1. Introduction
In December 2019, Wuhan (China) experienced a sudden surge in an atypical respiratory illness cases. The illness was found to be caused by a novel virus which was formally named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is the causative agent of the current COVID-19 pandemic that has taken a heavy toll worldwide [
1]. Almost all countries in the world have been affected by COVID-19, and as of 29 November 2022, more than 638 million cases with more than 6.6 million deaths have been reported. As of writing this report, more than 825,000 cases with 9,459 fatalities have been recorded in Saudi Arabia up to 29 November 2022 [
2]. COVID-19 vaccines are now regarded as the most promising preventive measure against the pandemic [
3].
Several efficacious COVID-19 vaccines are being used worldwide. By June 2021, 25 candidate vaccines in various phases of development had been approved [
4]. The BNT162b2 mRNA vaccine manufactured by Pfizer-BioNTech was the first vaccine to be approved in Saudi Arabia in December 2020 [
5]. The ChAdOx1 nCoV-19 (AZD1222) vaccine manufactured by Oxford-AstraZeneca was the second vaccine approved in the Kingdom in February 2021 [
6]. Finally, in July 2021, the Moderna mRNA-1273 was the third vaccine approved in the country [
7].
Since December 2020, Saudi Arabia has started a mass vaccination program against COVID-19, prioritizing the most vulnerable people, including at-risk elderly people, patients with immunosuppressive conditions, residents of nursing homes, and front-line healthcare workers (HCWs). On 27 March 2021, the program was extended to people with disabilities and all other adult people, and on 17 June 2021, adolescents aged 12–15 years were included [
4]. In addition, since 19 December 2021, booster doses have been offered to individuals aged 18 years and older who completed the primary course (with two doses) at least six months previously [
8].
In order to ensure enduring immunity against COVID-19, booster doses are recommended for all people who received the recommended primary series [
4,
5]. A booster vaccination is even believed to be effective against the emerging strains of SARS-CoV-2 [
4,
9]. Some countries, including Saudi Arabia, have been able to stockpile enough COVID-19 vaccines to cover the primary series and booster doses for their residents [
4].
Unfortunately, many people across the world, including Saudi Arabians, have been hesitant to receive or even refuse to receive COVID-19 vaccines despite the intensive campaigns and drives undertaken by the authorities [
4,
9].
The vaccine hesitancy notion, which is a health belief model that involves a set or a combination of attitudes, behaviors, beliefs, and perceptions shared by a portion of a population, has grown significantly, resulting in a growing proportion of the population unwilling to take a vaccine. In order to understand vaccine hesitancy, various factors should be taken into consideration, including health belief models, psychological perspectives, and sociological viewpoints [
10].
In addition, the WHO EURO has proposed a “3 Cs” model that includes complacency (when people deem vaccines unnecessary), convenience (vaccines readily available), and confidence (primarily because of safety concerns) [
11]. Subsequently, the “5 Cs” model, a framework that was developed from research conducted in high-income countries which included confidence, complacency, constraints/convenience, risk calculation, and responsibility, noted these as key factors of COVID-19 vaccine hesitancy [
12]. The application of the 3 Cs and 5 Cs models can help formulate an achievable plan to address vaccine nonacceptance and hesitancy, particularly in resource-poor settings.
Despite the availability of these workable models, there has been limited research to explore public hesitancy toward COVID-19 booster vaccination. A study from Japan found public hesitancy toward booster vaccination to be 2.1%, stemming from an uncertain level of vaccine efficacy at the cost of adverse events [
13]. In Ethiopia, the COVID-19 hesitance prevalence ranged from 14.1% to 68.7%. This Ethiopian study showed that hesitance was multifactorial. The most identified factor included young age, female sex, residing in rural locations, inadequate knowledge, poor adherence to COVID-19 prevention efforts, and a bad attitude toward the COVID-19 vaccine. The negative effects of the vaccine and skepticism regarding its efficacy were frequent vaccine-specific predictors of COVID-19 vaccine reluctance [
14]. In Nigeria, vaccine hesitance was 68.5%. Ethnicity, Christianity, being a nurse or pharmacist, and skepticism about foreign vaccines were the factors [
15].
A study conducted in Europe found that, despite hesitance ranging from 6.4% in Spain to 61.8% in Bulgaria, messages communicating the benefits of vaccination significantly increase the willingness to take the COVID-19 vaccine. However, poor health information and fear of vaccine side effects contributed to the hesitance in studied European countries [
16].
In Middle Eastern countries, the studies are still limited, highlighting a need for more research on vaccination acceptance and uptake. Few of the studies available indicated that misinformation and religious factors play a vital role in determining vaccine acceptance. However, it was revealed that the belief of a plot against Arab and Muslims by Western powers drove hesitance among Middle Eastern people. In addition, concern about Halal-certified vaccines contributed to vaccine uptake refusal, which is similar to other previous vaccines introduced in the region [
17]. In Saudi Arabia, there are limited studies exploring the public’s willingness to receive a COVID-19 vaccine booster dose. The limited data suggest that about 20% of people are hesitant to take the COVID-19 booster vaccine, especially educated people. In addition, educated parents were more likely to be hesitant to get their children vaccinated [
17]. In Saudi Arabia, the limited data available suggest that about 20% of people are hesitant to take the COVID-19 booster vaccine, especially in people with higher education. In addition, educated parents were also more likely to be hesitant to get their children vaccinated [
17,
18]. However, to our knowledge, there are no further studies available to explore the reasons behind such hesitancy. Therefore, our study explored the COVID-19 vaccine booster dose acceptance rate in relation to sociodemographic characteristics of the Saudi population, as well as examining the public perception of and willingness to accept COVID-19 booster vaccination in order to understand the factors behind their reluctance and negative attitudes to better employ vaccination programs across the country.
4. Discussion
This study has explored the Saudi Arabian people’s willingness to receive a COVID-19 vaccine booster dose and identified the factors affecting this willingness. The results depicted that less than a quarter of the participants were reluctant to receive the booster vaccine. The majority would receive a COVID-19 booster vaccine and comply with other public health prevention measures (wearing masks, hand sanitization, etc.). Most participants were also concerned about emerging SARS-CoV-2 variants and followed COVID-19-related news updates, and these two factors had a statistically significant association with the acceptability of a COVID-19 booster vaccine. The study may have found a possible psychological factor, with an overwhelming majority preferring and showing confidence in Pfizer’s vaccine. In addition, age, marital status, and the prior receipt of an influenza vaccine were independent predictors of the willingness to receive the COVID-19 vaccine booster dose, whereas having a bachelor’s degree or above, not following the news about COVID-19 in the country, and mistrusting public health and healthcare professionals were associated with refusal to receive the COVID-19 vaccine boosters.
People resisted receiving vaccines due to certain factors, such as sociocultural factors, vaccine-related factors, and individual and group influences [
7]. The factors associated with hesitancy toward having a COVID-19 vaccine may include misconceptions and misinformation about vaccines, efficacy, the safety of vaccines, mistrust in the healthcare system, unfavorable outcomes, and a lack of appropriate knowledge regarding COVID-19 [
9]. Our study showed that only 13% (279/2101) of the participants were unwilling to receive a booster dose of the COVID-19 vaccine. This proportion is lower than what has been found in different studies across the globe. Folcarelli et al. found that the COVID-19 vaccine booster dose hesitancy rate was 24.7% in Italy [
9], whereas Kheil et al. found it to be 26.3% among adult Americans [
27]. COVID-19 vaccine booster dose hesitancy varies according to study settings and study country, and the hesitancy level reduced as the pandemic progressed. For example, in the USA, about 25.4% were hesitant to get vaccinated in January 2021; by May 2021, only 16.6% were hesitant [
27]. As time passes, public concerns about the booster doses continue to decline.
Our study has identified several factors associated with hesitancy toward COVID-19 vaccine uptakes, such as gender, age, marital status, and education level. Our results are in line with that of previous studies that showed some concerns about the possible adverse effects COVID-19 vaccines might have on the fetus and their possible contribution to infertility and miscarriages [
28,
29,
30].
Our study also shows that education level is associated with hesitancy toward COVID-19 vaccine uptake. This probably indicates that the more educated the participants are, the more cautious they are about vaccination [
31] and consequently become more hesitant. Hence, there is a need to raise awareness among educated people about COVID-19 vaccine booster dose safety. While there is no clear explanation to support why the majority of the unmarried (single) participants did not want to receive the COVID-19 vaccine booster dose, there is evidence to justify why more married people prefer receiving the booster doses, such as a moral obligation to protect their spouses and children, motivating them to receive the booster doses [
8,
31].
The observation that the majority of the participants were not working in healthcare settings and were unemployed may be explained by the randomness of the data collection. This is because evidence from other studies also indicates that healthcare workers are more knowledgeable in making better decisions in favor of receiving booster doses as opposed to nonhealthcare workers [
32]. However, it is also essential to note that some people experienced side effects from the first and second doses of the COVID-19 vaccines. Therefore, such people are not willing to receive the booster doses. This is supported by previous studies across Europe [
33], the United States [
34], and China [
35] that reported concerns about vaccine safety and adverse outcomes as the most important reasons for their vaccine hesitancy.
In line with these observations (that the majority of the participants were willing to receive a COVID-19 vaccine booster dose and believed that the booster dose would protect them from severe COVID-19 infection as the benefits outweighed the risks), this belief comes from much sensitization efforts, since, as the COVID-19 pandemic progresses, the sensitizations and lessons generated are appreciated more by the people [
27], resulting in the acceptance of boosters in 2022 by people who rejected them in 2021. This indicates that deliberate and sustained sensitization campaigns across the country should encourage people to receive booster doses. As per this study, the most common barriers to receiving vaccine boosters for COVID-19 in Saudi Arabia were information related. That is why the source of information and its credibility are vital. The majority of the participants (who had not received the booster doses) reported losing trust in MOH, the WHO, and healthcare practitioners. Since health information flows from the WHO through MOH to the health practitioners and then to the population, mistrust in these stakeholders is disastrous for a nation. Amicable solutions should, therefore, be sought to address the people’s loss of trust in these pertinent stakeholders [
26].
Participants’ level of susceptibility reduces their hesitancy toward a COVID-19 vaccine booster dose. Participants who reported having a comorbidity had a statistically significant association with hesitancy to booster doses. For example, participants who had respiratory diseases and obesity were reported to be less likely to resist the COVID-19 vaccine boosters. Studies showed that the booster doses are of high significance among immunocompromised individuals, and people with comorbidities were more susceptible to COVID-19 infection [
26,
27,
28,
29,
30,
31,
32,
33,
34,
35,
36]. Therefore, there is a lower hesitancy among the participants with comorbidities since they are the ones who become more sensitized to comply with all preventive measures. As individuals consult their healthcare professionals more often for their conditions, they are more educated and eager to get accurate information as they are worried about their general health, which makes them more accepting of the vaccine booster dose.
5. Strengths, Limitations, and Future Direction
Our study is novel, with a large sample size and our use of spatial identifiers, such as region of residence, to explore COVID-19 vaccine acceptance and hesitancy; the respondents were well distributed across various regions, age groups, employment statuses, and income compared with census data available through Saudi Arabia Statistics. Yet, some limitations were unavoidable. Our study was self-reported and, therefore, subject to information bias. Additionally, our study was conducted online, which means we may not have reached the vulnerable groups of the population, such as those who are illiterate or from a low socioeconomic background.
Qualitative studies could be appropriate for digging out other factors related to vaccine hesitancy with a focus on the attitudes of those who were vaccinated with a second dose. Additionally, clinical trials with larger sample sizes should be conducted to get a better and broad understanding regarding the acceptance and perceptions of the general population in association with the COVID-19 vaccine.
Ultimately, future studies should focus on continuous education, raising awareness programs, and establishing strategies to overcome the identified barriers to COVID-19 booster vaccination to combat the COVID-19 pandemic in Saudi Arabia effectively through listening to the concerns of the public and incorporating public perspectives in planning vaccine policies and programs, as well as the psychological factors influencing Saudi people’s vaccination intention.