Prevalence and factors associated with covid-19 vaccine hesitancy in Maranhão, Brazil

Oliveira, Bruno Luciano Carneiro Alves de; Campos, Marcos Adriano Garcia; Queiroz, Rejane Christine de Sousa; Alves, Maria Teresa Seabra Soares de Britto e; Souza, Bruno Feres de; Santos, Alcione Miranda dos; Silva, Antônio Augusto Moura da

doi:10.11606/s1518-8787.2021055003417

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Brasil

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Original Article • Rev. Saúde Pública 55 • 2021 • https://doi.org/10.11606/s1518-8787.2021055003417 copy

Prevalence and factors associated with covid-19 vaccine hesitancy in Maranhão, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVES:

To estimate the prevalence and factors associated with hesitancy in getting the vaccine against SARS-CoV-2 in Maranhão, Brazil.

METHODS:

This is a cross-sectional population-based study conducted from October 19 to 30, 2020. The estimates were calculated based on clustering, stratification, and non-response. A three-stage sampling was adopted, considering stratum, census tracts, and domicile. After systematic analysis, thirty sectors were selected in each stratum, totaling 150 sectors. Each sector contained a fixed number of 34 households, thus totaling 5,100 households. One individual within each household (resident for at least six months and aged one year or more) was selected by a simple random sampling. We questioned participants about their vaccination intention. Univariate association between independent variables and the outcome were verified using descriptive analysis (weighted frequencies) and Pearson's chi-square test (p < 0.05). Robust multivariate analysis was performed using a three-level hierarchical model.

RESULTS:

We found 17.5% (95%CI 16.1–19.1%) of the 4,630 individuals interviewed to report hesitancy to be vaccinated against covid-19. After final model adjustment, vaccination hesitancy was statistically higher among residents of the cities of Imperatriz (24.0%; RP = 1.48; IC95% 1.09–2.02) and municipalities of the Grande Ilha de São Luís (20.7%; RP = 1.34; 95%CI 1.02–1.76), female individuals (19.8%; RP = 1.44; 95%CI 1.20–1.75), older adults (22.8%; RP = 1.79; IC95% 1.30–2.46), evangelicals (24.1%; RP = 1.49; 95%CI 1.24–1.79), and those without reported symptoms (18.6%; RP = 1.24; 95%CI 1.02–1.51). We found no statistical differences for other socioeconomic and demographic characteristics, as well as variables related to the labor market, behaviors, and health conditions of the interviewees.

CONCLUSION:

The prevalence of vaccine hesitancy in Maranhão and its association with individual, contextual, and clinical factors enable us to identify the groups and contexts of greatest resistance, requiring special attention from public strategies to ensure wide vaccination.

DESCRIPTORS:
Coronavirus Infections, prevention & control; Vaccination Refusal, psychology; Health Knowledge, Attitudes, Practice; Health Surveys

Variables		Vaccine hesitancy				p^a a Pearson chi-square test.
		Yes		No
		%	95%CI	%	95%CI
General population		17.5	16.1–19.1	82.5	80.9–83.9
Cities stratum
	< 20,000 inhabitants	14.0	11.7–16.6	86.0	83.4–88.3	0.0036
	20 to 100,000 inhabitants	16.6	14.1–19.5	83.4	80.5–85.9
	> 100,000 inhabitants	16.9	14.4–19.7	83.1	80.3–85.6
	Imperatriz	24.0	18.1–31.1	76.0	68.9–81.9
	Grande Ilha^b b Includes the capital, São Luís.	20.7	17.6–24.3	79.3	75.7–82.4
Gender
	Female	19.8	17.9–21.9	80.2	78.1–82.2	0.0001
	Male	13.2	11.3–15.5	86.8	84.5–88.7	0.0001
Age group (in years)
	0–19	13.1	10.0–16.9	87.9	83.1–90.0	0.0003
	20–59	16.7	14.9–18.7	83.3	81.3–85.1
	≥ 60	22.8	19.5–26.4	77.2	73.6–80.5
Color/ethnicity^c c Does not account for Asian and indigenous ethnicities due to low frequency.
	White	17.4	14.2–21.2	82.6	78.8–85.8	0.166
	Brown/Mixed race	18.0	16.1–20.0	82.0	80.0–83.9
	Black	14.8	11.8–18.5	85.2	81.5–88.2
Education level^d d n differs from 4,563.
	Complete primary education	17.8	16.0–19.8	82.2	80.2–84.0	0.231
	Complete secondary education	18.2	15.5–21.4	81.8	78.6–84.6
	Complete tertiary education	13.7	10.3–18.0	86.3	82.0–89.7
Household income (R$)^d d n differs from 4,563.
	< 1,000	15.7	13.0–19.0	84.3	81.0–87.0	0.3731
	From 1,000 to < 2,000	18.6	16.4–21.0	81.4	79.0–83.6
	≥ 2,000	17.5	14.9–20.3	82.5	79.7–85.1
Has health insurance
	No	17.4	15.9–19.0	82.6	81.0–84.1	0.4879
	Yes	19.5	14.2–26.1	80.5	73.9–85.8	0.4879
Religion
	Catholic	15.2	13.6–17.0	84.8	83.0–86.4	0.0001
	Evangelical	24.1	20.7–27.9	75.9	72.1–79.3
	Does not have one	20.0	14.2–27.4	80.0	72.6–85.8
	Others	12.7	5.6–26.3	87.3	73.7–94.4
Number of residents in the household
	1	21.0	17.2–25.3	79.0	74.7–82.8	0.120
	2	19.1	16.5–21.9	80.9	78.1–83.5
	≥ 3	16.8	15.0–18.8	83.2	81.2–85.0
Used public transportation during the pandemic
	No	16.4	14.5–18.4	83.6	81.6–85.5	0.074
	Yes	19.2	16.9–21.6	80.8	78.4–83.1	0.074

Variables		Vaccine hesitancy				p^a a Pearson chi-square test.
		Yes		No
		%	95%CI	%	95%CI
Keeps working face-to-face
	No	17.5	15.1–20.2	82.5	79.8–84.9	0.0564
	Yes	13.7	10.8–17.2	86.3	82.8–89.2
	Didn't work outside the home before the pandemic	18.8	16.7–21.2	81.2	78.8–83.3
Works remotely, even if partially
	No	17.1	14.9–19.7	82.9	80.3–85.1	0.4353
	Yes	15.1	11.4–19.7	85.0	80.3–88.7
	Didn't work before the pandemic	18.2	16.2–20.5	81.8	79.5–83.4
Lost the job or experienced a reduction in household income
	No	17.2	15.1–19.6	82.8	80.4–84.9	0.8049
	Yes	16.5	12.5–21.4	83.5	78.7–87.5
	Didn't work before the pandemic	18.0	15.8–20.4	82.0	79.6–84.2
Received Bolsa Família aid
	No	17.9	16.1–19.8	82.1	80.2–83.9	0.5468
	Yes	16.9	14.4–19.7	83.1	80.3–85.6	0.5468
Received emergency aid
	No	18.5	16.3–21.0	81.5	79.1–83.7	0.2632
	Yes	16.8	14.9–18.9	83.2	81.1–85.1	0.2632
Received unemployment insurance
	No	16.3	14.5–18.3	83.7	81.7–85.5	0.1791
	Yes	14.9	0.7–30.4	85.1	69.6–93.5
	Didn't work before the pandemic	19.4	17.0–22.0	80.6	78.0–83.0

Variables		Vaccine hesitancy				p^a a Pearson's chi-square test.
		Yes		No
		%	95%CI	%	95%CI
Compliance with non-pharmacological interventions from the pandemic onset until the survey date
Social isolation^b b Never or almost never leaves home – at most once every 15 days.
	No	18.1	16.3–20.0	81.9	80.0–83.7	0.2968
	Yes	16.3	13.8–19.1	83.7	80.9–86.2	0.2968
Use of masks^c c Wears masks every time he/she leaves home and never or hardly ever removes it from the face.
	No	18.1	16.2–20.2	81.9	79.8–83.8	0.3828
	Yes	16.7	14.6–19.3	83.3	80.9–85.4	0.3828
Hand hygiene^d d Performs hand hygiene six times or more per shift.
	No	17.9	16.1–20.0	82.1	80.0–84.0	0.4760
	Yes	16.8	14.6–19.3	83.2	80.7–85.4	0.4760
Physical distancing^e e Never or hardly ever stays less than 1.5 meters away from other people.
	No	17.4	15.7–19.2	82.6	80.8–84.3	0.7608
	Yes	17.9	15.2–21.0	82.1	79.4–84.8	0.7608
Received medical diagnosis^f f Suspected covid19.
	No	17.4	15.9–19.0	82.6	81.0–84.1	0.5401
	Yes	19.3	13.8–26.4	80.7	73.6–86.2	0.5401
Frequency of symptoms possibly related to covid-19^g g The following symptoms were considered: fever, chills, sore throat, cough, dyspnea, anosmia, ageusia, diarrhea, nausea/vomiting, headache, fatigue, and myalgia. They were classified into: no symptoms; one or two symptoms, provided they were not anosmia/hyposmia or ageusia/dysgeusia; three or more symptoms (including anosmia/hyposmia or ageusia/dysgeusia).
	No symptoms	18.6	16.6–20.9	81.4	79.1–83.4	0.3990
	One to two symptoms	16.4	12.5–21.2	83.6	78.8–87.5
	Three or more symptoms	16.6	14.3–19.1	83.4	80.9–85.7
Has undergone a covid-19 diagnostic testing^h h RT-PCR, rapid test, or serology. before the survey
	No	17.7	16.1–19.3	82.3	80.7–83.9	0.6455
	Yes	16.5	12.4–21.6	83.5	78.4–87.6	0.6455
SARS-CoV-2 serology identified in the survey
	Positive	18.8	16.4–21.5	81.2	78.5–83.6	0.1894
	Negative	16.7	15.0–18.7	83.3	81.3–85.1	0.1894

Variables		Distal block		Distal + intermediate block		Distal + intermediate + proximal block
Variables		RP^a a Adjusted by each other.	95%CI	RP^b b Adjusted for gender, stratum, age group, ethnicity, religion, number of residents, and use of public transportation. We found no association among variables from intermediate factors.	95%CI	RP^c c Adjusted for gender, stratum, age group, religion, compliance with non-pharmacological interventions, covid-19 testing before and during the survey.	95%CI
Cities stratum
	< 20,000 inhabitants	1.00	-----
	20 to 100,000 inhabitants	1.11	0.88–1.40
	> 100,000 inhabitants	1.15	0.91–1.46
	Imperatriz	1.48	1.09–2.02
	Grande Ilha	1.34	1.02–1.76
Gender
	Male	1.00	-----
	Female	1.44	1.20–1.75
Age group (in years)
	0–19	1.00	-----
	20–59	1.29	0.95–1.74
	≥ 60	1.79	1.30–2.46
Religion
	Catholic	1.00	-----
	Evangelical	1.49	1.24–1.79
	Does not have one	1.38	0.96–2.00
	Others	0.85	0.40–1.82
Frequency of symptoms possibly related to covid-19^d d The following symptoms were considered: fever, chills, sore throat, cough, dyspnea, anosmia, ageusia, diarrhea, nausea/vomiting, headache, fatigue, and myalgia. They were classified into: no symptoms; one or two symptoms, provided they were not anosmia/hyposmia or ageusia/dysgeusia; three or more symptoms (including anosmia/hyposmia or ageusia/dysgeusia).
	Three or more symptoms					1.00	-----
	One to two symptoms					1.08	0.80–1.47
	No symptoms					1.24	1.02–1.51

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[1] Correspondence: Bruno Luciano Carneiro Alves de Oliveira, Universidade Federal do Maranhão, Faculdade de Medicina, Departamento de Medicina I, Praça Gonçalves Dias, 21 65020-240 São Luís, MA, Brasil. E-mail: oliveira.bruno@ufma.br