Understanding the determinants of COVID-19 vaccination intention and willingness to pay: findings from a population-based survey in Bangladesh

The coronavirus disease 2019 (COVID-19), which emerged in Wuhan, Hubei Province, China at the end of 2019, has caused a large global outbreak and has become a major public health crisis [1, 2]. COVID-19 is a highly transmittable viral infection caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [3]. On March 11, 2020, the World Health Organization (WHO) declared the emergence of COVID-19 as a pandemic [4] which has affected more than 172 million people worldwide [5]. In Bangladesh, approximately 802,305 confirmed cases of COVID-19 were reported as of June 1, 2021, with a death toll of 12,660 [6]. This pandemic has severely affected people’s physical and psychological well-being [7‐11], health system [12, 13] and also caused a major global economic recession [14].

Vaccines are the most effective strategy to protect the population from the devastating outcomes of COVID-19 [15, 16]. More than 287 potential vaccines are being developed and over 102 clinical trials have recently been released [16, 17]. Some have shown positive results, leading to a number of countries approving specific vaccines for implementation in vaccination programs. Meanwhile, by June 1, 2021, over 1.9 billion doses of the COVID-19 vaccine had been administered in 231 locations [18]. Bangladesh began mass vaccination on February 8, 2021 [19]. Despite considerable progress towards the vaccination program, there is some hesitancy about the COVID-19 vaccine [20]. Understanding public perception is crucial in order to achieve high vaccination coverage, especially for newly emerging infectious diseases such as COVID-19 [21‐23]. According to recent studies on public acceptance of COVID-19 vaccination, the intention to take the vaccine ranged from 67 to 91% across countries such as India, Saudi-Arabia, Canada, the United States, and China [24‐29]. There are multiple factors that may influence people’s vaccination intentions. Several demographic factors and perception of the disease risk have been found to be significantly associated with COVID-19 vaccination intent [28‐30]. The health belief model (HBM) is one of the most commonly used models to determine factors associated with vaccination intention [31, 32] and has been used in many previous studies [33‐35]. The HBM comprises several main constructs: perceived susceptibility, severity, benefits, barriers, self-efficacy to engage in a behavior, and cues to action [31]. Perceived stigma is also used for identifying determinants of vaccination intent [25]. In terms of HBM, perceived benefits (i.e. decreasing the chance of infection and making people less worried about infection) and barriers (i.e., being concerned about their efficacy) to vaccination were found to be significant in affecting vaccination intention [35, 36]. In addition, attitudes and experience regarding vaccination history, and convenience have been shown to be the major predictors of vaccination intention [29, 30].

Willingness-to-pay (WTP) refers to the maximum amount, in monetary terms, that an individual would be willing to allocate to obtain the benefits of a program [37]. The decision to vaccinate depends on the WTP of an individual in order to obtain increased health benefits [38]. HBM constructs have been used to explain WTP for influenza vaccination [34, 39]. In a previous study, the WTP for COVID-19 vaccination was found to be influenced by a variety of socioeconomic factors [36]. In addition, no-affordability barriers [35], as well as being aware of the perceived risks associated with higher WTP [38]. More evidence around public acceptance and WTP for the COVID-19 vaccine is essential to evaluate the success of vaccination programs, and to provide insights into future pricing considerations and demand forecasts.

To date, no research has been carried out in Bangladesh on people’s acceptance of the COVID-19 vaccine, the WTP, and the influencing factors and obstacles to vaccination coverage. The current study is aimed at determining the intention and WTP for a COVID-19 vaccine and other associated factors among people in Bangladesh.

Vaccines are a key solution to halting the escalation of pandemics such as COVID-19. The government of Bangladesh began the COVID-19 vaccination roll-out on February 8, 2021 [42]. As with any new vaccine, the COVID-19 vaccine raises concerns. The present study examined how likely people will be to take a COVID-19 vaccine and investigate whether people are willing to pay for it. Our finding represents one of the first estimates of the intention to receive the vaccine among Bangladeshi people and can be used to guide projections of future vaccine uptake and successful implementation of the COVID-19 vaccination program in Bangladesh.

In this study, the majority of participants (65.5%) reported a definite or probable intention to receive a COVID-19 vaccine, which is comparable with recent studies conducted in Saudi Arabia and the United States [25, 28]. A higher proportion of COVID-19 vaccine intention has been reported in similar studies conducted in China, India, Indonesia, and Malaysia, ranging from 83.5 to 94.3% [24, 27, 35, 36]. It may be possible that when the study was conducted, the outbreak of COVID-19 in Bangladesh was largely under control, and also there was a lack of adequate information about the vaccine. Participants in this study had a low level of perceived susceptibility to COVID-19, according to the HBM construct, which is consistent with previous studies [35, 36] and suggests that the Bangladeshi people were not aware of the possibility of the resurgence of COVID-19, making them feel less vulnerable. Our findings suggest that participants’ intention to receive a COVID-19 vaccine was dependent on various socio-demographic factors. In particular, older age was found to be a significant influential factor for the COVID-19 vaccine intention. This finding is justified by the fact that elderly people are at an increased risk of COVID-19 infection both in terms of its severity and also mortality [43]. Our findings highlight the need for education intervention focusing particularly on younger age groups. The participants’ education level was also found to be a significant factor in COVID-19 vaccine intention in the bivariate analysis, although it was not significant in the multivariate analysis. Similar results were shown in other earlier studies in Bangladesh, illustrating that individuals with a higher educational background had more knowledge and awareness regarding COVID-19 [44, 45].

The COVID-19 epidemic has had a significant impact on people all across the world, affecting work, income, and physical and mental health [46‐48]. The present study found that having family members who had been infected and the perception of COVID-19’s impact on daily life, studies/work, and physical/mental health were significant factors in the bivariate analysis, agreeing with a recent study among Chinese citizens [29]. Majority of the study participants agreed that vaccination is an effective way to prevent and control COVID-19, and this was a significant factor for participant’s intention to receive a vaccine, agreeing with 89.5% of Chinese residents who thought that vaccination is an effective way to prevent and control COVID-19 [29]. This positive attitude towards COVID-19 vaccination and the significant impact that it would have on their life explains the intention to receive a vaccine among people in Bangladesh. Multivariable analysis found that vaccination intention was associated with participant’s beliefs [e.g., Health Belief Model (HBM)] towards COVID-19, consistent with previous studies [34, 36, 49]. In particular, our findings suggest that perceived susceptibility to being infected with COVID-19 and the perceived benefits of and barriers to COVID-19 vaccination are the most important HBM constructs influencing participants’ intention to receive a COVID-19 vaccine. Participants with high perceived susceptibility to being infected with COVID-19 expressed increased vaccination intention, consistent with previous studies [25, 35]. While less than half of the participants (45.4%) were worried about the likelihood of contracting COVID-19, relatively few (25.3%) perceived themselves as at high risk of becoming infected. This indicates the need to increase public education and awareness about risk, in order that preventive actions can be taken to improve COVID-19 pandemic control [50].

The findings of this study also suggest participants' lower perceived benefits of COVID-19 vaccination and relatively higher perceived barriers to getting COVID-19 vaccination. In contrast, a similar study conducted in China showed high perceived benefits and low perceived barriers towards COVID-19 vaccination among the participants [36]. This may be the reason why Bangladeshi people showed a lower intention to receive a COVID-19 vaccine compared to Malaysian and Chinese people [29, 35]. Public health intervention programs that focus on increasing awareness of the benefits of COVID-19 vaccination and reducing the identified barriers are therefore essential. The multivariate analysis found concern about the safety of the COVID-19 vaccination as a significant barrier to vaccination intention, with similar findings reported in other studies related to the new vaccine [51], suggesting that information regarding the safety and efficacy standards should be made available to the general public. Another significant barrier was the worry about possible side effects of the COVID-19 vaccine. Bangladesh has experienced various negative events associated with vaccine malpractices and scandals, which have resulted in the public losing confidence in the COVID-19 vaccines [52], which may be implied in this study, as a considerable proportion of reported concerns regarding the possibility of side-effects of COVID-19 vaccines.

This study revealed that the majority of participants (72.9%) were willing to pay for a COVID-19 vaccine. This finding is comparable with a recent study in Indonesia, which found 78.3% of participants had WTP for a COVID-19 vaccine [38]. Multivariate analysis found that WTP for a vaccine was significantly influenced by socio-demographic factors such as younger age, male sex, higher education level, and residing in an urban area. Younger people reported higher WTP for a COVID-19 vaccine, consistent with a recent study in China [36]. A Malaysian study found higher education levels, professional and managerial occupations, and higher income groups were associated with higher WTP [35]. An Indonesian study found that higher income and high perceived risk among healthcare workers were associated with higher WTP [38]. Good self-rated health status and perceived effectiveness of the vaccine for prevention and control of COVID-19 were also found as significant factors for participants’ WTP for the COVID-19 vaccine. In addition, the perceived severity of the pandemic was also associated with a higher WTP. As HBM constructs were significantly associated with WTP, the HBM model should be used to inform the development of interventions to promote vaccination against COVID-19 as a priority for expenditure.

Over 40% of the participants who intended to receive a COVID-19 vaccine wanted to get vaccinated as soon as possible. Studies conducted in China and India found people’s intention to get prompt COVID-19 vaccination was 52.5 and 65.8% respectively [24, 29]. The majority of vaccine intent participants reported that both types of vaccine (domestically-made or imported) were acceptable, while the imported vaccine was more frequently preferred compared to the domestically-made (22.9% vs 14.8%) in contrast to a study in China which found that the majority of participants preferred a domestically-made vaccine over foreign-made (64.2% vs 11.9%) [36].

Our findings suggest that information about the safety and efficacy of the COVID-19 vaccines should be made public on a regular basis and timely health education and communications by public health and government sources such as healthcare professionals are critical to alleviating public concerns as well as improving confidence and compliance with the COVID-19 vaccine [23, 53].

There are some limitations to the current study that need to be considered when interpreting the results. Firstly, this study is a cross-sectional study design that cannot establish causal inferences. Secondly, the responses were based on self-reporting and may be subject to self-reporting bias and a tendency to report socially desirable responses. Thirdly, the use of an online survey and convenience sampling may result in sampling bias, so results may not apply to the wider community due to a lack of representative samples. Finally, the study was hypothetical in nature as it was conducted before the COVID-19 vaccine became available in Bangladesh, so results may now differ in practice. However, we believe that we have captured some really important information about the COVID-19 vaccine. Further research is needed to gather more data about the COVID-19 vaccine and WTP since over 9.9 million doses of the COVID-19 vaccine have been given in Bangladesh as of June 1, 2021 [18].

This study reflected that a sizeable proportion of Bangladeshi people intended to receive a COVID-19 vaccine. Low perceived susceptibility to being infected with COVID-19, as well as concern about side effects, and the safety of any new vaccine were identified as key factors in people's unwillingness or hesitation to receive a vaccine. Furthermore, the majority of participants had a willingness to pay for a COVID-19 vaccine. This study has important implications for facilitating public health and government authorities to design and deliver targeted intervention programs to enhance public acceptance of the COVID-19 vaccination in Bangladesh.