COVID-19 vaccine hesitancy in five Western Balkan countries

Abstract Background The vaccine hesitancy is a matter of global concern with inadequate global uptake postponing the moment of reaching herd immunity and bringing the COVID-19 pandemics under control. Countries in the Western Balkans struggle with vaccine hesitancy, trying to bring vaccine acceptance and ways to improve it into the focus. Methods A cross-sectional study on vaccine hesitancy was conducted from July to September 2021 and included adult population from Albania, Bosnia and Herzegovina, North Macedonia, Montenegro and Serbia (1605 individuals). Convenience sampling was applied using anonymized online questionnaire (shared through social media) measuring, among others, trust in societal factors, social responsibility and, the credibility of information sources about COVID-19 vaccines. Results The highest degree of trust in societal factors was found in North Macedonia (M = 3.65, SD = 1.06), followed by Montenegro (M = 3.50, SD = 1.19) and Serbia (M = 3.24, SD = 1.26). In Albania 44.7% respondents believed in reluctance of pharmaceutical companies to publish detailed research reports on the risks of adverse reactions to COVID-19 vaccines. The view that the health authorities when they encourage vaccination do so with the best intentions supported 66,3% respondents in North Macedonia and 49% in Albania and Serbia. The highest level of social responsibility (M = 4.12, SD = 1.09) was revealed in North Macedonia. Primary care physicians, health professionals in media, webpages of public health institutions, and scientific literature are the most trusted sources of information about COVID-19 in all countries. Conclusions The study demonstrated moderate trust in societal factors and moderately high level of social responsibility in all countries. The health professionals enjoy the greatest trust, which implies that medical doctors, especially physicians in primary health care should have a pivotal role in promoting vaccination and educating the general public in the Western Balkans.

Vaccine hesitancy is a relatively new concept, developed by WHO's Strategic Advisory Group of Experts (SAGE) on Immunization in 2014 as a response to the growing awareness of the decline in global confidence in vaccination. Vaccine hesitancy is a context-specific behavioural phenomenon whose occurrence ranges between full acceptance and complete refusal of vaccines. Several studies have explored factors that influence people's decision to get vaccinated and in 2018 WHO and UNICEF conducted a joint study to explore the reasons for vaccine hesitancy. The study aimed to determine the reported rate of vaccine hesitancy across the globe and the reasons for hesitancy. In most studies three top reasons were identified. 1) vaccine safety concerns, 2) lack of knowledge and awareness of vaccine importance, and 3) religion, culture, gender and socio-economic issues regarding vaccines. Other factors contributing are negative perception of vaccine efficacy, safety, convenience, and price. Some of the consistent sociodemographic groups that were identified to be associated with increased hesitancy included: women, younger participants, and people who were less educated, had lower income, had no insurance, lived in a rural area, and self-identified as a racial/ ethnic minority. Vaccine hesitancy is associated with the global crisis of trust in science and institutions, namely lack of political trust, which can be defined as public judgment that the system and its representatives are responsive and reliable. Furthermore, distrust in one institution is related to distrust in other, indicating the unidimensional phenomenon. This kind of distrust is exemplified by the appearance of infodemic -an overabundance of information. In addition, support for conspiracy theories related to COVID-19 which correlates with the scepticism towards vaccination has significantly higher rates among Balkans' populations.

Background:
The vaccine hesitancy is a matter of global concern with inadequate global uptake postponing the moment of reaching herd immunity and bringing the COVID-19 pandemics under control. Countries in the Western Balkans struggle with vaccine hesitancy, trying to bring vaccine acceptance and ways to improve it into the focus.

Methods:
A cross-sectional study on vaccine hesitancy was conducted from July to September 2021 and included adult population from Albania, Bosnia and Herzegovina, North Macedonia, Montenegro and Serbia (1605 individuals). Convenience sampling was applied using anonymized online questionnaire (shared through social media) measuring, among others, trust in societal factors, social responsibility and, the credibility of information sources about COVID-19 vaccines.

Results:
The highest degree of trust in societal factors was found in North Macedonia (M = 3.65, SD = 1.06), followed by Montenegro (M = 3.50, SD = 1.19) and Serbia (M = 3.24, SD = 1.26). In Albania 44.7% respondents believed in reluctance of pharmaceutical companies to publish detailed research reports on the risks of adverse reactions to COVID-19 vaccines. The view that the health authorities when they encourage vaccination do so with the best intentions supported 66,3% respondents in North Macedonia and 49% in Albania and Serbia. The highest level of social responsibility (M = 4.12, SD = 1.09) was revealed in North Macedonia. Primary care physicians, health professionals in media, webpages of public health institutions, and scientific literature are the most trusted sources of information about COVID-19 in all countries.

Conclusions:
The study demonstrated moderate trust in societal factors and moderately high level of social responsibility in all countries. The health professionals enjoy the greatest trust, which implies that medical doctors, especially physicians in primary health care should have a pivotal role in promoting vaccination and educating the general public in the Western Balkans.