We designed a cross-sectional descriptive study using an online Arabic survey. The survey was validated and revised in focus group piloting. We originally intended to distribute it to randomly selected Lebanese phone numbers to obtain an unbiased nationally representative sample, but during piloting, this method needed to be aborted because of low response rates (less than 1%), likely due to mistrust of messages received from an unknown phone number. Given these constraints, we changed our distribution methods to convenience “snowball” sampling, a method described in a later section that had successfully been used elsewhere in the Middle East [14,21]. The recruitment and survey period occurred from January 29, 2021, to March 11, 2021.

The target population was all adults living in Lebanon. Although all adults living in Lebanon were eligible, they needed to access the self-administered online survey tool on a mobile phone or computer. The survey was in Arabic, so participants had to be literate in Arabic or assisted by someone who was.

Using a convenience “snowball” sampling method, the research team initiated recruitment by sending a recruitment message in Arabic to their contacts and organizations. Participants interested in the study proceeded to the survey via a link in the recruitment message, which also invited participants to forward the message to their contacts. It could be sent through WhatsApp, SMS, social media, and email. There was no follow-up to determine whether individuals who received the recruitment message completed or forwarded the survey. No incentives were provided for participation.

The survey (see Multimedia Appendix 1 and Multimedia Appendix 2) was created using the Qualtrics online survey platform [22]. It was anonymous, self-administered, and required basic literacy in Arabic. The survey content was created by the research team (the majority of whom were fluent in Arabic and English), used several other SARS-CoV-2 vaccine perception studies as a guide [23,24], and was tailored to the Lebanese context. It was piloted in small groups of contacts of the research team of varying educational backgrounds and health literacy and revised prior to survey launch.

The survey included 31 multiple-choice and free-response questions (depending on branch points, participants were not asked each question), divided into an introduction with the informed consent document, followed by questions about screening, demographics, experience with COVID-19, and perceptions of SARS-CoV-2 vaccination. No identifying data were collected. Participants were asked to provide informed consent and affirm that they were 18 years or older, were living in Lebanon, and had heard of “coronavirus” (as SARS-CoV-2 and COVID-19 are referred to in Lebanon). If they declined, the survey automatically ended. If they passed these questions, they proceeded with the survey. After starting the survey, participants had 48 hours before responses were automatically recorded. Participants were prevented from multiple survey attempts on the same device via a Qualtrics feature based on browser cookies.

This study was approved by the Institutional Review Boards of the University of California, Berkeley (Protocol number 2020-11-13811); the Modern University for Business and Science, Lebanon (Project number MU-20201207-19); and Stanford University (by reliance agreement with the University of California, Berkeley, eProtocol number 59832). Informed consent was obtained from all participants prior to the survey; a waiver of written informed consent was granted given that written consent would have been the only identifying information collected.

Data were downloaded as a .csv file and translated into English using Microsoft Excel [25]. Data cleaning and statistical analysis were performed in R computer software and focused on description rather than identifying causal links [26].

Of the 1390 participants who initiated the survey, 1185 (85.3%) provided informed consent and passed screening to begin the main survey. Among this group, 1103 (1103/1185, 93.1%) participants completed the entire survey. Selected sample demographic characteristics of those who passed screening are summarized in Table 1. For full sample demographic characteristics, see the expanded table in Table S1 in Multimedia Appendix 4.

Compared with the demographics of residents of Lebanon in general, our sample population had a higher representation of individuals who identified with the Druze religion and were young, female, well-educated, and from the Mount Lebanon region (Table 1). Underrepresented in our sample were older adults; refugees; non-Lebanese citizens; members of the Sunni and Shi’a religions; and individuals from the less populated governorates of Akkar, Baalbek-Hermel, Nabatieh, North, and South.

Most frequently, participants intending to vaccinate cited the following motivations: to protect themselves, their families, and the public and to end the pandemic and return to normal life (Table 3). Somewhat frequently given reasons for intending to vaccinate included trusting science and research and feeling like there was “no other choice” given the state of the pandemic.

Among participants who did not intend to be vaccinated, the most frequent reasons for vaccine hesitancy were concerns about safety given the fast development and limited testing of the vaccines, fears about side effects, and doubts about efficacy (Table 3). Somewhat frequently cited concerns leading to vaccine hesitancy were mistrust in the Lebanese government.

The most commonly provided reasons for uncertainty about whether participants planned to receive the vaccine were similar: concerns about safety given the fast development and limited testing of the vaccines, fears about side effects, and doubts about efficacy (Table 3). Somewhat frequently mentioned concerns included mistrust of the Lebanese government and health care system, potential fraud in storage or marketing of the vaccines, wanting more information about the vaccines, and needing more time to decide which vaccine to receive.

Our findings of rates of vaccine acceptance and vaccine hesitancy in Lebanon were similar to those of studies in other countries in the Middle East and across the world. The vaccine acceptance of 46.1% in our sample was similar to rates in Kuwait (53.1%) and Qatar (45%-60%), higher than rates in Jordan (28.4%), and somewhat lower than in Saudi Arabia (64.7%) [21,31-33]. Rates of vaccine acceptance in our study were also similar to a large survey of 15 developed countries across the globe, in which 54% of respondents indicated they intend to vaccinate [34]. However, as systematic reviews of vaccine perception studies showed, vaccine acceptance and hesitancy have varied with time throughout the pandemic, with a trend toward decreasing acceptance throughout 2020 [18,35]. Indeed, our results show lower rates of vaccine acceptance than a survey in April 2020 and May 2020 that included a question about acceptance of hypothetical SARS-CoV-2 vaccines, in which 69.3% of Lebanese residents stated they would be willing to receive a vaccine; it is important to note that, at this time, no vaccines were developed or approved and the survey’s population was predominantly male and younger than ours [13]. In contrast, our study found higher rates of intent to vaccinate than an online convenience survey in November 2020 and December 2020, in which only 21.4% of participants intended to be vaccinated [14]. Notably, the study’s sample was smaller, more predominantly female, and younger than ours, and it took place prior to mass vaccination in most of the world, including in Lebanon. It also did not directly assess motivations for intention to or not to vaccinate. Our study found lower rates of vaccine acceptance than the vaccine acceptance rate of 87% among 800 university students surveyed in May 2021 and June 2021 at a prominent Lebanese university [36].

Our findings of trends toward increased vaccine hesitancy in women, younger age groups, unemployed individuals, and individuals with lower education attainment are generally consistent with findings in the Middle East and globally, with the exception that, in Kuwait and Qatar, hesitancy was higher in older populations [14,31,32,35,37-39]. Although we attempted to assess the association of vaccine hesitancy with religion and income, 2 important demographic variables in Lebanon, 15.9% and 36.3% of participants skipped questions about religion and income, respectively, demonstrating the topics’ sensitive natures. Therefore, we do not recommend inferences about differences in vaccine acceptance or hesitancy by religion or income from our study. Similarly, refugees (56/1185, 5.1%) were underrepresented in our sample. Although no significant difference in vaccine acceptance by refugee status emerged, further focus on vaccination in refugees in Lebanon is merited given their multiple vulnerabilities. One survey among Syrian refugees in Lebanon in January 2021 and February 2021 found that 66% of respondents would accept a “safe and free” vaccine [40].

The timing of our survey period spanned the initiation of vaccination in Lebanon. Although our data suggested increased vaccine acceptance among participants who completed the survey after initiation of vaccination, this must be interpreted cautiously. We believe that the differences in vaccine acceptance before and after initiation of vaccination more likely reflect significant differences in populations surveyed during these periods, given the selection bias inherent in the convenience sampling method.

The logistical considerations about which we asked can provide some guidance for vaccination efforts in Lebanon. The most commonly selected sources of news about COVID-19 were television, social media, and internet websites, with television and internet websites most trusted. Focusing dissemination of vaccine promotion efforts on television, social media, and internet websites could be most efficient to reach those with vaccine hesitancy.

Survey respondents reported preferring to receive the vaccine at familiar, established health care sites. Although temporary dedicated vaccination centers were not popular, a small but significant number of participants (106/899, 11.8%) stated they would prefer vaccination at home by a visiting medical professional, a potentially important means of reaching vulnerable patients unable to travel. We also asked whether a financial incentive would change participants’ minds so that they decide to vaccinate; overwhelmingly, they indicated that it would not (589/599, 98.3%).

Despite financial hardships in Lebanon, barriers to vaccine access (cost, transportation, proximity to medical care) were not cited frequently as concerns in our study. This might be explained by the fact that it has become common for governments worldwide to distribute the vaccine free of charge. There were relatively few concerns about vaccine properties like number of required doses, country of origin, or specific vaccine brands. Also uncommon was opposition to vaccines in general (ie, not specific to SARS-CoV-2 vaccines). This is consistent with previous studies in Lebanon showing moderate uptake of routine vaccinations [41-45]. Although several participants in our study cited conspiracy theories as reasons for not vaccinating, these were relatively uncommon, especially compared with a study in other Arabic-speaking countries, which found rates of belief in conspiracy theories of over 50% [33].

Perhaps the most actionable information generated in this study involves motivations for vaccine acceptance and vaccine hesitancy. The relatively large proportion of participants who were uncertain about vaccination—34.0%—provides a public health opportunity and imperative in the effort to achieve mass vaccination in Lebanon. The majority of concerns about SARS-CoV-2 vaccination involved absence of reliable information and data regarding safety, testing, and efficacy. Increasing public availability in Lebanon of high-quality, accessible information about the SARS-CoV-2 vaccines could assuage such concerns and increase vaccine acceptance. Vaccine promotion campaigns could also use messaging based on the most frequently provided reasons for intending to vaccinate: to protect oneself, protect loved ones, and end the pandemic. Based on our results about common COVID-19 news sources, we recommend disseminating clear, consistent, verifiable safety and efficacy information on television, social media, and news websites. Given the prevalence of mistrust in the government, third parties (like health care organizations) might be most trusted, especially if they are able to provide transparency and reassurance about proper vaccine acquisition and storage to allay concerns about fraud.

Our study has several important limitations. First and foremost, our sample is unlikely to be representative of the general population because of the sampling strategy. Although we attempted to mitigate this by collecting important demographic and experiential characteristics, the bias remains, and several important demographic groups were underrepresented, most notably older adults, members of Shi’a and Sunni religions, residents outside of Beirut and Mount Lebanon, non-Lebanese citizens, and those who identify as refugees. Second, participation required literacy in Arabic, internet access, and digital literacy, potentially excluding some populations (though >80% of refugees in Lebanon have access to mobile technology like WhatsApp) [46]. Third, some participants did not answer all questions, possibly causing nonresponse bias. Finally, vaccine hesitancy, perceptions, and concerns may be changing rapidly over time; our results should be interpreted as pertaining to the time period during which the survey was conducted.

This cross-sectional study assessed intentions to vaccinate against SARS-CoV-2 among adults residing in Lebanon, analyzed characteristics associated with vaccine acceptance and hesitancy, and described motivations for and concerns about vaccination. We recommend disseminating clear, consistent, evidence-based safety and efficacy information on vaccines via most commonly selected news sources: television, social media, and news websites. Repeated assessments of intentions to vaccinate, concerns regarding vaccination, and changes in motivations should be performed, especially with the goal of assessing the perspectives and needs of populations that were underrepresented in this study.