine the vaccine’s effectiveness. Further studies are required to evaluate the factors and strategies that help healthcare organizations and governments reduce the reluctance to use the COVID-19 vaccine among populations worldwide.

Keywords

COVID-19, Global trends, Reluctance , vaccination.

Corresponding author: Muhammad Mohsin khan

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 khan MM et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: khan MM, Shah N and Daie M. Systematic review of COVID-19 vaccine acceptance and hesitancy: global perspectives and implications. [version 2; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:440 (https://doi.org/10.12688/f1000research.148376.2) First published: 02 May 2024, 13:440 (https://doi.org/10.12688/f1000research.148376.1) Latest published: 23 Aug 2024, 13:440 (https://doi.org/10.12688/f1000research.148376.2)

Revised Amendments from Version 1

This revised version of our article incorporates several important updates and clarifications based on valuable feedback from peer reviewers. Key changes include:

1. Introduction Revision: We have updated the second paragraph of the introduction to specify the time period, now stating "As of 5th June 2023, 12.13 billion vaccine doses have been administered worldwide" instead of "to date."

2. Grammatical Corrections: A thorough review and correction of grammatical errors have been performed to enhance clarity and readability.

3. Methodology Enhancement: The methodology section now includes a specific date range for the article search, detailing that articles were searched from March 2020 to January 2023. This provides a clearer context for the exclusion of pre-pandemic articles.

4. PRISMA Flowchart Update: The PRISMA flowchart has been revised to include reasons for excluding articles during the second screening, providing greater transparency in the study's selection process.

5. Table Modification: A new column has been added to the table, highlighting the acceptance and hesitancy towards vaccines. This addition aims to present the data in a more organized and informative manner.

6. Conclusion Streamlining: The conclusion has been condensed to focus only on the core points of the paper, ensuring an impactful summary of the findings.

These revisions aim to improve the accuracy, clarity, and comprehensiveness of the study, addressing all the reviewer comments and suggestions to enhance the overall quality and presentation of the research.

See the authors' detailed response to the review by Mohammed Salim Karattuthodi

Introduction

COVID-19 is a virus belonging to the family Corona viridae. They can affect both humans and animals. According to Caserotti et al., COVID-19 is a severe acute respiratory syndrome caused by a novel virus. It can lead to several respiratory outcomes and cause mild infections such as a common cold. Coronavirus originated among humans in Wuhan, China, in 2019, and later spread across the globe. In addition, Fung et al. stated that the COVID-19 outbreak has severely affected several countries worldwide.⁶^,⁸ In 2020, the World Health Organization (WHO) declared COVID-19 as a global pandemic. During that year, 66 regions outside China reported 8,568 confirmed cases, with Italy and Iran having a higher prevalence. In 2020, the total number of confirmed COVID-19 cases worldwide reached 118,638,190, resulting in 2,632,074 deaths. The United States had the highest rate of confirmed COVID-19 cases, followed by Brazil and India as the second- and third-highest regions, respectively. Hanney et al. reported that in 2020, the UK had the sixth highest prevalence of COVID-19, with over 306,000 cases and 43,000 deaths.⁹ According to WHO, as of now, there have been 550,218,992 reported cases of COVID-19 worldwide, with 6,343,783 reported deaths due to the infection. The current statistics of COVID-19 by region are shown in below mentioned Figure 1.

Figure 1. Current Statistics of COVID-19 by Region.

Source: Ref. 22.

The above graph indicates that the prevalence of COVID-19 is at its peak in Europe and America. The WHO further reported that 12 037, 259, and 035 vaccines will be administered in 2022 to reduce the global prevalence of COVID-19. The graph below shows that 62.2% of people had received at least one dose of the COVID-19 vaccine. Notably, 57.8% of the population has received two or three doses of the COVID-19 vaccine. To date, 12.13 billion vaccine doses have been administered worldwide. As of July 5, 2023, a total of 12.13 billion vaccine doses have been administered worldwide. On average, approximately 5.51 million vaccine doses are administered daily.

The current trends of protection against COVID-19 emphasize that over 7.81 billion people have been administered the vaccine dose.¹⁴ However, Zhao et al. stated that the acceptance rate towards COVID-19 vaccination in developing countries such as Nigeria needs to be higher because of a lack of education or awareness of prevention strategies to control the COVID-19 outbreak.²⁴^,²⁵ A high acceptance rate among the population is necessary to improve the administration rate of the COVID-19 vaccine.¹⁴ Thus, there is a dire need to reduce the population’s reluctance to receive COVID-19 vaccination worldwide, which will ultimately lead to prevention and control strategies against COVID-19 and improve health outcomes across the globe.

Figure 2. Vaccinations of COVID-19.

Source: Ref. 15.

According to Al-Amer et al., organizations and governments worldwide have made vaccination for COVID-19 mandatory to enhance the vaccination rate.⁴ Governments and institutions have implemented several policies to make COVID-19 vaccination mandatory. For example, proof of at least one or two doses of vaccination is mandatory for working in specific roles and settings, or attending school. An employee cannot receive his/her salary without administering one or two doses of COVID-19 vaccines, and a student cannot sit in the classroom without administering vaccination globally. These policies are ethically justified as they protect the health and well-being of the population. However, policies may pose issues for individual autonomy, liberty, and other adverse effects. These issues have made the vaccination of COVID-19 unsuccessful to some extent and caused reluctance among people towards COVID-19 vaccination worldwide. In this regard, the following study proposes to conduct a comprehensive literature review to evaluate the resistance to COVID-19 vaccination and explain the current trends related to COVID-19 immunization experienced by the global population.

Aim and objectives

The main aim of this study was to evaluate reluctance to vaccinate against COVID-19 worldwide. This study primarily focused on the current global perspective of COVID-19 prevention. This study established a series of goals.

• To explore the current trends associated with COVID-19 vaccination faced globally Population.
• To evaluate the factors and barriers that occur in the acceptance of COVID-19 vaccination.
• To explore the rate of reluctance to vaccinate COVID-19 among populations worldwide.

Research question

The research question formulated to be addressed through this systemic literature review is

• What is the reluctance to vaccinate against COVID-19 and explain the current barriers related to COVID-19 vaccination faced by the global population?

Methods

Research strategy

The research approach adopted by the study involved conducting an extensive review of the secondary data and thoroughly examining the relevant literature from March 2020 till January 2023. Internet and electronic databases were used to select research articles to obtain secondary sources. Six articles were chosen from ScienceDirect, Google Scholar, and PubMed to conduct a systematic literature review. The keywords used for the selection of articles were “COVID-19,” “Global trends,” Reluctance, “and “vaccination.” The selected articles that were most suitable for the topic consisted of global trends related to COVID-19 vaccination.

Inclusion and exclusion criteria

The study utilized inclusion and exclusion criteria to sift through relevant data. Articles that served as determinants of COVID-19 vaccines were included in the research. It is essential that the study encompasses articles that are performed and surveyed globally and written in English. This study focuses solely on articles that can be published as research articles. Articles published before the COVID-19 pandemic were not included in the study. Articles published before the COVID-19 pandemic, March, 2020 were not included in the study. Additionally, articles that provided survey information on particular groups, such as healthcare workers or students, were not considered in this study.

Selection of studies using preferred reporting items for systematic reviews and meta-analyses flowchart (PRISMA)

The reporting items for systemic literature review usually identified the PRISMA flowchart, as it provides evidence-based items for results synthesis.¹⁷ The PRISMA flowchart highlights the number of relevant literature reviews eligible to provide significant information related to the research question. The flowchart also includes the excluded articles and duplicate literature reviews.

The flow chart (Figure 3) above shows that the PRISMA flowchart helped retrieve studies from the databases after putting keywords on each database. After removing duplicates and screening the articles based on the abstract and availability of full-text articles, seven articles were selected and reviewed.

Figure 3. PRISMA flowchart.

Data analysis

A thematic analysis technique was used to analyse the findings of the selected articles following a systematic review. This technique enabled the researcher to determine patterns and themes in the findings of studies on people’s reluctance to vaccinate COVID-19 worldwide.

A review of previous studies was conducted to evaluate the rate of reluctance to vaccinate COVID-19 among populations across the world. Thematic analysis was used to present the findings of this systematic literature review, and each article was reviewed under the following themes:

COVID-19 vaccine reluctance worldwide

Sallam stated that the term vaccine reluctance reflects a delay in the vaccination acceptance rate.²⁰ The refusal rate of vaccination is likely to affect the rate of vaccine administration among the entire population. Some factors that influence the reluctance to accept vaccination include changing people’s attitudes towards the availability of vaccine services. These factors included complacency, suitability, and motivation. Complacency refers to a decreased perception of disease risk; hence, vaccination appears unnecessary. The term confidence denotes the belief in the vaccination approach, which includes safety, effectiveness, and all perspectives of healthcare organizations. The term suitability entails affordability, availability, and delivery in the context of comfort.

Other complexities affecting COVID-19 vaccination reluctance were analysed using a triad of epidemiologically related environments, mediators, and human factors. These factors include the environment, public health policies, socioeconomic factors, and reports circulated through social media.²⁰ Other disease-related factors involve the perception of vaccines that consist of the rate of efficacy, efficiency, and, most importantly, safety. Human factors depend on information, past experience, education, and income levels.

According to Kabir et al., COVID-19 has caused 1.7 million deaths and 80 million cases worldwide in 2020.¹⁰ The research team and pharmaceutical companies have contributed significantly to the formulation of effective and safe vaccines against COVID-19. Preventive actions have been implemented to stop the transmission of COVID-19 between individuals. Although efforts to establish a vaccine have resulted in massive success for COVID-19 vaccination, several significant hindrances can stimulate reluctance regarding the availability of COVID-19 vaccination.¹²

The major challenge in implementing COVID-19 vaccination is the unfair distribution and long-term efficacy of vaccination worldwide. Another significant challenge is to control efforts to reduce the negative consequences of COVID-19 vaccines in specific countries. The access rate of the COVID-19 vaccine relies mainly on the immunity rate of the population to control the spread of pathogens, depending on the reproductive number of infectious diseases. The range of immunity observed in individuals is approximately 60-70% for mandatory virus transmission.²³ A high rate of immunity is required for the vaccine to be effective in protecting human factors and achieving the goal of reducing the COVID-19 effect.

Implications of COVID-19 vaccine uptake and the acceptance rate of the COVID-19 vaccine worldwide

According to Adu et al., the rate of COVID-19 vaccination tends to be higher in low- and middle-income countries, with 4.98 billion people receiving one dose of the COVID-19 vaccine globally in 2022.³ Healthcare practitioners and organizations have reported that high administration and acceptance of effective vaccines are required to substantially reduce the COVID-19 outbreak. It is estimated that the vaccine needs an efficacy of approximately 95-85%, along with a population range from 63-75%, to get protected to achieve herd immunity against the pandemic infection. Recently, there have been potential implications of attitudes identified from COVID-19 vaccination that have been increasing over time, representing the positive movement of the population towards vaccination. The study also revealed the religious affiliation predicted from COVID-19 vaccination, mainly in Jordan, Somalia, Malaysia, and Ethiopia, including common demographic factors.³ Demographic factors are mainly linked to the vaccination uptake of COVID-19, including sex, differences in marital status, level of education, residence area, and various affiliations of religion that cause refusal of COVID-19 vaccines.

Moreover, Abu-Odah, Su, and Musa conducted a descriptive qualitative study to evaluate the unwillingness of individuals to be vaccinated against the COVID-19 vaccine and determine suggestions to enhance the vaccination level in Palestine.² The results of the study demonstrated that the unwillingness of people in Palestine to get vaccinated against the COVID-19 vaccine was due to several factors, such as the spread of invalid rumours, conspiracy theories, misinformation that they received regarding the vaccine, their side effects on social media, and doubts towards vaccines purchased by the government. There is a pressing need to develop motivational techniques, including monetary rewards, to encourage individuals to receive the COVID-19 vaccine. Implementing these strategies can motivate individuals to be vaccinated.

Furthermore, approximately 63% of the global population received only one dose of the COVID-19 vaccine by 2022.¹⁶ Around 10.94 billion doses are estimated to not reach the global population. Rural areas and countries have lower vaccination rates than those in urban areas. Their ages largely determine the percentage of fully vaccinated individuals. International agencies such as the European Medicines Agency have authorized four vaccines. These vaccines consisted of two DNA-based vaccines (ChAdOx1 nCov-19 and Ad26.COV2.S) and two mRNA-based vaccines (BNT162b2 and mRNA-1273). Administering vaccines is highly correlated with decreasing SARS-COV-2 death rates.¹³ Although the COVID-19 vaccine has proven to be effective, it has been associated with adverse side effects such as thrombocytopenia, thrombosis, and haemorrhage. These outcomes have caused some individuals to be hesitant to receive the COVID-19 vaccine during the COVID-19 outbreak. Approximately 5% of people in the United States reported experiencing allergic reactions and other side effects. In Europe, over 7.2 million people hesitate to be vaccinated against COVID-19 and need assurance about its safety.¹⁸ Additionally, these populations include a large ratio of unwilling adults based on the causes of covariates, such as sociodemographic factors.

Demonstrations have proven that the COVID-19 vaccine has been created to hinder or diminish the spread of COVID-19 on a global scale.²⁰ No treatment has been discovered specifically for the COVID-19 pandemic, and the implication of the vaccine is necessary for the population. However, a study by Million et al. evaluated that the acceptance of vaccination for COVID-19 can be influenced by the vaccine’s safety, efficacy rate, causes of adverse effects, belief in the government’s authority, and religious beliefs, which are the primary factors that inhibit the uptake rate of the COVID-19 vaccine.¹² The COVID-19 vaccine, which is designed to prevent or mitigate the spread of the COVID-19 infection worldwide, has only been received by 28.3% of the population in low-income countries.²⁰ This means that the benefits of the COVID-19 vaccine have not yet been fully realized on a global scale. Moreover, Adu et al. demonstrated the benefits perceived from vaccination and indicated that vaccine acceptance rate improvement could decrease the outbreak of the COVID-19 pandemic.³

Research findings indicated that many senior citizens received complete vaccination, including booster shots.¹⁶ The data from early surveys of lower-middle and high-income brackets show that the number of vaccine doses administered to high-income and upper-middle individuals is significantly higher than that administered to low-income individuals. The other factors that cause disinclination to vaccinate against COVID-19 are the effective cost, vaccination schedules, and, most importantly, reliability decisions for vaccine uptake. The findings of these studies are related to the results of the Yoneoka et al. study, which showed that the acceptance rate of COVID-19 vaccination was low in Africa due to a low rate of poverty and lack of knowledge about the effectiveness and potency of COVID-19 vaccines against the COVID-19 outbreak.²³

A large proportion of adults are estimated to be unwilling to participate in vaccination due to socio-demographic factors.¹⁸ The challenges faced against the uptake of COVID-19 in Europe were mainly due to women’s low educational levels. Compared to European countries, the acceptance rate of the COVID-19 vaccine was higher in the UK and Canada during the pandemic.¹⁸ Middle Eastern countries also showed lower acceptance rates, and Russia reported a lower acceptance rate in terms of safety and efficacy issues. However, the major challenge of COVID-19 vaccination was to control the negative consequences caused by the vaccination of COVID-19. A sufficient level of immunity is necessary to achieve the desired range of vaccine effectiveness, which in turn can help mitigate the impact of COVID-19 on human health. Cases of anaphylaxis with several types of allergic reactions occur mainly after vaccination.¹³ This study examined a particular factor: apprehension related to needles or blood. This factor has been recognized as a source of anxiety in smaller communities. These are also related to population safety concerns as vaccines can induce allergic reactions. These factors might make people more resistant to COVID-19 vaccination worldwide.

Findings

The Table 1 below shows the findings of each article in this systematic literature review. The table contains the author’s name, study design, aim, and study outcomes.

Table 1. Aggregate analysis of included studies.

No	Author	Study design	Aim of study	Outcomes	Acceptance and hesitancy towards vaccines
1	Norhayati et al. (2022).¹²	Systemic research method	The study aims to review the estimated rate of COVID-19 acceptance worldwide.	The result shows the proportion rate of COVID-19 vaccines which is highly effective in south-east Asia and most effective in males.	High acceptance in Southeast Asia and among males
2	Adu et al. (2023).³	Systemic research method	The study aims to estimate the demographic, psychological, and social factors causing reluctance to COVID-19 vaccination uptake.	The study reveals a decreased rate of hesitancy of the COVID-19 vaccine due to its negative effect.	Decreased hesitancy overall
3	Sallam (2021).²⁰	Systemic literature review	The study aims to evaluate the acceptance and reluctance rate of COVID-19 vaccination in different countries.	The acceptance rate of COVID-19 vaccination consists of 60%, and there are major hindrances due to negative consequences.	60% acceptance; significant hesitancy due to negative consequences
4	Novak et al. (2022).¹³	Systemic literature review	The study's main aim is to analyse the negative factors that decrease the implementation of the COVID-19 vaccine.	The administration of COVID-19 vaccination shows adverse effects in the worldwide population, such as hypersensitivity reactions.	Hesitancy due to adverse effects like hypersensitivity reactions
5	Paul et al. (2021).¹⁸	Cross-sectional study	The study aims to identify the predictive factors for COVID-10 vaccination as a current trend worldwide.	The study reveals that there are several ethical considerations as well as a socioeconomic background that encourage the reluctance to COVID-19 vaccination.	Hesitancy due to ethical considerations and socioeconomic factors
6	Parimi et al. (2022).¹⁶	Systemic literature review	The study aims to decrease the growth of pandemic infection through COVID-19 vaccination.	The study shows a decrease in the death rate that increases the potential rate of COVID-19 vaccination.	Increased acceptance due to decreased death rate
7	Abu-Odah, Su, and Musa (2022).²	Descriptive qualitative study	The study aims to evaluate the unwillingness of individuals to get vaccinated against the COVID-19 vaccine and determine suggestions to enhance the vaccination level in Palestine.	The results of the study demonstrated that the unwillingness of people in Palestine to get vaccinated against the COVID-19 vaccine was due to several factors such as the spread of invalid rumours, conspiracy theories, and misinformation that they received regarding the vaccine and their side effects on the social media and doubts towards vaccines that the government purchased. It is also evaluated that there is an urgent need to formulate motivational strategies such as financial incentives to motivate people to get vaccinated with the COVID-19 vaccine.	Significant hesitancy due to misinformation and conspiracy theories; suggestions for increasing acceptance through incentives

Discussion

The findings of this systematic literature review showed that a high rate of reluctance towards vaccinate for COVID-19 resulted in an increased mortality rate. The COVID-19 vaccine has the potential to decrease the mortality rate caused by infection. The dose of the COVID-19 vaccine helps decrease severe symptoms of the disease and the death rate worldwide. The study also showed that several vaccines were developed for treating COVID-19 based on DNA and RNA. However, many of them need to be more effective against infection due to access to different regional variants. Each vaccine has a different acceptance rate and depends on population variability. Several pharmaceutical companies have contributed significantly to the generation of safe and effective vaccines against the COVID-19 pandemic. The factors required to increase the availability of vaccine services are competency, feasibility, and affordability. Most populations worldwide believe that media reporters regulate information or that rare events have adverse effects.

According to Dudley et al., vaccination is the most effective solution for controlling the COVID-19 pandemic and achieving a high level of immunity in the community.⁷ Thus, the advantages of vaccination depend mainly on the acceptance rate of the population. The pooled proportion of COVID-19 shows the factors related to a religious perspective that ranged from 52 to 74% in South Asia with the highest rate and in the Eastern Mediterranean Sea with the lowest rate.¹ The low rate in Middle Eastern countries is due to a wide range of false beliefs and conspiracies regarding the administration of vaccines. The evaluation showed that the vaccination rate in Middle Eastern countries is higher in males than females. A noticeable trend suggests that males are less likely to believe in theories but are more inclined to receive the COVID-19 vaccine. On the other hand, females are more concerned about safety and efficacy issues related to the doses of COVID-19 vaccines. The distrust in the female population regarding the vaccination of COVID-19 is higher and covers a significant proportion of the population.

These beliefs among the female population are due to a lack of information related to COVID-19 vaccines; therefore, females show low interest in perceiving the benefits of the COVID-19 vaccine. The effectiveness of COVID-19 vaccines can only be determined through their administration, as they help identify the treatment gap. This determination of gaps helps researchers improve the treatment of COVID-19. In several countries, the vaccine access rate depends on the immunity rate of the population.²³ Several countries, such as Africa, have chosen to administer COVID-19 vaccinations after being influenced by positive reviews from populations in other countries.¹⁹

The hesitancy of vaccines due to several pieces of evidence indicates their adverse effects.¹⁶ Adverse effects interfere with routine vaccination, mainly by inhibiting the vaccine’s safety efficacy. Paul et al. indicated factors of reluctance to vaccinate against COVID-19 in European countries whose populations are unwilling to take up vaccination.¹⁸ Adu et al. stated that healthcare practitioners believe that in the case of a reoccurrence of the pandemic, vaccination is an effective strategy that helps reduce death rates and enhances the possibility that the population will be affected.³ A study found that people worldwide expect long-term efficacy results from COVID-19 vaccines.²¹ Researchers are willing to conduct more preclinical trials to develop vaccines with greater efficacy and fewer adverse effects to meet the population’s expectations.

Conclusion and recommendations

Conclusions

This study aimed to analyze the reluctance to vaccinate COVID-19 patients worldwide based on current global trends. Seven relevant articles were reviewed, revealing key factors and barriers to COVID-19 vaccine acceptance. Common themes included regional differences in vaccine access and effectiveness, and challenges such as unfair distribution and long-term efficacy. A systematic review indicated that low-income countries benefit less from vaccination, with significant reluctance influenced by misinformation and adverse effects. Overall, achieving global vaccination coverage remains a challenge due to these barriers and the ongoing uncertainty about the vaccine’s acceptance.

Limitations

The researcher encountered several limitations when conducting this systematic review. One of the significant limitations was the risk of bias, including article selection bias, which might have provided insufficient findings to determine the reluctance and factors that promote reluctance among people to the COVID-19 vaccine across the globe. Another major limitation was the unavailability of full-text, high-impact articles, which affected the findings and provided limited results and outcomes.

Recommendations

This study is a systematic literature review of global findings. However, there is a need to address several regions and countries individually for the study. There is a need to implement other research methods, such as quantitative and qualitative methods, to achieve diversified results in the study. There is a suggestion to create efficient tactics and regulations that can increase the effectiveness of COVID-19 vaccines and diminish people’s hesitancy towards vaccination.¹¹ To achieve this objective, policymakers should create effective policies to promote vaccination. Individuals could be required to present their vaccination cards to ensure that they receive their salary. Addressing the challenges and disadvantages of vaccine implementation is recommended for various organizations and government sectors, including NGOs. Furthermore, the researcher must cater to several factors other than the vaccine, such as managing the potency of the vaccine, the role of the vaccine, and its role in boosting the immunity of a person suffering from COVID-19 and aged people who have less immunity in the body.⁵ Therefore, there is a need to address the role of doctors, nurses, and other medical staff by conducting a primary qualitative study.

Ethics and consent

Ethical approval and consent were not required.

Data availability statement

Underlying data

No Data are associated with this article.

Extended data

In conducting this systematic review, we did not generate any extended data beyond what is presented in the main body of the manuscript and its extended materials.

Name of the repository: Zenodo.org; Systematic Review of COVID-19 Vaccine Acceptance and Hesitancy: Global Perspectives and Implications, DOI: https://doi.org/10.5281/zenodo.10967086.

This project contains the following underlying data:

License: Systematic Review of COVID-19 Vaccine Acceptance and Hesitancy: Global Perspectives and Implications. By Muhammad Mohsin khan, Noman Shah, Mhran Daie is marked with CC0 1.0 Universal.

Reporting guidelines

PRISMA 2020 checklist for Systematic Review of COVID-19 Vaccine Acceptance and Hesitancy: Global Perspectives and Implications, DOI: https://doi.org/10.5281/zenodo.10967086.

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VERSION 2 PUBLISHED 02 May 2024

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¹ Neurosurgery, Hamad Medical Corporation, Doha, Doha, Qatar

Muhammad Mohsin khan
Roles: Conceptualization, Methodology, Project Administration, Supervision, Writing – Original Draft Preparation

Noman Shah
Roles: Validation, Writing – Review & Editing

Mhran Daie
Roles: Investigation, Visualization

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

Revised

Published: 23 Aug 2024, 13:440

https://doi.org/10.12688/f1000research.148376.2

version 1

Published: 02 May 2024, 13:440

https://doi.org/10.12688/f1000research.148376.1

© 2024 khan MM et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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khan MM, Shah N and Daie M. Systematic review of COVID-19 vaccine acceptance and hesitancy: global perspectives and implications. [version 2; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2024, 13:440 (https://doi.org/10.12688/f1000research.148376.2)

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Open Peer Review

Version 2

VERSION 2

PUBLISHED 23 Aug 2024

Revised

Views

Reviewer Report 06 Feb 2025

Rano K Sinuraya, Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran (Ringgold ID: 61809), Bandung, West Java, Indonesia; Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia

Not Approved

https://doi.org/10.5256/f1000research.168291.r356141

Abstract section:
1. The sentence “Internet and electronic databases were used to select research articles to obtain secondary sources” could be improved as “Electronic databases, including ScienceDirect and Google Scholar, were employed to search for relevant literature.”
2. Additionally, the sentence “The selected articles showed data collection results from different research journals” does not add significant value and can be removed.
3. I suggest rewriting the abstract in a more structured manner to clearly and concisely present the results or findings of this systematic review. Moreover, the abstract lacks a conclusion, which should be included to summarize the key takeaways of the study.

Introduction section:
1. Please add the year for the sentence at the end of the first paragraph. Similarly, the years should also be mentioned for Figures 1 and 2.
2. Cross-check the citations to ensure consistency between the text and references. Some citations do not match the referenced content. For example, the first sentence of the fourth paragraph in the introduction does not align with Reference. Please verify this issue throughout the manuscript.
3. The aim, objective, and research questions should be consolidated into a single paragraph and integrated into the preceding section for better readability.

Methods section:
1. The phrase “Internet and electronic databases” should be avoided when describing how articles were searched. Instead, simply state that "search engines such as Google Scholar and ScienceDirect were used to collect relevant articles."
2. The use of “reluctance” as a keyword raises questions, especially since “vaccine hesitancy” is already a widely recognized and indexed term in the selected databases. Additionally, “vaccine hesitancy” is used in the manuscript title. ScienceDirect itself includes “vaccine hesitancy” as a search keyword in its system, as shown here:
https://www.sciencedirect.com/topics/medicine-and-dentistry/vaccine-hesitancy and https://www.sciencedirect.com/topics/nursing-and-health-professions/vaccine-hesitancy
3. A robust search strategy is necessary to ensure the study’s validity and reproducibility. Please provide a detailed description of the search strategy used in this systematic review. Did the authors utilize Boolean operators? ScienceDirect has its own search strategy, which is similar to PubMed.
4. In systematic reviews, the PICO strategy and inclusion/exclusion criteria are commonly applied to improve article selection quality and minimize bias. While the approach may vary based on the review type, it is essential to include details about these aspects in the methodology. Additionally, please explicitly mention the PICO criteria used.
5. Verify the accuracy of article counts in Figure 3 (PRISMA Flowchart) and ensure all numbers are correctly placed in each box.
6. The section titled “Selection of studies using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Flowchart (PRISMA)” does not seem necessary under Methods. Instead, the PRISMA results should be thoroughly explained so that the study remains reproducible.
7. The explanation of thematic analysis lacks clarity. How was this analysis conducted in the study? The authors mention that this technique helped identify patterns and themes in vaccine hesitancy research, but further elaboration is needed.
8. Sections titled “COVID-19 Vaccine Reluctance Worldwide” and “Implications of COVID-19 Vaccine Uptake and Acceptance Rate Worldwide” do not seem to belong in the Methods section. These topics appear more appropriate for the Results or Discussion section

Results section:
1. It is unclear whether the authors included review articles or systematic reviews as part of their findings (Table 1). If the study reviewed other review articles, it is questionable whether this can still be considered a systematic review.
2. The methodology for article selection is not clearly defined. Further explanation is needed on how the selected articles were chosen.
3. Based on the presented findings, this article appears to be more of a narrative review than a systematic review. If that is the case, the terminology should be adjusted accordingly.
4. Ensure that the PRISMA guidelines for reporting systematic reviews are strictly followed.

Discussion section:
1. The Discussion section requires significant improvement and should be rewritten systematically.
2. The current discussion does not effectively capture the study’s findings, nor does it incorporate comparisons with previous research to enrich the interpretation.
3. To enhance the quality of the discussion, the authors should follow PRISMA guidelines, which recommend:
a) Providing a general interpretation of results in the context of existing evidence
b) Discussing any limitations of the reviewed studies
c) Identifying potential biases in the review process
d) Exploring the implications of the findings for practice, policy, and future research

Conclusion section:
1. The conclusion is difficult to assess due to the poor validity and reliability of the methodology and presented results.
2. The authors mention “risk of bias” as a limitation, but no details are provided on how bias analysis was conducted or what the results were. This should be clearly stated to improve the study's credibility.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

No
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

No
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Health Economics; Health Technology Assessment; Vaccination; Childhood Immunization; Clinical Pharmacy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Version 1

VERSION 1

PUBLISHED 02 May 2024

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Reviewer Report 11 Jun 2024

Mohammed Salim Karattuthodi, Department of Pharmacy Practice, Manipal Academy of Higher Education (MAHE), Udupi, Karnataka, India

Approved with Reservations

https://doi.org/10.5256/f1000research.162676.r277533

I would like to thank the editor for providing an opportunity to review this paper. It is well written. However, the following are some of my suggestions:-

In the second paragraph of the introduction, the statement "To date, 12.13 billion vaccine doses have been administered worldwide. " is better to mention the time period instead of ‘to date’.

Check for grammatical errors.

Even though, the " Articles published before the COVID-19 pandemic were not included in the study." this statement has been mentioned, it is better to mention the from and to date of searching the articles, in the methodology.

In the PRISMA flowchart, add the reasons for excluding articles during the second screening.

The table can also have a separate column that highlights the acceptance and hesitancy towards vaccines.

I feel the conclusion can be briefed to include only the core points of the paper.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

Yes
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Vaccine, Clinical Pharmacy, Infections

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Author Response 28 Jun 2024

Muhammad Mohsin khan, Neurosurgery, Hamad Medical Corporation, Doha, Qatar

28 Jun 2024

Author Response
Thank you very much for your insightful comments and the time you dedicated to review. I greatly appreciate your feedback and suggestions. Please find my responses to your comments below: ... Continue reading
Thank you very much for your insightful comments and the time you dedicated to review. I greatly appreciate your feedback and suggestions. Please find my responses to your comments below:

Introduction Revision:

Comment: In the second paragraph of the introduction, the statement "To date, 12.13 billion vaccine doses have been administered worldwide." is better to mention the time period instead of 'to date'.

Response: Thank you for this suggestion. I have revised the statement to specify the time period. It now reads: "As of 5th June 2023, 12.13 billion vaccine doses have been administered worldwide."

Grammatical Corrections:

Comment: Check for grammatical errors.

Response: I have thoroughly reviewed the manuscript for grammatical errors and made the necessary corrections to enhance clarity and readability.

Methodology Enhancement:

Comment: Even though "Articles published before the COVID-19 pandemic were not included in the study." this statement has been mentioned, it is better to mention the from and to date of searching the articles, in the methodology.

Response: I appreciate your suggestion. The methodology section has been updated to include the specific date range: "Articles were searched from March 2020 to January 2023."

PRISMA Flowchart Update:

Comment: In the PRISMA flowchart, add the reasons for excluding articles during the second screening.

Response: The PRISMA flowchart has been revised to include the reasons for excluding articles during the second screening, providing greater transparency in the study's selection process.

Table Modification:

Comment: The table can also have a separate column that highlights the acceptance and hesitancy towards vaccines.

Response: Thank you for this valuable suggestion. I have updated the table to include a separate column highlighting the acceptance and hesitancy towards vaccines, which should present the data more clearly.

Conclusion Streamlining:

Comment: I feel the conclusion can be briefed to include only the core points of the paper.

Response: I agree that a concise conclusion would be more effective. The conclusion has been revised to focus only on the core points of the paper, ensuring it remains succinct and impactful.

Thank you once again for your valuable feedback. Your comments have significantly contributed to improving the quality of this paper.
Thank you very much for your insightful comments and the time you dedicated to review. I greatly appreciate your feedback and suggestions. Please find my responses to your comments below:

Introduction Revision:

Comment: In the second paragraph of the introduction, the statement "To date, 12.13 billion vaccine doses have been administered worldwide." is better to mention the time period instead of 'to date'.

Response: Thank you for this suggestion. I have revised the statement to specify the time period. It now reads: "As of 5th June 2023, 12.13 billion vaccine doses have been administered worldwide."

Grammatical Corrections:

Comment: Check for grammatical errors.

Response: I have thoroughly reviewed the manuscript for grammatical errors and made the necessary corrections to enhance clarity and readability.

Methodology Enhancement:

Comment: Even though "Articles published before the COVID-19 pandemic were not included in the study." this statement has been mentioned, it is better to mention the from and to date of searching the articles, in the methodology.

Response: I appreciate your suggestion. The methodology section has been updated to include the specific date range: "Articles were searched from March 2020 to January 2023."

PRISMA Flowchart Update:

Comment: In the PRISMA flowchart, add the reasons for excluding articles during the second screening.

Response: The PRISMA flowchart has been revised to include the reasons for excluding articles during the second screening, providing greater transparency in the study's selection process.

Table Modification:

Comment: The table can also have a separate column that highlights the acceptance and hesitancy towards vaccines.

Response: Thank you for this valuable suggestion. I have updated the table to include a separate column highlighting the acceptance and hesitancy towards vaccines, which should present the data more clearly.

Conclusion Streamlining:

Comment: I feel the conclusion can be briefed to include only the core points of the paper.

Response: I agree that a concise conclusion would be more effective. The conclusion has been revised to focus only on the core points of the paper, ensuring it remains succinct and impactful.

Thank you once again for your valuable feedback. Your comments have significantly contributed to improving the quality of this paper.
Competing Interests: No competing interests Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 28 Jun 2024

Muhammad Mohsin khan, Neurosurgery, Hamad Medical Corporation, Doha, Qatar

28 Jun 2024

Author Response
Thank you very much for your insightful comments and the time you dedicated to review. I greatly appreciate your feedback and suggestions. Please find my responses to your comments below: ... Continue reading
Thank you very much for your insightful comments and the time you dedicated to review. I greatly appreciate your feedback and suggestions. Please find my responses to your comments below:

Introduction Revision:

Comment: In the second paragraph of the introduction, the statement "To date, 12.13 billion vaccine doses have been administered worldwide." is better to mention the time period instead of 'to date'.

Response: Thank you for this suggestion. I have revised the statement to specify the time period. It now reads: "As of 5th June 2023, 12.13 billion vaccine doses have been administered worldwide."

Grammatical Corrections:

Comment: Check for grammatical errors.

Response: I have thoroughly reviewed the manuscript for grammatical errors and made the necessary corrections to enhance clarity and readability.

Methodology Enhancement:

Comment: Even though "Articles published before the COVID-19 pandemic were not included in the study." this statement has been mentioned, it is better to mention the from and to date of searching the articles, in the methodology.

Response: I appreciate your suggestion. The methodology section has been updated to include the specific date range: "Articles were searched from March 2020 to January 2023."

PRISMA Flowchart Update:

Comment: In the PRISMA flowchart, add the reasons for excluding articles during the second screening.

Response: The PRISMA flowchart has been revised to include the reasons for excluding articles during the second screening, providing greater transparency in the study's selection process.

Table Modification:

Comment: The table can also have a separate column that highlights the acceptance and hesitancy towards vaccines.

Response: Thank you for this valuable suggestion. I have updated the table to include a separate column highlighting the acceptance and hesitancy towards vaccines, which should present the data more clearly.

Conclusion Streamlining:

Comment: I feel the conclusion can be briefed to include only the core points of the paper.

Response: I agree that a concise conclusion would be more effective. The conclusion has been revised to focus only on the core points of the paper, ensuring it remains succinct and impactful.

Thank you once again for your valuable feedback. Your comments have significantly contributed to improving the quality of this paper.
Thank you very much for your insightful comments and the time you dedicated to review. I greatly appreciate your feedback and suggestions. Please find my responses to your comments below:

Introduction Revision:

Comment: In the second paragraph of the introduction, the statement "To date, 12.13 billion vaccine doses have been administered worldwide." is better to mention the time period instead of 'to date'.

Response: Thank you for this suggestion. I have revised the statement to specify the time period. It now reads: "As of 5th June 2023, 12.13 billion vaccine doses have been administered worldwide."

Grammatical Corrections:

Comment: Check for grammatical errors.

Response: I have thoroughly reviewed the manuscript for grammatical errors and made the necessary corrections to enhance clarity and readability.

Methodology Enhancement:

Comment: Even though "Articles published before the COVID-19 pandemic were not included in the study." this statement has been mentioned, it is better to mention the from and to date of searching the articles, in the methodology.

Response: I appreciate your suggestion. The methodology section has been updated to include the specific date range: "Articles were searched from March 2020 to January 2023."

PRISMA Flowchart Update:

Comment: In the PRISMA flowchart, add the reasons for excluding articles during the second screening.

Response: The PRISMA flowchart has been revised to include the reasons for excluding articles during the second screening, providing greater transparency in the study's selection process.

Table Modification:

Comment: The table can also have a separate column that highlights the acceptance and hesitancy towards vaccines.

Response: Thank you for this valuable suggestion. I have updated the table to include a separate column highlighting the acceptance and hesitancy towards vaccines, which should present the data more clearly.

Conclusion Streamlining:

Comment: I feel the conclusion can be briefed to include only the core points of the paper.

Response: I agree that a concise conclusion would be more effective. The conclusion has been revised to focus only on the core points of the paper, ensuring it remains succinct and impactful.

Thank you once again for your valuable feedback. Your comments have significantly contributed to improving the quality of this paper.
Competing Interests: No competing interests Close
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Version 2

VERSION 2 PUBLISHED 02 May 2024

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2
Version 2 (revision) 23 Aug 24		read
Version 1 02 May 24	read

Mohammed Salim Karattuthodi, Manipal Academy of Higher Education (MAHE), Udupi, India
Rano K Sinuraya, Faculty of Pharmacy, Universitas Padjadjaran (Ringgold ID: 61809), Bandung, Indonesia; Universitas Padjadjaran, Bandung, Indonesia

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Reviewer Report

1 Views

06 Feb 2025 | for Version 2

1 Views Cite this report Responses(0)

Not Approved

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

No
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

No
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Health Economics; Health Technology Assessment; Vaccination; Childhood Immunization; Clinical Pharmacy

Respond to this report

Responses (0)

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Reviewer Report

13 Views

11 Jun 2024 | for Version 1

Mohammed Salim Karattuthodi, Department of Pharmacy Practice, Manipal Academy of Higher Education (MAHE), Udupi, Karnataka, India

13 Views Cite this report Responses(1)

Approved With Reservations

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Partly
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

Yes
If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.)

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Vaccine, Clinical Pharmacy, Infections

Respond to this report

Responses (1)

Author Response

28 Jun 2024

Muhammad Mohsin khan, Neurosurgery, Hamad Medical Corporation, Doha, Qatar

Thank you very much for your insightful comments and the time you dedicated to review. I greatly appreciate your feedback and suggestions. Please find my responses to your comments below:

Introduction Revision:
- Comment: In the second paragraph of the introduction, the statement "To date, 12.13 billion vaccine doses have been administered worldwide." is better to mention the time period instead of 'to date'.
- Response: Thank you for this suggestion. I have revised the statement to specify the time period. It now reads: "As of 5th June 2023, 12.13 billion vaccine doses have been administered worldwide."
Grammatical Corrections:
- Comment: Check for grammatical errors.
- Response: I have thoroughly reviewed the manuscript for grammatical errors and made the necessary corrections to enhance clarity and readability.
Methodology Enhancement:
- Comment: Even though "Articles published before the COVID-19 pandemic were not included in the study." this statement has been mentioned, it is better to mention the from and to date of searching the articles, in the methodology.
- Response: I appreciate your suggestion. The methodology section has been updated to include the specific date range: "Articles were searched from March 2020 to January 2023."
PRISMA Flowchart Update:
- Comment: In the PRISMA flowchart, add the reasons for excluding articles during the second screening.
- Response: The PRISMA flowchart has been revised to include the reasons for excluding articles during the second screening, providing greater transparency in the study's selection process.
Table Modification:
- Comment: The table can also have a separate column that highlights the acceptance and hesitancy towards vaccines.
- Response: Thank you for this valuable suggestion. I have updated the table to include a separate column highlighting the acceptance and hesitancy towards vaccines, which should present the data more clearly.
Conclusion Streamlining:
- Comment: I feel the conclusion can be briefed to include only the core points of the paper.
- Response: I agree that a concise conclusion would be more effective. The conclusion has been revised to focus only on the core points of the paper, ensuring it remains succinct and impactful.

Thank you once again for your valuable feedback. Your comments have significantly contributed to improving the quality of this paper.

View more View less

Competing Interests

No competing interests

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Systematic review of COVID-19 vaccine acceptance and hesitancy: global perspectives and implications.

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Figure 1. Current Statistics of COVID-19 by Region.

Figure 2. Vaccinations of COVID-19.

Aim and objectives

Research question

Methods

Research strategy

Inclusion and exclusion criteria

Selection of studies using preferred reporting items for systematic reviews and meta-analyses flowchart (PRISMA)

Figure 3. PRISMA flowchart.

Data analysis

COVID-19 vaccine reluctance worldwide

Implications of COVID-19 vaccine uptake and the acceptance rate of the COVID-19 vaccine worldwide

Findings

Table 1. Aggregate analysis of included studies.

Discussion

Conclusion and recommendations

Conclusions

Limitations

Recommendations

Ethics and consent

Data availability statement

Underlying data

Extended data

Reporting guidelines

References

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