Predicting the COVID-19 vaccine receive intention based on the theory of reasoned action in the south of Iran – BMC Public Health – BMC Public Health

Study design

This cross-sectional study was conducted from May 2021 to July 2021 in the South of Iran with a web-based self-administered questionnaire. The statistical population of this study included people over 18years old living in 4 southern provinces of Iran (Hormozgan, Kerman, Bushehr and Fars), who had not received COVID-19 vaccine.

Hormozgan province lies in the far south of Iran. It is located in the north side of strait of Hormoz. Kerman province resides in the northern side of Hormozgan province, while Fars and Bushehr provinces are adjacent to the western side. These four southern provinces in Iran have many sociocultural features in common.

When the present research was conducted, according to Iran vaccination document, in the whole country and the above-mentioned provinces, the medical staff as well as all population over 75years of age were being vaccinated. The mortality rate was high in these provinces due to the incomparable temperature, inadequate vaccination, recurrent religious holidays (and the resultant overcrowd). The data collection occurred at the same time as the 5th peak of the pandemic.

Data were collected using a questionnaire designed on the Pors Line platform, an online survey platform in Iran (https://survey.porsline.ir) and was provided to the target group through social media. The questionnaire began with an information letter about the studys purpose, how to answer questions, and informed consent to participate in the study.

Regarding to the existing limitations due to the outbreak of COVID-19 and the impossibility of distributing questionnaires in paper form, data were sent to Hormozgan, Kerman, Fars, Bushehr provinces (which are the southern provinces of Iran) through various social media (WhatsApp, Telegram, Linkedin), email, channels and news agencies, public relations of University of Medical Sciences, Red Crescent, Municipality and University Student Research Committee. We recruited participants through a self-selection sampling method and posted an online survey link. After publishing the questionnaire link, the people who received it were asked to complete the questionnaire (if they wished) and send it to other people they know. Finally, the participants registered their answers by clicking the submit button. To emphasize on the greater participation of individuals in the study, messages and links to participate in the study were resent as a reminder two weeks after the first submission.

Also, with the cooperation of health centers in the studied provinces, a questionnaire link was sent to all people covered by healthcare centers in villages and cities. In this study, according to the data collection method, there was no limit on the number of samples.

On the first page of the questionnaire, the purpose of the study was clearly explained and the completion of the questionnaires was completely voluntary. Inclination criteria were at least 18years old and not receiving the COVID-19 vaccine.

The inclusion criteria were: the age over 18years, not having been vaccinated, living in cities and villages in the 4 provinces of Hormozgan, Kerman, Bushehr and Fars.

The exclusion criteria was incomplete questionnaires.

The data collection tool was an online questionnaire. The questionnaire was designed based on studies conducted and articles reviewed [8, 13, 14] and the validity of the questionnaire was assessed by content validity method.

To check the content validity, the questionnaire was prepared using valid sources and books and related scientific papers and the necessary proposed corrections were made qualitatively and quantitatively with the approval of 2 experts in health education and health promotion. 7 people were consulted from different socioeconomic statuses, and their comments were used to revise the questionnaire content.

In the qualitative method, experts were asked to review the tool based on the criteria of grammar, use of appropriate words, placement of items in the right place and proper scoring, and provide the necessary feedback.

The reliability of the questionnaire was reviewed and confirmed by assessing the internal correlation of variables (calculating Cronbachs alpha coefficient). The questionnaire consisted of two parts. The first part was demographic information including age, gender, marital status, education level, employment status, underlying diseases, history of smoking, history of individual and family infection with COVID-19, history of receiving the flu vaccine and source of information on COVID 19 vaccines.

The second part of the questionnaire included the constructs of TRA. The construct of attitude towards behavior (to what extent the desired behavior is desirable, pleasant, useful or enjoyable for the person) is influenced by the construct of behavioral beliefs (beliefs of the person about the result of performing a behavior) and outcomes evaluation (the value that a person considers about the result of a behavior) [15]. The construct of behavioral beliefs consisted of 7 questions of 5-item (highly agree to highly disagree) (e.g., I believe in the efficacy and safety of existing COVID-19 vaccines). The outcomes evaluation structure also included 7 questions of 5-Likert (very good to very bad) (e.g., the efficacy and safety of COVID-19 vaccines are very good). Attitude score was obtained from the multiplication of the behavioral beliefs construct in the outcomes evaluation construct.

The construct of subjective norms (the amount of social pressure perceived by an individual to perform behavior, that is, the reflection of social effect and influence on the individual) is influenced by the construct of normative beliefs (belief in whether certain people approve or reject the behavior) [16] and the construct of motivation to comply (individuals motivation to comply the wishes of others and accept their expectations) [17]. The normative belief construct consisted of 6 questions 5-Likert (highly agree to highly disagree) (e.g., my family members agree to receive the COVID-19 vaccine). The construct of motivation to comply also consisted of 6 questions 5-Likert (very important to not important at all) (e.g., family members advice to receive the COVID-19 vaccine is very important for me) subjective norms score was obtained from the multiplication of normative beliefs construct in the motivation to comply substructure.

The behavioral intention construct also consisted of 3 questions 5-Likert (highly agree to highly disagree) (e.g., I intend to receive the vaccine if it is time for the COVID-19 vaccine). The score of COVID-19 vaccine receive intention was obtained from the mean score of 3 related questions.

The structure of the theory is depicted in Fig.1.

Theory of Reasoned Action TRA (Fishbein & Ajzen, 1975)

Frequency, percentage, mean and standard deviation indices were used to describe the data. The assumptions of parametric tests including the T-test and ANOVA were tested and confirmed initially. To test the normality of distribution, the skewness and kurtosis were tested. The skewness was divided by the skewness standard deviation to estimate Fishers exact test, found to range between 1.96 and+1.96. Thus, the normality of data was confirmed. To test the homogeneity of data, Levens test was used. The estimated p-value was over 0.05. To test the linearity of independent variables, VIF was used, which was found to be below 1.2 for all independent variables. T-test statistical tests and one-way analysis of variance were used to test hypotheses and to investigate the relationship between COVID-19 vaccine receive intention and demographic variables (age, gender, occupation, education, marital status, chronic disease, smoking, place of residence, history of receiving the flu vaccine, history of COVID-19, information sources) and multiple linear regression was used to determine the relationship between the constructs of TRA and COVID-19 vaccine receive intention. Also, the statistical technique of path analysis and structural equations modeling (SEM) were used in order to determine how the theoretical structures relate and their effect on each other, to confirm or reject the conceptual model determined for the COVID-19 vaccine receive intention.

There were no missing data in the present study. From the 3034 subjects who returned the completed questionnaires, 478 subjects (15%) stated that they had not received the coronavirus vaccine. They did not meet the inclusion criteria and were, thus, excluded from the study. The final analysis was done with a sample of 2500 subjects.

All statistical calculations and hypothesis testing were conducted using SPSS21 and Amos21 software and a significant level of hypotheses tests was considered 0.05.

All the procedure was done in accordance with the Declaration of Helsinki. The study was approved by the ethics committee of Hormozgan University of Medical Sciences (# IR.HUMS.REC.1400.071). The ethics committee approved the online survey as well as the online consent. All participants who consented to take part in the study were assured that participation was voluntary, and that they could withdraw any time. Besides, the data were anonymized, securely stored and analyzed for publication.

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Predicting the COVID-19 vaccine receive intention based on the theory of reasoned action in the south of Iran - BMC Public Health - BMC Public Health