Evaluation of the Therapy Protocols and Vaccines Applied in the COVID-19 Pandemic

Despite a plethora of research on vaccine developments and the adverse effects of the vaccine worldwide, there are several research studies on COVID-19 vaccine hesitancy or rejection. The objectives of this study were to investigate the impact of the COVID-19 vaccine on treatment and the factors that contributed to the vaccine concerns. Methods: After one month of being approved by the ethics committee, a descriptive cross-sectional research was conducted using online resources. Samples were randomly selected from the study population. The current study included adults (>18 years old) who were randomly selected from different provinces of Turkey. Results: Most participants were young adults 18–23 years old (47.9%), female (64.8%), married (36.1%), with university education (70.4%), and without medical illness (60.9%) (mean age = 28 years old). Both vaccination doses were given to 53% of the individuals. The most frequent symptom was discomfort at the injection site (0.14%), followed by asthenia muscle pain (0.01%) and edema (24.5%) at the injection site. More symptoms were reported by women than by men. Social media accounts and websites of professional organizations, namely the Dental Association, the Ministry of Health, and the World Health Organization (WHO), were the main sources of COVID-19 information. Hesitancy was induced by concerns about side effects (67.7%), safety (69.7%), lack of information (43.1%), inadequate data on the vaccine clinical trials (55.9%), lack of information on how long protective and effectiveness of vaccines (69.4%), lack of information on how effectiveness against variants (74.8%), think COVID-19 is not dangerous (69.7%), not effectiveness (22.6%) of the vaccine, not safe (32.6%), change my genetic make-up and cause it reproductive sterilite (20.2%), high number of deaths due to COVID-19 (60.8%), the presence of dangerous materials such as aluminum, mercury and others in the content of vaccines, concerns about the country producing the vaccine (38.2%), being afraid of the injection (22%), being against vaccination in general (11%), negative news in the press and social media (38.6%), being risky for only people over 60 (15.9%), having a strong immune system (38.4%), religious (4.7%) and cultural factors (7.4%), believing in natural and traditional medicine (25.4%), and being influenced by friends or family members (19.6%). Hesitancy to accept the COVID-19 vaccine was observed in subjects with hypercholosterolemia and diabetes mellitus. In conclusion, Vaccine hesitancy was primarily related to safety apprehensions. Educational and demographic traits were associated with vaccine admissibility.

in Turkey, with more than 22 thousand mortalities by January 14, 2022 [3].To date, a recommended therapeutic regimen for COVID-19 is not available.While in vitro studies have demonstrated the antiviral activity of many drugs against SARS-CoV-2, their safety and efficacy in humans have not been determined.Drugs such as lopinavir-ritonavir, chloroquine, hydroxychloroquine, ribavirin, and interferon-alpha and -β are being tested in trials [4,5].
To prevent the COVID-19 infection, which contributes to a high economic and medical burden, a safe and effective prophylactic vaccine is urgently needed [6].Furthermore, there is no effective treatment for coronavirus infection [7][8][9].Currently, there are nine COVID-19 vaccines that have been developed and approved for emergency use [10][11][12].These vaccines are AstraZeneca/Oxford Vaccine, COVAXIN, Covovax, Moderna, Pfizer/BionTech, Johnson & Johnson, Sinopharm, Sinovac, and Nuvaxovid [13].Pfizer-BioNTech announced that their mRNA vaccine was 90% effective in November 2020, and since then, the UK and the USA have immediately authorized the emergency use of the vaccine.WHO then approved the vaccine for emergency use [14,15].Turkey aims to immunize more than 70% of its population to end the pandemic using low-cost, safe, effective, and accessible vaccines.China initiated phase III clinical trial of COVID-19 vaccine with inactivated virus in Turkey starting from September 2020 and vaccination strategies have been determined [16].The willingness of the public to get vaccinated is essential for the success of vaccination programs.The problems in vaccination strategies that need to be addressed include limited doses of vaccine supply, vaccine storage, targeted subjects who will receive the vaccine first, and whether the public is willing to get vaccinated or not [17].Worldwide, immunization programs cost billions of dollars [18]. Three million of the 50 million inactivated vaccine shots Turkey ordered have already arrived [17].It is intended to vaccinate eligible adults over the age of 18 following the emergency use authorization, commencing with healthcare professionals and the elderly [16].
Worldwide, more than 6 billion doses of the COVID-19 vaccine have been administered [3].Unfortunately, particularly in nations in Africa and Southeast Asia, vaccination rates are much lower than what would be required to contain the pandemic.Due to logistical and financial limitations, vaccination regimens widely vary around the world, which has an immediate influence on the frequency of COVID-19 infections.A growing concern for the success of vaccination programs is also the public's acceptance of vaccines and vaccine reluctance.The public's acceptance of vaccines depends on knowledge of their efficacy, safety, and side effects.Uncertainty regarding the COVID-19 vaccine's length of protection or the need for a booster dose also contributes to vaccination resistance [19].The rates of vaccination against many diseases that can be prevented, however, are lower than anticipated.Even if the most effective vaccination is given, if people refuse to take it, it will have no effect on the transmission of a disease [20,21].For instance, outbreaks of measles and seasonal influenza have been observed in the USA and other countries, although they are preventable with vaccination [22,23].Vaccine hesitancy has hampered the target of achieving herd immunity as it requires high vaccination rates.Knowledge, attitude, and perception of the general population toward vaccination are pertinent to vaccine strategy.However, insights of the Turkish general public into vaccination are lacking, in particular which demography favors vaccination and which does not.In the age of social media, the dissemination of fast and unreliable information through social media aids in misunderstanding the importance of vaccination, especially before and after the COVID-19 pandemic.Understanding public perception and acceptance of information from social media can help in designing accurate and easy-to-understand materials that can be disseminated from a health agency social media account to the public.To what extent can vaccine hesitancy amongst Turkish citizens help policymakers implement strategies to reach out to Turkish citizens to improve their understanding and importance of vaccination to prevent severe diseases.Assessment of vaccine perspectives among Turkish citizens on their willingness to accept the COVID-19 vaccine can fill the research gaps on the knowledge, attitude, and perception of the citizens on vaccination and its importance.
Currently, the perception and acceptance of COVID-19 vaccine among Turkish citizens is unknown.Questionnaires on their perception of vaccines can be disseminated through social media to unravel how adequate their knowledge of vaccines is, as well as their perception of vaccines, which can either be negative or positive.Furthermore, the questionnaires can also identify demography that is hesitant to receive vaccinations for mitigation strategies from respective bodies to address this issue.We designed this questionnaire-based study to investigate Turkish citizens' perspectives on the COVID-19 vaccine's effects on treatment and vaccine types, as well as its side effects and acceptance for any future COVID-19 vaccines.

2-1-Study Design and Participants
This descriptive cross-sectional online investigation was conducted after one month of being approved by the ethics committee.Subjects were selected from the population using a random sampling method.The current study included adults who were randomly selected from different provinces of Turkey.The questionnaires were created using Google Forms in electronic format.The access link was then disseminated online via email, WhatsApp, Telegram, Instagram, and Facebook, among other services.
Every Turkish citizen who was older than 18 and had access to social media platforms and the internet was qualified to participate as long as they agreed to take part in the study.The questionnaire asked questions on the participants' sociodemographic traits, their knowledge of the COVID-19 vaccine and its therapy, as well as their acceptance and concerns about the vaccine.Individuals who responded to the survey through social media platforms for one month were included in the study.Figure 1 indicates the flowchart of the study methodology.

2-2-Ethical Issue
This study was conducted in compliance with the Declaration of Helsinki.The ethics committee of Firat University of Medical Sciences approved the study protocol (FU 2022/32).The first page of the online form contained informed consent.Participants were allowed to fill out the questionnaire after being informed of the study's goals and its confidentiality and anonymity policies.

2-3-Questionnaires
A questionnaire was prepared in accordance with earlier published studies with modifications [18,[24][25][26][27][28][29][30] to evaluate the level of knowledge of the COVID-19 vaccine and the treatment, acceptance, and concerns of the COVID-19 vaccine.Those questionnaires were designed by a group of experts to ensure the questionnaires given to the targeted populations were unbiased, easy to understand, and unambiguous.Data were collected from four parts of the questionnaires: sociodemographic characteristics, knowledge of the COVID-19 vaccine and treatment, acceptance and concerns about the COVID-19 vaccine, and information sources.In the first part of the sociodemographic questionnaire prepared by the researchers based on the literature, variables included age, gender, family type, marital status, educational status, monthly income status, any disease, presence of chronic disease, smoking and alcohol use status, and nutritional status.The participants' knowledge of COVID-19 and its vaccinations is tested in the second section of the questionnaire.The third section of the questionnaire asks participants about their knowledge and attitudes towards the COVID-19 vaccine, therapy, effectiveness, side effects, and safety.The survey's final section asks questions on COVID-19 vaccination acceptance and safety concerns.

Independent variables:
Living with someone who has a higher risk of developing severe COVID-19, such as an elderly relative or a family member who has comorbid conditions, is undergoing long-term medical treatment, or is Data Analysis taking chronic medication, is one risk factor.Other risk factors include age, gender, level of education, household income, the presence of any chronic or allergic diseases, a history of COVID-19 infection, and the presence of any chronic or allergic diseases.

2-5-Statistical Analyses
We utilized the statistical program International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) version 22 to evaluate the results of a study (SPSS, Inc., Chicago, IL).Categorical variables of participant properties were defined using descriptive statistics, percentages n(%).According to the features of the variables, percentage, mean, and chi-square tests are used in statistical analyses.The relationships between the demographic information and the survey items were assessed using the chi-square test.The standard deviation was provided together with the means (mean±SD).Statistics were considered significant at P<0.05.

3-Results
A total of 1003 respondents participated in the survey, and 944 of them completed the online questionnaire.Table 1 indicates the baseline properties and attitude towards COVID-19 of this study population, containing 612 female participants (64.8%).Approximately half (47.9%) of the participants were 18-23 years old.In total, 65 individuals who were not vaccinated with the COVID-19 vaccine joined in the survey.A large majority of participants were female, and the mean age of participants was 28 years old.The majority of the participants were young adults (18-23 years old) (47.9%), female (64.8%), single (61.1%), with university education (70.4%), and without medical illness (60.9%).53% of the participants have received two doses of the vaccine.Less than half of the participants had completed a high level of education (n=238, 25.5%), and was classified to have a middle income.Married participants represented 36.1% of the sample.One third of the participants mentioned to be concerned for a close family member getting infected, with women stating more often to be concerned than men.Pain on the site of injection was the most prevalent symptom, followed by asthenia, muscle pain, and swelling on the site of vaccine administration.Females complain of more symptoms than males.Primary sources, i.e., websites and social media accounts, that majority of the participants (68.6%) obtained information from included the WHO, the Ministry of Health, and the Dental Association.Informational gatherings held in institutions, medical professionals' personal websites or social media accounts, friends, family, and neighbours, among other sources, as well as scientific articles published on COVID-19, communication groups such as WhatsApp, Telegram, BIP, SMS, newspapers or magazines, and electronic media (TV, Radio).(see Table 2 and Figure 3).

4-Discussion
The goal of the current study was to assess Turkish citizens' awareness of COVID-19 treatment, their behavior and attitudes towards sharing information about COVID-19 treatment, and the causes of COVID-19 vaccine concerns.Our findings revealed that the knowledge of the Turkish population on COVID-19 was adequate.While they were willing to take the COVID-19 vaccine, some of them were hesitant to get vaccinated because of certain factors that included uncertainty on the efficacy of the vaccine, the vaccine side effects, and the lack of clinical data on the safety and effectiveness of the vaccine.These findings provide insights on how receptive the Turkish population is to the COVID-19 vaccine and illuminate the future management of a new emerging infectious disease that has the potential to become a pandemic.
We found that most subjects surveyed were worried to receive the COVID-19 vaccine because of the uncertainty of the side effects associated with the vaccine.There is currently little research being undertaken to evaluate the effects of COVID-19 on therapy and the level of knowledge among the Turkish population regarding COVID-19 vaccination, vaccine types, and COVID-19 vaccine side effects.Available studies assessed treatment use among healthcare workers, and even fewer were focused on treatments and vaccines as a preventive measure among the general public.Lack of knowledge of vaccinations may be caused by inadequate educational preparation, a low socioeconomic level, or reliance on peer laypeople for information [31,32].The majority of Malaysians surveyed on acceptance of the COVID-19 vaccine demonstrated insufficient knowledge of the vaccine [27].In Turkey, the COVID-19 vaccine acceptance rate was 66% based on an early research carried out online in May 2020 with a sample size of 3936.Meanwhile, the rate was higher among Turkish healthcare workers in a study conducted in December 2020.A global vaccine acceptance survey from 23000 participants in 23 countries conducted in 2022 revealed that the acceptance rate has increased from 75.2% to 79.1%.Nevertheless, the hesitancy to get vaccinated has been observed to increase in eight countries, with South Africa and the UK showing the highest trend (52.1%).The respondents surveyed also reported COVID-19 illnesses (36.6%), while 24% reported that they received treatment that included monoclonal antibodies, ivermectin, Paxlovid, and molnupiravir [33].
Apprehensions on safety, effectiveness, and side effects were represented as three major causes of COVID-19 immunization hesitation among healthcare workers in the great majority (> 75%) of studies [34][35][36][37].Among the other reasons for COVID-19 vaccination apprehensions were a lack of knowledge about the vaccines, the idea that the disease does not exist or is not a serious one, vaccine development speed, policies on vaccine development, unfavorable news from social media, previous COVID-19 infections or health conditions, and the advice not to trust authorities, medical professionals, or pharmaceutical companies [35][36][37][38].In a study performed in Turkey, 50% of healthcare professionals had complications due to the COVID-19 vaccine, and 51.4% of healthcare professionals indicated that they did not rely on the statements of the Ministry of Health and the WHO on COVID-19 vaccines [38].
Another important source of vaccination worry is the COVID-19 vaccine, which is the subject of numerous disputes and unfavorable press (35.7%) [39].Social media channels have been especially effective at spreading concerns about vaccinations [40].Unverified claims from the media that the virus was created in laboratory and the vaccine contained non-halal porcine materials as well as caused diseases such as autism, cerebral palsy, and infertility have influenced public perception towards getting vaccinated [41].This has subsequently facilitated the emergence of the antivaccination movement.Although earlier studies suggested that the use of mass media, which included scholarly journals, newspapers, and medical websites, can help improve health-risk behaviors in the community, many people currently prefer to obtain information from social media [42].Verified health information shared on social media transmits fast and successful spread of information [27,43].Moreover, excess knowledge can cause misinformation, media fatigue, and the spread of false news [27,44].Health literacy is also a crucial aspect of defining the efficacy of understanding and evaluating knowledge [27,30].
A study performed in Canada with 2,761 respondents found that the most important reasons for vaccine rejection were that the vaccine was new and wanting to see other people's vaccination results.74% of healthcare professionals who refused to vaccinate reported that they would agree to vaccinate in the future [45].As healthcare professionals are frontiers in the management and treatment of patients, the percentage of them who refuse to get vaccinated aids in the transmission of nosocomial infections to immunocompromised patients.

5-Conclusion
In conclusion, our study revealed that knowledge of the Turkish population on COVID-19 was adequate.Nevertheless, vaccine hesitancy was noted in some individuals surveyed that were amplified by misinformation from social media accounts and uncertainty regarding the safety and effectiveness of the vaccine.Our results are insightful for the dissemination of accurate, creative, and informative information from the respective bodies to tackle vaccine hesitancy among the Turkish population.The government will be able to develop strategies to increase public awareness and demand for the COVID-19 vaccine with the help of the study's findings.

5-1-Limitations of the Study
This study has some limitations.Half of the participants in this study were young subjects because we adopted online tools for data collection that are more easily accessible to the younger generation than those of the older generation.This demographic distribution may not mirror the demography of the Turkish population.Thus, the demography of subjects in future studies should be distributed accordingly to reflect the Turkish population.Another limitation is the crosssectional study, and the cause-and-effect link could not be established.Recall bias amongst participants for self-reporting of diseases might also occur during the survey.However, a survey is the most common approach for data collection in epidemiology studies as it is convenient and cost-effective.Finally, we only collected declarative data and were unable to control answer accuracy.

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Knowledge of Covıd-19 Vaccine;  Treatment and Acceptance;  Concerns of COVID-19 vaccine and information sources.

Figure 2 .
Figure 2. The participants' knowledge attitude towards COVID-19 vaccine and treatment, and effectiveness, side effects, safety of COVID-19 vaccine.A) Have you been vaccinated?B) Were there any side effects after vaccination?C) How long did the symptoms of the side effects of the COVID-19 vaccine?D) Have you caught COVID 19 after vaccination?E) Have you been vaccinated other than the COVID 19 vaccine?