Table of content

Introduction …………………………………………………………………………..
Background and literature review …………………………………………………..
Problem statement ……………………………………………………………………
Significance of the study ……………………………………………………………..
Study objectives
·      Main objective ……………………………………………………………………
·      Specific objectives ………………………………………………………………..
 Questions …………………………………………………………………………….
Hypothesis ……………………………………………………………………………
Definitions ……………………………………………………………………………
Methodology
 Design …………………………………………………………………………………………………
  Population and Sampling ………………………………………………………………………
 Setting ……………………………………………………………………………………………….
 Participants ………………………………………………………………………………………..
 Instrument to data collection …………………………………………………………………
 Variables ……………………………………………………………………………………………
 Limitations …………………………………………………………………………………………
 Field work administrative part ………………………………………………………………
 Ethical consideration ……………………………………………………………………………
 Data analysis ………………………………………………………………………………………

References ……………………………………………………………………………..

1
 Abstract

Corona virus resulted in many severe respiratory infections outbreaks. A novel

coronavirus was first appeared in Wuhan City – China, known as (COVID-19). The
transmission may occur in the existence of an aerosol in a closed environment and
permanent inhalation of high aerosol concentrations; causing a serious problem for the
person and the whole world in general. Because COVID-19 is a pandemic problem,
many studies and researches have been done worldwide. The problem statement of this
study focused on the individuals who didn’t get the vaccine, since the disease lead to
many problems ranging between healthy and financial states. Therefore, vaccination is
considering the significant solution to solve this problem, since it’s associated to the
improvement of successful prevention and treatment approaches. The aim of this study is
to identify the barriers and beliefs that expected to affect the individual’s ability or desire
to be vaccinated. This study uses a cross sectional quantitative study design that use a
questionnaire. The target population consists of 150 Palestinian individuals who are
living in Bethlehem city, Ramallah city and Beir-Zeit. Ethical consideration taken into
account in this study, and a consent form prepared for the participants. The results will
follow analysis using SPSS program.

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Title: Barriers related factors of COVID-19 vaccination among adult in Palestine.

Introduction

Corona virus is a zoonotic derivative disease, which has been resulted in many severe respiratory
infections outbreaks in the previous years, and it was reported as an important, dangerous
pathogen of public health significance (Xu, J. Zhao, S. Teng. et al. 2020)1. Those outbreaks were
arising in the 21st century, firstly in 2002 which known as severe acute respiratory syndrome
(SARS), then in 2012 known as Middle East respiratory syndrome (MERS) (Cui, J. Li, F. Shi, L.
2019)2. Lately, in 2019, a novel coronavirus of unknown etiology was first appeared in China,
particularly in Wuhan City named as coronavirus disease 2019 (COVID-19), which caused by
novel Cov severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and announced as an
outbreak, which spread quickly worldwide, causing a very high rate of mortality and morbidity
(Xu, X. Chen, P. Wang, J. et al. 2020)3.

COVID-19 is an enveloped, positive sense, single stranded RNA virus which has a glycoprotein
crown- like surface (Singhal, T. 2020)4. Coronaviruses mainly divided as α, β, γ, and δ groups
(Chan, F. To, K. Tse, H. et al. 2013)5. Studies in literature have been exhibited that humans and
some animals such as rodents, camels, and bats are considering the α and β corona gene sources,
while γ and δ corona derived source from the birds (Chan, F. Kok, H. Zhu, Z. et al. 2020)6. The
virus route of transmission among individuals is mainly via respiratory droplets. Close contact
plays an important role in spreading of the virus. In addition to that, the transmission may occur in
the existence of aerosol in a closed environment and permanent inhalation of high aerosol
concentrations (Holshue, L. DeBolt, C. Lindquist, S. et al. 2020)7. Hence, different mitigation
strategies and suppression have been established by WHO to control and prevent the virus
spreading. These include; isolation, quarantine, social distancing, and hygiene protocols which all
followed to drop the level of virus spreading (Alanezi, F. Aljahdali, A. Alyousef, S. et al. 2020) 8.
The range of the virus incubation period is 2-14 days (Assiri, A. Al-Tawfiq, A. Al-Rabeeah, A. et
al. 2013)9. COVID -19 clinical features ranging from asymptomatic state to an acute respiratory
syndrome. Including; sore throat, cough, headache, breathlessness, fatigue, and myalgia (Tanus, S.
2020)10.

COVID -19 vaccines are considering the most important and effective solution for this pandemic
disease. Where the viral protein structure and genome allow the improvement of the vaccine (Shin,
D. Shukla, S. Chung, H. et al. 2020)11. The development of the vaccines has some challenges;
3
 these include the vaccines development itself and the hesitancy and barriers that avoid people form
taking the vaccine worldwide. fear, communicable disease, governmental agencies and healthcare
trust all plays an important role in creating the hesitancy and barriers of taking the vaccine (Kreps,
S. Prasad, S. Brownstein, S. et al. 2021)12. In addition to the vaccine, the awareness regarding the
virus plays an important role in the prevention of the infection, also it’s critical to regulate the
community awareness during outbreak because suitable civic intervention through the outbreak is
informed by the disease transmission public perception, effective treatment, and the availability of
the vaccine (Abed El Kader, Y. Altaher. A. Alnajjar, B. et al. 2019)13.

Background and literature review

The first appearance of Coronavirus was in 1960s, where the symptoms of the disease displayed as a

mild influenza-like, hence this kind of virus is able to infect a wide range of vertebrates such as

camels, snakes, bats, and other animals (Weiss, S. Navas-Martin, S. 2005)14. However, other new

strains of the virus arise every few years introducing fatal pandemics and epidemics (Yang, Y.

2020)15. According to the literature, all previous infections of coronaviruses are zoonotic origin,

where SARS-CoV passed over to humans in 2002 and again in 2003, in China, Guangdong province

and Foshan (Xu, H. He, F. Evans, R. et al. 2004)16.

In 2012, another outbreak of Coronavirus strain has been first appeared in Jeddah city - Saudi

Arabia, which passed over many other countries (Hunter, C. Nguyen, D. Aden, B. et al. 2016)17.

South Korea recorded the major numbers of infections according to the outbreak in 2015, which

result from South Korean people who used to visit Arabian Peninsula (Osong Public Heal Res

Perspect. 2015)18. In 2019, a new stain of the virus called COIVD-19 has been first appeared in

Wuhan city - China, that also involves some wildlife types, followed by a giant outbreak has been

observed in China, that finally spread to all countries around the world. Therefore, the virus has been

announced by WHO as a pandemic disease (Chan, J. 2020)19.

In Palestine, the first case of infection appeared in Bethlehem city on 2020, where a Greek tourists

group visited the city and some of them were COVID-19 positive, leading to spread the virus. So the

4
government started the restrictions early after the appearance of the virus, subsequently a decline in

the infection cases were noticed (Qutob, N. Faisal, A. Zaidan, S. et al. 2020)20.

Vaccines are considering the most effective and useful technical ways for controlling the disease.

However, the vaccines development has definitely been a challenge, where more challenging to

accomplish strong vaccine as a result of several barriers. In United State, a review study was being

done that concentrated on 2 types of barriers; the attitudinal and structural. The former barriers take

the perceptions that influence the willingness of at risk people to look for and receive a service.

Whereas the later barriers are systemic matters that affect the individual's ability to get the service,

involving transportation, time, clinic, outlet location, and cost. Finding that there are beliefs about

fear, communicable disease, governmental agencies and healthcare trust. Public trust is found as a

barrier that is of specific importance. Some recommendations have been made that aim to develop

the vaccination programs effectiveness, such as creating a public support and get benefit of the social

media to encourage vaccination (Zhang, Y. Fisk, J. 2021)21.

Another review was done in Pakistan, that aims to discusses the potential harmful impacts of

conspiracy theories and myths correlated to COVID-19 and its vaccine rejections as well as other

programs of the vaccine. Finding that the hesitancy of COVID-19 vaccine referred to several factors,

such as anti-vaccine misrepresentation, incorrect religious beliefs, and lack of awareness and

knowledge. The recent condition concerning anti-vaccine beliefs is directing towards terrible

outcomes. It increases the concern that will individuals trust and take the new vaccines despite all

anti-vaccine activities and COVID-19 correlated conspiracy theories and myths (Ulla, S. Khan, J.

Tahir, A. et al. 2021)22.

A quantitative study design has been done in Australia, that aims to review and gather the conspiracy

theories and rumors in 2019 and 2020. The results showed that 637 vaccine associated items: rumors

account for 91%, while conspiracy theories account 9% from fifty-two countries. From 578 rumors,

5
36% were associated with the development of vaccine, access, and availability, while 20% were

associated with mortality and morbidity, 8% were associated to the vaccine effectiveness, safety, and

acceptance. Finally, the rest were associated with other categories. Of the 637 items, 83% were found

to be false, 5% were found to be true, 10% were ambiguous, and 2% were overstated (Islam, S.

Kamal, A. Kabir, A. et al. 2021)23.

In China, cross-sectional study design was done that aims to study the tries to understand the vaccine

of COVID-19 request and hesitancy by evaluating the public’s vaccination purpose. The results

showed that 3541 broad answers were received, where 54.6% reported probably yes, and 28.7% give

a definite yes. The awareness that vaccination lowers the probability of getting COVID-19 under the

apparent benefit concept, and not being worried regarding the new COVID-19 vaccines efficacy

under the supposed barriers construct were appeared to be the highest important odds of a definite

purpose to take the vaccine (Lin, Y. Hu, Z. Zhao, Q. et al. 2020) 24. Another cross sectional

questionnaire survey was done in the same country that aims to explain COVID-19 vaccine intention

among 3 different professional risk groups and recognize the vaccination factors intention since it is

available in the country. The results showed that students had 64.6% of the vaccination intention,

followed by a higher ratio 72.4% of the public transportation employees, and 79.9% for health care

employees. The barriers were recognized as negative influences of vaccine intention among the 3

working groups. As for public transportation employees and students, perceived advantages and

signals to action were recognized as protective factors, and signals to action had a positive influence

on vaccine intention of health care employees. Tailored involvements are stimulated to decrease

vaccination barriers, progress health beliefs and encourage COVID-19 vaccination intentions

(Tianyu, J. Xudong, Z. Hanqian, W. et al. 2021)25.

In Egypt, a cross sectional study design was done that aims to study the level of hesitancy regarding

COVID-19 vaccination and figure out the barriers and factors that may affect the decision of taking

the vaccine. Finding that 90.5% have an awareness regarding the importance of the vaccine, while

6
46% had a hesitancy, and 6% rejected or positively accepted the vaccine. The most important

barriers regarding the vaccination were insufficient data concerning the vaccination’s adverse effects

and inadequate knowledge about the vaccine itself (Shima, S. Eman, S. Ibrahim, K. et al. 2021)26.

Another international study was done in Canada, Australia, New Zealand, U.S, and England to

examines the people’s psychological beliefs that influence the vaccination barriers, also hesitancy

regarding the vaccine, and health beliefs concerning the disease severity and risk along with multiple

variables like religion, age, income, and altruism. The results showed that the most important barriers

regarding this issue were conspiracy beliefs, trust in the vaccination approval, and the perceived

vaccine efficiency for protecting individuals. Older individuals, those who are looking for work, and

the ones who get the influenza vaccine are considering the most likely ones to be vaccinated against

new COVID-19. The outcomes have implications for developing the strategies of communication

targeting people about the advantages of vaccination focusing mainly on younger people, and to

progress the transparency of the government regarding the vaccine’s efficiency and side effects (Paul,

B. Daniel, M. Graham, M. 2021)27.

In Jordan, a cross sectional study design was done that aims to figure out the Jordanian intent to get

the vaccine. Finding that 27.5% were at intermediate risk of COVID-19 complications, while 30.4%

were at extreme risk. The general knowledge about the virus symptoms, route of transmission,

accessibility to treatment and protective protocols were high. The answers regarding taking the

vaccine when it is available accounts for 36.8% of no, and 26.4% were not sure. The reason for that

referred to lack of confidence regarding the vaccine and the use of vaccine (Walid, Q. Anan, J.

2021)28. In Syria, a qualitative study design has been done that aims to assess the level of awareness

regarding COVID-19 among individuals, and evaluate their knowledge about the protection

techniques. The results showed that, most of individuals have moderate knowledge regarding the

virus. In addition to find that there are four important factors which play an important role in the

awareness level, these factors including; the occupation, education, the educational level, and age

(Bonyan, R. Al-Karasneh, F. El-Dahiyat, F. et al. 2020)29.

7
In Palestine, a cross sectional survey has been done that purposes to study the fundamental

awareness, knowledge, and personal hygiene concerning COVID-19 during the outbreak in Gaza

strip. They found that most of people in the strip have enough knowledge and awareness regarding

the virus in term of symptoms, host sources, causative agents, incubation period, route of

transmission, prevention and treatment. In addition to that, they have a good knowledge about the

healthy practices and personal hygiene during COVID-19. But, a significant ratio of people doesn’t

stick to the hygiene protocol. Low percent of people have to educate the avoidance physical contact

and maintain a social distance between others (Altaher, A. Elottol, A. Jibrel, M. et al. 2021)30.

Problem statement

COVID-19 disease has been spread rapidly worldwide, becoming an infectious life-threatening

pandemic disease. The existence of this virus generated a lot of healthy and economical difficulties in

the whole countries worldwide. In Palestine, COVID - 19 lead to many healthy problems for many

infected patients, in addition to many patients who passed away in a young age. The economical and

financial status got back leading to create serious problems for many families. Getting the vaccine

solve a big problem but the hesitancy of taking it exacerbate the situation. From here, it’s important

to stand on this issue and take it into consideration, to understand the reasons and barriers that

prevent people from getting the vaccine in Palestine, and trying to solve the problem, in order to

protect our people and our country as a general.

Significance of the study

COVID –19 is one of the most recent, dangerous and important issue that captured the whole world.

According to the many healthy, psychological, physical, financial, and economical bad side effects

that occurred as a result of the virus, vaccination is considering the significant solution to solve this

problem, since it’s associated to the improvement of successful prevention and treatment approaches.

But in many countries all over the world the decision of taking the vaccine is not easy for many

8
individuals. Many barriers and factors affect the hesitancy and acceptance of the vaccine were

present, therefore it’s important to make a study in our country to figure out the barriers and factors

that prevent Palestinian individuals from taking the vaccine. This will strongly associate in

understanding the problems that individuals may have, in addition to figure out their point of view

regarding the vaccine issue.

Study objectives:

 Main objective:
The main aim of this study is to discover the barriers and beliefs that expected to affect the
individual’s ability or desire to be vaccinated.

 Specific objectives

1. To figure out the level of awareness and health practices regarding COVID-19 among Palestinian
people.

2. To demonstrate the basic knowledge regarding COVID-19 vaccine among Palestinian

individuals.

Questions

The present study seeks to answer the following questions:

1. What is the basic information that Palestinian individuals have regarding COVID-19?

2. What is the level of the awareness that individuals have regarding the virus and the vaccine?

3. What are the barriers that prevent people from taking the vaccine?

4. What are the beliefs that people have regarding the vaccine?

Hypothesis

Taking into consideration, the set objectives, questions of the study, the study addresses
the main hypotheses:

H0: There is low level of awareness among Palestinian individuals regarding COVID-19, the it’s
vaccine.

9
H1: There is a high knowledge and awareness regarding the virus and the vaccine among
individuals.

H2: There are some barriers that prevent individuals from taking the vaccine.

H3: Fear of vaccination is the main barrier that prevent individuals from getting it.

H4: The more negative rumors spread about COVIDE 19 vaccines, the more people refuse to get the
vaccine.

H5: People who have less level of education are more likely to refuse the vaccine.

Definitions

Pandemic disease: Is the disease which mainly infectious that spread worldwide
and most of the time its a life-threating disease.31

Awareness: This term in relation to COVID-19 is being alerts and conscious of the
virus, having information regarding it, the way of transmission, symptoms that may
appear, and the possible prevention ways.

Barriers: In term of COVID-19, they are the obstacles or factors which are keep
individuals away from taking the vaccine.

Methodology

Design
The study used a cross sectional quantitative study design that use a questionnaire. This
questionnaire is divided into two parts; the first one is the socio-demographic part that
take into account the gender, age, educational levels, material status. While the second
part includes the informative questions that designated to answer the suggested questions
of the study and figure out the barriers that prevent individuals from taking the vaccine,
and the awareness level regarding the vaccine.

Population and Sampling

The target population consists of 150 Palestinian individuals who are living in Bethlehem
city, Ramallah city and Beir-Zeit. The selection of the individuals will be non probability
convenience with a limitation to exclude the individuals who are less than 16 years old,
because they are the category which are allowed to get the vaccine, plus this category is
10
mature enough and can take the responsibility to answer the questions in the
questionnaire. Hence, the age of participants will be above 16 years old, including both
sex males and females with different educational level and different work places.

Setting
This study will be done in six different places include; AL-Manarah and AL-Saa’a
roundabouts in Ramallah, Beit-Zeit university and the area around it, in Beir-Zeit, and
Bab-Zuqaqa area and Cinema area in Bethlehem city.

Participants
This study followed a non probability convenience selection of 150 individuals from
different places and different sex, age, educational levels, and work places.

Instrument to data collection

The questionnaire of 20 items scale will be used to assess the the barriers that affect the
decision of getting the vaccine, in addition to the knowledge and awareness level
regarding COVID-19 and the vaccination. 5-point Likert scale (strongly agree, agree,
neither, disagree and strongly disagree) will be used to measure responses.

Variables
* Independent variables: level of education, rumors, gender, marital status, knowledge,
awareness.
* Dependent variable: Not getting the vaccine.

Limitations
The limitations that may faced in this study including the treatment with the participants,
because we are treating with different kinds of people with different minds that may not
accept the idea of participating in the study, some may apologize because they don’t
have enough time to fill the questionnaire, others may afraid of participating in such
study, some are not interested at all, some may be tough, ect. Other limitation includes
finding the targeted participants, because most of people got the vaccine so may be it’s
not easy to find them. Other, including the place of collecting the samples, hence there
are some selected places only, which make it limited to specific areas.

11
Field work administrative part
The questionnaire will be distributed by non probability convenience selection to 150
individuals in different places. Those specific places are selected mainly because they
contain a very large gathering of people, so the study will contain a diverse collection of
people. The distribution procedure will be supervised by five students who are doing this
study.

Tasks to complete Period of time

Research proposal 1 Nov – 25 Nov
Constructed the questionnaire 15 Jan – 30 Jan
Ethical approval 1 Feb – 10 Feb
Data collection 10 Feb – 10 Mar
Data entry and analysis 10 Mar – 25Mar
Writing the research result and discussion 25 Mar – 25 April

Ethical consideration
All the ethical relevant principles in the study will be followed, starting with obtaining
the permission from Beir-Zeit University research and ethical committee to make the
study, then from the ministry of health. Also all Participants’ consent in this study will be
obtained after notifying them about their rights to refuse, participate or withdraw at any
time.

Data analysis
The questionnaire items will be rated on a 1–5 Likert scale (1=strongly disagree,
2=disagree, 3=neither, 4=agree and 5=strongly agree), the highest score will indicate a
great level agreement on the question by the population. After the data will be collected,
it will be organized and analyzed. A computer program (SPSS) will be used. Data will be
analyzed by using descriptive statistics, which include means and standard deviations
analysis, table and figures may be drawn and from the collected data.

12
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