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Original Article
The determinants of SARS-CoV-2 vaccine hesitancy in a rural area of an Indonesia–Philippines border island: A mixed-method study
Determinantes de la indecisión ante la vacuna contra el SARS-CoV-2 en una zona rural de una isla fronteriza entre Indonesia y Filipinas: estudio de métodos mixtos
Chandrayani Simanjorang
Corresponding author
simanjorangyani@gmail.com

Corresponding author.
, Nansy Pangandaheng, Yeanneke Tinungki, Gitalia Putri Medea
Health Department, State Polytechnic of Nusa Utara
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the goal is to vaccinate 181 million Indonesians to achieve herd immunity in populations 18 years and over&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The targeted immunization rate can be hampered by the presence of vaccine hesitancy among communities&#46; Vaccine hesitancy is the delay in vaccine acceptance or refusal of vaccination despite the availability of vaccination services&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Vaccine hesitancy is a worldwide phenomenon&#46; A cross-sectional study on COVID-19 vaccine hesitancy among caregivers from the USA&#44; Canada&#44; Israel&#44; Spain&#44; Japan and Switzerland showed its prevalence to be 35&#37; &#40;95&#37; CI&#8239;&#61;&#8239;32&#8211;37&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In concordance&#44; the prevalence of Measles Rubella &#40;MR&#41; vaccine hesitancy varied from 14&#46;1&#37; in India to 33&#37; in Indonesia&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> A recent study in urban area of Indonesia&#44; also found a 35&#44;2&#37; of vaccine hesitancy&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; the results of these studies cannot represent rural areas in Indonesia&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There has been limited research on the determinants and prevalence of vaccine hesitancy in rural areas using a mixed method&#46; Sangihe Island is one of the outer islands of Indonesia&#44; which is directly adjacent to the Philippines&#46; As an island that constitutes mostly rural areas&#44; it must be prioritised in handling the pandemic due to various limitations&#44; including limited access to health services&#44; limited information and a middle-average income &#40;IDR 2&#46;69 million per person per month&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Meanwhile&#44; the number of COVID cases in North Sulawesi reached 15&#44;670&#44; of which 313 were in the Sangihe Island&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Therefore&#44; this study aims to comprehensively determine the prevalence and determinants of the SARS-CoV-2 vaccine hesitancy&#46; The results of this study can inform governments&#8217; and decision makers&#8217; policies regarding the SARS-CoV-2 infection vaccination program in Indonesia&#44; which is an archipelagic country&#44; and other countries in Southeast Asia that have the same characteristics&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0035" class="elsevierStylePara elsevierViewall">This study uses a sequential explanatory mixed-method approach&#44; which is a method that combines quantitative and qualitative data where the qualitative data aims to expand and deepen the results of the quantitative data&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> Quantitative data were collected using cross-sectional data collection&#46; Meanwhile&#44; qualitative data were collected through in-depth interviews to explore information about people&#8217;s perceptions of the SARS-CoV-2 vaccine&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Population and study setting</span><p id="par0040" class="elsevierStylePara elsevierViewall">The study was conducted on an Indonesian-Philippines border island called the Sangihe Island of North Sulawesi&#46; Residents mostly live in rural areas&#46; This island is a district with 15 sub-districts that has a population of approximately 130&#44;000 people&#46; There are two public hospitals&#44; and the referral hospital is a provincial-level hospital 10&#8239;h away by motorboat&#46; At the time of the study&#44; a vaccination program for health workers followed by educators and the general population was in progress&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Quantitative data collection targets were adult residents &#40;aged &#8805;18 years&#41; of Sangihe Island&#44; and the samples were recruited from across the 15 sub-districts&#46; Those who worked in health sectors were excluded from this study&#46; Quantitative data collection was conducted from 16 February 2021 to 28 February 2021&#46; The study was conducted after the Sinovac vaccine was available in Indonesia&#44; which showed an efficacy of 65&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The sample calculation used a sample size formula for estimating proportion&#44; namely n&#8239;&#61;&#8239;Z<span class="elsevierStyleInf">1-&#945;&#47;2</span> P&#40;1-P&#41;&#47;d&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;14</span></a> where the P-value is the proportion of vaccine acceptance from previous studies in Indonesia&#44; namely 64&#46;8&#37; &#40;P&#8239;&#61;&#8239;0&#46;65&#41;&#46; The value of d &#40;acceptable standard deviation&#41; was 5&#37; &#40;d&#8239;&#61;&#8239;0&#46;05&#41;&#44; and a 95&#37; confidence degree &#40;Z&#945;&#8239;&#61;&#8239;1&#46;96&#41; showed the total value of N&#8239;&#61;&#8239;350 samples&#46; To adjust for the sampling method&#44; a design effect of 1&#46;5 was used&#44; and the final sample size was 525&#46; Snowball sampling was used for quantitative sampling&#46; Priority for participation was given to the population in sub-districts geographically spread out and easy to reach&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the qualitative phase&#44; we interviewed at least 30 adult citizens from five sub-districts&#46; The samples &#40;participants&#41; were selected using a purposive sampling technique&#46; The research instrument was the researcher himself who used an interview guide&#46; The questions in the interview guide aimed to find out the public&#8217;s perceptions regarding the SARS-CoV-2 vaccine and the reasons why they accepted&#47;rejected the vaccination&#46; Qualitative data collection was conducted from 1 March 2021 to 14 March 2021&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0060" class="elsevierStylePara elsevierViewall">To assess respondents&#8217; perceptions of the SARS-CoV-2 vaccine&#44; respondents were asked questions about their willingness to be vaccinated&#46; The answers &#8216;hesitate&#47;refuse&#8217; or &#8216;accept&#8217; and the reason if the answer was &#8216;hesitate&#47;refuse&#8217; were gathered&#46; Several explanatory variables were also collected through questionnaires&#46; Specifically&#44; these were socio-demographic variables&#44; such as age&#44; gender&#44; education&#44; occupation&#44; religion&#44; marital status&#44; source of information on the vaccine&#44; income&#44; willingness to pay and economic status&#46; Economic status was categorised as &#8216;poor&#8217; for those living below the national poverty line&#44; or around IDR 354&#44;000 per person per month&#59; as &#8216;vulnerable&#8217; for those living above the poverty line but with a non-negligible risk of falling into poverty&#44; or between IDR 354&#44;000 and IDR 532&#44;000 per person per month&#59; as &#8216;aspiring middle class&#8217; for those no longer living in poverty or vulnerability but who are not yet economically secure&#44; or between IDR 532&#44;000 and IDR 1&#46;2 million per person per month and &#8216;middle&#47;upper class&#8217; for economically secure Indonesians with little chance of falling into poverty or vulnerability&#44; or more than IDR 1&#46;2 million per person per month&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Another variable is the knowledge variable related to the SARS-CoV-2 vaccine&#44; which was assessed using 15 questions&#46; Participants with 60&#37; or more correct answers were categorised as having &#8216;good knowledge&#8217;&#44; and participants with fewer than 60&#37; correct answers were categorised as having &#8216;poor knowledge&#8217;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data collection</span><p id="par0070" class="elsevierStylePara elsevierViewall">The quantitative research instrument used was a questionnaire taken from previous research and validated&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The enumerator distributed questionnaires to the first group of participants via social media&#44; a WhatsApp group and email&#46; Next&#44; the first group was asked to distribute the link of questionnaires to the second group and so on&#46; Once a participant opened the questionnaire link&#44; they filled in the informed consent or willingness to become a participant&#46; For people who did not have internet access&#44; questionnaires were distributed in hardcopy&#44; and the enumerator asked for the willingness of participants to continue to carry out their health protocols due to the pandemic&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Internal validity was maintained by enforcing good data management practices&#46; Each participant had a unique ID to prevent double counting&#46; It was unlikely that one participant filled out the questionnaire two times &#40;offline and online&#41; because the offline questionnaire was only for those who did not have internet access&#46; Data collection was carried out using non-probability sampling so that it could not guarantee the representation of the entire population on one island &#40;district&#41;&#46; However&#44; the sample came from all existing sub-districts&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The qualitative research instrument was an interview guide for in-depth interviews&#46; The questions in the guide aimed to find out people&#8217;s perceptions regarding the SARS-CoV-2 vaccination&#46; The research instrument was the researcher using interview guidelines&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The interviewer had a postgraduate degree with experience conducting qualitative research in the health sector&#46; The interviewer was also a resident in the research community who understood the local language and customs&#46; The interview began after obtaining approval by explaining the purpose and motive of the study&#46; Each interview took at least 45&#8239;min&#8211;30&#8239;min for exploring the participants&#8217; perceptions of vaccination and 15&#8239;min for the introduction&#46; The privacy of informants was maintained by conducting interviews in a special room without the presence of non-participants&#46; All information provided by the informant was kept strictly confidential&#46; All interview processes were recorded with the participants&#8217; consent&#46; Field notes were taken during interviews&#46; At the end of the interviews&#44; a summary was presented to the participants for the validation of the data collected&#46; Transcription was carried out using a verbatim format within 2 days of data collection to prevent information loss&#46; The interviewer&#39;s relationship with the participants was equal&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">Data analysis for the quantitative phase was conducted using a logistic regression model to clarify the determinants of SARS-CoV-2 vaccine hesitancy&#46; The first step was to perform a bivariate &#40;chi-squared&#41; analysis to select a candidate as the independent variable&#46; Associations between explanatory variables and vaccine hesitancy were analysed separately&#46; In the second step&#44; all variables with a P-value &#8804;0&#46;25 &#40;age group&#44; education&#44; occupation and marital status&#41; in the first step were included in the adjusted analysis&#46; The crude odds ratio &#40;OR&#41; and adjusted odds ratio &#40;aOR&#41; in the multivariate analysis were assessed at <span class="elsevierStyleItalic">&#945;</span>&#8239;&#61;&#8239;0&#46;05 with a 95&#37; confidence interval &#40;95&#37; CI&#41;&#46; All statistical analyses used SPSS software &#40;25th version&#44; International Business Machines Corp&#46;&#44; New York&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Data analysis for the qualitative phase was carried out using the Colaizzi method&#46; We conducted triangulation to maintain the validity of the data&#46; Triangulation was carried out by more than one researcher in analysing and collecting data to avoid researcher subjectivity&#46; In addition&#44; the researchers did member checking by validating the data from participants&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical considerations</span><p id="par0100" class="elsevierStylePara elsevierViewall">The protocol of this study was approved by the Health Research Ethics Committee of Manado Health Polytechnic&#44; Ministry of Health &#40;KEPK&#46;01&#47;02&#47;008&#47;2021&#41;&#46; All participants were informed of the purpose of this study and were asked to provide their informed consent&#46; All personal information was kept confidential and not reported in this paper&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Quantitative part</span><p id="par0105" class="elsevierStylePara elsevierViewall">A total of 584 people aged 18&#8211;89 years participated in this study&#59; 19 respondents worked as health workers&#44; and 8 respondents who did not complete the questionnaire were completely excluded from the research data&#46; The total number of respondents included was 557 &#40;95&#46;3&#37; response rate&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The prevalence of SARS-CoV-2 vaccine hesitancy was found to be 63&#46;9&#37; &#40;95&#37; CI&#58; 59&#46;8&#37;&#8211;67&#46;9&#37;&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the association between socio-demographic characteristics and vaccine hesitancy&#46; In the first step &#40;before the adjustment&#41;&#44; there were three variables that were significantly related to vaccine hesitancy&#58; education&#44; knowledge towards the SARS-CoV-2 infection vaccination and willingness to pay&#46; After the adjustment&#44; the results showed that respondents with a diploma&#47;university education were less likely to hesitate to get vaccinated compared to those with a primary&#47;junior high school education &#40;aOR&#58; 0&#46;40&#59; 95&#37; CI&#58; 0&#46;22&#8211;0&#46;70&#41;&#46; Those who were senior high school graduates were less likely to be hesitant about the vaccine compared to those who were primary&#47;junior school graduates &#40;aOR&#58; 0&#46;32&#59; 95&#37; CI&#58; 0&#46;14&#8211;0&#46;73&#41;&#46; Respondents who had poor knowledge of the SARS-CoV-2 vaccine were 2&#46;17 times more hesitant to get the vaccine compared to those who had good knowledge of the vaccination &#40;aOR&#58; 2&#46;17&#59; 95&#37; CI&#58; 1&#46;41&#8211;3&#46;34&#41;&#46; Those who had a willingness to pay were likely less hesitant to get the vaccine compared to those who were not willing to pay &#40;aOR&#58; 0&#46;12&#59; 95&#37; CI&#58; 0&#46;07&#8211;0&#46;20&#41;&#46; Other variables were not significantly associated with vaccine hesitancy &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Of the total respondents who stated their hesitancy&#47;refusal towards the SARS-CoV-2 vaccine &#40;n&#8239;&#61;&#8239;356&#41;&#44; the majority of the reasons given were &#8216;not sure of safety&#8217; &#40;36&#37;&#41; and &#8216;fear of side effects&#8217; &#40;27&#37;&#59; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Qualitative part</span><p id="par0120" class="elsevierStylePara elsevierViewall">In this study&#44; 30 participants were interviewed&#44; and data saturation occurred in all participants&#46; All participants were domiciled in Sangihe Island District&#44; with ages 22&#8211;64 years&#44; with the highest level of education being high school education&#44; and the majority of respondents worked as housewives&#46; Participants consisted of 17 women &#40;13 men&#41;&#44; and all participants were Sangihe people&#46; Of all participants interviewed&#44; 22 refused to get vaccinated&#47;were doubtful about vaccination&#44; and 8 participants had received the vaccination &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the respondents&#8217; perceptions of the SARS-CoV-2 vaccination&#46; From the results of in-depth interviews&#44; people&#8217;s perceptions of vaccination were divided into two categories&#44; namely accepting and rejecting&#47;doubting the vaccination&#46; Both categories can be a supporting and an inhibiting factor in the vaccination process&#46; Based on quotations from respondents who were willing to get vaccinated&#44; the majority thought that vaccines would increase immunity&#44; be safe&#44; be free and reduce cases&#44; and they appreciated the government&#8217;s efforts&#46;<span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">&#8216;I am willing &#40;to get the vaccination&#41;&#8230; that&#8217;s a good &#40;effort&#41; anyway&#44; if there is a vaccine&#44; it means we are already protected from the virus&#8230;&#46; It&#8217;s safe to go anywhere if there is a vaccine&#59; you just have to follow the protocol&#44; although you have already been vaccinated&#8217;&#46; &#40;P2&#41;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">&#8216;The important thing is that &#40;as long as the vaccination&#41; is free and safe&#44; I am willing to be vaccinated&#8217;&#46; &#40;P19&#41;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">&#8216;If you have to &#40;get the vaccine&#41;&#44; you have to be willing to for your safety&#8230;&#46; Instead of living like this&#8212;living with a mask &#40;at all times&#41; and the pandemic won&#8217;t go away &#40;if you don&#8217;t get vaccinated&#41;&#46; So for our safety&#44; let&#8217;s get vaccinated&#46; Besides&#44; if there is a free vaccination&#44; why not&#8217;&#63; &#40;P3&#41;</p></span></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> also shows respondents&#8217; reasons for hesitating&#47;refusing vaccination&#46; The majority of responses from almost all respondents who refused the vaccination complained about the lack of information regarding the SARS-CoV-2 vaccination&#46; Other reasons were related to side effects&#44; religious beliefs&#44; safety and fear of syringes&#46;<span class="elsevierStyleDisplayedQuote" id="dsq0010"><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">&#8216;I am not yet ready to be vaccinated&#59; I don&#8217;t know how this vaccination will be conducted&#44; about its safety and the side effects&#8230;even though it&#8217;s free&#44; but if it&#8217;s not ready&#44; I still don&#8217;t want to&#46; I will just keep wearing my mask &#40;to prevent the virus spreading&#41;&#8217;&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">&#8216;I&#8217;m not ready to be vaccinated because I don&#8217;t know what the vaccine is&#46; If I am asked for vaccination&#44; I will not be fully ready&#8230;&#46;Well&#44; maybe there should be socialisation or education from health workers about the vaccination first to the public so that people will know what this vaccination is all about&#8217;&#46; &#40;P13&#41;</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">&#8216;&#40;I am&#41; not willing to be vaccinated because some people say that there is a microchip in the vaccine&#44; maybe &#40;this is the program from&#41; the antichrist&#8230;&#40;<span class="elsevierStyleItalic">the respondent smiles</span>&#41;&#46; I read in the <span class="elsevierStyleItalic">Book of Revelation</span> about the antichrist that the sign of the antichrist is the presence of a chip&#46; Then&#44; I heard the news on TV that the vaccine also has a chip&#8230;&#40;<span class="elsevierStyleItalic">the respondent chuckles</span>&#41;&#8217;&#46; &#40;P16&#41;</p><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">&#8216;&#8230;because the information concerning this vaccine circulating in the community is still lacking &#40;I am not willing to be vaccinated&#41;&#44; only when there is more information about the vaccine&#44; then &#40;I will consider that&#41; it&#8217;s safe to be vaccinated&#44; and I will be willing &#40;to get one&#59; <span class="elsevierStyleItalic">The respondent showed his confused facial expression</span>&#41; but I still have doubt &#40;about the vaccination&#41;&#8230;&#46;&#8217;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">&#8216;The health workers said that the vaccination is good &#40;for your health&#41;&#44; but I don&#8217;t want to be vaccinated because I&#8217;m still afraid of the syringe&#8217; &#40;P17&#41;&#46;</p></span></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">The prevalence of vaccine hesitancy against the SARS-CoV-2 vaccine was found to be 63&#46;9&#37; &#40;95&#37; CI&#58; 59&#46;8&#37;&#8211;67&#46;9&#37;&#41;&#46; Previous studies demonstrated that vaccine hesitancy in urban areas in Indonesia was 35&#46;2&#37;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and was almost the same as other studies in Indonesia that used the 50&#37; vaccine effectiveness scenario with a vaccine hesitancy of 33&#46;0&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Both studies were conducted at a time when the SARS-CoV-2 vaccine was still in the development stage&#46; Vaccine hesitancy in general studies across various countries has been in the range of 12&#37;&#8211;18&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16&#44;17</span></a> Apart from the general population&#44; SARS-CoV-2 vaccine hesitancy has also been found in health workers&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> The much higher prevalence of SARS-CoV-2 vaccine hesitancy in this study compared to previous studies is somewhat surprising&#46; This is because this study was conducted at a time when the vaccination campaign was being carried out by the government&#44; and the president&#44; and other influencers subsequently&#44; had already received the first injection of the vaccine&#44; an event broadcast live on national TV&#46; The differences are mainly due to the study population and a social context where participants&#8217; access to information was very limited&#46; These findings are of serious concern&#44; as the government is trying to ensure widespread SARS-CoV-2 vaccination in all regions of Indonesia&#46; Another possibility is the efficacy of the SINOVAC vaccine &#40;63&#37;&#41;&#46; Previous research found that if the vaccine is 95&#37; effective&#44; 93&#46;3&#37; of participants would like to be vaccinated when the vaccine is provided for free by the government&#46; However&#44; this percentage decreases to 67&#46;0&#37; if vaccine efficacy is 50&#37;&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">A multivariate analysis &#40;adjusted analysis&#41; was performed to determine factors related to vaccine hesitancy&#46; There are three factors associated with vaccine hesitancy&#44; including the level of education&#44; knowledge of the SARS-CoV-2 infection vaccination and willingness to pay&#46; The higher the education&#44; the less likely it is for vaccine refusal&#46; These results are supported by the findings of other studies where education level is one of the factors related to vaccine hesitancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;20</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">This study proves that participants who do not have sufficient knowledge of the SARS-CoV-2 vaccination are twice as likely to refuse the vaccination compared to participants who have good knowledge&#44; which is similar to the findings of other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;21&#44;22</span></a> There is no study regarding knowledge of COVID-19 vaccination in the first month of vaccination for the general population &#40;January to February 2021&#41; in Indonesia&#46; However&#44; from a study in Malaysia conducted at the end of 2020&#44; it was found that 62&#37; of respondents had poor knowledge of the COVID-19 vaccine&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Access to information is very limited in rural areas&#44; which causes people to not get comprehensive information regarding the SARS-CoV-2 vaccination&#46; Therefore&#44; the role of the local government in socialisation and education related to vaccination is very much needed&#46; The increased knowledge is effective in increasing immunization coverage&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">A previous study found that 21&#46;6&#37; of rural residents were willing to pay for the vaccination&#46; The willingness to pay for the vaccination in that study was related to income&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> This figure is not significantly different from the findings of this study&#44; in which the proportion of rural residents willing to pay for the vaccination was 20&#46;1&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In this study&#44; the willingness to pay was one of the factors that influenced a person to accept or refuse the vaccination&#46; This means that people who are not willing to pay for vaccines will tend to refuse vaccination&#46; This may be related to the fact that the majority of participants in this study fell into the category of poor economic status&#46; This is also supported by research that found that families with lower incomes are more likely to refuse vaccination&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;26</span></a> Therefore&#44; the Indonesian government&#8217;s decision to provide the COVID-19 vaccination for free to all populations in Indonesia is very appropriate and should encourage a higher vaccination rate&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In this study&#44; information on the reasons for receiving or refusing vaccination was extracted both qualitatively and quantitatively&#46; Based on the quantitative results&#44; the reasons for rejecting the vaccination from the largest to the smallest proportions included doubt of its safety&#44; fear of side effects&#44; doubt of its effectiveness&#44; no trust in the vaccination&#44; religious beliefs and comorbidities&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Meanwhile&#44; based on the results of in-depth interviews &#40;qualitative data&#41;&#44; two categories of vaccine acceptance were found&#44; namely acceptance and refusal&#47;hesitation&#46; The majority of respondents refused the vaccination&#46; Lack of information related to the vaccination and the importance of vaccination were the reasons most participants cited for rejecting the vaccination&#46; These results are in line with the quantitative results where vaccine-related knowledge is one of the factors associated with hesitancy towards vaccination&#46; Meanwhile&#44; the most cited reason for receiving the vaccine was that the vaccination can increase the body&#39;s immunity against SARS-CoV-2&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The reason for vaccine refusal that cannot be revealed from the quantitative results is the factor of Christian religious belief&#46; Some participants believed circulated rumours that there is a microchip in the vaccine that is a symbol of the Antichrist&#46; In a previous study in Indonesia&#44; measles vaccination was also associated with Muslim religious beliefs where the vaccination coverage for the Muslim population was lower due to the presence of haram in the vaccine&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> However&#44; the SARS-CoV-2 vaccine has been declared halal by the Indonesian Ulama Council&#44; so it is not one of the reasons for vaccine rejection in this study&#46; Rejection based on unfounded rumours about a microchip in the SARS-CoV-2 vaccine is not surprising&#46; A theologian from Indonesia even conducted a study to refute this rumour&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> In a previous study in Jordan&#44; it was found that high vaccine hesitancy was associated with the belief of the conspiracy that the SARS-CoV-2 vaccination would implant a microchip into a person&#8217;s body to control the person&#8217;s movements&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Of course&#44; further studies are needed to determine the relationship between local Christian religious beliefs and the hesitancy towards SARS-CoV-2 vaccination&#46; However&#44; the findings of this study can become a serious concern for religious leaders&#44; especially in Christian-majority areas such as the study area&#46; Local governments can support Christian religious leaders to straighten out information related to rumours of microchips in the SARS-CoV-2 vaccination&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The adopted sequential explanatory mixed methods are the strength of this study&#46; This study provides more comprehensive data&#44; as it explored reasons for doubt&#47;refusal against vaccination to facilitate recommendations for targeted interventions to increase the rate of COVID-19 vaccination&#46; The limitation of this study lies in the sampling method that used non-probability sampling&#44; so there is the potential of sampling bias&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusion</span><p id="par0175" class="elsevierStylePara elsevierViewall">Most residents in rural areas refused&#47;were doubtful towards the SARS-CoV-2 vaccination &#40;63&#46;9&#37;&#41;&#46; Education level&#44; vaccine-related knowledge and willingness to pay were found to be predictive factors towards vaccine hesitancy&#46; The reasons for refusing&#47;hesitating are doubt regarding the safety and effectiveness of the vaccine&#44; fear of the side effects&#44; lack of trust in the vaccination and Christian religious beliefs&#46; Health workers and local religious leaders can be trained to provide education to reach the public directly regarding the safety and importance of the SARS-CoV-2 vaccination&#46; Local government regulation on the obligation to vaccinate can be another solution to vaccination problems&#46; Thus&#44; the hope of achieving vaccination coverage for 181 million Indonesians can be realised&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have declared that no competing interest exists&#46;</p></span></span>"
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              "titulo" => "Population and study setting"
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              "titulo" => "Ethical considerations"
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          "titulo" => "Results"
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              "titulo" => "Quantitative part"
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          "titulo" => "Conflicts of interest"
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          "identificador" => "xack641344"
          "titulo" => "Acknowledgments"
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        11 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2021-05-26"
    "fechaAceptado" => "2022-02-15"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1587007"
          "palabras" => array:4 [
            0 => "SARS-CoV-2 infection"
            1 => "Vaccination"
            2 => "Hesitancy"
            3 => "Indonesia"
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          "palabras" => array:4 [
            0 => "Infecci&#243;n por coronavirus"
            1 => "Vacunaci&#243;n"
            2 => "Indecisi&#243;n"
            3 => "Indonesia"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The SARS-CoV-2 vaccination program campaign has been underway in Indonesia for people aged &#8805;18 years&#46; The program&#8217;s success can be hampered by vaccine hesitancy in communities&#46; This study aims to elucidate the determinants of SARS-CoV-2 vaccine hesitancy in a rural area of the Indonesia&#8211;Philippines border island Sangihe&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A mixed-methods study was conducted&#59; a quantitative part involving a cross-sectional survey was carried out among participantes aged &#8805;18 years to determine the prevalence and determinants of SARS-CoV-2 vaccine hesitancy&#46; The qualitative part involved in-depth interviews to explore the perceptions towards the SARS-CoV-2 vaccine&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Result</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Among 557 participantes&#44; the prevalence of vaccine hesitancy was 63&#46;9&#37; &#40;95&#37; CI&#58; 59&#46;8&#8211;67&#46;9&#41;&#46; In the adjusted analysis&#44; three factors affected vaccine hesitancy&#58; education &#40;aOR&#58; 0&#46;40&#59; 95&#37; CI&#58; 0&#46;22&#8722;0&#46;70&#41;&#44; knowledge of the SARS-CoV-2 vaccine &#40;aOR&#58; 2&#46;17&#59; 95&#37; CI&#58; 1&#46;41&#8211;3&#46;34&#41; and willingness to pay &#40;aOR&#58; 0&#46;12&#59; 95&#37; CI&#58; 0&#46;07&#8211;0&#46;20&#41;&#46; The majority of reasons for refusing the vaccine included doubt regarding its safety and effectiveness&#44; the fear of side effects&#44; lack of information regarding the vaccine and local Christians&#8217; religious beliefs&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This study found that most adults in the area were hesitant about the SARS-CoV-2 vaccine&#46; Lack of knowledge&#44; a low level of education and misinformation were factors that greatly affected vaccination hesitancy&#46; The government&#44; by involving religious leaders&#44; is expected to pay serious attention to the dissemination of accurate and convincing information to the public regarding the safety and importance of the SARS-CoV-2 vaccine&#46;</p></span>"
        "secciones" => array:4 [
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            "titulo" => "Background"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La campa&#241;a de vacunaci&#243;n contra la infecci&#243;n por SARS-CoV-2 se viene desarrollando en Indonesia para personas &#8805; 18 a&#241;os&#46; El &#233;xito de este programa puede verse obstaculizado por la presencia de dudas sobre las vacunas en las comunidades&#46; Este estudio tiene como objetivo identificar los determinantes de la indecisi&#243;n en relaci&#243;n a la vacunaci&#243;n por la infecci&#243;n por coronavirus en una zona rural de la isla fronteriza entre Indonesia y Filipinas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio de m&#233;todos mixtos realizado con una parte cuantitativa que incluye una encuesta transversal realizada entre participantes de &#8805; 18 a&#241;os para determinar la prevalencia y los determinantes de la indecisi&#243;n en relaci&#243;n a la vacunaci&#243;n contra la infecci&#243;n por SARS-CoV-2&#46; La parte cualitativa consisti&#243; en entrevistas en profundidad para explorar la percepci&#243;n hacia la vacuna contra la infecci&#243;n por SARS-CoV-2&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultado</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Entre 557 participantes&#44; la prevalencia de indecisi&#243;n ante la vacuna fue del 63&#44;9&#37; &#40;IC del 95&#37;&#58; 59&#44;8&#8211;67&#44;9&#37;&#41;&#46; En el an&#225;lisis ajustado&#44; hay 3 factores que inciden en la indecisi&#243;n ante la vacuna&#44; a saber&#44; educaci&#243;n &#40;ORa&#58; 0&#44;40&#59; IC 95&#37;&#58; 0&#44;22&#8211;0&#44;70&#41;&#44; conocimiento de la vacuna&#44; infecci&#243;n por coronavirus &#40;ORa&#58; 2&#44;17&#59; IC 95&#37;&#58; 1&#44;41&#8211;3&#44;34&#41; y disposici&#243;n a pagar &#40;ORa&#58; 0&#44;12&#59; IC del 95&#37;&#58; 0&#44;07&#8211;0&#44;20&#41;&#46; La mayor&#237;a de las razones para rechazar la vacuna incluyen la duda de su seguridad y eficacia&#44; el temor a sus efectos secundarios&#44; la falta de informaci&#243;n sobre la vacuna y el factor de la creencia religiosa cristiana&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Este estudio encuentra que la mayor&#237;a de los adultos en zonas rurales dudan sobre la vacuna&#46; La infecci&#243;n por coronavirus&#44; la falta de conocimiento&#44; el nivel de educaci&#243;n y la desinformaci&#243;n son factores que afectan en gran medida a la aceptaci&#243;n de la vacunaci&#243;n por parte de una persona&#46; Se espera que el gobierno&#44; al involucrar a los l&#237;deres religiosos&#44; preste mucha atenci&#243;n a la difusi&#243;n de informaci&#243;n precisa y convincente para el p&#250;blico sobre la seguridad e importancia de la vacuna contra la infecci&#243;n por coronavirus&#46;</p></span>"
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                  \t\t\t\t" scope="col">Hesitancy n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primary&#47;junior school&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Senior high school&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diploma&#47;university&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Civil servant&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Farmer&#47;laborer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Private sector employee&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">87 &#40;15&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Others&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">125 &#40;22&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89 &#40;71&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Religion</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Christian&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">477 &#40;85&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">299 &#40;62&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Islam&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Catholic&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Single&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Economic status</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Poor&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">213 &#40;69&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vulnerable&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aspiring middle class&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Middle&#47;upper class&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">24 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;41&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;64 &#40;0&#46;19&#8211;2&#46;15&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Knowledge towards COVID-19 vaccine</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Good&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">212 &#40;38&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">99 &#40;46&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>36&#8211;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Education</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Primary&#47;junior school&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Senior high school&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">56&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diploma&#47;university&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gender</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">40&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">60&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Civil servant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Housewife&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Farmer&#47;laborer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Acceptance towards COVID-19 vaccine</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13&#46;3&nbsp;\t\t\t\t\t\t\n
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec9105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect5065">What is known&#63;</span><p id="par0005" class="elsevierStylePara elsevierViewall">The existence of vaccine hesitancy has been known in several urban areas&#46; In India was 14&#46;1&#37; and in Indonesia was 33&#37;&#46;</p></span><span id="sec1010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect4170">What does it contribute&#63;</span><p id="par6715" class="elsevierStylePara elsevierViewall">The majority the previous studies used cross-sectional study design&#46; The design of this study produces more comprehensive data because it explores the reasons for doubt&#47;refusal to vaccination so that it can provide recommendations for targeted interventions as a way to increase the coverage of COVID-19 vaccination&#46;</p></span></span>"
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                        "link" => "https&#58;&#47;&#47;www&#46;euro&#46;who&#46;int&#47;en&#47;health-topics&#47;health-emergencies&#47;coronavirus-covid-19&#47;covid-19vaccines-and-vaccination"
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                            0 => "S&#46; Swaminathan"
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                        "link" => "https&#58;&#47;&#47;www&#46;who&#46;int&#47;docs&#47;default-source&#47;coronaviruse&#47;act-accelerator&#47;1-covid-19-vaccine-coverage&#46;pdf&#63;sfvrsn&#61;b4b17450&#95;5"
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                  "contribucion" => array:1 [
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                      "titulo" => "Indonesia to vaccinate 181 million as Covid cases&#44; deaths rising fast"
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                            0 => "Jakarta Globe"
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                    0 => array:1 [
                      "WWW" => array:2 [
                        "link" => "https&#58;&#47;&#47;jakartaglobe&#46;id&#47;news&#47;indonesia-to-vaccinate-181-million-as-covid-cases-deaths-rising-fast"
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                            0 => "R&#46;M&#46; Jacobson"
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                    0 => array:2 [
                      "doi" => "10.1016/j.mayocp.2015.09.006"
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                        "tituloSerie" => "Mayo Clin Proc"
                        "fecha" => "2015"
                        "volumen" => "90"
                        "paginaInicial" => "1562"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26541249"
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                      "titulo" => "Caregiver willingness to vaccinate their children against COVID-19&#58; cross sectional survey"
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Article information
ISSN: 24451479
Original language: English
DOI:10.1016/j.enfcle.2022.03.002
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