Coronaviruses (Latin: corona = crown) are positive-sense single-stranded large, enveloped RNA viruses that infect humans and other animals. COVID-19 generally causes mild to moderate symptoms such as fever, cough, nasal congestion, and other signs of upper respiratory tract infection, with an incubation period of 5 days (range: 0–24 days)^[3]. However, some patients may develop severe pneumonia or gastrointestinal symptoms, and about 5% may, in late stages, develop acute respiratory distress syndrome (ARDS), septic shock, and/or multiple organ failure^{[4, 5]}.Older adults, and people with a weak immune system are high-risk groups that are more susceptible to complications of COVID-19, including hospitalisation, disease and death.

The main clinical management of confirmed symptomatic COVID-19 patients involves symptomatic management and oxygen therapy, with mechanical ventilation for patients with lungs failure. Many antiviral drugs are being actively tested; however, none have been specifically approved for COVID-19^[6]. Given that, we do not have experience in treating COVID-19; the consequences of repeated epidemics will be unacceptably high mortality, severe economic disruption, and major changes to our way of life, including social distancing and self-isolation. Therefore, the development of an effective vaccine has been essential, and the benefit will be even greater if it can be used to prevent recurrence or 

continuous epidemics. The ability of viruses to achieve pandemic spread and viral replication is reduced by establishing higher levels of community (herd) immunity ^[7].

Whether protection is gained by the rapid development of an effective vaccine or by repeated waves of infection over the next few years until approximately 75% of people develop immunity ^[7].These options must be considered in terms of the risk: benefit calculations.

 In the past century, vaccination has progressively been seen not only as one of “medicine’s greatest life-savers”, but also as the ideal form of intervention against infectious diseases ^{[8, 9]}. Therefore, in order to stop the spread of COVID-19 across the world, governments have turned a hopeful eye towards research and development of a vaccine against this new disease ^[10]. However, while scientists succeeded in discovering a number of vaccines that have now been approved by many governments, high vaccination coverage in the public has not been achieved in most countries. One reason for this is that the public may be hesitant to take the vaccine, despite it being made available by their government ^{[10, 11]}. For many years, public doubt and uncertainty about vaccines has become an increasingly important global issue ^{[12, 13]}. Vaccine hesitancy (negative attitudes towards vaccines) was included as one of the ten threats to global health in 2019 by the WHO, and whether COVID-19 vaccines will be accepted and widely used in countries will be affected by the attitude and knowledge of the public regarding the vaccines ^[10].

This study selected dental patients and their companions because of the ease of reaching of this sample during their emergency visit to dental departments especially during the COVID-19 lockdown period in Jordan and other countries.

In Jordan, the Ministry of Health (MOH) has started a vaccination programme against COVID-19 and Jordanian citizens are recommended to receive the COVID-19vaccines by many health agencies. Analyses of Jordanian knowledge and attitudes towards COVID-19 vaccination can provide areas for development to enhance vaccination rates in the Jordanian population. Hence, this study aimed to evaluate their knowledge and attitude towards COVID-19 vaccines.

 Methods

Study design

This study is a descriptive cross-sectional survey in which a sample of dental patients and their companions (aged 18–72 years ) were approached in dental department of the Jordanian Royal Medical Services (JRMS) in three major regions (north, middle, and south) of Jordan between April and June 2021. The principal investigators developed a structured questionnaire based on a previously published research ^{[14, 15]}. The questionnaire was developed in Arabic language because Arabic is the main spoken language for 98% of the Jordanian citizens. The questionnaire was originally formulated in English, translated to Arabic, and then back translated to English by different translator and the two English versions were found to be comparable. An expert panel assessed the content validity of the developed survey. To confirm face validity, the questionnaire was given to 25 individuals and changes were implemented based on their comments. The data of these participants was not included in the final study. The self-administered questionnaire was given to participants that attended the dental clinic for emergency dental treatments and their escorts. We explained to them the purpose of the study and the estimated timing needed to fill the questioner (8 to 10 minutes) and we took a verbal approval for that .The investigator was available during the time of the questionnaire filling to provide any required information needed by the volunteer.adults, 61% strongly agreed that it is important for healthy adults over the age of 65 to get a COVID-19 vaccine. Also 76% strongly agreed that COVID-19 is a serious disease in adults with serious medical problems, so the vaccine should be given to prevent the disease. In addition, 33.6% of participants strongly agreed that they do not need the vaccine, but 42.2% strongly agreed that they required the vaccine to prevent COVID-19. Finally, 7.8% of participants strongly agree that they are not susceptible to COVID-19 disease, while 73% strongly disagree that they are not susceptible to COVID-19 (Table IV and fig.3).

The acceptance of COVID-19 vaccines among the sample where 31.3% of the participants are willing to take a vaccine, 23.3% will refuse to take it, 33.8% are undecided, and only 11.6% have already taken it.

Table IV:  Participants’ attitudes (N = 1072)

  (N = number)

A convenience sampling method was used in this study. To calculate the required sample size, Kish formula was used at a 95% significance level and a 3-percentage-point margin of error. The estimated sample size was 1014; however, 1072 participants were included in the study.

According to Department Of Statistics in Jordan, Statistical Yearbook of Jordan 2021, Jordanian population is a young population with 63. 19% between 14_65 years old and only 3.95% above 65 years age. Additionally, most of the population is distributed over the country's regions; where about 62.8% of the population lives in the central region; and about 9.4% of the population lives in the south region. While the northern region lives in it about 27.8% of the population

Therefore, it is crucial to evaluate the level of knowledge and attitudes to SARS-CoV-2 and the acceptance of COVID-19 vaccination, of those who are eligible for the vaccination, from this group as they represent a large portion of the community.

The study inclusion criteria required all participants to be literate dental patients seeking dental care at dental departments of the Jordanian Royal Medical Services (JRMS) and their escorts, aged 18 years or older and to be native Arabic speakers.

The first section of the study questionnaire covered general information about participants, including name, ID number, gender, age and their living place. The second section contained 26 questions, where 1–8 covered the knowledge and opinions of COVID-19 among the participants. Responses to these questions were framed as yes, no, or do not know. Question numbers 9 and 10 were designed to measure the acceptance of COVID-19 vaccines and the sources, while questions number 11–19 measured the knowledge of COVID-19 vaccination among the participants. Questions 20–26 aimed to measure the attitudes of the Jordanian sample towardsCOVID-19 vaccination. Responses to attitude questions were framed as a 5-point scale (Strongly agree, Agree, Neutral, Disagree, and Strongly disagree).This study was approved by the higher ethical committee of the JRMS. Study objectives were explained to every participant and verbal informed consent was given before the administration of the questionnaire.

Statistical analysis

Anonymous data were numerically coded and entered into an Excel spreadsheet (Microsoft® Office Excel). All statistical analyses were conducted using IBM SPSS software version 25 (Chicago, IL, USA).

The frequency distribution for categorical variables was used to describe the demographic characteristics of the study participants, whereas the mean and standard deviation were used to describe the continuous variables. Seventeen questions were used to score the data regarding COVID-19 and COVID-19 vaccines. We performed additional analysis to classify the study participants as having good knowledge or poor knowledge regarding COVID-19 disease and COVID-19 vaccines. COVID-19 disease and COVID-19 vaccines scores were combined to 17 questions. The median score was 11, the IQR ranged from 8.5 to 13.5 and the maximum score was 17. Scores equal or above the median (=>11) were considered good knowledge, while scores less than < 11 were considered poor knowledge. we have used the median as a cut-off.

There were seven questions on the participants’ attitudes, and they were scored on a 5-point Likert scale for a total of 35 points. An attitude score ≥ 23 (cut-off ≥ 65%) was considered a positive attitude, while attitude score < 23 was considered a negative attitude.

Results

 Among the 1072 participants, 11.6 %( n = 124) had received a COVID-19 vaccine. In total, 53.9% had good knowledge of the COVID-19 vaccine, and 68.8% had positive attitudes.

Around 38.6% of participants reported that COVID-19 vaccines are effective against preventing COVID-19; however, 27.4% erroneously reported that COVID-19 can be treated with the COVID-19 vaccine. Moreover, 70.9% thought that the COVID-19 vaccine is important for older adults. Overall, 75.6% strongly agreed that COVID-19 is a serious disease in older adults, and that they should take a vaccine to prevent COVID-19.

In this study, we invited 1162 dental patients and their escorts at JRMS to participate in the study and 1072 subjects agreed to participate (a response rate of 92%). The participants were between 18 and 72 years old, the mean age of participants was 35.4± 11.3 years.

Demographic characteristics of the study participants are presented in (Table I). Around half of the participants were female patients. Regarding the distribution of participants in Jordan, around half of the participants were from middle Jordan that contains the largest population in Jordan.

Table I: Demographic characteristics of the study participants (N = 1072)

N=number

Regarding participants’ knowledge about COVID-19, almost nine out of ten participants knew that it is a viral disease, and believed that COVID-19 is a contagious disease. Meanwhile, nearly eight in 10 patients believed that older adults are at higher risk of COVID-19; adults with serious medical problems are at higher risk of getting seriously illness by SARS-CoV-2 and reported that COVID-19 could occur 

at any time of the year. In the same way, 40.3% believed that COVID-19 could be treated with antibiotics. These results are shown in Table II and fig.1.

Table II:  Knowledge about COVID-19 (N = 1072)

(N = number)

 Figure1: knowledge about COVID-19

 Regarding participants’ knowledge of COVID-19 vaccination. In total, Around a quarter of interviewed patients reported of participants reported that COVID-19 vaccines are effective against 

preventing COVID-19, Meanwhile, one third of participants believed that COVID-19 can be treated with COVID-19 vaccines and that COVID-19 vaccines are safe. Almost half of all study participants reported that COVID-19 vaccines have side effects but could prevent serious complications of COVID-19 among older adults In addition, Seven out of ten participants reported that COVID-19 vaccines are important for adults and adults with serious medical problems (Table III and fig.2).

Table III:  Knowledge about the vaccines (N = 1072)

(N = number)

Figure 2: knowledge about COVID-19 vaccines.