Article for the students of Psychology

1. Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=vhos20
Hospital Topics
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/vhos20
Attitude towards Covid-19 Vaccine: A Cross-
Sectional Urban and Rural Community Survey in
Punjab, Pakistan
Iqra Mushtaque, Muhammad Riaz Dasti, Misbah Mushtaq & Ahmad Ali
To cite this article: Iqra Mushtaque, Muhammad Riaz Dasti, Misbah Mushtaq & Ahmad Ali (2021):
Attitude towards Covid-19 Vaccine: A Cross-Sectional Urban and Rural Community Survey in
Punjab, Pakistan, Hospital Topics, DOI: 10.1080/00185868.2021.2001399
To link to this article: https://doi.org/10.1080/00185868.2021.2001399
Published online: 03 Nov 2021.
Submit your article to this journal
View related articles
View Crossmark data

2. Hospital Topics
Attitude towards Covid-19 Vaccine: A Cross-Sectional Urban and Rural
Community Survey in Punjab, Pakistan
Iqra Mushtaquea
, Muhammad Riaz Dastib
, Misbah Mushtaqc
and Ahmad Alid
a
Department of Psychology, Bahauddin Zakariya University, Multan, Pakistan; b
Department of Education, Bahauddin Zakariya
University, Multan, Pakistan; c
Combined Military Hospital (CMH), Lahore, Pakistan; d
Department of Sociology, Bahauddin Zakariya
University, Multan, Pakistan
ABSTRACT
The study’s objective was to ascertain the general public’s attitudes regarding the covid-19
vaccine in Pakistan. A cross sectional design and e-survey was conducted by 1647 general
public. The sample was divided into two sections: urban (702) and rural (945). The majority
of participants were between the ages of 18 and 45. The urban participants believe it is
safe. Those who live in large cities and have a college degree or above have a positive
attitude towards vaccines and do not find any religious reason not to be vaccinated.
Individuals from rural areas seem to be skeptical of getting vaccines and they refuse to
receive them. Individuals with little education, little information, and a low annual income
express a strong mistrust of the vaccine’s benefits.
Introduction
According to the World Health Organization,
viral infections are on the increase and pose a
significant public health risk (Cascella et al.
2020). A new viral infection has emerged at the
end of 2019, known as corona virus; severe acute
respiratory syndrome (SARS-CoV-2) (Dhama
et al. 2020; Rodriguez-Morales et al. 2020).
Corona viruses are members of the Coronaviridae
family, which infect a wide range of hosts, caus-
ing symptoms and infections ranging from the
common cold to extreme illnesses like covid-19
(Zhu et al. 2020). Corona viruses that have
recently emerged pose a potential threat to global
public health. The current covid-19 outbreak is
the third such outbreak in humans in the last
two decades (Munster et al. 2020). The corona
virus can cause various symptoms, ranging from
asymptomatic or mild symptoms to severe or
fatal illness (Esakandari et al. 2020). SARS-CoV-2
is a virus that causes covid-19 that differs from
other corona viruses that cause minor diseases
in humans, such as the common cold (Baloch
et al. 2020). Compared to non-extreme cases of
covid-19, severe cases were more likely to have
more comorbidities, the most common of which
were diabetes, hypertension, and thyroid disor-
ders (Alqahtani et al. 2020).
Every year, vaccines help save millions of lives.
They work by conditioning and preparing the
immune system to recognize and fight microor-
ganisms like viruses. When the body is later
exposed to specific virus, it will kill them and
prevent infections (WHO 2021). In the United
States, three vaccines are currently approved and
recommended to avoid covid-19: (1) Pfizer corona
virus BioNTech’s vaccine and (2) Moderna’s
corona virus vaccine (CDC 2021). In addition,
the CDC announced those three covid-19 vac-
cines, Janssen’s covid-19 vaccine, AstraZeneca’s
covid-19 vaccine, and Novavax’s covid-19 vaccine
are currently undergoing or planning large-scale
(Phase 3) clinical trials as of December 28, 2020
(CDC 2019). Two variations of the AstraZeneca/
Oxford COVID-19 vaccine have been certified
for emergency use by the WHO, allowing them
to be delivered internationally through COVAX.
© 2021 Taylor & Francis Group, LLC
CONTACT Muhammad Riaz Dasti riazdasti@bzu.edu.pk Department of Education, Bahauddin Zakariya University, Bahadur Sub-Campus Layyah,
Multan, Pakistan
https://doi.org/10.1080/00185868.2021.2001399
KEYWORDS
Vaccine;
negative attitude;
religion obligation

3. 2 I. MUSHTAQUE ET AL.
The vaccines were developed by AstraZeneca-SKBio
(Republic of Korea) and the Serum Institute of
India. On February 8th, the WHO’s Strategic
Advisory Group of Experts on Immunization
(SAGE), which makes recommendations for vac-
cination use in communities, evaluated the vac-
cine (i.e. recommended age groups, intervals
between shots, advice for specific groups such as
pregnant and lactating women). According to the
SAGE, the immunization is recommended for all
age groups 18 and higher (WHO 2021).
Different vaccines protect the body in various
ways, but when both vaccines are used, the body
has a supply of memory T-lymphocytes and
B-lymphocytes that will know how to fight the
virus in the future. It’s also worth noting that it
typically takes a few weeks after vaccination for
the body to produce B-and T-lymphocytes. As a
result, following immunization, a person may
become infected with the virus that causes
covid-19 and become ill as a result of the vaccine
failing to give adequate protection. The last hope
for ending the pandemic is vaccines to prevent
the corona virus epidemic in 2019. A corona
virus vaccine would aid the individual in avoiding
covid-19 infection. Alternatively, if individual
taken covid-19 vaccine, they might be able to
prevent becoming seriously ill or suffering from
severe complications (Mayo Clinic 2021).
According to the World Health Organization,
the epidemic has delayed the distribution of
life-saving regular immunizations, and vaccine
hesitancy remains a global issue, with rates as
high as 70% in some countries (Kim et al. 2020).
Pakistan is currently suffering in the 3rd wave
of covid-19, and has 710,829 confirmed cases and
15,229 deaths reported nationally (April 09,
2021). Much has been written about the per-
ceived covid-19 (Lin, Wang, et al. 2020), com-
munities’ attitudes toward covid-19 (Qian et al.
2020), and poor low-income countries’ health
systems (Hopman, Allegranzi, and Mehtar 2020).
However, there has been little research on how
communities’ attitudes toward covid-19 vaccina-
tion, as well as barriers to covid-19 vaccination
uptake (Ahmed et al., 2020), especially in low
and middle-income countries like Pakistan. Fatmi
et al. 2020, conducted a study among Pakistani
communities on the knowledge, attitude and
practices toward covid-19. The rural population
had inadequate knowledge and poor practice
toward covid-19 implementations. This is made
more difficult in communities where literacy is
low and traditional, cultural, and religious prac-
tices can stymie implementation.
Pakistan’s Ministry of Health has announced
that it will use and purchase Sinopharm and
Cansino vaccines from China. Pakistan is cur-
rently vaccinating frontline healthcare workers
and senior citizens with Sinopharm doses donated
by China (Dawn News 2021). Because of the
intervention of the Covid-19 vaccine, the gov-
ernment, front-line workers (e.g., doctors, med-
ical staff), the media, and celebrities have
requested the general public to get the Covid-19
vaccine. The government’s official Facebook Page
was used by UNICEF Pakistan’s country office
to promote the immunization program by posting
videos and creating post “vaccine work for all”
(UNICEF 2020). Prime minister of Pakistan
Imran Khan urges people to get vaccinate (Khaleej
Times 2021).When it comes to advertising the
COVID-19 vaccination, a scientific–religious con-
flict occurs. Religious leaders have a moral obli-
gation to steer their followers toward the good
by disseminating and promoting information, but
they also have a moral obligation to follow sci-
entific conclusions. This comes following allega-
tions of religious leaders disobeying this
commitment by spreading false information about
the vaccine, whether knowingly or unwittingly
(Hegarty 2021). Now the process of vaccination
has started in Pakistan. The current study aims
to investigate the Pakistani population’s attitude
towards uptake of the covid-19 vaccine.
Material and Method
A cross-sectional study was carried out among
the general population of Pakistan. In this
research, an online questionnaire was used due
to the transmission of covid-19 through human
interaction to investigate the public attitudes and
factors that affect covid-19 vaccination uptake in
Pakistan. The study was comprised of two sam-
ples; the urban area of Pakistan and Pakistan’s
rural area. 70% of population of Pakistan are
living in rural areas. The reason of the two group

4. Hospital Topics 3
is to access the equal representation of commu-
nities. The sample size was calculated by G-power
analysis.
A self administered questionnaire was created
using a validated questionnaire from Barry et al.
study on seasonal influenza vaccination (Barry,
Aljammaz, and Alrashed 2020). It was subse-
quently converted into an online form using
Google® forms and distributed for public com-
pletion using social media platforms (Facebook,
Whatsapp, Instagram, and approaching partici-
pants via snowball sampling). The questionnaire
has initially been in English. It was also trans-
lated into Urdu for the population of the rural
areas. Because Urdu is the national language of
Pakistan, only an Urdu-translated data collection
instrument was distributed to ensure the accuracy
of the responses. The survey divided into two
sections: the first asked about respondents’
socio-demographic characteristics; gender, age
groups, education level, employment, marital sta-
tus, religion, and the second about the attitude
and barriers to covid-19 vaccination uptake. A
consent form was taken from the participants.
From February, 25, 2021 to March, 25, 202l, 1788
responses were received. Those who were not
willing to participate in the survey were excluded.
Incomplete information or incomplete forms were
also excluded. The response rate was 92%.
Data Analysis
The first step is, the collected data is
double-checked for accuracy, and errors are
removed. The research is then carried out using
descriptive and inferential methods. In the
descriptive analysis, the data is tabulated, and
frequencies and percentages are measured in
Microsoft Excel. Pearson’s chi-square test (a prob-
ability test) is used with SPSS to calculate the
likelihood ratio of the relationship between public
opinion in Pakistan and the covid-19 vaccine.
The chi-square test is also used to calculate the
chances of observed variables/frequencies match-
ing each other and their significant association.
If the p-value is greater than 0.05, there is no
relationship between the observed variables/fre-
quencies. If the p-value is less than 0.05, there
is a good correlation.
Result and Discussion
The respondent’s personal information is shown
in Table 1. The table depicts the characteristics
of the two sample groups. People from Pakistan’s
Punjab province completed the online survey.
Both males and females participated voluntarily
in this survey of 1647 participants, 702 from
metropolitan regions and 945 from rural areas.
The majority of respondents were males (52%)
from urban areas and (77%) from rural areas.
The majority of the participants were middle-aged
adults (18–40), with 50% from cities and 75%
from rural areas; the remainder were young
adults and the elderly. Furthermore, 77% of
respondents from rural areas had a high school
diploma, and the proportion of married people
was 92%. On the other hand, the proportion of
urban respondents with a college degree (34%)
and a postgraduate degree (34%) was higher, and
the majority of them were married (66%) and
employed (57%). The unemployment rate in cities
is higher (42%) than in rural areas (37%) .
When making medical decisions, people or
patients may turn to their religious and moral
convictions. People rely on religion and spiritu-
ality, beliefs that influence nutrition, animal-based
remedies, modesty, and vaccinations (Swihart and
Martin 2020). Because Pakistan is a Muslim
country, and 97% of those who took part were
Muslims, only 3% of those of other religions took
part (Table 1).
The health insurance policy results were quite
surprising, revealing that only 10 participants had
given a health insurance policy, while the remain-
ing 692 had never taken any health insurance
policy. The provincial government is mostly
incharge of health care. The health sector in the
country is facing considerable challenges, and the
federal and provincial governments trying to
increase their budget allocation for health, par-
ticularly development investment, to ensure that
more and higher-quality health facilities are avail-
able throughout the country. According to
sources, as of August 2020, the sehat sahulat
program (SSP) covered up to PKR 60,000 in
treatment expenditures per family per year,
including inpatient medical and surgical treat-
ments, emergency treatment, maternity care,

5. 4 I. MUSHTAQUE ET AL.
post-hospital therapy, and transportation costs
(Sehat Insaf Card 2020).
People living in poverty, people with impair-
ments (in Azad Jammu and Kashmir, Gilgit
Baltistan, Islamabad Capital Territory, and
Punjab), and transgender people benefited from
the Prime Minister’s National Health Program
(SSP) across Pakistan. PHIMC has been tasked
with implementing the Sehat Sahulat Program
(SSP) on behalf of Punjab. SSP intends to provide
access to high-quality medical care through a
micro insurance system. All residents of the Dera
Ghazi Khan and Sahiwal divisions, as well as all
residents of Punjab’s 29 district constituencies,
are currently eligible for free healthcare services
under the Sehat Sahulat Program. All Punjab cit-
izens will have access to free healthcare by the
end of this year (PHIMC 2021). As, Pakistan is
a developing country, but the ratio of poverty is
alarming, and participants (87%) show that they
can not buy vaccines (Table 1). Urban and rural
areas respondents highlighted a barrier to buying
vaccines. Pakistan’s government took a great ini-
tiative to provide free vaccines, and registration
has started on March 30 (https://covid.gov.pk/
covid19).
Table 2 demonstrates that respondents in the
urban area sample had a favorable attitude about
the covid-19 vaccination. Knowing the role and
relevance of vaccination, according to Lorenz
et al. (2013), improved vaccination uptake by
fourfold (Cialdini et al. 2006). They discovered
that 65% of respondent thought the covid-19
vaccine was safe, and 66% thought it was effective
against covid-19. According to the WHO (2021),
talking about uncertainty, dangers, and vaccina-
tion availability in a plain, dependable, empathic,
and constructive manner would aid in the devel-
opment of trust. Gallant et al. (2020) believe that
health care workers should be given open and
honest information regarding the vaccine’s safety
and the likelihood of probable side effects, which
can range from minor symptoms to more com-
plex and unique adverse effects.
According to the participant information sheet,
the majority of participants are Muslims, and
when asked if they believe there is a religious
need to get vaccinated, 87% of individuals replied
no. According to a fatwa given by the Dar-ul-Ifta
Pakistan, vaccination against the new coronavirus
COVID-19 has been ruled "lawful" and "permis-
sible" within Islamic Shariah, or jurisprudence
(The News 2021).
Table 2 contrasted the responses of rural areas
to the covid-19 vaccination. The end effect is
dreadful. Previous studies on the population in
Table 1. Socio-demographic characteristics of the participants (N = 1647).
Urban area (702) Rural area (945)
Variables F(%) F(%)
Gender
Male 369(52.56) 732(77.46)
Female 333(47.44) 213(22.54)
Age level
<18 113(16.09) 29(3.06)
18–45 355(50.56) 712(75.34)
45+ 234(33.35) 204(21.58)
Qualification
High school 213(30.34) 730(77.24)
College degree 245(34.91) 150(15.87)
Postgraduate 244(34.75) 65(6.87)
Marital status
Married 468(66.67) 872(92.27)
Unmarried 234(33.33) 73(7.73)
Religion
Islam 695(99.14) 910(96.29)
Any other religion 7(0.86) 35(3.71)
Employment 407(57.99) 595(62.96)
Unemployed 295(42.01) 350(37.03)
Taken health insurance policy
Yes 10(1.42) –
No 692(98.58) 945(100.00)
Do you able to buy covid-19 Vaccine?
Yes 100(12.24) 185(19.57)
No 602(87.76) 760(80.43)

6. Hospital Topics 5
rural areas to assess their knowledge about
covid-19 revealed that people have insufficient
awareness and poor safety practices (Fatmi et al.
2020). As a result, rural people’s attitudes repre-
sent a barrier that inhibits corona vaccination
uptake. Only 36% of people believed the Covid-19
vaccination was safe and necessary for their
health. On the other side, 63% of respondents
were unsure if covid-19 was safe. As a result,
76% of people are unwilling to be vaccinated. In
a report on seasonal influenza vaccinations, Barry,
Aljammaz, and Alrashed (2020) discovered that
295 participants (58.6%) chose to forgo seasonal
influenza immunizations, and 252 (50.1%) were
concerned about the vaccine’s negative effects.
According to Wang et al. (2020), nearly half of
individuals who planned to receive the COVID-19
vaccination (47.8%) stated that they would wait
until the vaccine’s safety was established before
receiving it, and that their vaccine hesitancy was
due to vaccine safety concerns.
According to Paul, Steptoe, and Fancourt
(2021), negative attitudes toward vaccination are
a substantial public health problem in the United
Kingdom. General vaccine skepticism, as well as
worries about long-term negative effects, would
be obstacles to achieving COVID-19 population
protection by immunization. The majority of
respondents (82.0%) are concerned about the
COVID-19 vaccine being faulty/fake, and 75.1%
are concerned about the vaccine’s price, according
to Lin, Hu, et al. (2020). They also stated that
the potential side effects of COVID-19 vaccine
will interfere with their daily activities (68.5%),
and the majority of respondents are concerned
about the safety of COVID-19 immunization
(72.6%). The potential barriers to COVID-19
immunizations identified in this study, primarily
worries about vaccine adverse effects, have also
been noted in other vaccine implementation stud-
ies (Mullard 2020).
According to Warren, Kisely, and Siskind
(2021), structural barriers to vaccination include
access, acceptability, facility awareness, cost, and
other practical considerations. Table 3 shows the
Pearson’s chi-square test results, which show a
correlation between the covid-19 vaccination and
the general public’s opinion regarding vaccines.
Figure 1 shows that among all respondent
(41.5%) indicated that they are willing to get
Covid-19 vaccine and an additional, more male
than women participant showed willingness
toward vaccination (26% vs 15%, p < 0.001, chi
square = 74.24). Gender has been identified as
a major concern during this outbreak. While pre-
vious research has indicated that women are more
likely to engage in preventative behavior, the cur-
rent study found that they are less likely to
Table 2. Attitude toward Covid-19 Vaccine uptake (N = 1647).
Items RU (702) f(%) RR (945) f(%)
Do you think covid-19 vaccine is safe? Yes 462(65.8)
No 240(34.2)
Yes 343(36.3)
No 602(63.7)
Do you think vaccine is effective against covid-19? Yes 466(66.4)
No 236(33.6)
Yes 462(48.9)
No 483(51.1)
Do you think covid-19 vaccine is important to your health? Yes 415(59.1)
No 287(40.9)
Yes 356(37.7)
No 589(62.3)
Are you willing to be vaccinated against covid-19? Yes 465(66.2)
No 237(33.8)
Yes 219(23.1)
No 724(76.9)
Do you think there is any religious restriction regarding vaccination? Yes 87(12.4)
No 615(87.6)
Yes 500((52.9)
No 495(52.1)
Note. RU = response urban, RR = responses rural.
Table 3. Pearson’s chi-square test giving significant p-value of attitude toward Covid-19 vaccine uptake of Pakistani society.
Test statistics
Do you think
COVID-19 vaccine is
Safe
Do you think vaccine
is effective against
COVID-19
Do you think
COVID-19 vaccine is
important to your
health
Are you willing to be
vaccinated against
COVID-19
Do you think there is
any religious
obligation regarding
vaccination?
Chi-Square 70.205a
75.356a
23.339a
74.051a
397.128a
df 1 1 1 1 1
Asymp. Sig. .000 .000 .000 .000 .000
Note. a
0 cells (0.0%) have expected frequencies less than 5. The minimum expected cell frequency is 351.0.

7. 6 I. MUSHTAQUE ET AL.
believe that the vaccine will protect individuals
who receive it and are less eager to take the
vaccine than men (Fisher et al. 2020;
Khubchandani, Saiki, and Kandiah 2020). Getting
a vaccine may be regarded a risk, and study com-
paring men and women’s decision-making and
risk-taking based on a psychological risk person-
ality evaluation suggests that women are more
cautious and take longer to examine risk
(Inglehart and Norris 2000). Surprisingly, fear of
needles was a prominent factor in ladies’ reluc-
tance to get immunized in Malta (Neumann-Böhme
et al. 2020).
Figure 2 depicts the participants’ positive atti-
tude toward vaccination, along with age groups
(7% for ages <18, vs 29% for ages 18–45 and 5%
for ages more than 45, p
<
0.001, chi square =
112.48) among those who intend to receive the
vaccine. These findings are supported by other
study (Szilagyi et al. 2021).
The current study revealed that vaccine appre-
hension is a binary choice. At one end of the
range, urban residents are eager to embrace vac-
cines, while rural residents are vehemently
opposed to vaccinations. These folks are more
likely to postpone immunization or to accept but
be hesitant about vaccination. Changing attitudes
is easier, according to social psychology theories,
if they are within the "latitude of acceptance"
(Maccoby 1962; Brownell 1992; Crano and Prislin
2006). As a result, campaigns aimed towards this
varied group of people in the middle of the spec-
trum are the most effective. Campaigns are
unlikely to persuade people who are vehemently
opposed to vaccination, thus they should be
avoided at first. Cohorts of people can be encour-
aged to move from knowledge to action by using
communication efforts that promote group
methods.
Conclusion
The COVID-19 pandemic is still inflicting havoc
on people’s lives and livelihoods all across the
world, but the COVID-19 immunization offers a
glimmer of hope for the future. The current study
revealed minimal comprehension and hesitancy
attitudes for COVID-19 vaccines in rural areas
of Punjab, Pakistan. The findings show that
health officials should launch rapid health edu-
cation initiatives and deliver more accurate infor-
mation. Policymakers should take steps to give
accurate understanding, good attitudes, and opin-
ions about COVID-19 vaccinations in order to
counteract vaccine hesitancy, which is enabled
and fostered by misinformation in the media.
Limitations
There are some limitations of the research.
Although the sample size is sufficient, it may
not be representative of the entire Pakistani
population, so conclusions should be inter-
preted with caution. Furthermore, because the
majority of the writers came from the same
province, Punjab, the authors were unable to
receive equal responses from all provinces of
the country.
Funding
The author(s) reported there is no funding associated with
the work featured in this article.
Figure 1. Intention to get Covid-19 vaccination by gender.
Figure 2. Intention to get Covid-19 vaccination by age group.

8. Hospital Topics 7
References
Baloch, S., M. A. Baloch, T. Zheng, and X. Pei. 2020. The
coronavirus disease 2019 (COVID-19) pandemic. The
Tohoku Journal of Experimental Medicine 250 (4):271–8.
doi: 10.1620/tjem.250.271.
Barry, M. A., K. I. Aljammaz, and A. A. Alrashed. 2020.
Knowledge, attitude, and barriers influencing seasonal
influenza vaccination uptake. Canadian Journal of
Infectious Diseases and Medical Microbiology 2020:7653745.
Brownell, J. 1992. Book reviews: Persuasion: Theory and
research. Daniel J. O’Keefe. Newbury Park, CA: Sage
Publications, 1990. Journal of Business Communication
29 (1):83–5. doi: 10.1177/002194369202900107.
Cascella, M., M. Rajnik, A. Cuomo, S. C. Dulebohn, and
R. D. Napoli. 2020. Features, evaluation, and treatment
of coronavirus. [Updated October 4, 2020]. In StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK554776.
CDC. 2019. How vaccines work. Accessed January 25, 2021.
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/
different-vaccines/how-they-work.html.
CDC. 2021. Vaccines. Accessed January 25, 2021. https://
www.cdc.gov/coronavirus/2019-ncov/vaccines/
different-vaccines.html.
Cialdini, R. B., L. J. Demaine, B. J. Sagarin, D. W. Barrett,
K. Rhoads, and P. L. Winter. 2006. Managing social
norms for persuasive impact. Social Influence 1 (1):3–15.
https://doi.org/10.1080/15534510500181459.
Crano, W. D., and R. Prislin. 2006. Attitudes and persua-
sion. Annual Review of Psychology 57 (1):345–74. doi:
10.1146/annurev.psych.57.102904.190034.
Dawn News. 2021. Two more COVID-19 vaccines approved
for use in Pakistan. Dawn News. Accessed March 18,
2021. https://www.dawn.com/news/1613116.
Dhama, K., S. Khan, R. Tiwari, S. Sircar, S. Bhat, Y. S.
Malik, K. P. Singh, W. Chaicumpa, D. K. Bonilla-Aldana,
A. J. Rodriguez-Morales, et al. 2020. Coronavirus disease
2019-COVID-19. Clinical Microbiology Reviews 33
(4):e00028-20. doi: 10.1128/CMR.00028-20.
Esakandari, H., M. Nabi-Afjadi, J. Fakkari-Afjadi, N.
Farahmandian, S.-M. Miresmaeili, and E. Bahreini. 2020.
A comprehensive review of COVID-19 characteristics.
Biological Procedures Online 22:1–10. doi: 10.1186/
s12575-020-00128-2.
Fatmi, Z., S. Mahmood, W. Hameed, I. Qazi, M. Siddiqui,
A. Dhanwani, and S. Siddiqi. 2020. Knowledge, attitudes
and practices towards COVID-19 among Pakistani resi-
dents: Information access and low literacy vulnerabilities.
Eastern Mediterranean Health Journal 26 (12):1446–55.
doi: 10.26719/emhj.20.133.
Fisher, K. A., S. J. Bloomstone, J. Walder, S. Crawford, H.
Fouayzi, and K. M. Mazor. 2020. Attitudes toward a po-
tential SARS-CoV-2 vaccine: A survey of U.S. adults.
Annals of Internal Medicine 173 (12):964–73. doi: 10.7326/
M20-3569.
Gallant, A. J., P. Flowers, K. Deakin, N. Cogan, S.
Rasmussen, and D. Young. 2020. Barriers and enablers
to influenza vaccination uptake in adults with chronic
respiratory conditions: Applying the behaviour change
wheel to specify multi-levelled tailored intervention con-
tent. MedRxiv.
Hegarty, S. 2021. Vaccines and the danger of religious mis-
information. BBC News. https://www.bbc.com/news/av/
health-56416683.
Hopman, J., B. Allegranzi, and S. Mehtar. 2020. Managing
COVID-19 in low- and middle-income countries. JAMA
323 (16):1549. doi: 10.1001/jama.2020.4169.
Inglehart, R., and P. Norris. 2000. The developmental the-
ory of the gender gap: Women’s and men’s voting behav-
ior in global perspective. International Political Science
Review 21 (4):441–63. doi: 10.1177/0192512100214007.
Khaleej Times. 2021. Covid-19: Pakistan PM Imran Khan
urges people to vaccinate. Khaleej Times. https://www.
khaleejtimes.com/coronavirus-pandemic/covid-1
9-pakistan-pm-imran-khan-urges-people-to-vaccinate.
Khubchandani, J., D. Saiki, and J. Kandiah. 2020. Masks,
gloves, and the COVID-19 pandemic: Rapid assessment
of public behaviors in the United States. Epidemiologia
1 (1):16–22. doi: 10.3390/epidemiologia1010004.
Kim, E., K. Mulcahy, L. McGorman, C. Sasser, Velasco, T.
Wynter, and P. Xu. 2020, September 3. New available
survey data shares insights on COVID-19 prevention and
a potential vaccine. Facebook Research. https://research.
fb.com/blog/2020/09/new-available-survey-data-shares-ins
ights-on-covid-19-prevention-and-a-potential-vaccine/.
Lin, X., X. Wang, Z. Peng, R. Wang, P. Wang, Z. Li, Y. Zhou,
H. Lei, C. Li, W. Liu, et al. 2020. Current situation of the
corona virus disease under active control and prevention
in China, outside Hubei Province: A real-world epidemio-
logical analysis. Accessed February 20, 2020. SSRN. https://
ssrn.com/abstract=3543594 or doi: 10.2139/ssrn.3543594.
Lin, Y., Z. Hu, Q. Zhao, H. Alias, M. Danaee, and L. P.
Wong. 2020. Understanding COVID-19 vaccine demand
and hesitancy: A nationwide online survey in China.
PLoS Neglected Tropical Diseases 14 (12):e0008961. doi:
10.1371/journal.pntd.0008961.
Lorenz, R. A., M. M. Norris, L. C. Norton, and S. C.
Westrick. 2013. Factors associated with influenza vacci-
nation decisions among patients with mental illness.
International Journal of Psychiatry in Medicine 46 (1):1–
13. doi: 10.2190/PM.46.1.a.
Maccoby, N. 1962. Social judgment: Assimilation and contrast
effects in communication and attitude change. American
Journal of Sociology 68 (1):126–7. doi: 10.1086/223278.
Mayo Clinic. 2021. Coronavirus-vaccine. Accessed January
25, 2021. https://www.mayoclinic.org/diseases-conditions/
coronavirus/indepth/coronavirus-vaccine/art-20484859.
Mullard, A. 2020. COVID-19 vaccine development pipeline
gears up. Lancet 395 (10239):1751–2. doi: 10.1016/
S0140-6736(20)31252-6.

9. 8 I. MUSHTAQUE ET AL.
Munster, V. J., M. Koopmans, N. van Doremalen, D. van
Riel, and E. de Wit. 2020. A novel coronavirus emerging
in China—Key questions for impact assessment . The
New England Journal of Medicine 382 (8):692–4. doi:
10.1056/NEJMp2000929.
Neumann-Böhme, S., N. E. Varghese, I. Sabat, P. P. Barros,
W. Brouwer, J. van Exel, J. Schreyögg, and T. Stargardt.
2020. Once we have it, will we use it? A European sur-
vey on willingness to be vaccinated against COVID-19.
The European Journal of Health Economics 21 (7):977–82.
doi: 10.1007/s10198-020-01208-6.
Paul, E., A. Steptoe, and D. Fancourt. 2021. Attitudes to-
wards vaccines and intention to vaccinate against
COVID-19: Implications for public health communica-
tions. The Lancet Regional Health—Europe 1:100012. doi:
10.1016/j.lanepe.2020.100012.
PHIMC. 2021. Punjab health initiative management com-
pany. https://phimc.punjab.gov.pk/.
Qian, X., R. Ren, Y. Wang, Y. Guo, J. Fang, Z.-D. Wu, P.-
L. Liu, T.-R. Han, and Members of Steering Committee,
Society of Global Health, Chinese Preventive Medicine
Association. 2020. Fighting against the common enemy
of COVID-19: A practice of building a community with
a shared future for mankind. Infectious Diseases of Poverty
9 (1):34. doi: 10.1186/s40249-020-00650-1.
Rodriguez-Morales, A. J., D. K. Bonilla-Aldana, G. J.
Balbin-Ramon, A. A. Rabaan, R. Sah, A. Paniz-Mondolfi,
P. Pagliano, and S. Esposito. 2020. History is repeating itself:
Probable zoonotic spillover as the cause of the 2019 novel
coronavirus epidemic. Le Infezioni in Medicina 28 (1):3–5.
Sehat Insaf Card. 2020. Sehat Sahulat program. https://se-
hatinsafcard.com/.
Swihart, D., and R. Martin. 2020. Cultural religious com-
petence in clinical practice. February 17, 2020. https://
www.ncbi.nlm.nih.gov/books/NBK493216/.
Szilagyi, P. G., K. Thomas, M. D. Shah, N. Vizueta, Y. Cui,
S. Vangala, and A. Kapteyn. 2021. National trends in the
US public’s likelihood of getting a COVID-19 vaccine—
April 1 to December 8, 2020. JAMA 325 (4):396. doi:
10.1001/jama.2020.26419.
The News. 2021. COVID-19 vaccine “legal,” “permissible”
under Islamic law: Dar-ul-Ifta Pakistan. The News.
https://www.thenews.com.pk/latest/808245-covid-1
9-vaccine-legal-permissible-under-islamic-law-dar-ul-ifta-
pakistan.
UNICEF. 2020. Amplifying immunization efforts during the
COVID19 pandemic Pakistan insights for impact project
with Facebook. UNICEF. https://www.unicef.org/pakistan/
stories/amplifying-immunization-efforts-durin
g-covid19-pandemic.
Wang, J., R. Jing, X. Lai, H. Zhang, Y. Lyu, M. D. Knoll,
and H. Fang. 2020. Acceptance of COVID-19 vaccination
during the COVID-19 pandemic in China. Vaccines 8
(3):482. doi: 10.3390/vaccines8030482.
Warren, N., S. Kisely, and D. Siskind. 2021. Maximizing
the uptake of a COVID-19 vaccine in people with
severe mental illness: A public health priority. JAMA
Psychiatry 78 (6):589–590. doi: 10.1001/jamapsychia-
try.2020.4396.
WHO. 2021. February 15. WHO lists two additional
COVID-19 vaccines for emergency use and COVAX
roll-out. WHO. https://www.who.int/news/item/15-0
2-2021-who-lists-two-additional-covid-19-vaccines-fo
r-emergency-use-and-covax-roll-out.
Zhu, N., D. Zhang, W. Wang, X. Li, B. Yang, J. Song, X.
Zhao, B. Huang, W. Shi, R. Lu, et al. 2020. A novel
coronavirus from patients with pneumonia in China,
2019. The New England Journal of Medicine 382 (8):727–
33. doi: 10.1056/NEJMoa2001017.