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COVID-19 vaccine causes of acceptance and rejection among ‎university students ‎in Baghdad
Sahyma Ali 1, Raid Hashim 2* and Israa Ali3
1    Ministry of Health, Alrusafa directorate, Baghdad, Iraq; [email protected],
2    Al-Rasheed University College; [email protected],
3  Ministry of Health, Alrusafa directorate, Baghdad, Iraq; [email protected],
*Corresponding author. v[email protected]
Available from:


Despite numerous recommendations concerning individual and social ‎preventive measures, including quarantine, wearing a mask, physical distancing, and ‎handwashing, vaccination with effective and safe vaccines is still the most effective ‎measure to break the chain of coronavirus SARS-Co2 transmission; still, vaccine ‎hesitancy is a significant barrier to achieve high vaccination coverage against infectious ‎diseases.‎
An observational cross-sectional study was conducted among students of ‎different universities (medical and non-medical) in Baghdad city Iraq using an online ‎structured google form questionnaire from October 20 to November 20, ‎‎2021, and a final number of 658 students were included in the study. Causes of ‎acceptance and rejection of the coronavirus vaccine were tested through the questionnaire.‎  
Of the total 658 participants, 557(84.7%) had received the vaccine before the ‎start of the study and only 101 (15.3%) were not vaccinated; of them, more than half ‎‎, 58(57.4%) were willing to, and the remaining 43(42.6%) refused to receive COVID-19 ‎vaccination. Accordingly, the acceptance rate of the vaccine among the total ‎participants was 93.5%, and the rejection rate was only 6.5%.‎  
The most chosen cause of vaccine acceptance was that they believed the vaccine ‎protected them, their families and the community against COVID-19 infection and its ‎complications with 63.5%. The most chosen rejection cause was fear of side effects ‎of the vaccine, with 62% of the rejecting participants, followed by 28% having doubts about the vaccine's efficiency in protecting against COVID-19 infection.‎
In this study, although the majority of the participants were willing to be ‎vaccinated, still around one-third of them were under pressure from the government ‎obligations and did not accept the vaccine due to their own convictions; education ‎programs should be designed and directed to remove barriers to negative vaccine ‎beliefs and perception to increase the vaccine coverage in the community.‎
Keywords: COVID-19 vaccination, university students, vaccine acceptance, vaccine ‎rejection.‎

Globally, the coronavirus disease 2019 (COVID-19) caused by the novel severe acute ‎respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused illness and death in different populations ‎more than any other pandemic in the last hundred years. As of October 22, ‎‎2021, nearly 242 million people had been infected, while 4.9 million had died ‎worldwide1.‎
The pandemic of COVID‐19 is considered a global challenge for all countries worldwide to contain its spread. Efforts and campaigns for prevention, early diagnosis, ‎and medical management are being led by the World Health Organization (WHO) and ‎numerous research teams and clinical experts worldwide. There are nonspecific ‎antiviral medications for COVID‐19, and among the used drugs, few showed success ‎in reducing mortality among patients with COVID‐19; in addition, compliance of ‎humans with social distancing and using face masks for prevention is unguaranteed. ‎Thus, the best strategy to control and gradually silence this pandemic is to develop ‎an effective vaccine2. ‎
In December 2020, several vaccines were authorized to prevent COVID-19 infection ‎, and although vaccines have been a successful measure of disease prevention for ‎decades, however, vaccine hesitancy and refusal are significant concerns globally, ‎prompting the World Health Organization (WHO) to declare this uncertainty among ‎the top 10 health threats in 20193.‎
World Health Organization defines vaccine hesitancy as a "delay in accepting or refusing safe vaccines despite availability of vaccine services." It is caused by ‎complex and different specific factors that vary across time, place, and other ‎vaccines and is influenced by issues such as complacency, convenience, confidence, ‎and sociodemographic contexts. Vaccine hesitancy could be related to misinformation ‎and wrong theories often spread online, including social media4.‎
As mentioned above, vaccines are one of the most effective tools for protecting ‎people against COVID-19. It is not uncommon for governments and institutions to ‎mandate specific actions or types of behavior to protect the wellbeing of ‎individuals or communities and overcome vaccine refusal. Such policies ‎can be ethically justified, as they may be crucial to protecting the health and wellbeing of ‎the public; still, critical ethical considerations and caveats should be explicitly ‎evaluated and discussed by governments and/or institutional policy-makers who may ‎be considering mandates for COVID-19 vaccination5.‎
In Iraq, significant transmission and the rise in case numbers put enormous pressure ‎on hospitals, intensive care units, and health workers. While preventive measures ‎can effectively reduce virus transmission, their effectiveness depends on strict ‎application by all citizens. The vaccines arrived in March 2021, ‎accompanied by the launch of a nationwide vaccination campaign that hoped to be a ‎game-changer in the battle against COVID-19.‎
In Iraq, as in other countries worldwide, hesitancy and refusal of COVID-19 ‎vaccination is challenging as the acceptance rate in most Arab countries is not high ‎6. For this reason, this study aims to explore the level of COVID‐19 vaccine ‎acceptance and refusal among university students and determine the factors and ‎barriers that may affect vaccination decision‐making among them since they are ‎considered an important target group for vaccination now as the study returned ‎from online to actual in-school study this year.‎


Study Design and Setting
An observational cross-sectional study was conducted ‎among students of different universities (medical and non-medical) in Baghdad city ‎Iraq using an online structured google form questionnaire from October 20 to ‎November 20, 2021; a total number of 693 participants answered the ‎questionnaire of those 35 answers were discarded as they did not meet the research ‎credibility and the remaining 658 were included in the study.‎ We have used Gmail as the main way of contact with participants after an initial announcement about the study in the social groups of medical students in Baghdad universities.

‎The questionnaire
The researchers designed and developed the questionnaire after literature reviews 7-9. The questionnaire was developed in  ‎English and then translated into Arabic, the primary language in Iraq. ‎A panel of experts confirmed the content validity of the questionnaire. It was designed ‎using google Forms and distributed online to the students.‎
The questionnaire consisted of three main parts; the first included the sociodemographic ‎characteristics of the participants, whether they received the COVID-19 vaccine or not; the second part had the causes of acceptance to receive the vaccine, which should ‎be answered by those who received or willing to receive the vaccine soon or in the ‎future. In contrast, the third part contains the causes of refusal of the vaccine, which should be ‎answered by those who rejected the vaccine. All of the questions were assigned ‎to be mandatory responses to items to avoid incompleteness and missing data.‎

‎Ethical consideration
Research ethical approval and permission from Baghdad ‎Al-Rusafa health directorate for collection of data and performance of the study and ‎permission was taken from all the participants with confidentiality and privacy of data ‎were guaranteed during the study, the collected personal information was stored in ‎secure folders that could only be accessed by the researchers and protected from any ‎unauthorized access.‎ The privacy and confidentiality and how to be guaranteed were explained to all participants.

‎Data Analysis
All data were collected into the Excel sheet and statistically ‎analyzed using SPSS software version 26; simple descriptive analyses, including ‎frequencies and percentages, were computed for demographic characteristics, and the ‎chi-square test was used to find associations between sociodemographic ‎factors and the acceptance or rejection of the participants to the vaccine, a P ‎value of equal or less than 0.05 is considered significant


The study included 658 students from different universities in Baghdad; of those, 367 ‎‎(55.8%) were medical students (including medicine, dentistry and pharmacy) and 291 ‎‎(44.2%) were non-medical students, 374(56.8%) were female, 284 (43.2%) were ‎male.‎
Age was not a parameter in our study since all the participants were in the same age ‎group (18-24 years).‎
‎622(94.9%) of the participants were unmarried, 32 (4.9%) were married, and only 4 ‎‎(0.6%) were divorced or widows; regarding chronic diseases, the majority, 594 (90.3%), ‎had no chronic diseases (table1).‎

Table1. Sociodemographic characteristics and their effect and association with acceptance and rejection of COVID-19 vaccine

Of the participants, 557(84.7%) had received the vaccine before the start of the study ‎, and only 101 (15.3%) were not vaccinated; of them, more than half, 58(57.4%), were ‎willing to, and the remaining 43(42.6%) refused to receive COVID-19 vaccination. ‎Accordingly, the acceptance rate of the vaccine among the total participants was ‎‎93.5%, and the rejection rate was only 6.5% (Table 1).‎
Of those who received or were willing to receive the vaccine and were allowed to ‎choose more than one cause, 63.5% accepted to receive the vaccine because they ‎believed that it protected them, their families and the community against COVID-19 ‎infection and its complications. In contrast, 37% accepted the vaccine because of the ‎obligation put by the government and the university to attend classes and continue ‎their study, and 47.6% mentioned that the cause of acceptance was the pressure of ‎their families to receive the vaccine, which may reflect the belief of these families in ‎the effectiveness of the vaccine in the protection of their sons and daughters from ‎infection (table 2).‎

Table 2. Causes of acceptance of the COVID -19 vaccine among the participants who accept the vaccine
Regarding the causes of rejection of the vaccine,  again, the participants who rejected the ‎vaccine were allowed to choose more than one cause, and the most frequently selected ‎reason was that they were afraid of the side effects of the vaccine, with 62% of the ‎rejecting participant, followed by 28% had doubts in the efficiency of the vaccine in ‎protection against COVID-19 infection, then 18.6% reject the vaccine as their ‎families refused it. At the same time, 14.7% and another 14% rejected the vaccine because they feared its effect on their chronic diseases and due to the information found in ‎social media against the vaccine, respectively.‎
None of the participants who rejected the vaccine chose each of the two causes, which ‎are not believing in the existence of COVID-19 infection and taking the vaccine can ‎lead to the spread of the disease to others (table 3).‎

Table 3. Causes of rejection of the COVID-19 vaccine among those who reject the vaccine

We tried to find if there is any association between the sociodemographic ‎characteristics and the acceptance or rejection of the vaccine; in a total of 615 who ‎accepted the vaccine, the females had a higher acceptance rate (57.3%) compared to ‎receiving males (42.7%), but no statistical significance found.‎
There was a statistically significant association between the type of study and accepting ‎the vaccine as those with medical studies 55.8% received the vaccine compared to ‎those of non-medical studies with only 44.2%.‎
As the vast majority of the participant students were not married (94.5%) so, the ‎majority of those who accepted the vaccine was also not married (94.5%) among the ‎total vaccine acceptant, but what is noted is that all those divorced or widows ‎accepted the vaccine, but since they represent only 0.7% of the total participants, again ‎they constituted a small portion of those who accept the vaccine (0.6%).‎
‎ The same thing applied to those with no chronic disease as they represent 90.3% of ‎the total participants, so 91% of those who accepted the vaccine had no chronic ‎diseases, but again statistically significant association was not found (Table 1).  ‎
Regarding rejection of the vaccine in a total of 43 rejecting participants, the only ‎statistically significant association was found with marital status as a higher ‎rejection rate (95.3%) in the non-married compared to (4.7%) in those who were ‎married. ‎
Those with no chronic illness rejected the vaccine (81.4%) more than those with chronic ‎diseases (18.6%), but no great effect of the sex or type of study was found on the ‎rejection of the vaccine (Table 1).‎


Vaccination coverage is highly influenced by its acceptability, while vaccine hesitancy is ‎a barrier to achieving high vaccination coverage against infectious diseases. Therefore, ‎understanding its determinants is necessary to aid acceptability and tackle vaccine ‎hesitancy, and this is applied to the COVID-19 vaccine10.‎
Our study was conducted on university students since they are an essential ‎knowledgeable part of the community to assess their acceptance and rejection of the ‎COVID-19 vaccine and the factors affecting their will regarding receiving it.‎
The study showed a high acceptance rate among participants of 93.5% compared to ‎‎56.3% in a study on university students in the United Arab Emirates11 and only 37.3% ‎of medical students in Uganda12 and 34.9% of Egyptian medical students2.‎
This high acceptance was in the majority (63.5%) due to the belief of the importance of ‎the vaccine in protection against the COVID-19 infection, and 47.6% accept the vaccine ‎under the will and pressure of their families which may also reflect the belief of the ‎parents in the importance of the vaccine in the protection of their sons and daughters, this ‎in the collection reveals that education, positive attitude and beliefs are related to higher ‎willingness to vaccination and higher coverage rate which is found in a study on medical ‎students in Europe13.‎
In addition, 37% accept the vaccine due to the obligations and rules put by the ‎government and the university; this factor also causes a higher acceptance score among ‎students in a study done in South Carolina14.‎
Although the rejection rate was low (6.5%) we tried to find the factors that caused this ‎decision, here the fear of side effects of the vaccine was the most chosen factor (62%); the ‎same finding was found in a Turkish study on nursing students15 and a study among ‎Malaysians7 and Bangladesh16 where this was the most causative factor for ‎hesitancy and refused of the vaccine. Although primarily non-serious, side effects can ‎make vaccination a disagreeable experience and side effect concerns are among the most ‎common causes of vaccine hesitancy; for example, a recent US poll found 90% of ‎COVID-19 vaccination refusers were more worried about vaccine side effects than ‎COVID-19 infection itself which may be related to psychological factors17. ‎
The next commonest cause (28%) of rejection was that they believed the vaccine was not ‎effective in protecting them against the infection same as in the Malaysian study (8) and the ‎same in a study in Saudi Arabia which showed the majority of refusers may accept the ‎vaccine if additional studies confirmed safety and effectiveness18.‎
‎14% of rejecting students mentioned that they rejected the vaccine due to the effect of ‎information on social media; this reflected the negative effect of the misinformation found ‎on social media on the acceptance of vaccination, as in the study done in the United ‎Kingdom and the United States which showed that scientific-sounding misinformation is ‎more strongly associated with declines in COVID-19 vaccination intent19.‎
It is noted that no one of the rejecters chose the causes that they do not believe in the ‎existence of COVID-19 infection. If they receive the vaccine, they may spread the ‎virus to others, which are wrong belief found around the population, but our ‎study group (university students) found it to be away from these beliefs. ‎
Regarding sociodemographic characteristics, the female students had a higher acceptance ‎rate which is the same as the study on Czech university students20.‎
A statistically significant association was found regarding the type of study with ‎acceptance of the vaccine as the medical had a higher acceptance rate (55.8%) compared ‎to non-medical students (44.2%); the same finding was found in a study done in Pakistan ‎as medical students were more willing to get vaccinated, largely owing to their ‎knowledge and understanding of vaccines21, this explanation could be applied to our ‎study, in addition to their increased risk of exposure during their study courses in the ‎hospitals and medical centers that make them willing to be vaccinated.‎
Students with no chronic diseases had a higher acceptance rate compared to those with ‎chronic diseases since there is only 9.7% of the total participant had chronic diseases, but ‎we found that of a total of 64 students with chronic diseases, the acceptance rate was  87.5% ‎which is still lowest than 94% found in the remaining 594 students without chronic ‎conditions; also this could be related to fear from the effect of the vaccine on the chronic ‎diseases which contributed to 14% of the causes of vaccine rejection in this study. ‎
There is a statistically significant association between marital status and rejection of the ‎vaccine, where the non-married had a higher rejection rate among those who rejected the ‎vaccine (95.3%), and this could be related to the small percentage of the married students ‎‎(4.9%) compared to 94.5% of non-married among the total participants. This is contrary ‎to a study done in China, where vaccine rejection was higher among the married ‎population22.‎
At the time of the start of this research, we directed our study to the university students ‎since they were targeted to be vaccinated by the government as their study returned from ‎the remote online to the regular university in presence lectures, which necessitated their ‎protection against COVID-19 infection by vaccination.‎


The majority of the participants were willing to be vaccinated, still around one-third ‎of them were under pressure the government obligations and did not accept the vaccine ‎due to their conviction; others accepted the vaccine due to the will of their families ‎, which reflects that although there is a pandemic and the best way to protect themselves ‎and others is vaccination, still, there is some degree of hesitation even in the educated ‎groups as the university students in our study.‎ As we tried to find the most important causes of vaccine rejection, which were fear of ‎the side effects of the vaccine and doubt about the efficiency of the vaccine, so, the ‎COVID-19 pandemic immunization and education programs should be designed and ‎directed to remove barriers to negative vaccine beliefs and perception to increase the ‎vaccine coverage in the community.‎ Further studies are needed on other and broader groups of the Iraqi population and focus ‎on the effect of vaccine education and an attempt to change attitudes and beliefs on vaccine ‎acceptance.‎ The rules and legislations put by the government by making the COVID-19 ‎vaccination a must for entering college classes and public places play an important role in ‎increasing vaccine coverage.‎
Author Contributions: Conceptualization, Shayma Ali.; methodology, Israa Ali.; software, Raid Hashim; validation, Raid ‎Hashim, Shayma Ali and Israa Ali; formal analysis, Shayma Ali and Israa Ali; investigation, Raid ‎Hashim; resources, Israa Ali; data curation, Shayma Ali; writing—original draft preparation, ‎Shayma Ali; writing—review and editing, Raid Hashim; visualization, Raid Hashim; supervision, ‎Israa Ali; project administration, Shayma Ali; funding acquisition, Israa Ali. ‎
Funding: This research received no external funding.‎
Institutional Review Board Statement: The study was conducted following the Declaration of Helsinki and approved by the Ethics Committee of the Iraqi ministry of health.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Written informed consent has been obtained from the participants to publish this paper.
Data Availability Statement: Not applicable
Conflicts of Interest: The authors declare no conflict of interest

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Received: January 15, 2023 / Accepted: February 25, 2023 / Published:15 March 2023

Citation: Ali S, Hashim R, Ali I. COVID-19 vaccine causes of acceptance and rejection among ‎university students ‎in Baghdad. Revis Bionatura 2023;8 (1) 59.    
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