COVID-19 vaccine hesitancy among the adult population in Bangladesh: A nationwide cross-sectional survey.

INTRODUCTION: Studies related to the COVID-19 vaccine hesitancy are scanty in Bangladesh, despite the growing necessity of understanding the population behavior related to vaccination. Thus, the present study was conducted to assess the prevalence of the COVID-19 vaccine hesitancy and its associated factors in Bangladesh to fill the knowledge gap. METHODS AND MATERIALS: This study adopted a cross-sectional design to collect data from 1497 respondents using online (Google forms) and face-to-face interviews from eight administrative divisions of Bangladesh between 1-7 February 2021. We employed descriptive statistics and multiple logistic regression analysis.
RESULTS: The prevalence of vaccine hesitancy was 46.2%. The Muslims (aOR = 1.80, p ≤ 0.01) and the respondents living in the city corporation areas (aOR = 2.14, p ≤0.001) had more hesitancy. There was significant variation in vaccine hesitancy by administrative divisions (geographic regions). Compared to the Sylhet division, the participants from Khulna (aOR = 1.31, p ≤0.001) had higher hesitancy. The vaccine hesitancy tended to decrease with increasing knowledge about the vaccine (aOR = 0.88, p≤0.001) and the vaccination process (aOR = 0.91, p ≤ 0.01). On the other hand, hesitancy increased with the increased negative attitudes towards the vaccine (aOR = 1.17, p≤0.001) and conspiracy beliefs towards the COVID-19 vaccine (aOR = 1.04, p≤0.01). The perceived benefits of COVID-19 vaccination (aOR = 0.85, p≤0.001) were negatively associated with hesitancy, while perceived barriers (aOR = 1.16, p ≤0.001) were positively associated. The participants were more hesitant to accept the vaccine from a specific country of origin (India, USA, Europe).
CONCLUSIONS: Our findings warrant that a vigorous behavior change communication campaign should be designed and implemented to demystify negative public attitudes and conspiracy beliefs regarding the COVID-19 Vaccine in Bangladesh. The policymakers should also think about revisiting the policy of the online registration process to receive the COVID-19 vaccine, as online registration is a key structural barrier for many due to the persistent digital divide in the country. Finally, the government should consider the population's preference regarding vaccines' country of manufacture to reduce the COVID-19 vaccine hesitancy.

Introduction

The development of vaccination is significant public health-related progress though anti-vaccination attitudes, behavior, and associated misconceptions are widely prevalent [1]. The evidence shows that the effectiveness of vaccination programs has been affected by vaccine hesitancy [2], where hesitancy has been defined as a “delay in acceptance or refusal of vaccination despite the availability of vaccination services” [3]. Hesitancy regarding the Coronavirus diseases 19 (COVID-19) vaccination is prominently visible around the world [4] in such a period when the effort towards reaching herd immunity has been targeted to achieve through the vaccination coverage [5].

The Government of Bangladesh (GoB) has launched the biggest-ever vaccination program nationwide to vaccinate 80% (over 130 million) of the country’s total population with the COVID-19 vaccines in four stages [6] though nearly 34% population are below 18 years old [7]. The GoB has published a national deployment and vaccination plan for the COVID-19 vaccination that requires an online registration to receive the COVID-19 vaccine. According to the plan, the GoB has targeted to vaccinate 117 million population aged 18 years and above. However, as of 3 August 2021, only 14% of the targeted people have been registered to receive vaccination, of whom 57% received the 1st dose vaccine with a significant variation by gender (men 61%, women 39%) and administrative regions (Dhaka (19%) received more vaccination than other administrative divisions) [8]. Overall, only 8% of the targeted population have received the first dose of vaccination, while 4% received the second dose of vaccination [8]. Simultaneously, incidents about the lack of interest among the population about the vaccine uptake and lack of response about the registration process have been repeatedly reported in the media, showing vaccine hesitancy among the population.

The studies conducted around the world to explore the COVID-19 vaccine hesitancy has shown that various socio-economic and demographic variables, different constructs of health belief model (HBM) [9, 10], level of knowledge related to the vaccine [11, 12], attitude towards COVID-19 vaccination [12, 13], conspiracy beliefs regarding the origin, effectiveness, and consequences of receiving vaccines [14, 15], preventive behavioral practices related to COVID-19 [16, 17], newness, safety, and probable side effects of the vaccine [18] as primarily responsible for vaccine hesitancy.

Studies related to vaccine hesitancy, COVID-19, or other diseases, are scanty in Bangladesh, despite the growing necessity of understanding the people’s vaccination-related behavior. Few studies have been conducted in Bangladesh to assess the COVID-19 vaccine hesitancy, which has reported a vaccine hesitancy rate between 25.4% to 50% [13, 19–22]. However, the findings of these studies are not representative of the context of Bangladesh and have the following limitations: small sample size [20, 21]; collecting data using only the online platform [19-21] despite having an apparent existence of a digital divide across the country [23]; and non-use of psychological and behavioral variables related to vaccine hesitancy [22]. Thus, a nationwide survey was conducted to assess the prevalence of the COVID-19 vaccine hesitancy and its associated factors in Bangladesh to fill the knowledge gap recruiting respondents from all the eight administrative divisions of the country.

Materials and methods

Description of the study setting

This study was conducted in Bangladesh. The country has a strong primary healthcare system that provides services at the doorsteps of citizens. As a result, it has a successful childhood vaccination coverage of more than 85% [24]. Bangladesh has also made remarkable progress in poverty reduction, maintained by sustained economic growth. Poverty has declined from 43.5% in 1991 to 14.3% in 2016, based on the international poverty line of $1.90 per day [25]. The country has a 166.5 million population, which is about 2.11% of the world population. However, most of the population is still very young, with a median age of 27.6 years. The rate of urban population is 37.4% of the total population. The population density is 1125 per square kilometer, and 88.4% of the population are Muslims. The sex ratio is 100.2, and the total fertility rate is 2.04 [26]. The life expectancy at birth is 72.6 years (71.1 for men and 74.2 for women). The literacy rate is 74.7% among the adult population aged 15 years and above (77.4% for men and 71.9% for women) [26]. We collected data from all the eight administrative divisions of Bangladesh. S1 Map shows the districts from where data for this study were collected. The samples were proportionately distributed to the population size of the divisions.

Study population and inclusion and exclusion criteria

This study was conducted among the population aged 18 years and above using a cross-sectional research design. Thus, the population aged 18 years and above, living in Bangladesh, and knowing about the COVID-19 vaccine were used as the selection criteria for the face-to-face interview. The age of 18 years was considered because the vaccine was not available for people younger than 18 years when this study was conducted. In addition to the criteria used in the face-to-face interview, reading and writing and internet use were used as the selection criteria for the online survey. On the other hand, pregnancy, breastfeeding, and the presence of any severe chronic illness were considered as the exclusion criteria for selecting respondents for this study.

Sample size

We used the following formula to calculate the sample size: (Z2pq/e2)Deff*NR. We used Z-score for 95% confidence interval (Z = 1.96), prevalence (p) of willingness to accept a COVID-19 vaccine from an earlier study (p = 0.325) [13], margin of error (e = 0.03); design effect (Deff = 1.6) for sampling variation; and a non-response rate (NR = 10%). The calculated sample size was 1635, distributed for face-to-face and online surveys using a 2:1 ratio considering the country’s digital divide. However, 112 respondents did not consent to participate in the study (101 in the face-to-face survey and 11 in the online survey). The response rate was 93.1 percent (91.9% in face-to-face surveys and 97.7% in online surveys). We also had to exclude 26 respondents who did not know about the COVID-19 vaccine. Thus, the final sample for this study was 1497 for analysis (1022 (68.3%) from face-to-face survey and 475 (31.7%) from online survey). The data is now placed in the Mendeley open research data repository [27].

Modes of data collection

Data were collected between 1–7 February 2021. We collected data using both online and face-to-face interviews. The online data were collected through Google Forms using the Bengali language. The participants to whom the survey link was sent through e-mail, WhatsApp, or Facebook were requested to fill-up the form and circulate the link in their network to reach more people. In addition, the research team members circulated the survey link in their respective professional and social networks through the snowball process. The online link was valid for three days. The online data were downloaded, and divisional distribution was assessed. Data were then collected from the remaining sample size for each division through a face-to-face interview using quota sampling. We used a non-probability sampling technique as the complete list of the adult population was not available. Due to budgetary constraints, a listing of the households was also not possible. The duration for the face-to-face data collection was four days. The graduate and post-graduate level students of the University of Dhaka were recruited and trained to collect the data. We trained the data collectors through the online platform google meet. The training included discussions on how to conduct face-to-face data collection and quota sampling strategy.

Ethical approval and participant’s consent

We took ethical approval (registration number - 391310l2021) from the National Research Ethics Committee of the Bangladesh Medical Research Council (BMRC). Participation in this study was entirely voluntary, and no incentive was provided to the participants. For the face-to-face interview, the interviewer informed the scopes and implications of the study to the respondents and requested to participate voluntarily. The interviewer did not interview the respondents if they declined to participate. For the online survey, the respondents voluntary and informed consent was sought by using the question “do you agree to participate in this study after reading the information about this research?” which had a binary response option. The respondents who consented to participate voluntarily in the survey then needed to click on the “Continue” option and only then were they directed to complete the Google Forms. The respondents could not participate in this study if their answers to this consent question were “no.”

Measures

We selected variables and items for constructing scales from the previous studies [12, 28–32] and then mixed and customized the different items to develop the scale for the Bangladesh context. The data collection tool was pretested to validate using the face-to-face interview to determine respondents’ understanding of the questions, comprehensiveness of the questionnaire, and wording, length, and sensitivity of the questions. We calculated internal consistency using Cronbach’s alpha (α) to assess the reliability of the items used in the scales. We developed a total of ten scales, of which seven scales had an α between 0.700 to 0.857, and three had an α between 0.612 to 0.657. The reliability analysis of seventy percent of our scales was good as the α ranged between 0.7 and 0.8 [33]. The discussion below provides a detailed discussion on scale development, and the items used in these scales are available at https://osf.io/e4xph/.

Outcome variable: Vaccine hesitancy

We used two questions to measure this study’s outcome variable, which is the COVID-19 vaccine hesitancy. First, we asked the respondents what they would do if they got the chance to take the COVID 19 vaccine for free? The responses to this question were: 1 = Surely, I will take it; 2 = Probably I will take it; 3 = I will delay taking it; 4 = I am not sure what I will do; 5 = Probably I will not take it; 6 = Surely, I will not take it. The responses 1 = Surely, I will take it and 2 = Probably I will take it were considered vaccine acceptancy, and the rest indicated vaccine hesitancy. The second question was what they would do if their family or friends thought of taking COVID 19 vaccine? The responses to this question were: 1 = Strongly encourage them; 2 = Encourage them; 3 = Ask them to delay getting the vaccine; 4 = I will not say anything about it; 5 = Discourage them to take the vaccine; 6 = Forbid them to take the vaccine. The responses 1 = Strongly encourage them and 2 = Encourage them were considered vaccine acceptancy, while the rest indicated vaccine hesitancy. The Cronbach Alpha (α) of these two items was 0.833, which shows good internal consistency. We combined these two items and calculated the prevalence of vaccine hesitancy if the respondents had hesitancy in any of the two items.

Independent variables

Socio-economic and demographic variables. We included the following socio-economic and demographic variables as the independent variables of this study: age, sex, religion, marital status, educational attainment, place of residence, administrative division, occupation, number of household members, and household income.

Behavioral practice to prevent COVID-19. We measured preventive behavioral practices related to COVID-19 using three four-point Likert scale items. The total score of these items ranged between 3 and 12, with a higher score indicating better preventive practices with the Cronbach alpha (α) 0.857.

Knowledge about the COVID-19 vaccine. We assessed the knowledge related to the COVID-19 vaccine using four five-point Likert scale questions. The total score of these items ranged between 4 and 20, with a higher score indicating higher knowledge with the Cronbach alpha (α) 0.643.

Knowledge about the vaccination process. Knowledge about the COVID-19 vaccination process was measured by six binary (yes = 1, no = 0) questions. The Cronbach alpha (α) of these six questions was 0.765, which shows good internal consistency. Thus, the higher scores indicated better knowledge.

COVID-19 vaccine conspiracy. Conspiracy related to the COVID-19 vaccine was measured using nine five-point Likert scale items (α = 0.716). The total score of these items ranged between 9 and 45, where a higher score indicated having higher conspiracy beliefs toward the COVID-19 vaccine.

Attitude towards COVID-19 vaccine. COVID-19 vaccine-related attitudes (α = 0.739) were assessed using six five-point Likert-type items. The total score of attitudes toward the COVID-19 vaccine ranged between 6 and 30, where a higher score indicated higher negative attitudes toward the COVID-19 vaccine.

Health Belief Model. The classical HBM consists of the following components: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers.

Perceived susceptibility. Two five-point Likert scale questions were used to measure the perceived susceptibility (α = 0.657) of the COVID-19.

Perceived severity. The perceived severity of the COVID-19 was measured using two five-point Likert scale questions, which had an α of 0.612.

Perceived benefits. Perceived benefits (α = 0.841) of the COVID-19 vaccination were measured using three five-point Likert scale questions.

Perceived barriers. The perceived barriers (α = 0.700) of getting the COVID-19 vaccination were measured using six five-point Likert scale questions.

Statistical analysis

We first employed univariate descriptive statistical analysis [percentage, mean, and standard deviation (SD)]. The Chi-square test and Point-biserial correlation were used to estimate the bivariate level statistics. The statistically significant (p ≤ 0.05) variables of the bivariate level were entered into the multiple logistic regression model after checking the assumptions and multicollinearity. The study was designed and reported following strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [34]. We analyzed the data using the Statistical Product and Service Solutions (SPSS) software, version 26.

Results

Characteristics of the participants

The average age of the respondents was 33.7 years, with an SD of 12.9 (). The highest proportion of respondents was from 18 to 24 years (28.9%). Among the respondents, 46.2% were women, while most respondents (86.9%) were Muslims. The married respondents were 61.6%, while only 20.6% had less than a secondary education level. The rural respondents were 64.3%, while 31.9% were from the Dhaka division. More than 30% of the respondents (31.6%) were students and unemployed. The mean household members were 5.0, while the mean household income was 37627 Taka (1 US$ = 84.8 Taka). Table 1 also shows that sample characteristics were almost nationally representative about age, sex, religion, marital status, place of residence, and the mean number of household members (Column 3, Table 1).

Table 1

Background characteristics of the study population (n = 1497).

Variables	Study sample, n (%)	National population (%)
Age (in years)
18–24	432 (28.9)	20.1
25–30	362 (24.2)	19.7
31–39	254 (17.0)	22.7
40–49	236 (15.8)	18.5
50+	213 (14.2)	19.1
Mean (SD)	33.7 (12.9)
Sex
Women	692 (46.2)	50.1
Men	805 (53.8)	49.9
Religion
Others	196 (13.1)	9.3
Muslim	1301 (86.9)	90.7
Marital status
Unmarried	575 (38.4)	34.8
Married	922 (61.6)	65.2
Education
No education	129 (8.6)	28.9
Primary	179 (12.0)	27.5
Secondary and higher secondary	448 (29.9)	43.6
Graduate	400 (26.7)
Masters and MPhil/PhD	341 (22.8)
Place of residence
Rural area	963 (64.3)	65.0
Urban area (other than city corporation)	179 (12.0)	35.0
City Corporation	355 (23.7)
Administrative division of Bangladesh
Barishal	114 (7.6)	5.7
Chattogram	253 (16.9)	20.1
Dhaka	478 (31.9)	25.1
Khulna	137 (9.2)	10.8
Mymensingh	108 (7.2)	7.8
Rajshahi	180 (12.0)	12.7
Rangpur	114 (7.6)	10.9
Sylhet	113 (7.5)	6.8
Occupation
Government, private, & NGO sector job	202 (13.5)
Professional	277 (18.5)
Homemakers	348 (23.2)
Students and unemployed	473 (31.6)
Agriculture and Day Laborer	102 (6.8)
Others	95 (6.3)
Household members, Mean (SD)	5.0 (2.0)	4.6
Household income, Mean (SD)	37627.2 (81295.9)

Prevalence of the COVID-19 vaccine hesitancy

Fig 1 shows that 42.9% of the respondents reported that they would surely receive the COVID-19 vaccine, if available for free, while 17.7% would probably receive it. Besides, 22.8% of respondents strongly encouraged their family members to receive the vaccine, while 37.5% encouraged their family members to take the vaccine (). On the other hand, 12.3% of the respondents stated that they would delay receiving the vaccine, followed by 13.2% who were unsure about what they would do, 7% would probably not receive it, and 6.9% would surely not receive the vaccine. Similarly, if the family or friends were thinking of receiving the COVID-19 vaccine, 16.8% of the respondents supported the statement that they would ask their family members or friends to delay receiving the vaccine. In comparison, 16.9% would not say anything about it, 2.9% would discourage their family members and friends from receiving the vaccine, and 3% would forbid their family members and friends to receive the vaccine.

Fig 1

Prevalence (%) of COVID-19 vaccine hesitancy among the study population (n = 1497).

Vaccine hesitancy by respondents’ background characteristics

Overall, 46.2% of the respondents had hesitancy to receive the COVID-19 vaccine. The hesitancy was statistically significantly (p < 0.05) associated with respondents’ religion, education, place of residence, the administrative division of Bangladesh (Table 2). The prevalence of hesitancy was higher among the Muslims, respondents from city corporation areas, and the Khulna division.

Table 2

COVID-19 vaccine hesitancy by the respondent’s characteristics (n = 1497).

Variables	Hesitancy (%)		P-value
	No	Yes
Age (in years)			0.137
18–24	51.6	48.4
25–30	53.0	47.0
31–39	60.6	39.4
40–49	50.4	49.6
50+	55.4	44.6
Sex			0.158
Women	51.9	48.1
Men	55.5	44.5
Religion			<0.001
Others	68.9	31.1
Muslim	51.6	48.4
Marital status			0.552
Unmarried	52.9	47.1
Married	54.4	45.6
Education			0.004
No education	49.6	50.4
Primary	57.5	42.5
Secondary and higher secondary	60.5	39.5
Graduate	49.5	50.5
Masters and MPhil/PhD	49.9	50.1
Place of residence			<0.001
Rural area	57.5	42.5
Urban area (other than city corporation)	57.0	43.0
City Corporation	42.3	57.7
Administrative division of Bangladesh			0.004
Barishal	57.9	42.1
Chattogram	52.6	47.4
Dhaka	54.2	45.8
Khulna	40.1	59.9
Mymensingh	56.5	43.5
Rajshahi	59.4	40.6
Rangpur	46.5	53.5
Sylhet	63.7	36.3
Occupation			0.159
Government, private, & NGO sector job	48.0	52.0
Professional	56.3	43.7
Homemakers	52.3	47.7
Students and unemployed	53.5	46.5
Agriculture and Day Laborer	63.7	36.3
Others	55.8	44.2
Total	53.8	46.2

Vaccine hesitancy by behavioral practices to prevent COVID-19

Fig 2 shows the prevalence of vaccine hesitancy by the participants’ behavioral practices towards COVID-19 prevention. It shows that respondents who never wore a mask in going out of home and avoided crowded places had more vaccine hesitancy than their counterparts though these findings were not statistically significant. However, the respondents who were never conscious about using sanitizer or hand wash had significantly higher vaccine hesitancy (45.9%) than those who were regularly conscious (42%).

Fig 2

Vaccine hesitancy (%) by behavioral practices to prevent COVID-19 (n = 1497).

Vaccine hesitancy by knowledge about the COVID-19 vaccine and vaccination process

Fig 3 illustrates the prevalence of vaccine hesitancy by knowledge about the COVID-19 vaccine. The respondents who strongly disagreed that the COVID-19 vaccine has very mild side effects were more hesitant (58.7%) to receive the vaccine than those who agreed (24.9%) with the statement. In addition, the participants who had incorrect knowledge about the vaccination process were more hesitant than those who had correct knowledge (Fig 4). For example, the vaccine hesitancy was higher (48.9%) among the respondents who did not know about the correct doses of the COVID-19 vaccine compared to those who knew the correct doses of the vaccine (38.6%).

Fig 3

Vaccine hesitancy (%) by knowledge about the COVID-19 vaccine (n = 1497).

Fig 4

Vaccine hesitancy (%) by knowledge about the COVID-19 vaccination process (n = 1497).

Vaccine hesitancy by attitude towards COVID-19 vaccine and vaccine conspiracy belief

Table 3 depicts the prevalence of hesitancy by attitudes towards the COVID-19 vaccine and its conspiracy beliefs. The respondents who had more negative attitudes and conspiracy beliefs had more hesitancy to accept the COVID-19 vaccine. For example, the respondents who did not trust the COVID-19 vaccine had more hesitation (59.6%) than those who trusted the COVID-19 vaccination (28.6%). Furthermore, the respondents who believed that the vaccine would probably not work had more hesitancy (62.5%) than those who did not believe it (34.8%). On the other hand, the respondents who strongly agreed that the Coronavirus is a myth to force vaccinations on people had higher hesitancy (61.5%) than those who did not agree with the statement (40.1%). In contrast, the respondents who strongly agreed that the COVID-19 vaccines made in India, America, and Europe are not safer had more hesitancy.

Table 3

Vaccine hesitancy by attitude and conspiracy towards COVID-19 vaccine (n = 1497).

Variables and Items	Hesitancy (%)			P-value
	Disagree a	No opinion	Agree b
Attitude towards COVID-19 Vaccine
I think the COVID-19 vaccine probably will not work	34.8	64.2	62.5	< .001
I do not trust the COVID-19 vaccine	28.6	52.4	59.6	< .001
I think the COVID-19 vaccine is unnecessary	37.9	63.9	68.1	< .001
I think it is not important to get a vaccine to protect people from the COVID-19	37.7	64.2	55.0	< .001
I do not need a COVID-19 vaccine because I am healthy and at low risk for infection	30.0	59.1	62.3	< .001
I do not need a COVID-19 vaccine because even if I get infected, I will not become seriously ill	30.8	57.6	64.6	< .001
Conspiracy belief regarding COVID-19 vaccine
Pharmaceutical companies are encouraging the spread of Coronavirus to make a profit through selling vaccine	37.0	55.8	54.4	< .001
The Coronavirus is a myth to force vaccinations on people	40.1	58.0	61.5	< .001
Drug companies cover up the side effects of vaccines	29.6	53.0	60.5	< .001
People are deceived about the effectiveness of vaccines	31.4	54.1	60.7	< .001
COVID-19 vaccine can result into autism	33.4	52.5	52.9	< .001
A coronavirus vaccination could give one coronavirus	33.9	55.4	51.8	< .001
COVID-19 vaccines made in America and Europe are not safer than those made in other countries	41.4	48.3	52.2	0.011
COVID-19 vaccines made in China and Russia are not safer than those made in other countries	40.3	48.3	45.3	0.052
COVID-19 vaccines made in India are not safer than those made in other countries	26.3	46.1	53.6	< .001

a. Includes strongly disagree and disagree.

b. Includes strongly agree and agree.

Vaccine hesitancy by the constructs of health belief model

The prevalence of vaccine hesitancy by the health belief model components is presented in Table 4. The respondents who strongly disagreed with the statements related to perceived benefits were more hesitant to receive a vaccine. For example, the respondents who strongly disagreed with the statement that “I think the complications of the COVID-19 will decrease if I get vaccinated and then get infected with the Coronavirus” had more hesitancy (65.1%) than those who agreed to the statement (31.4%). On the other hand, the respondents who strongly agreed with the statements related to perceived barriers were also more hesitant to receive the COVID-19 vaccine. For instance, the respondents who strongly agreed that registering for the COVID-19 vaccination was difficult for them had more hesitancy (51.8%) than those who disagreed with the statement (38.5%).

Table 4

Vaccine hesitancy by health belief model related to COVID-19 vaccine (n = 1497).

Health Belief Model	Hesitancy (%)			P-value
	Disagree a	No opinion	Agree b
Perceived Susceptibility
I am worried about the likelihood of getting infected by COVID-19	50.2	57.5	38.7	< .001
I am at high risk of COVID-19 because of my health conditions	46.7	51.1	35.5	0.001
Perceived Severity
I will be very sick if I get infected by COVID-19	49.5	53.7	33.1	< .001
I am very concerned that I could die from COVID-19	47.6	48.8	38.6	0.01
Perceived Benefits
I think vaccination is good because it will make me less worried about COVID-19	60.2	62.8	34.9	< .001
I believe vaccination will decrease my risk of getting infected by COVID-19	65.5	60.7	33.7	< .001
I think the complications of COVID-19 will decrease if I get vaccinated and then get infected with the Coronavirus.	65.1	56.3	31.4	< .001
Perceived Barriers
I am worried that the possible side effects of the COVID-19 vaccination would interfere with my usual activities	28.2	56.3	43.6	< .001
I am concerned about the efficacy of the COVID-19 vaccine	28.2	56.3	43.6	< .001
I have a concern that I may receive faulty/fake COVID-19 vaccine	27.6	47.3	51.6	< .001
It concerns me that the development of a COVID-19 vaccine is too rushed to test its safety properly	25.8	51.7	57.9	< .001
I am concerned about the long-term side effects of the COVID-19 vaccination	28.4	49.2	51.1	< .001
Registering for COVID-19 vaccination is difficult for me	38.5	54.0	51.8	< .001

a. Includes strongly disagree and disagree.

b. Includes strongly agree and agree.

Predictors of COVID-19 vaccine hesitancy

After checking the assumptions and multicollinearity, the significant independent variables at the bivariate level were then entered into the multiple logistic regression model (). We produced three models. The first model included the socio-economic and demographic characteristics of the study population, while the second model included all the variables of model 1 plus knowledge, attitudes, conspiracy beliefs, and behavioral practices related to the COVID-19 vaccine. The third model included all the variables of model 2 plus all the components of HBM. All the regression models were highly significant. The Nagelkerke R2 of the final regression model (model 3) was 0.37. Moreover, compared to model 1, successive models had higher R2, and lower -2 Log-likelihood, showing better model fitting.

According to model 3, the Muslims (aOR = 1.80, p ≤ 0.01) and the respondents of city corporation areas (aOR = 2.14, p ≤0.001) were more likely to be hesitant than that of others. Compared to the Sylhet division, the participants from Khulna (aOR = 1.31, p ≤0.001) had higher hesitancy. With increasing the knowledge about vaccine (aOR = 0.88, p≤0.001) and knowledge about vaccination process (aOR = 0.91, p ≤ 0.01), hesitancy tended to decrease. On the other hand, with increasing negative attitudes (aOR = 1.17, p ≤0.001) and conspiracy beliefs towards vaccine (aOR = 1.04, p≤0.01), the hesitancy increased. The perceived benefits of COVID-19 vaccination (aOR = 0.85, p ≤0.001) reduced the hesitancy, while perceived barriers (aOR = 1.16, p ≤0.001) increased the hesitancy.

Discussions

The study found that about 14% of the respondents have asserted their intention not to receive the vaccines, while 16.8% have reported that they would suggest their friends and families delay receiving COVID-19 vaccines. The study also found that 2.9% of the respondents would discourage their family members from receiving the vaccination, and 3% forbid their family members. Overall, this study found a prevalence of 46.2% hesitancy to receive the COVID-19 vaccine, which is a higher estimate than Kabir et al. (31%) [20], Ali and Hossain (32.5%) [13], and Mahmud et al. (38.8%) [21]. This higher prevalence may partly be explained because the existing studies were conducted in Bangladesh [13, 20, 21] as a rapid assessment of the situation, resulting from participant selection bias. The existing studies also had a small sample size and conducted the online survey [20, 21]. However, data were collected through online and face-to-face interviews from a nationwide sample covering all eight administrative divisions in our study. Therefore, the findings of our study provide a more accurate estimate of COVID-19 vaccine hesitancy among the adult population living in Bangladesh.

Our study shows that religion was significantly associated with vaccine hesitancy, which is in line with other studies of low and middle-income countries from both non-COVID-19 [35] and COVID-19 contexts [36]. The Muslims had more hesitancy about the receipt of coronavirus vaccination in the current study. The notion of considering vaccines as ‘medical assault’, doubts regarding the ingredients of the vaccines (doubts over the inclusion of ingredients like pork gelatin) may play a role behind the increased hesitancy of Muslim people regarding COVID-19 vaccines [14, 37]. The COVID-19 vaccines have been considered a ‘western plot’ to sterilize Muslim women in Asian countries like Pakistan. Thus vaccine has been largely discouraged by the community [37, 38]. Similarly, in different earlier non-COVID-19 examples of the middle-income countries like Malaysia, such as in the cases of measles, mumps, and rubella (MMR), religious ruling against vaccines considering them as ‘haram’ (forbidden) due to the suspected presence of ingredients derived from pigs, receiving vaccines were discouraged [39]. Religious fatalism among the Muslims, including the beliefs that ‘everything is in the hands of Allah,’ and sense of inability of avoiding death when it is the will of Allah, influences the perception of health among Muslims [40] and such perspectives on health, in this case, is possibly growing vaccine hesitancy among the Muslims [41].

The findings of this study show that respondents from the city corporation areas are more hesitant about the uptake of the COVID-19 vaccines. Due to having more exposure to the different online and offline sources of information, the residents of the city corporation have more possibility of producing fear-driven stigma and conspiracy beliefs regarding COVID-19 vaccines, which may explain their higher level of vaccine hesitancy. In a non-COVID-19 context (dengue vaccine), the broader access towards negative media information in urban areas regarding vaccines has been found responsible for a high level of vaccine hesitancy in other low-middle-income countries, like the Philippines [42]. However, another study on the COVID-19 context in Bangladesh found that rural inhabitants were more likely to experience vaccine-related hesitancy than their urban counterparts [22].

Our study shows that the hesitancy decreased with increased knowledge about the COVID-19 vaccine and its associated processes. Thus, the vaccine-related knowledge, which creates awareness regarding vaccine’s role in decreasing the risks of the diseases among individuals, plays a role in lessening vaccine hesitancy [43]. Furthermore, being knowledgeable and aware of the vaccine is a significant predictor of vaccine hesitancy in other studies conducted in COVID-19 [44] and non-COVID-19 [45, 46] contexts in lower-middle-income countries like India and Malaysia. Thus, it leaves ample scopes for circulating evidence-based information about the COVID-19 vaccine among people to increase vaccine uptake.

Attitudes toward the COVID-19 vaccine have been appeared to be one of the strongest predictors of vaccine hesitancy. The negative attitudes towards the COVID-19 vaccine, including perceiving less importance of vaccines, and mistrust about effectiveness, were associated with increasing vaccine hesitancy among the respondents of this study. A negative or anti-COVID-19 vaccination attitude is formed because of the low confidence in vaccine safety [47] and vaccine benefits [48], concerns regarding potential side effects [49], and also the newness of the vaccine [50]. The finding of this current study is in line with other studies conducted in Bangladesh and other lower-middle-income countries, where it was shown that people having a more negative attitude towards the COVID-19 vaccines are less willing to receive the vaccine [22, 51].

The conspiracy beliefs about the COVID-19 vaccines regarding pharmaceutical companies’ roles, vaccine manufacturers, and consequences of vaccination have been responsible for increasing the vaccine hesitancy in our study. In various studies conducted in lower-middle-income countries like Pakistan, conspiracy narratives have been regarded as the seed bearer of vaccine hesitancy and considered responsible for resistance against the COVID-19 vaccination programs [14]. Furthermore, the hesitancy towards receiving the COVID-19 vaccines has been significantly influenced by different conspiracy beliefs in some Arab countries like Jordan and Kuwait [15]. Furthermore, various conspiracies, including misinformation regarding the origin of the virus, COVID-19 vaccines trials [15], suspicions around vaccine manufacturers (pharmaceuticals companies and country of origin) [15, 52] regarding vaccine efficacy and safety, have been considered as responsible in other studies conducted in the context of developing countries like Kuwait and Uganda for fueling pre-existing fears, fostering mistrust, doubts, and cynicism over new vaccines, and lowering the COVID-19 vaccination intention of people [53].

The study used the constructs of HBM as independent variables to predict vaccine hesitancy. It was found that perceived benefits and barriers components of HBM were strongly predicting the prevalence of vaccine hesitancy among individuals. Our study found a strong negative association between perceived benefits and the COVID-19 vaccine hesitancy. Considering a particular action (in this case, receiving vaccination) as effective in preventing a disease, which is perceived benefits according to HBM constructs, motivates individuals in adopting the behaviors [54]. On the other hand, perceived barriers were positively associated with vaccine hesitancy in our study. Different perceived structural and attitudinal barriers have been found in other studies conducted in the context of Bangladesh and other developing countries like Egypt [20, 55] as responsible for the vaccine hesitancy, such as lack of information about the vaccination and its adverse effects [55], not getting access to the vaccination coverage [56], affordability issues [57], individual’s negative concerns regarding side effects and efficacy of the vaccine [58].

This study explored the prevalence and determinants of the COVID-19 vaccine hesitancy in Bangladesh, which will help the policymakers develop tailored messages to combat the vaccine hesitancy among the people and increase its uptake. However, some limitations of this study should be considered in interpreting the results. First, this study used non-probability sampling; therefore, we should be careful about the generalization of the findings. Second, though this study tried to represent the national population in terms of age, sex, residence, region, marital status, and religion, the distribution of education among the respondents is to some extent not comparable to national data. Third, this study collected self-reported data that may suffer from reporting bias to some extent. Finally, this research used a cross-sectional study design which can not establish causality.

Conclusions

This nationwide survey provides crucial evidence that nearly half of the adults (46.2%) in Bangladesh are hesitant to receive the COVID-19 vaccine. Thus, the study’s findings warrant serious attention of the concerned public health authorities in Bangladesh as the government aims to vaccinate 80% of the total population to bring the pandemic under control. Our findings suggest that negative attitudes, mistrust, and conspiracy beliefs regarding the COVID-19 vaccine are widely prevalent among the people in Bangladesh. Therefore, a vigorous behavior change communication campaign involving community people should be designed and implemented to demystify negative public attitudes towards the vaccine. Besides, it is important to ensure that proper knowledge regarding the COVID-19 vaccine and vaccination process is continuously circulated through effective mass media channels, e.g., online, TV news, and social media. In this regard, public health messaging which emphasis trust in vaccine safety, effectiveness, and benefits can play a significant role. The policymakers should also think about revisiting the policy of the online registration process to receive the COVID-19 vaccine, as we found that online registration is a key structural barrier for many due to the persistent digital divide in the country. It particularly prevents women and the population from the lower socio-economic strata from receiving the COVID-19 vaccine. In this regard, initiatives like text message services using mobile phone operators can ease the registration process as more than 75% of Bangladeshis own a mobile phone. Finally, the government should consider the population’s preference regarding vaccines’ country of manufacture to reduce vaccine hesitancy and increase voluntary uptake of the COVID-19 vaccine.

Study area from where data were collected.

(TIF)

Click here for additional data file.

3 Jun 2021

PONE-D-21-14374

COVID-19 Vaccine Hesitancy among the Adult Population in Bangladesh: A Nationally Representative Cross-sectional Survey

PLOS ONE

Dear Dr. Hossain,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript covers an important aspect related to COVID vaccine. I  also suggest you to check for grammatical errors throughout the manuscript

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PLOS ONE

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1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The study has been done well. However, some suggestions to improve the paper are as follows.

1. Please mention how the items for the various scales used in the study were developed and validated,

2. Mean score of the hesitancy scale should not be used to calculate hesitancy rather the proportion of participants who were not willing to take/recommend the vaccine to family members should be considered for vaccine hesitancy. Use of the previous method has led to overestimation of vaccine hesitancy in the study.

3. Accuracy of the scale cannot be calculated by dividing the mean score of the scale by overall score (Line 257-259).

4. Comparing the proportion with vaccine hesitancy with the respondent’s characteristics will be more appropriate than mean score of vaccine hesitancy (Table 2). Computing the overall score for each predictor variable and categorising it and comparing it with the proportion with vaccine hesitancy would be more meaningful than comparing mean scores with each question under a predictor variable. Also, the responses of for each question under a predictor variable can be clubbed into categories namely agree, disagree and no opinion and then be compared (Table 3 and Table 4).

Reviewer #2: Comments

At the outset, congratulations to the authors for conducting this timely study that carries public health importance in the context of the ongoing COVID-19 pandemic.

Abstract

- Abstract provides a balanced summary. The methods section under the abstract shall indicate the study setting (total administrative divisions included) and duration of the study.

Methods:

- Describe study setting: total population of Bangladesh, proportion of urban or rural population, sex ratio, life expectancy, literacy rate, economic status, and other factors that have influence on the vaccine hesitancy.

- Please indicate the exact number of participants from the online and face-to-face surveys.

- The sampling strategy used for selecting participants from the districts of administrative divisions of Bangladesh for the face-to-face interviews shall be included. Describe how (sampling procedure) and where (setting) the participants were chosen within each district.

- Please include the reference number and the date of approval of ethics clearance under the ‘ethical approval’ section

- What was the rationale behind choosing margin of error of 0.03 and design effect of 1.6 in sample size calculation?

- Please include what was considered as non-response by an individual during face-to-face interviews?

- Regarding staff involved in face to face interviews: Who were involved in data collection and their training before data collection shall be described in brief.

- The study claims to be a nationally representative survey. However, the methodology described doesn’t reflect a robust sampling strategy to support the claim. The limitations of the study admits the non-probability sampling method used and cautions the generalizability of the study findings. So, kindly justify or changes shall be made as appropriate in the manuscript.

Results:

- The results are described in detail and are in line with the proposed study objectives. However, I would like to see 95% CI for the summary estimates.

- Multiple sub-group analysis was done in this study and I am not sure if the sample size is enough to test for multiple statistical tests. Authors are requested to consult a bio-statisticians for analysis.

- What were the response rates for the online and face-to-face surveys? Kindly include.

- Please add (N=?) in the titles of the tables

Discussion:

- Region specific data (Bangladesh/other LMICs) on determinants of COVID-19 vaccine hesitancy shall be highlighted in the discussion. This could substantiate the study findings as well as broaden the scope of study results in the international context.

- It may be necessary to broaden to the public health dimension i.e. recommendations or possible actions that could be undertaken to deal with the determinants of COVID-19 vaccine hesitancy

**********

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Reviewer #1: Yes: Sonali Sarkar

Reviewer #2: Yes: Sitanshu Sekhar Kar

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5 Aug 2021

PONE-D-21-14374: COVID-19 Vaccine Hesitancy among the Adult Population in Bangladesh: A Nationwide Cross-sectional Survey

Reviewer 1

Comment 1: Please mention how the items for the various scales used in the study were developed and validated,

Our Response: Thanks for your attention on this important point. We have addressed this issue in the lines between 163-173 of the cleaned version, which reads as follows:

We selected variables and items for constructing scales from the previous studies [12,28-32] and then mixed and customized the different items to develop the scale for the Bangladesh context. The data collection tool was pretested to validate using the face-to-face interview to determine respondents' understanding of the questions, comprehensiveness of the questionnaire, as well as wording, length and sensitivity of the questions. We calculated internal consistency using Cronbach’s alpha (α) to assess the reliability of the items used in the scales. We developed a total of ten scales, of which seven scales had an α between 0.700 to 0.857, and three scales had an α between 0.612 to 0.657. The reliability analysis of seventy percent of our scales was good as the α ranged between 0.7 and 0.8 [33]. The discussion below provides a detailed discussion on scale development, and the items used in these scales are available at https://osf.io/e4xph/.

Comment 2: Mean score of the hesitancy scale should not be used to calculate hesitancy rather the proportion of participants who were not willing to take/recommend the vaccine to family members should be considered for vaccine hesitancy. Use of the previous method has led to overestimation of vaccine hesitancy in the study.

Our Response: Thanks for this comment. We agree with you and have followed your recommendation and revised the calculation, reflected in the lines between 176-190 of the cleaned version. However, the new calculation increased the hesitancy rate. Now the hesitancy rate is 46.2% which was 41.1% earlier.

Comment 3: Accuracy of the scale cannot be calculated by dividing the mean score of the scale by overall score (Line 257-259).

Our Response: Thanks for this comment, which is also related to the previous comment. We have deleted this line and followed your recommendation as mentioned above.

Comment 4: Comparing the proportion with vaccine hesitancy with the respondent’s characteristics will be more appropriate than mean score of vaccine hesitancy (Table 2). Computing the overall score for each predictor variable and categorising it and comparing it with the proportion with vaccine hesitancy would be more meaningful than comparing mean scores with each question under a predictor variable. Also, the responses of for each question under a predictor variable can be clubbed into categories namely agree, disagree and no opinion and then be compared (Table 3 and Table 4).

Our Response: Thank you for this comment. We have followed you and revised the Table 2, 3, and 4. Accordingly, we have now used logistic regression instead of linear regression. Table 5 shows the findings of logistic regression.

Reviewer 2

Comment 1: Abstract- Abstract provides a balanced summary. The methods section under the abstract shall indicate the study setting (total administrative divisions included) and the duration of the study.

Our Response: Thanks for this comment. We have added this in the abstract. Please see line 31 in the cleaned version.

Comment 2: Methods:- Describe study setting: total population of Bangladesh, proportion of urban or rural population, sex ratio, life expectancy, literacy rate, economic status, and other factors that have influence on the vaccine hesitancy.

Our Response: We appreciate your comment to improve our manuscript by adding this point. We have described the study setting. Please see lines 108 to 119 of the cleaned version.

Comment 3: Please indicate the exact number of participants from the online and face-to-face surveys.

Our Response: Thanks a lot for this important comment. We have added this information. Please see lines 130 to 131 of the cleaned version.

Comment 4: The sampling strategy used for selecting participants from the districts of administrative divisions of Bangladesh for the face-to-face interviews shall be included. Describe how (sampling procedure) and where (setting) the participants were chosen within each district.

Our Response: Thanks a lot for highlighting this point. Please see lines 141 to 160 of the cleaned version where we have addressed your comment.

Comment 5: Please include the reference number and the date of approval of ethics clearance under the ‘ethical approval’ section

Our Response: Please see line 249 of the cleaned version where we have addressed this query.

Comment 6: What was the rationale behind choosing margin of error of 0.03 and design effect of 1.6 in sample size calculation?

Our Response: Thanks a lot for this important question. We have used the prevalence of vaccine hesitancy (p) from a previous study conducted in Bangladesh. The prevalence rate was 32.5% that means the value of p in our formula was 0.325. With this value of p, we could use a margin of error of 0.05, which is normally suggested. However, to increase our sample size considering a nationwide survey, we reduced the margin of error to increase the sample size. On the other hand, the design effect is normally suggested between 1.5 to 3.0. Thus, we adopted 1.6 appropriate for this study.

Comment 7: Please include what was considered as non-response by an individual during face-to-face interviews?

Our Response: Thanks for this important question. The respondents who did not consent to take part in the study and who consented to participate in the study but did not know about the COVID-19 vaccine were considered as non-response. Please see lines 126 to 130 of the cleaned version where we have addressed this issue.

Comment 8: Regarding staff involved in face to face interviews: Who were involved in data collection and their training before data collection shall be described in brief.

Our Response: Please see lines 157 to 160 of the cleaned version where we have described this.

Comment 9: The study claims to be a nationally representative survey. However, the methodology described doesn’t reflect a robust sampling strategy to support the claim. The limitations of the study admits the non-probability sampling method used and cautions the generalizability of the study findings. So, kindly justify or changes shall be made as appropriate in the manuscript.

Our Response: Thanks a lot for your significant observation. We agree with you and thus, revised our title.

Comment 10: Results:- The results are described in detail and are in line with the proposed study objectives. However, I would like to see 95% CI for the summary estimates.

Our Response: The findings of the adjusted odds ratio have been reported with 95%CI. Please see Table 5.

Comment 11: - Multiple sub-group analysis was done in this study and I am not sure if the sample size is enough to test for multiple statistical tests. Authors are requested to consult a bio-statisticians for analysis.

Our Response: Thanks for your observation. We did not do any sub-group analysis, e.g., different analyses for men and women. We just conducted statistical analysis to establish the association between the outcome variable and independent variables. The analysis was used to select variables for multiple logistic regression. Our team has a Biostatistician, and we are confident that we had enough samples for conducting multiple regression analysis.

Comment 12: What were the response rates for the online and face-to-face surveys? Kindly include.

Our Response: Thanks for this observation. Please see lines 126 to 130 of the cleaned version where we have addressed this issue.

Comment 13: Please add (N=?) in the titles of the tables

Our Response: We have addressed this comment in all the figures and tables. We appreciate your observation.

Comment 14: Discussion:- Region specific data (Bangladesh/other LMICs) on determinants of COVID-19 vaccine hesitancy shall be highlighted in the discussion. This could substantiate the study findings as well as broaden the scope of study results in the international context.

Our Response: Thanks for this advice. Region specific data (Bangladesh/other LMICs) on determinants of COVID-19 vaccine hesitancy is highlighted now in the discussion.

Comment 15: It may be necessary to broaden to the public health dimension i.e. recommendations or possible actions that could be undertaken to deal with the determinants of COVID-19 vaccine hesitancy.

Our Response: Thanks for this significant comment. We have addressed this issue in the conclusion section now.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

7 Sep 2021

PONE-D-21-14374R1COVID-19 Vaccine Hesitancy among the Adult Population in Bangladesh: A Nationwide Cross-sectional SurveyPLOS ONE

Dear Dr. Hossain,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 22 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Leeberk Raja Inbaraj, MD

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: N/A

Reviewer #4: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for accepting and modifying the manuscript as per the suggestions. There's a lot of improvement in the manuscript. Though the manuscript has been written in an intelligible way, the language needs corrections at multiple places. The writeup appears to be verbose, can be pruned to convey the same message in lesser words.

Reviewer #3: (No Response)

Reviewer #4: General comments: 1. Sentences need to be framed in correct English, to be understandable by the reader. Line 62-63, Line 94 (should be plural-studies, as we aim to look for multiple related studies to say this fact) not very clear. 2. Table formatting and alignment needed overall. 3. Result section cannot have terms like about, nearly, near to. Be confident about the percentages obtained from your research. 4. Avoid using mass people repeatedly, mass in itself explains it (Line 83-84).

Comment-1 How was sample size decided for online and face to face interview? Needs more clarity on this.

Comment-2 How were participants consented and approached for both the modes of data collection?

Comment-3 Please specify inclusion and exclusion criteria clearly in the beginning of the study methodology.

Study methodology needs more specification regarding study setting-mention names of the blocks in which study was set up. Presently everything is scattered over the places. It will create confusion in readers mind. Have proper sub headings for methodology section.

Comment-4 Fig 3, 4 , Table 3,4 needs percentage inclusion in paragraph written for them, Plain text not making much sense.

Comment-4 Please justify why was non probability sampling was chosen.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Sonali Sarkar

Reviewer #3: No

Reviewer #4: Yes: rchhokar

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22 Oct 2021

PONE-D-21-14374R1: COVID-19 Vaccine Hesitancy among the Adult Population in Bangladesh: A Nationwide Cross-sectional Survey

Reviewer 1

Comment 1: Thank you for accepting and modifying the manuscript as per the suggestions. There's a lot of improvement in the manuscript. Though the manuscript has been written in an intelligible way, the language needs corrections at multiple places. The writeup appears to be verbose, can be pruned to convey the same message in lesser words.

Our Response: Thanks a lot for your comments. We have edited the manuscripts according to your suggestion.

Reviewer 4:

Comment 1: Sentences need to be framed in correct English, to be understandable by the reader. Line 62-63, Line 94 (should be plural-studies, as we aim to look for multiple related studies to say this fact) not very clear.

Our Response: Thanks a lot, pointing this out. We have taken care of this issue in the manuscript.

Comment 2: Table formatting and alignment needed overall.

Our Response: We are sorry that we could not identify any table formatting and alignment issue. We understand that it can be addressed during the production phase if there is any such issue.

Comment 3: Result section cannot have terms like about, nearly, near to. Be confident about the percentages obtained from your research.

Our Response: Thanks a lot for raising this critical point. We are confident about the percentages that we have reported in the table. We wrote in that style to avoid numbers at the beginning of the sentence. However, we have revised the manuscript thoroughly to address your comment.

Comment 4: Avoid using mass people repeatedly, mass in itself explains it (Line 83-84).

Our Response: Thank you. We have addressed this.

Comment 5: How was sample size decided for online and face to face interview? Needs more clarity on this.

Our Response: We decided to follow a 2:1 ratio for interviewing samples using face-to-face and the online survey considering the country's digital divide. We have provided this justification.

Comment 6: How were participants consented and approached for both the modes of data collection?

Our Response: Thanks a lot for raising this question. We have added a description of this issue in the Ethical Approval Participant’s Consent section.

Comment 7: Please specify inclusion and exclusion criteria clearly in the beginning of the study methodology. Study methodology needs more specification regarding study setting-mention names of the blocks in which study was set up. Presently everything is scattered over the places. It will create confusion in readers mind. Have proper sub headings for methodology section.

Our Response: We have thoroughly worked on these issues and revised our methodology section.

Comment 8: Fig 3, 4 , Table 3,4 needs percentage inclusion in paragraph written for them, Plain text not making much sense.

Our Response: Thanks a lot for this suggestion. We have revised figures 2 to 5 and tables 3 and 4.

Comment 9: Please justify why was non probability sampling was chosen.

Our Response: Thanks a lot for this question. Now, we have justified the adoption of non-probability sampling.

Submitted filename: Response to reviewers Plain Text.docx

Click here for additional data file.

15 Nov 2021

PONE-D-21-14374R2COVID-19 Vaccine Hesitancy among the Adult Population in Bangladesh: A Nationwide Cross-sectional SurveyPLOS ONE

Dear Dr. Hossain,

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Reviewers' comments:

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Reviewer #1: All comments have been addressed

Reviewer #4: All comments have been addressed

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Reviewer #1: Yes

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #4: Yes

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Reviewer #4: Yes

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Reviewer #1: (No Response)

Reviewer #4: Thank you for modifying the manuscript, it looks much better now.

Comment-1: Line 177-it should be respondents, remove single quotation mark

Comment 2: line 178-179, 181,183- double quotation marks instead of single are recommended

comment 3: line 203-204, 209, single quotation can be removes, as in other places in the same paragraph.

Please check for similar changes across the manuscript if present.

Comment 4: table -1, "Total" in the end is not well clear. In my opinion it can be removed, as table heading has n=1497 mentioned already

Comment 5: table 2 ,3 and 4, in the table title "%", can be removed, as the table below shows data well in % as mentioned in the column 2 of the table. Again, "Total ", not required in the end of the table in my opinion.

Comment 6: Line 364-365, "I think the complications.....Coronavirus", should be in quotations.

Comment 7:Footnote of the table 4 can be without quotation

Comment 8:Line 88 mentions HBM, need not repeat the full form in Line 246.

**********

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Reviewer #1: No

Reviewer #4: No

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15 Nov 2021

PONE-D-21-14374R2: COVID-19 Vaccine Hesitancy among the Adult Population in Bangladesh: A Nationwide Cross-sectional Survey

Reviewer 4:

Comment-1: Line 177-it should be respondents, remove single quotation mark.

Our Response: Thanks a lot for identifying this typo. We have removed the single quote.

Comment 2: Line 178-179, 181,183- double quotation marks instead of single are recommended.

Our Response: We appreciate your observation and we have modified accordingly.

Comment 3: Line 203-204, 209, single quotation can be removes, as in other places in the same paragraph. Please check for similar changes across the manuscript if present.

Our Response: We accept your observations and revised the manuscript accordingly. Thanks a lot.

Comment 4: Table -1, "Total" in the end is not well clear. In my opinion it can be removed, as table heading has n=1497 mentioned already.

Our Response: We agree with you and deleted the total.

Comment 5: Table 2 ,3 and 4, in the table title "%", can be removed, as the table below shows data well in % as mentioned in the column 2 of the table. Again, "Total ", not required in the end of the table in my opinion.

Our Response: Thanks a lot for your comments. We agree about the deletion of % from the table title of tables 2, 3, and 4. However, we believe the “Total” in table 2 is required as the reader will not be able to get this information from the rest of the table.

Comment 6: Line 364-365, "I think the complications.....Coronavirus", should be in quotations.

Our Response: Thanks a lot! We have used the double quote mark.

Comment 7: Footnote of the table 4 can be without quotation.

Our Response: Thanks a lot! We have removed the quotation from the Footote.

Comment 8: Line 88 mentions HBM, need not repeat the full form in Line 246.

Our Response: Thanks a lot! We have corrected this.

Submitted filename: Response to reviewers Plain Text.docx

Click here for additional data file.

18 Nov 2021

COVID-19 Vaccine Hesitancy among the Adult Population in Bangladesh: A Nationwide Cross-sectional Survey

PONE-D-21-14374R3

Dear Dr. Hossain,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Leeberk Raja Inbaraj, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

1 Dec 2021

PONE-D-21-14374R3

COVID-19 Vaccine Hesitancy among the Adult Population in Bangladesh: A Nationwide Cross-sectional Survey

Dear Dr. Hossain:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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on behalf of

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Academic Editor

PLOS ONE

Table 5

Factors affecting COVID-19 vaccine hesitancy among adult population in Bangladesh using multiple logistic regression (n = 1497).

Independent variables	Model 1	Model 2	Model 3
	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)
Religion (Others as RC)
Muslim	2.29 (1.62, 3.22)***	2.17 (1.48, 3.18)***	1.80 (1.22, 2.66)**
Education (Masters and MPhil/PhD as RC)
No education	1.41 (0.89, 2.24)	0.69 (0.40, 1.20)	0.83 (0.47, 1.46)
Primary	0.97 (0.64, 1.47)	0.62 (0.38, 1.02)	0.70 (0.42, 1.17)
Secondary and higher secondary	0.83 (0.60, 1.16)	0.61 (0.41, 0.90)*	0.63 (0.42, 0.95)
Graduate	1.24 (0.91, 1.71)	1.20 (0.84, 1.72)	1.18 (0.81, 1.70)*
Place of residence (Rural as RC)
Urban area (other than city corporation)	0.88 (0.62, 1.25)	1.17 (0.78, 1.75)	1.19 (0.79, 1.80)
City Corporation	2.06 (1.52, 2.78)***	2.00 (1.42, 2.81)***	2.14 (1.50, 3.05)***
Administrative division of Bangladesh (Sylhet as RC)
Barishal	1.47 (0.92, 2.34)	1.06 (0.62, 1.82)	1.19 (0.68, 2.10)
Chattogram	1.05 (0.68, 1.62)	0.81 (0.49, 1.35)	0.77 (0.45, 1.29)
Dhaka	2.37 (1.41, 4.00)***	1.23 (0.66, 2.27)	1.31 (0.69, 2.47)***
Khulna	1.22 (0.71, 2.12)	0.90 (0.47, 1.74)	0.88 (0.44, 1.78)
Mymensingh	1.01 (0.61, 1.65)	0.56 (0.31, 1.01)	0.59 (0.32, 1.09)
Rajshahi	2.35 (1.35, 4.11)	1.32 (0.70, 2.49)	1.32 (0.69, 2.52)
Rangpur	0.84 (0.49, 1.46)**	0.51 (0.27, 0.97)*	0.49 (0.25, 0.96)
Behavioral practice to prevent COVID-19		1.00 (0.96, 1.05)	1.01 (0.96, 1.06)
Knowledge about the COVID-19 vaccine		0.86 (0.81, 0.91)***	0.88 (0.82, 0.93)***
Knowledge about the vaccination process		0.90 (0.84, 0.97) **	0.91 (0.84, 0.98) **
Conspiracy belief regarding COVID-19 vaccine		1.08 (1.05, 1.12) ***	1.04 (1.01, 1.12) **
Attitude towards COVID-19 vaccine		1.23 (1.18, 1.27) ***	1.17 (1.12, 1.22) ***
Health Belief Model
Perceived susceptibility			0.93 (0.85, 1.01)
Perceived severity			0.93 (0.85, 1.02)
Perceived benefits			0.85 (0.79, 0.91) ***
Perceived barriers			1.16 (1.11, 1.22) ***
Model Summary
-2 Log likelihood	1976.95	1649.14	1587.36
Cox & Snell R Square	0.06	0.24	0.27
Nagelkerke R Square	0.08	0.33	0.37

aOR: Adjusted Odds Ratio; 95% confidence interval in the parenthesis

* = P≤0.05

** = P≤0.01

*** = P≤0.001; RC = Reference category.