Public response to the second COVID-19 booster vaccination in Bangladesh: exploring the intersection of health status, education, and vaccine acceptance

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Despite the therapeutic potential of priming vaccine doses, the waning immunity from COVID-19 vaccines and the first booster vaccination underscore the unprecedented importance of administering a second booster dose to protect public health. This study aimed to assess the willingness of general people in Southern Bangladesh to receive a second COVID-19 booster or a new vaccine and the factors influencing their acceptance. Using a validated paper-based semi-structured questionnaire, this cross-sectional study employed a face-to-face data collection approach from April 1 through May 31, 2024, during the nationwide spread of the SARS-CoV-2 Delta variant. Binary logistic regression analysis was used to explore the crude significance of each predictor variable to the dependent variable. The pooled willingness for a second COVID-19 booster was 44.2% (95% CI: 42.1 − 46.3) among respondents. Underlying health conditions (AOR = 3.2, 95% CI: 1.58 − 5.43), education (AOR = 3.6, 95% CI: 1.89 − 5.96), area of residence (AOR = 1.7, 95% CI: 0.93 − 3.64), vaccine confidence (AOR = 3.9, 95% CI: 1.93 − 5.77), and equal safety (AOR = 2.48, 95% CI: 1.01 − 4.95) were significantly associated with acceptance of a second booster vaccine. In addition, this study found that perceived side effects (AOR = 1.89, 95% CI: 0.89 − 4.81) were a barrier and a key reason for skepticism about a second COVID-19 booster dose. The second booster vaccine dose is particularly essential for older adults, immunocompromised individuals, and other high-risk groups. These findings indicated that less than half of respondents across all demographic groups were willing to accept a second COVID-19 booster vaccine, while medical illness, education, and confidence were three key predictors of second booster acceptance. This study highlights the need for regionalized education and trust-building efforts to address booster hesitancy, with implications for global public health efforts. Health sciences/Health care Health sciences/Health occupations COVID-19 booster dose underlying health education Bangladesh Figures Figure 1 Introduction The rapid spread of Coronavirus disease-19 (COVID-19) has underscored the therapeutic potential of mass vaccinations in protecting global health. COVID-19 infection, caused by SARS-CoV-2, leads to severe acute respiratory syndrome among human beings. As with SARS and MERS viruses, SARS-CoV-2, a novel Coronavirus, is a positive sense single-stranded RNA (+ ssRNA) virus [ 1 ]. SARS-CoV-2 is extremely contagious and spreads rapidly throughout the global population, affecting people of all ages and health conditions [ 2 ]. While everyone is vulnerable to COVID-19 infection, older adults and those with comorbid conditions are most at risk. The available data, however, indicate that older people and those with underlying health conditions are more likely to be infected with COVID-19 [ 3 ]. Vaccines are effective interventions that can reduce the high burden of infectious diseases, disability, death, and inequality worldwide [ 4 ]. Infections, hospitalizations, and mortality from COVID-19 can be reduced using mRNA vaccines. It has been shown that mRNA vaccines significantly reduce the incidence of severe diseases during the delta and omicron waves with minimal risk of adverse events [ 5 ]. The COVID-19 vaccine priming doses were administered daily to over 40 million people worldwide, with a small proportion administered to people in low-income countries. Vaccination against SARS-CoV-2 provides hope for an end to the pandemic if all countries have equal access and optimal uptake [ 6 ]. With the spread of COVID-19, new variants of the virus are expected as the virus changes. However, studies have shown a decline in primer vaccine effectiveness over time and an increase in hospitalization rates following breakthrough infections among immunocompromised and comorbid patients [ 7 , 8 ]. Vaccine effectiveness against severe SARS-CoV-2 infections among New Yorkers has declined from 91.7–79.8%, according to another study. This study, however, also found that the vaccine remains highly effective against hospitalizations [ 7 ]. Vaccine-induced immunity has maintained high effectiveness against severe SARS-CoV-2 cases. With the emergence of highly transmissible variants with greater potency to trigger breakthrough infections, a significant decrease in protection against new SARS-CoV-2 infection has been noted [ 8 ]. There is, however, the possibility that variants such as B.1.617.2 could induce similar viral loads in fully vaccinated and unvaccinated individuals within the first five days of infection [ 9 , 10 ]. The eventual need for a second COVID-19 booster vaccine dose has been discussed extensively, primarily in light of concerns about possible waning immunity, the transmission of breakthrough infections, and the emergence of new viral variants that are more transmissible [ 11 ]. An analysis of 30 published studies suggests that the third dose of COVID-19 vaccine reduced infection risk by 88–92% and converted immunoglobulin-G by 95 to 100% [ 12 ]. Several countries have adopted a COVID-19 booster vaccine in response to new variants of SARS-CoV-2 (Delta and Omicron), and early evidence from the vaccine booster supports its efficacy [ 13 ]. Globally, several studies examined the willingness of the general public to receive a first COVID-19 booster dose and reported varying acceptance rates across the continents. Public acceptance of the first booster was associated with a number of multidimensional factors, including equal safety, repeated immunity, the arrival of new variants, efficacy, and community protection, whereas booster hesitancy was correlated with adverse side effects after priming COVID-19 vaccinations and concerns about serious side effects after booster doses [ 14 ]. Vaccine hesitancy is a growing concern in public health [ 15 ], presenting a significant obstacle to achieving widespread vaccination coverage and herd immunity. A similar phenomenon was observed during the COVID-19 pandemic [ 16 ]. Booster dose hesitance and public acceptance of a second booster dose will, at some point, play a role in determining the public health response to the pandemic. Booster vaccination, however, produces broad but incomplete immunity against SARS-CoV-2 variants, including the Delta variant. Real-world evidence indicates that first booster doses have waned over time against new COVID-19 variants and hospitalization, especially for the Delta strain of COVID-19 [ 17 ]. Despite the fact that the third dose of a COVID-19 vaccine is safe and immunogenic [ 18 ], studies focusing on the second booster dose are scarce [ 19 , 20 ]. While a first booster is recommended for most adults, a second booster is particularly important for older adults, immunocompromised individuals, and other high-risk groups to enhance their protection against severe COVID-19. Bangladeshi people have yet to accept a fourth COVID-19 vaccine dose; assessing the public response to the second COVID-19 booster vaccine was thus a potential; no literature is available on this topic. This study contributes region-specific evidence and incorporates a conceptual understanding of vaccine confidence and public trust to assess the complex interplay of individual, social, and systemic factors affecting second booster uptake among the people in southern Bangladesh. Methods Study design A face-to-face survey was conducted from April 01 to May 31, 2024, during the spread of the SARS-CoV-2 Omicron variant across the country, following the STROBE guidelines. The study was conducted at Khulna divisional region, a coastal region with a diverse landscape, including urban areas, agricultural lands, and the Sundarbans mangrove forest, a UNESCO World Heritage Site. In this Division, urban and rural areas combine, with Khulna city being the most populous urban center. As of the 2022 census, Khulna division has an estimated 18.03 million people, while the urban areas have around 5.22 million people. Ten districts make up Khulna Division and we defined district towns as urban areas, upozilla towns as sub-urban areas, and all other as rural areas. The study involved human subjects, thus following the Declaration of Helsinki [ 21 ]. The experimental protocol was evaluated by the institutional review committee (IRC) as part of the approval process for the project. Since no clinical intervention was involved, the IRC approved this study as exempt. However, the reference number of ethical clearance certificate was JUST-BIO-PHA-02052023. Participants Participants in this study were aged 18 years and older who lived in the area for at least six months before the survey and agreed to provide data on consequences of COVID-19 booster vaccination. Informed consent was obtained from all the participants. Individuals who refused informed consent, pregnant or lactating women, those with any mental or physical disability (accompanied by a caretaker), and unvaccinated people were excluded from the study. Eleven trained enumerators were appointed for data collection and they visited 708 adult respondents, 71 of whom declined to provide consent, 21 who refused to contribute due to time constraints and 12 who were not vaccinated with primer doses. The survey responses were guaranteed to be confidential, and all survey participants were informed about the uses and anonymization of the data. No financial or in-kind rewards were given to survey participants, and no external funding was provided. Sample size determination The sample size was calculated by using the single population proportion formula n= ( Z α/2) 2 p (1-p) /d 2 n = sample size z = is the standard value corresponding to the desired level of confidence and Confidence interval of 95% is assumed (Zα/2 = 1.96) d = margin of error (5%) p = is the estimated proportion of an attribute that is present in the population. We considered a non-response rate of 10% and design effect 1.5 during the adjustment of final sample size of 550 plus. Sampling Procedure A multistage sampling method was used to reach the study unit. Khulna division has a total of ten district cities and a metropolitan city. Three of these ten cities were selected by the lottery method, followed by simple random sampling of sub-cities within each city, and finally, systematic sampling of rural participants within each sub-city. Measures and instruments The questionnaire items were adopted from a theoretical analysis of the relevant literature on the topic in regional and global settings [ 14 , 19 , 20 , 22 ]. The questionnaire consisted three sections: socio-demographic overview, medical illness, and booster vaccine-specific characteristics. The questionnaire was originally developed in English and translated into Bengali (local language) with the assistance of a national public health expert. An independent translator translated the questionnaire from English to Bangla and back again to establish validity. In general, the questionnaire took 15–20 minutes to complete all sections. Validity and reliability of the instrument Theoretical analysis and a comprehensive review of relevant literature were conducted to ensure the accuracy of the measurements. A panel of public health experts content-validated and face-validated the questionnaire items, ensuring relevance and clarity. The questionnaire was primarily analyzed with 20 non-selected participants in order to ensure its clarity, wording, and to make sure that none of the questions were difficult to understand and the results of the pilot test were later excluded. An evaluation of the psychometric properties of the survey consenting was conducted in order to determine if the questions effectively captured the topic. The reliability of the measurements was confirmed using Cronbach's alpha value estimated at 0.81, which was considered coherent for confirming its internal consistency [ 23 ]. The study described variables Dependent variable Willingness to accept a second COVID-19 booster vaccine. Independent/ predictor variables Age, Sex, Marital status, Educational levels, COVID-19 positive experience, Medical illness, Residence, Booster effectiveness, Trust in public health systems, Stronger vaccine confidence, Positive attitude towards a COVID-19 booster vaccine, Equal vaccine safety, Perceived risk of being further infection, Perceived booster side effects. A conceptual analysis of recent reviews led to the selection of variables based on a theoretical investigation [ 14 , 22 ]. Operational definitions Willingness of COVID-19 booster vaccine acceptance: Those who were volunteer to uptake a second COVID-19 booster vaccine Unwillingness of COVID-19 booster vaccine acceptance: Those who were refused to receive a second COVID-19 booster vaccine Data collection An in-person interview approach was used to collect Data from the respondents. A multistage sampling method was used to reach the study unit. Khulna division has a total of ten districts cities and a metropolitan city. The lottery method was used to select five district cities from the Khulna division and three sub-district cities, and then stratified random sampling was used to sample sub-cities within each city, and finally, systematic sampling was used within the sub-cities to reach remote participants. Five teams with one female and one male trained member each conducted interviews and recorded the responses on paper-based questionnaires. Male and female enumerators interviewed the male and female respondents, respectively. At the beginning of the conversation, it was explained to the participants how the study would be conducted, how long it would take, and the benefit it would provide. The research supervisor assured the quality of the data collection process. Participants consented to the researchers using their anonymous data for academic purposes by completing the questionnaire and submitting it to them. The face-to-face interview confirmed a direct interpersonal interaction between the interviewer and the interviewee, and this approach is more likely to elicit complete or formulate the interviewee, whereas incomplete data submissions were rejected. Data quality control The questionnaire was pre-tested before it was modified to ensure the quality of the data. Data collectors and supervisors were trained for one day on the objectives, relevance, confidentiality, respondent's rights, informed consent, and interview techniques. All questionnaires were checked for completeness, missing values, and unlikely responses. Incomplete questionnaires were excluded. The principal investigator and supervisors were made spot-checking and reviewing the filled questionnaire to ensure completeness and consistency of the information. Data analysis The collected data were checked visually for its completeness and the responses were coded and entered into the computer using Excel version-10. Then data were exported to windows of Statistical Package for Social Science (SPSS) version 25 for data analysis. During the process of analysis, descriptive statistics were used to provide an overall and coherent presentation and description of the data. Binary logistic regression analysis was employed to see the crude significant relation of each independent variable to the dependent variables. Assumption tests for binary regression analysis were evaluated and assessed for multicollinearity within the regression model used. Odds ratio with 95% CI was performed on variables to determine the strength of association of variables. P -value less than or equal to 0.05 was taken as a cut-off value to be significant. Results Socio-demographic characteristics of the participants Table 1 displays socio-demographic characteristics of the study participants. Out of the total 708 visited individuals, 604 of them were included in the final analysis giving a response rate of 85.3%. The mean age of the respondent was 41.57 (SD ± 12.622) years. The majority 177 (29.3%) of the respondents was between 18 and 28 years old, followed by the age group 29 − 38, 148 (24.5%). The largest portions of the participants have primary level education 179 (29.6%), followed by higher secondary and above 175 (29.0%). Housekeepers accounted for the highest percentage (33.6%), followed by farmers or day laborers with 30.6%, and employees with different professions with 109 (18.0%). Male participants were 328 (54.3%) and female were 276 (45.7%). Regarding marital status majority of respondent 356 (58.9%) were currently married, and 478 (79.1%) were Muslim by religion. Minor fractions of participants had a COVID-19 positive history and the majority of participants 482 (79.8%) received the first COVID-19 booster dose. The pooled acceptance of a second COVID-19 booster was 267 (44.2%) and the pooled hesitance was 337 (55.8%) among the study peoples. Table 1 Distribution of the study participants, by socio demographic characteristics Variable Category Frequency Percentage Age 18–28 Years 177 29.3 29–38 Years 148 24.5 39–48 Years 129 21.4 49–58 Years 81 13.4 59 Years and above 69 11.4 Sex Male 328 54.3 Female 276 45.7 Marital status Single 190 31.5 Married 356 58.9 Divorced/ widowed 58 9.6 Religion Muslim 478 79.1 Hindu 123 20.4 Others 3 0.5 Educational status Have no formal education 137 22.7 Primary 179 29.6 Secondary 113 18.7 Higher secondary and above 175 29.0 Occupations Employed 109 18.0 Business 77 12.7 Farmer/day labors 184 30.5 Housekeeper 203 33.6 Others 31 5.1 Exposure to COVID-19 Yes 196 32.5 No 368 60.9 Not willing to tell 38 6.3 Received 1st booster Yes 482 79.8 No 112 18.5 Second booster Acceptance Yes 267 44.2 Unsure 133 22.0 No 204 33.8 Medical and vaccine related variables Table 2 shows descriptive results of medical and vaccine related characteristics of respondents. In this study, 229 (37.9%) reported an underlying health illness, and 315 (52.2%) expressed trust in public health systems. More than half of the people had positive attitudes towards booster shots 308 (51.0%), strong vaccination confidence 321 (53.1%), and belief that booster shots are safe 324 (53.6%) and effective 329 (54.5%) against SARS-CoV-2. The majority of the participants 421(69.7%) was concerned about the possibility of becoming infected with SARS-CoV-2 in the future and confirmed that booster doses were crucial. Nevertheless, a significant portion of people 357 (59.1%) were worried about vaccine induced side effects (58.3% had mild symptoms, 28.8% had moderate symptoms, and 12.9% had severe symptoms) after receiving a first booster shot. Table 2 Medical and vaccine related characteristics Variables Category Frequency Percentage Medical illness Yes 229 37.9 No 375 62.1 Booster vaccine effectiveness Yes 329 54.5 No 275 45.5 Trust in public health systems Yes 315 52.2 No 289 47.8 Stronger booster vaccine confidence Yes 321 53.1 No 283 46.9 Positive attitude towards a booster vaccine Yes 308 51.0 No 296 49.0 Believed that booster vaccines are generally as safe as primer doses Yes 324 53.6 No 280 46.4 Perceived risk of being further infected with covid-19 in the future Yes 421 69.7 No 183 30.3 Fear of booster side effects Yes 357 59.1 No 229 37.9 How severe were your side effects symptoms? (N = 357) Mild Symptoms Not applicable 208 58.3 Moderate symptoms and sought help from a doctor Not applicable 103 28.8 Severe symptoms and was hospitalized Not applicable 46 12.9 Response to the second COVID-19 booster vaccine Figure 1 illustrates public response to the second COVID-19 booster vaccine in Khulna divisional region, Bangladesh. In this study, 42.2% (95% CI: 42.1 − 46.3) respondents were ready to accept a second COVID-19 booster vaccine anytime, 22.0% were unsure, and 33.8% respondents were not willing to accept a second COVID-19 booster vaccine (Fig. 1 ). Potential factors associated with the second COVID-19 booster vaccine responses Table 3 summarizes the results of binary logistic regression analysis. The acceptance of a second COVID-19 booster vaccine was significantly influenced by several multicultural factors. Respondents with higher secondary and above education were 3.6 times more likely to accept a second COVID-19 booster vaccine (AOR = 3.6, 95% CI: 1.89 − 5.96, p = 0.001) compared to those respondents who have no formal education. The likelihood of receiving a second booster dose was 1.7 times higher among urban than rural residents (AOR = 1.7, 95% CI: 0.93 − 3.64, p = 0.041). Respondents with medical illness were 3.2 times more likely to accept a second COVID-19 booster vaccine (AOR = 3.2, 95% CI: 1.58 − 5.43, p = 0.003) compared to their counter parts and respondents who have strong vaccine confidence were around 4 times more likely to accept a booster shot (AOR = 3.9, 95% CI: 1.93 − 5.77, p = 0.001) compared to those respondents having poor vaccine confidence. People who believed that the booster dose was equally safe as the priming vaccination were 2.4 times more likely to accept it (AOR = 2.48, 95% CI: 1.01 − 4.95, p = 0.028). However, vaccinated individuals who experienced vaccine side effects during primer and/or 1st booster vaccination were 1.86 times less likely (hesitance) to receive a second COVID-19 booster dose (AOR = 1.86, 95% CI: 0.89 − 4.81, p = 0.037) Table 3 Factors associated with willingness to accept a second COVID-19 booster vaccine Variable Category Acceptance β p -value AOR (95%CI) Yes No Age 18–28 Years (r) 76 (42.9%) 101(57.1%) − − − 29–38 Years 66 (44.6%) 82(55.4%) 0.224 0.211 0.98 (0.48 − 1.92) 39–48 Years 84 (65.1%) 45 (34.9%) 0.289 0.071 1.74 (0.76 − 3.94) 49–58 Years 59 (72.8%) 22 (27.2%) 0.236 0.083 1.85 (0.90 − 3.79) 59 Years and above 53 (76.8%) 16 (23.2%) 0.215 0.094 Sex Male 138 (42.1%) 190 (57.9%) 0.112 0.352 1.63 (0.98 − 2.71 Female (r) 128 (46.4%) 148 (53.6%) − − − Marital status Single (r) 71 (37.4%) 119 (62.6%) − − − Married 291 (53.6%) 165(46.4%) 0.312 0.106 0.48 (2.34 − 0.97) Divorced/ widowed 25 (43.1%) 33 (56.9%) 0.287 0.127 0.47 (0.15 − 1.42) Educational levels No formal education (r) 47 (34.3%) 90 (65.7%) − − − Primary education 71 (39.7%) 108 (60.3%) 0.447 0.241 1.45 (0.69 − 3.04) Secondary education 49 (43.4%) 64 (56.6%) 0.416 0.094 − Higher secondary and above 88 (50.3%) 87 (49.7%) 0.491 0.001 3.6 (1.89 − 5.96) COVID-19 positive experience Yes 134 (68.4%) 62 (31.6%) 0.128 0.372 − No (r) 83 (20.4%) 323 (79.6%) − − − Residence Rural (r) 84 (36.6%) 129 (63.4%) − − − Semi-urban 81 (46.8%) 92 (53.2%) 0.421 0.071 Urban 118 (51.7%) 110 (48.3%) 0.329 0.041 1.7 (0.93 − 3.64) Medical illness Yes 202 (88.2%) 27 (11.8%) 0.154 0.003 3.2 (1.58 − 5.43) No (r) 87 (23.2%) 288 (76.8%) − − −. Booster vaccine effectiveness Yes 291 (88.4%) 38 (11.5%) 0.231 0.056 − No (r) 55 (20.0%) 220 (80.0%) − − − Trust in public health systems Yes 185(58.7%) 130 (41.3%) 0.367 0.052 0.98 (0.59 − 1.65) No (r) 42 (14.5%) 247 (85.5%) − − − Vaccine confidence Yes 294 (91.6%) 27 (8.4%) 0.276 0.001 3.9 (1.93 − 5.77) No (r) 103 (36.4%) 180 (63.6%) − − − Positive attitude towards booster vaccination Yes 215(69.8%) 93 (30.2%) 0.402 0.068 4.2 (0.58 − 1.91) No (r) 57 (19.3%) 239 (80.7%) − − − Booster safety Yes 269 (83.0%) 55 (17.0%) 0.371 0.028 2.48 (1.01 − 4.95) No (r) 74 (26.4%) 206 (73.6%) − − − Perceived risk of being further infection Yes 311 (73.9%) 110 (26.1%) 0.279 0.219 0.75 (0.42 − 1.33) No (r) 107 (58.5%) 76 (41.5%) − − − Booster side effects Yes 241(67.5%) 116 (32.5%) -0.276 0.037 1.86 (0.89 − 4.81) No (r) 143 (62.4%) 86 (37.6%) − − − note : (r) indicates reference category , β = Beta coefficient, AOR = Adjusted odds ratio, CI = Confidence Interval Discussion Vaccination has long been a protocol for preventing and limiting infectious diseases globally, including COVID-19 [ 24 ]. In Bangladesh, the COVID-19 vaccination campaign has made notable strides, with millions of people receiving the initial doses, including a gradual roll-out of booster doses starting in late 2021. Due to the waning immunity from COVID-19 priming vaccines and the first booster, we conducted this study to evaluate public response to the second booster in Southern Bangladesh. In this study, 44.2% (95% CI: 54.2%, 62.5%) of respondents were willing to accept a second booster dose against COVID-19. A Greek study found that 62% of respondents were willing to receive vaccinations, 25.8% were unsure, and 12.3% were unwilling to receive a second booster vaccination [ 19 ]. According to healthcare participants who had not received the second COVID-19 booster dose in Italy, 52.6% showed a willingness to receive it, while 25.1% and 22.3% indicated that they had "no intention" or showed "uncertainty" [ 25 ]. This might be the difference in socio-demographic characteristics of respondents, like difference in educational status, age, occupation, and also differences in study period and the time during the pandemic when the studies were conducted. Studies conducted in the early stages when booster shots were poorly understood may differ from those conducted later when booster shots were better understood. Additionally, as time passes, more knowledge is gained about the booster vaccine and disease prevalence, which can influence whether a country accepts a second booster vaccination. The first booster shot had caused widespread confusion among country people regarding the side effects of the second booster shot. As a result, the average number of persons who have already received two priming doses varies considerably within the country for the acceptance of booster doses. This study revealed that second booster dose willingness was influenced by several factors, primarily categorized into three main groups: demographic factors (e.g., education, medical illness), psychological factors (e.g., confidence) and vaccine-specific factors (e.g., booster safety, side effects). Our findings shed new light on the complex determinants of COVID-19 second booster vaccine acceptance, revealing an intricate interplay between underlying health conditions, confidence, vaccine safety, and educational differences. COVID-19 is at higher risk of death in individuals with chronic conditions such as cancer, kidney disease, lung disease, diabetes, dementia, obesity, or heart disease [ 26 ]. People who have chronic medical illnesses are more likely to accept the COVID-19 second booster vaccine than those who do not have any medical problems. This might be because those who have medical illness might fear the severity of the SARS-CoV-2 infection since evidence supports that people with chronic medical illness are more vulnerable to the infection and the infection is more severe with people with underlying medical illness [ 27 ]. This is likely because individuals with chronic illnesses are at a higher risk of severe complications from SARS-CoV-2, making the booster vaccine a crucial protective measure. They are often more aware of the potential health risks posed by the virus and are motivated to reduce their vulnerability. Furthermore, chronic medical illness might decrease host immunity and thereby increase the risk of COVID-19 associated morbidity and mortality [ 28 ]. In China, a study examined the mental readiness of non-communicable chronic disease patients (18–59 years old) to accept the COVID-19 vaccine and found an acceptance rate of about 80.0% [ 29 ]. Another study in the same country found 70.6% vaccination willingness of patients with chronic diseases toward COVID-19 vaccines [ 30 ]. A recent study reported that a second booster dose was more likely to be accepted by patients who had combined chronic diseases [ 31 ]. Respondents who had higher secondary and above education are more likely to accept COVID-19 second booster vaccine. Social determinants like education have a strong association with COVID-19 vaccine willingness among people with underlying health conditions [ 32 ]. The importance of vaccines and their safety and efficacy were more concerned with people with a higher level of education. Those with low education were less willing to get the COVID-19 booster vaccine [ 33 ] and education level influenced how well people received the SARS-CoV-2 vaccine [ 34 ]. The people with higher secondary education and above may be able to get enough information about the booster vaccine and the disease through reading different sources and learning. Psychological antecedents accounted for the greatest variance in second booster vaccine acceptance, with perceived side effects in the booster vaccine and equal safety emerging as the most robust and significant factor. Concerns about vaccine safety and post-vaccination side effects were on the top of reasons for hesitancy or refusal of vaccines. Individuals who were confident about the safety of a second COVID-19 booster were more likely to accept it compared to those who were not. Skepticism about vaccine safety was a common reason for individuals not intending to pursue a primer vaccination against COVID-19. There was a significant difference in perceived side effects of second booster vaccination among the general people. The perception of potential harms associated with the vaccine also acts as a barrier to vaccine uptake. The willingness to receive priming vaccine was decreased by 5% when perceived potential harms for COVID-19 increased by one unit [ 35 ]. There has been growing evidence that fear of adverse effects increases vaccine hesitancy, and this concern was also predominant for booster doses in Asian areas [ 36 ]. Perceived side effects were identified as a barrier of COVID-19 primer vaccination drive in Bangladesh [ 37 ] and other nations [ 38 ]. These findings are consistent with our results. Respondents who have strong trust in the booster vaccine effectiveness are higher odds of accepting the second booster vaccine. It might be justifiable for those who have strong confidence and trust that the vaccine is safe to take it without fear of side effects. It aligns with the emphasis on trust in numerous previous studies, suggesting that enhancing public acceptance of vaccines could begin with bolstering trust and confidence [ 39 ]. Public health authorities can build trust on booster vaccine’s information to develop intentional messaging for the public. Acceptance was more likely to be influenced by confidence in the COVID-19 vaccine and feelings of hope from the booster than prior vaccination history [ 40 ]. This study mist addresses a few limitations, and the first being an insufficient sample size. The representativeness of the sample is small, as the study was conducted in only five districts within the Khulna Division. This limits the generalizability of the findings nationwide and may introduce selection bias. Moreover, certain population groups such as pregnant women and individuals with disabilities were excluded, potentially restricting the scope of the conclusions. Several health behavior theories have been applied to understand the complex phenomenon of vaccine hesitancy and a lack of theoretical grounding weakens the interpretability and generalizability of the findings. In addition, recall bias, selection bias, measurement bias, and social desirability bias were major limitations in interpreting the results of the study. Added value For the first time, this study assessed second COVID-19 booster vaccination willingness among the general people of southern Bangladesh using a multivariate framework, simultaneously assessing a variety of socio-demographic predictors to focus insight into their relative importance, such as gender, education, marital status, and age. We found low level of confidence in the second COVID-19 booster vaccination. Less than 50% of southern polls who were administered priming COVID-19 vaccines were confident about the booster vaccine therapy. The results of binary regression analysis and prior studies indicated that young people and those with lower education level are less likely to trust the second booster vaccine. Furthermore, unmarried person and co-morbid people were more likely than others to be vaccinated with booster dose-a finding that had been masked by different vaccine hesitancy measurements in previous studies. Using a binary logistic regression framework for inference, we quantified the link between COVID-19 second booster vaccine confidence and actual uptake, as well as the effects of socio-psychological and trust-related factors on booster vaccine confidence. Public willingness in the second COVID-19 booster vaccine uptake was associated with several multi-dimensional predictors, including equal safety, trust in healthcare facilities, booster effectiveness, and community care. Public health policy implications Second COVID-19 booster vaccine willingness among the people of the Southern region in Bangladesh indicated that a significant portion of them were still hesitant to receive it. It appears that public health campaigns aimed at boosting vaccine confidence are most effective among people who were underlying health, unmarried, and less educated. This study also demonstrates the importance of enhancing vaccine confidence and reducing side effects related misinformation to increase second booster vaccine confidence throughout the country. A country-specific approach to addressing vaccine hesitancy is also warranted, given the differences in individual drivers' effects on booster vaccine sentiments. Monitoring trends in adult people's perceptions of booster vaccines in real-time enables health policymakers and other stakeholders to develop and adjust strategies for enhancing second booster immunization and reducing the burden of future infectious diseases. The effectiveness of the booster vaccination program depends on continuous monitoring of confidence in the COVID-19 booster vaccine and its associated factors, as well as evaluating and adjusting the booster vaccination program. Conclusions The SARS-CoV-2 strain and waning immunity have recently prompted a second booster shot recommendation. Findings of this study indicated that less than half of respondents across all demographic groups were willing to accept a second COVID-19 booster vaccine, while educational status, pre-existing medical illness, vaccine confidence, booster safety, and perceived side effects were independent predictors of second vaccine acceptance. Due to the COVID-19 pandemic, informed decision-making is more important than ever, especially in regards to booster vaccines. People need to be informed of their continuing risks of infection, booster vaccines’ data, and encouraged to take advantage of boosters through positive, particularly optimistic emotions. The study findings explicitly linked to public health policy implications, particularly regarding health communication, institutional trust, and regional vaccine outreach strategies. Public health surveillance and regionalized health education intervention, building public trust in the booster vaccine, and improving the booster vaccine's safety all contribute to increasing the booster vaccine's acceptability among vulnerable groups. Future research should explore the long-term effectiveness of such interventions and address barriers like vaccine accessibility, misinformation, and logistical challenges in delivering booster doses to remote areas and people with underlying health. These steps are vital for improving booster vaccine uptake and ensuring broader protection against COVID-19 in the region. Abbreviations COVID-19 Coronavirus disease-2019 SARS-CoV-2 Severe Acute Respiratory Syndrome Coronavirus-2 mRNA messenger Ribo Nucleic Acid CDC Centers for disease control and prevention SAGE Strategic Advisory Group of Experts on Immunization H1N1 The influenza type-A virus WHO World Health Organization FDA Food and Drug Administration SD Standard Deviation CI Confidance Interval aOR Adjusted Odds Ratio Declarations Competing interests The authors declare that they have no competing interests. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Ethical approval : Approved as exempt. Consent for publication Not applicable Funding The author(s) received no specific funding for this work. Author Contribution D.N.R. conducted the field investigation, performed the experiments and drafted the manuscript. A.A. was responsible for formal data analysis and interpretation. M.R. assisted with data entry. M.S.P. contributed to statistical analysis, methodology design and data visualization. M.E.I. supervised the overall project administration, provided resources and led the conceptualization of the study. All authors reviewed and approved the final manuscript. Data Availability Full data for this research is available through the corresponding author up on request References Moreno-Eutimio, M. A., Lopez-Macias, C. & Pastelin-Palacios, R. Bioinformatic analysis and identification of single-stranded RNA sequences recognized by TLR7/8 in the SARS-CoV-2, SARS-CoV, and MERS-CoV genomes. Microbes Infect. 22 (4–5), 226–229 (2020). Clark, A. et al. Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study. Lancet Global Health . 8 (8), e1003–e1017 (2020). Ahmad, F. B. Provisional mortality data—united states, 2020. MMWR. Morbidity and Mortality Weekly Report, 70. (2021). Andre, F. E. et al. 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Factors related to preventive COVID-19 infection behaviors among people with mental illness. J. Formos. Med. Assoc. 119 (12), 1772–1780 (2020). Bajaj, V. et al. Aging, immunity, and COVID-19: how age influences the host immune response to coronavirus infections? Front. Physiol. 11 , 571416 (2021). Wang, J. et al. Willingness to accept COVID-19 vaccine among the elderly and the chronic disease population in China 17p. 4873–4888 (Human vaccines & immunotherapeutics, 2021). 12. Jiang, N. et al. Acceptance of COVID-19 vaccines in patients with chronic diseases: A cross‐sectional study. J. Clin. Nurs. 31 (21–22), 3286–3300 (2022). Li, M. et al. Effect of chronic diseases on willingness to receive the second COVID-19 vaccine booster dose among cancer patients: A multicenter cross-sectional survey in China. Am. J. Infect. Control . 52 (5), 533–540 (2024). Bulusu, A., Segarra, C. & Khayat, L. Analysis of COVID-19 vaccine uptake among people with underlying chronic conditions in 2022: a cross-sectional study. SSM-Population Health . 22 , 101422 (2023). Noh, Y. et al. Predictors of COVID-19 booster vaccine hesitancy among fully vaccinated adults in Korea: a nationwide cross-sectional survey . Epidemiol. health , 44. (2022). Lupu, D. & Tiganasu, R. Does education influence COVID-19 vaccination? A global view . Heliyon , 10 (3). (2024). Ruiz, J. B. & Bell, R. A. Predictors of intention to vaccinate against COVID-19: Results of a nationwide survey. Vaccine 39 (7), 1080–1086 (2021). Wong, L. P. et al. Intention to receive a COVID-19 vaccine booster dose and associated factors in Malaysia 18p. 2078634 (Human vaccines & immunotherapeutics, 2022). 5. Haque, M. M. A. et al. Acceptance of COVID-19 vaccine and its determinants: evidence from a large sample study in Bangladesh . Heliyon , 7 (6). (2021). Mori, Y. et al. Pre-impressions of the third COVID-19 vaccination among medical staff: a text mining-based survey. Vaccines 10 (6), 856 (2022). Wirawan, G. B. S. et al. Health beliefs and socioeconomic determinants of COVID-19 booster vaccine acceptance: An Indonesian cross-sectional study. Vaccines 10 (5), 724 (2022). Lin, C. et al. Changes in confidence, feelings, and perceived necessity concerning COVID-19 booster. Vaccines 11 (7), 1244 (2023). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6796973","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":493109624,"identity":"26974455-5015-41ec-bec9-2f123f93a1bc","order_by":0,"name":"Debendra Nath Roy","email":"","orcid":"","institution":"Jashore University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Debendra","middleName":"Nath","lastName":"Roy","suffix":""},{"id":493109627,"identity":"42b46e62-c9af-4b5b-8956-70a5a26ebc81","order_by":1,"name":"Asma Aktar","email":"","orcid":"","institution":"Jashore University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Asma","middleName":"","lastName":"Aktar","suffix":""},{"id":493109628,"identity":"66967c66-ac82-42f9-9bd7-59a91155687b","order_by":2,"name":"Mamunur Rashid","email":"","orcid":"","institution":"University of Rajshahi","correspondingAuthor":false,"prefix":"","firstName":"Mamunur","middleName":"","lastName":"Rashid","suffix":""},{"id":493109629,"identity":"64afe675-4000-4b42-9f03-14afbd6b3fb3","order_by":3,"name":"Shahnaj Parvin","email":"","orcid":"","institution":"University of Rajshahi","correspondingAuthor":false,"prefix":"","firstName":"Shahnaj","middleName":"","lastName":"Parvin","suffix":""},{"id":493109630,"identity":"7ac424f7-01e3-4595-ba4d-71b3815ba583","order_by":4,"name":"Ekramul Islam","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAp0lEQVRIiWNgGAWjYDACHhBRAWEzM7ARreUMyVoY20jRws9z9uGnm/PuJTawH37AXFBGhBbJ3nZj6dxtxYkNPGkGzDPOEaHF4DwbA1BLQmIDQw4DM28bEVrsz7Mx/86dA9TC/4ZILQa8bWzSuQ1ALRLE2iJx5hibdc6xBOM2iWcGh4nyC39PGvPtnJoE2X7+5IePiQoxOADFyAFSNIyCUTAKRsEowAMA18IubVn0v3oAAAAASUVORK5CYII=","orcid":"","institution":"University of Rajshahi","correspondingAuthor":true,"prefix":"","firstName":"Ekramul","middleName":"","lastName":"Islam","suffix":""}],"badges":[],"createdAt":"2025-06-01 17:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6796973/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6796973/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88135331,"identity":"82f8890b-c17c-496e-b2d9-d5c09bbb09a1","added_by":"auto","created_at":"2025-08-01 21:37:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":12570,"visible":true,"origin":"","legend":"\u003cp\u003ePublic response to the second COVID-19 booster vaccine\u003c/p\u003e","description":"","filename":"Onlinefloatimage12.png","url":"https://assets-eu.researchsquare.com/files/rs-6796973/v1/5fb5e406f7e66ccf80142f42.png"},{"id":88855574,"identity":"9ebc4e06-e44b-4111-a43b-20de540cafb2","added_by":"auto","created_at":"2025-08-12 06:31:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1111672,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6796973/v1/787d132f-85d1-4c31-aa62-dc0635f2ff81.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Public response to the second COVID-19 booster vaccination in Bangladesh: exploring the intersection of health status, education, and vaccine acceptance","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe rapid spread of Coronavirus disease-19 (COVID-19) has underscored the therapeutic potential of mass vaccinations in protecting global health. COVID-19 infection, caused by SARS-CoV-2, leads to severe acute respiratory syndrome among human beings. As with SARS and MERS viruses, SARS-CoV-2, a novel Coronavirus, is a positive sense single-stranded RNA (+\u0026thinsp;ssRNA) virus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. SARS-CoV-2 is extremely contagious and spreads rapidly throughout the global population, affecting people of all ages and health conditions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While everyone is vulnerable to COVID-19 infection, older adults and those with comorbid conditions are most at risk. The available data, however, indicate that older people and those with underlying health conditions are more likely to be infected with COVID-19 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Vaccines are effective interventions that can reduce the high burden of infectious diseases, disability, death, and inequality worldwide [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Infections, hospitalizations, and mortality from COVID-19 can be reduced using mRNA vaccines. It has been shown that mRNA vaccines significantly reduce the incidence of severe diseases during the delta and omicron waves with minimal risk of adverse events [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe COVID-19 vaccine priming doses were administered daily to over 40\u0026nbsp;million people worldwide, with a small proportion administered to people in low-income countries. Vaccination against SARS-CoV-2 provides hope for an end to the pandemic if all countries have equal access and optimal uptake [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. With the spread of COVID-19, new variants of the virus are expected as the virus changes. However, studies have shown a decline in primer vaccine effectiveness over time and an increase in hospitalization rates following breakthrough infections among immunocompromised and comorbid patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Vaccine effectiveness against severe SARS-CoV-2 infections among New Yorkers has declined from 91.7\u0026ndash;79.8%, according to another study. This study, however, also found that the vaccine remains highly effective against hospitalizations [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eVaccine-induced immunity has maintained high effectiveness against severe SARS-CoV-2 cases. With the emergence of highly transmissible variants with greater potency to trigger breakthrough infections, a significant decrease in protection against new SARS-CoV-2 infection has been noted [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There is, however, the possibility that variants such as B.1.617.2 could induce similar viral loads in fully vaccinated and unvaccinated individuals within the first five days of infection [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The eventual need for a second COVID-19 booster vaccine dose has been discussed extensively, primarily in light of concerns about possible waning immunity, the transmission of breakthrough infections, and the emergence of new viral variants that are more transmissible [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. An analysis of 30 published studies suggests that the third dose of COVID-19 vaccine reduced infection risk by 88\u0026ndash;92% and converted immunoglobulin-G by 95 to 100% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Several countries have adopted a COVID-19 booster vaccine in response to new variants of SARS-CoV-2 (Delta and Omicron), and early evidence from the vaccine booster supports its efficacy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Globally, several studies examined the willingness of the general public to receive a first COVID-19 booster dose and reported varying acceptance rates across the continents. Public acceptance of the first booster was associated with a number of multidimensional factors, including equal safety, repeated immunity, the arrival of new variants, efficacy, and community protection, whereas booster hesitancy was correlated with adverse side effects after priming COVID-19 vaccinations and concerns about serious side effects after booster doses [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eVaccine hesitancy is a growing concern in public health [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], presenting a significant obstacle to achieving widespread vaccination coverage and herd immunity. A similar phenomenon was observed during the COVID-19 pandemic [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Booster dose hesitance and public acceptance of a second booster dose will, at some point, play a role in determining the public health response to the pandemic. Booster vaccination, however, produces broad but incomplete immunity against SARS-CoV-2 variants, including the Delta variant. Real-world evidence indicates that first booster doses have waned over time against new COVID-19 variants and hospitalization, especially for the Delta strain of COVID-19 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the fact that the third dose of a COVID-19 vaccine is safe and immunogenic [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], studies focusing on the second booster dose are scarce [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. While a first booster is recommended for most adults, a second booster is particularly important for older adults, immunocompromised individuals, and other high-risk groups to enhance their protection against severe COVID-19. Bangladeshi people have yet to accept a fourth COVID-19 vaccine dose; assessing the public response to the second COVID-19 booster vaccine was thus a potential; no literature is available on this topic. This study contributes region-specific evidence and incorporates a conceptual understanding of vaccine confidence and public trust to assess the complex interplay of individual, social, and systemic factors affecting second booster uptake among the people in southern Bangladesh.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003e A face-to-face survey was conducted from April 01 to May 31, 2024, during the spread of the SARS-CoV-2 Omicron variant across the country, following the STROBE guidelines. The study was conducted at Khulna divisional region, a coastal region with a diverse landscape, including urban areas, agricultural lands, and the Sundarbans mangrove forest, a UNESCO World Heritage Site. In this Division, urban and rural areas combine, with Khulna city being the most populous urban center. As of the 2022 census, Khulna division has an estimated 18.03\u0026nbsp;million people, while the urban areas have around 5.22\u0026nbsp;million people. Ten districts make up Khulna Division and we defined district towns as urban areas, upozilla towns as sub-urban areas, and all other as rural areas. The study involved human subjects, thus following the Declaration of Helsinki [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The experimental protocol was evaluated by the institutional review committee (IRC) as part of the approval process for the project. Since no clinical intervention was involved, the IRC approved this study as exempt. However, the reference number of ethical clearance certificate was JUST-BIO-PHA-02052023.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eParticipants in this study were aged 18 years and older who lived in the area for at least six months before the survey and agreed to provide data on consequences of COVID-19 booster vaccination. Informed consent was obtained from all the participants. Individuals who refused informed consent, pregnant or lactating women, those with any mental or physical disability (accompanied by a caretaker), and unvaccinated people were excluded from the study. Eleven trained enumerators were appointed for data collection and they visited 708 adult respondents, 71 of whom declined to provide consent, 21 who refused to contribute due to time constraints and 12 who were not vaccinated with primer doses. The survey responses were guaranteed to be confidential, and all survey participants were informed about the uses and anonymization of the data. No financial or in-kind rewards were given to survey participants, and no external funding was provided.\u003c/p\u003e\n\u003ch3\u003eSample size determination\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated by using the single population proportion formula\u003c/p\u003e\u003cp\u003en= (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eZ α/2)\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2\u003c/span\u003e\u003c/sup\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ep (1-p)\u003c/span\u003e/d\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;sample size\u003c/p\u003e\u003cp\u003ez\u0026thinsp;=\u0026thinsp;is the standard value corresponding to the desired level of confidence and Confidence interval of 95% is assumed (Zα/2\u0026thinsp;=\u0026thinsp;1.96)\u003c/p\u003e\u003cp\u003ed\u0026thinsp;=\u0026thinsp;margin of error (5%)\u003c/p\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;is the estimated proportion of an attribute that is present in the population. We considered a non-response rate of 10% and design effect 1.5 during the adjustment of final sample size of 550 plus.\u003c/p\u003e\n\u003ch3\u003eSampling Procedure\u003c/h3\u003e\n\u003cp\u003eA multistage sampling method was used to reach the study unit. Khulna division has a total of ten district cities and a metropolitan city. Three of these ten cities were selected by the lottery method, followed by simple random sampling of sub-cities within each city, and finally, systematic sampling of rural participants within each sub-city.\u003c/p\u003e\n\u003ch3\u003eMeasures and instruments\u003c/h3\u003e\n\u003cp\u003eThe questionnaire items were adopted from a theoretical analysis of the relevant literature on the topic in regional and global settings [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The questionnaire consisted three sections: socio-demographic overview, medical illness, and booster vaccine-specific characteristics. The questionnaire was originally developed in English and translated into Bengali (local language) with the assistance of a national public health expert. An independent translator translated the questionnaire from English to Bangla and back again to establish validity. In general, the questionnaire took 15\u0026ndash;20 minutes to complete all sections.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eValidity and reliability of the instrument\u003c/h2\u003e\u003cp\u003eTheoretical analysis and a comprehensive review of relevant literature were conducted to ensure the accuracy of the measurements. A panel of public health experts content-validated and face-validated the questionnaire items, ensuring relevance and clarity. The questionnaire was primarily analyzed with 20 non-selected participants in order to ensure its clarity, wording, and to make sure that none of the questions were difficult to understand and the results of the pilot test were later excluded. An evaluation of the psychometric properties of the survey consenting was conducted in order to determine if the questions effectively captured the topic. The reliability of the measurements was confirmed using Cronbach's alpha value estimated at 0.81, which was considered coherent for confirming its internal consistency [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eThe study described variables\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eDependent variable\u003c/strong\u003e\u003cp\u003eWillingness to accept a second COVID-19 booster vaccine.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eIndependent/ predictor variables\u003c/strong\u003e\u003cp\u003eAge, Sex, Marital status, Educational levels, COVID-19 positive experience, Medical illness, Residence, Booster effectiveness, Trust in public health systems, Stronger vaccine confidence, Positive attitude towards a COVID-19 booster vaccine, Equal vaccine safety, Perceived risk of being further infection, Perceived booster side effects. A conceptual analysis of recent reviews led to the selection of variables based on a theoretical investigation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eOperational definitions\u003c/h3\u003e\n\u003cp\u003eWillingness of COVID-19 booster vaccine acceptance: Those who were volunteer to uptake a second COVID-19 booster vaccine\u003c/p\u003e\u003cp\u003eUnwillingness of COVID-19 booster vaccine acceptance: Those who were refused to receive a second COVID-19 booster vaccine\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eAn in-person interview approach was used to collect Data from the respondents. A multistage sampling method was used to reach the study unit. Khulna division has a total of ten districts cities and a metropolitan city. The lottery method was used to select five district cities from the Khulna division and three sub-district cities, and then stratified random sampling was used to sample sub-cities within each city, and finally, systematic sampling was used within the sub-cities to reach remote participants. Five teams with one female and one male trained member each conducted interviews and recorded the responses on paper-based questionnaires. Male and female enumerators interviewed the male and female respondents, respectively. At the beginning of the conversation, it was explained to the participants how the study would be conducted, how long it would take, and the benefit it would provide. The research supervisor assured the quality of the data collection process. Participants consented to the researchers using their anonymous data for academic purposes by completing the questionnaire and submitting it to them. The face-to-face interview confirmed a direct interpersonal interaction between the interviewer and the interviewee, and this approach is more likely to elicit complete or formulate the interviewee, whereas incomplete data submissions were rejected.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eData quality control\u003c/h2\u003e\u003cp\u003eThe questionnaire was pre-tested before it was modified to ensure the quality of the data. Data collectors and supervisors were trained for one day on the objectives, relevance, confidentiality, respondent's rights, informed consent, and interview techniques. All questionnaires were checked for completeness, missing values, and unlikely responses. Incomplete questionnaires were excluded. The principal investigator and supervisors were made spot-checking and reviewing the filled questionnaire to ensure completeness and consistency of the information.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe collected data were checked visually for its completeness and the responses were coded and entered into the computer using Excel version-10. Then data were exported to windows of Statistical Package for Social Science (SPSS) version 25 for data analysis. During the process of analysis, descriptive statistics were used to provide an overall and coherent presentation and description of the data. Binary logistic regression analysis was employed to see the crude significant relation of each independent variable to the dependent variables. Assumption tests for binary regression analysis were evaluated and assessed for multicollinearity within the regression model used. Odds ratio with 95% CI was performed on variables to determine the strength of association of variables. \u003cem\u003eP\u003c/em\u003e-value less than or equal to 0.05 was taken as a cut-off value to be significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eSocio-demographic characteristics of the participants\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays socio-demographic characteristics of the study participants. Out of the total 708 visited individuals, 604 of them were included in the final analysis giving a response rate of 85.3%. The mean age of the respondent was 41.57 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;12.622) years. The majority 177 (29.3%) of the respondents was between 18 and 28 years old, followed by the age group 29\u0026thinsp;\u0026minus;\u0026thinsp;38, 148 (24.5%). The largest portions of the participants have primary level education 179 (29.6%), followed by higher secondary and above 175 (29.0%). Housekeepers accounted for the highest percentage (33.6%), followed by farmers or day laborers with 30.6%, and employees with different professions with 109 (18.0%). Male participants were 328 (54.3%) and female were 276 (45.7%). Regarding marital status majority of respondent 356 (58.9%) were currently married, and 478 (79.1%) were Muslim by religion. Minor fractions of participants had a COVID-19 positive history and the majority of participants 482 (79.8%) received the first COVID-19 booster dose. The pooled acceptance of a second COVID-19 booster was 267 (44.2%) and the pooled hesitance was 337 (55.8%) among the study peoples.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of the study participants, by socio demographic characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;28 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e177\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u0026ndash;38 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u0026ndash;48 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49\u0026ndash;58 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 Years and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e328\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e276\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e356\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced/ widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eReligion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMuslim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e478\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHindu\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEducational status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHave no formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e179\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e113\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigher secondary and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eOccupations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e109\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eBusiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eFarmer/day labors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e184\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eHousekeeper\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e203\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eExposure to COVID-19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e368\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNot willing to tell\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eReceived 1st booster\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e482\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSecond booster\u003c/p\u003e\u003cp\u003eAcceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e267\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eUnsure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e204\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMedical and vaccine related variables\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows descriptive results of medical and vaccine related characteristics of respondents. In this study, 229 (37.9%) reported an underlying health illness, and 315 (52.2%) expressed trust in public health systems. More than half of the people had positive attitudes towards booster shots 308 (51.0%), strong vaccination confidence 321 (53.1%), and belief that booster shots are safe 324 (53.6%) and effective 329 (54.5%) against SARS-CoV-2. The majority of the participants 421(69.7%) was concerned about the possibility of becoming infected with SARS-CoV-2 in the future and confirmed that booster doses were crucial. Nevertheless, a significant portion of people 357 (59.1%) were worried about vaccine induced side effects (58.3% had mild symptoms, 28.8% had moderate symptoms, and 12.9% had severe symptoms) after receiving a first booster shot.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMedical and vaccine related characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFrequency\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eMedical illness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e375\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eBooster vaccine effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e45.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eTrust in public health systems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e315\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e52.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e47.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eStronger booster vaccine confidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e321\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e53.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e283\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003ePositive attitude towards a booster vaccine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e308\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e296\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eBelieved that booster vaccines are generally as safe as primer doses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e324\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e53.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e280\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003ePerceived risk of being further infected with covid-19 in the future\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e421\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eFear of booster side effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e357\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e59.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eHow severe were your side effects symptoms? (N\u0026thinsp;=\u0026thinsp;357)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild Symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate symptoms and sought help from a doctor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere symptoms and was hospitalized\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eResponse to the second COVID-19 booster vaccine\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates public response to the second COVID-19 booster vaccine in Khulna divisional region, Bangladesh. In this study, 42.2% (95% CI: 42.1\u0026thinsp;\u0026minus;\u0026thinsp;46.3) respondents were ready to accept a second COVID-19 booster vaccine anytime, 22.0% were unsure, and 33.8% respondents were not willing to accept a second COVID-19 booster vaccine (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003ePotential factors associated with the second COVID-19 booster vaccine responses\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the results of binary logistic regression analysis. The acceptance of a second COVID-19 booster vaccine was significantly influenced by several multicultural factors. Respondents with higher secondary and above education were 3.6 times more likely to accept a second COVID-19 booster vaccine (AOR\u0026thinsp;=\u0026thinsp;3.6, 95% CI: 1.89\u0026thinsp;\u0026minus;\u0026thinsp;5.96, p\u0026thinsp;=\u0026thinsp;0.001) compared to those respondents who have no formal education. The likelihood of receiving a second booster dose was 1.7 times higher among urban than rural residents (AOR\u0026thinsp;=\u0026thinsp;1.7, 95% CI: 0.93\u0026thinsp;\u0026minus;\u0026thinsp;3.64, p\u0026thinsp;=\u0026thinsp;0.041). Respondents with medical illness were 3.2 times more likely to accept a second COVID-19 booster vaccine (AOR\u0026thinsp;=\u0026thinsp;3.2, 95% CI: 1.58\u0026thinsp;\u0026minus;\u0026thinsp;5.43, p\u0026thinsp;=\u0026thinsp;0.003) compared to their counter parts and respondents who have strong vaccine confidence were around 4 times more likely to accept a booster shot (AOR\u0026thinsp;=\u0026thinsp;3.9, 95% CI: 1.93\u0026thinsp;\u0026minus;\u0026thinsp;5.77, p\u0026thinsp;=\u0026thinsp;0.001) compared to those respondents having poor vaccine confidence. People who believed that the booster dose was equally safe as the priming vaccination were 2.4 times more likely to accept it (AOR\u0026thinsp;=\u0026thinsp;2.48, 95% CI: 1.01\u0026thinsp;\u0026minus;\u0026thinsp;4.95, p\u0026thinsp;=\u0026thinsp;0.028). However, vaccinated individuals who experienced vaccine side effects during primer and/or 1st booster vaccination were 1.86 times less likely (hesitance) to receive a second COVID-19 booster dose (AOR\u0026thinsp;=\u0026thinsp;1.86, 95% CI: 0.89\u0026thinsp;\u0026minus;\u0026thinsp;4.81, p\u0026thinsp;=\u0026thinsp;0.037)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with willingness to accept a second COVID-19 booster vaccine\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eAcceptance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAOR (95%CI)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;28 Years\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (42.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e101(57.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u0026ndash;38 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66 (44.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82(55.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.98 (0.48\u0026thinsp;\u0026minus;\u0026thinsp;1.92)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u0026ndash;48 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (65.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (34.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.74 (0.76\u0026thinsp;\u0026minus;\u0026thinsp;3.94)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49\u0026ndash;58 Years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (72.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (27.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.236\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.85 (0.90\u0026thinsp;\u0026minus;\u0026thinsp;3.79)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 Years and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53 (76.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (23.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.094\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e138 (42.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e190 (57.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.352\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.63 (0.98\u0026thinsp;\u0026minus;\u0026thinsp;2.71\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e128 (46.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e148 (53.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71 (37.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e119 (62.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e291 (53.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e165(46.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.312\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.48 (2.34\u0026thinsp;\u0026minus;\u0026thinsp;0.97)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced/ widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (43.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (56.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.287\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.47 (0.15\u0026thinsp;\u0026minus;\u0026thinsp;1.42)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEducational levels\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo formal education\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (34.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90 (65.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71 (39.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e108 (60.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.447\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.241\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.45 (0.69\u0026thinsp;\u0026minus;\u0026thinsp;3.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (43.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64 (56.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.416\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.094\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigher secondary and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88 (50.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87 (49.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.491\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.6 (1.89\u0026thinsp;\u0026minus;\u0026thinsp;5.96)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCOVID-19 positive experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e134 (68.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62 (31.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83 (20.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e323 (79.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eResidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84 (36.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e129 (63.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSemi-urban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81 (46.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92 (53.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.421\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e118 (51.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e110 (48.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.7 (0.93\u0026thinsp;\u0026minus;\u0026thinsp;3.64)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMedical illness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e202 (88.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (11.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.2 (1.58\u0026thinsp;\u0026minus;\u0026thinsp;5.43)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87 (23.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e288 (76.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBooster vaccine effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e291 (88.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 (11.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.231\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.056\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 (20.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e220 (80.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTrust in public health systems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e185(58.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e130 (41.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.367\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.98 (0.59\u0026thinsp;\u0026minus;\u0026thinsp;1.65)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (14.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e247 (85.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVaccine confidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e294 (91.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (8.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.276\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.9 (1.93\u0026thinsp;\u0026minus;\u0026thinsp;5.77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e103 (36.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e180 (63.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePositive attitude towards booster vaccination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e215(69.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93 (30.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.402\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.068\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.2 (0.58\u0026thinsp;\u0026minus;\u0026thinsp;1.91)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57 (19.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e239 (80.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBooster safety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e269 (83.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55 (17.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.371\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.48 (1.01\u0026thinsp;\u0026minus;\u0026thinsp;4.95)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74 (26.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e206 (73.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePerceived risk of being further infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e311 (73.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e110 (26.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.279\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.219\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.75 (0.42\u0026thinsp;\u0026minus;\u0026thinsp;1.33)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e107 (58.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76 (41.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBooster side effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e241(67.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116 (32.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.276\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.86 (0.89\u0026thinsp;\u0026minus;\u0026thinsp;4.81)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003csup\u003e(r)\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e143 (62.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86 (37.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003enote\u003c/em\u003e: \u003csup\u003e\u003cem\u003e(r)\u003c/em\u003e\u003c/sup\u003e \u003cem\u003eindicates reference category\u003c/em\u003e, β\u0026thinsp;\u003cem\u003e=\u0026thinsp;Beta coefficient, AOR\u0026thinsp;=\u0026thinsp;Adjusted odds ratio, CI\u0026thinsp;=\u0026thinsp;Confidence Interval\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eVaccination has long been a protocol for preventing and limiting infectious diseases globally, including COVID-19 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In Bangladesh, the COVID-19 vaccination campaign has made notable strides, with millions of people receiving the initial doses, including a gradual roll-out of booster doses starting in late 2021. Due to the waning immunity from COVID-19 priming vaccines and the first booster, we conducted this study to evaluate public response to the second booster in Southern Bangladesh. In this study, 44.2% (95% CI: 54.2%, 62.5%) of respondents were willing to accept a second booster dose against COVID-19. A Greek study found that 62% of respondents were willing to receive vaccinations, 25.8% were unsure, and 12.3% were unwilling to receive a second booster vaccination [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. According to healthcare participants who had not received the second COVID-19 booster dose in Italy, 52.6% showed a willingness to receive it, while 25.1% and 22.3% indicated that they had \"no intention\" or showed \"uncertainty\" [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This might be the difference in socio-demographic characteristics of respondents, like difference in educational status, age, occupation, and also differences in study period and the time during the pandemic when the studies were conducted. Studies conducted in the early stages when booster shots were poorly understood may differ from those conducted later when booster shots were better understood. Additionally, as time passes, more knowledge is gained about the booster vaccine and disease prevalence, which can influence whether a country accepts a second booster vaccination. The first booster shot had caused widespread confusion among country people regarding the side effects of the second booster shot. As a result, the average number of persons who have already received two priming doses varies considerably within the country for the acceptance of booster doses.\u003c/p\u003e\u003cp\u003eThis study revealed that second booster dose willingness was influenced by several factors, primarily categorized into three main groups: demographic factors (e.g., education, medical illness), psychological factors (e.g., confidence) and vaccine-specific factors (e.g., booster safety, side effects). Our findings shed new light on the complex determinants of COVID-19 second booster vaccine acceptance, revealing an intricate interplay between underlying health conditions, confidence, vaccine safety, and educational differences. COVID-19 is at higher risk of death in individuals with chronic conditions such as cancer, kidney disease, lung disease, diabetes, dementia, obesity, or heart disease [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. People who have chronic medical illnesses are more likely to accept the COVID-19 second booster vaccine than those who do not have any medical problems. This might be because those who have medical illness might fear the severity of the SARS-CoV-2 infection since evidence supports that people with chronic medical illness are more vulnerable to the infection and the infection is more severe with people with underlying medical illness [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This is likely because individuals with chronic illnesses are at a higher risk of severe complications from SARS-CoV-2, making the booster vaccine a crucial protective measure. They are often more aware of the potential health risks posed by the virus and are motivated to reduce their vulnerability. Furthermore, chronic medical illness might decrease host immunity and thereby increase the risk of COVID-19 associated morbidity and mortality [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In China, a study examined the mental readiness of non-communicable chronic disease patients (18\u0026ndash;59 years old) to accept the COVID-19 vaccine and found an acceptance rate of about 80.0% [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Another study in the same country found 70.6% vaccination willingness of patients with chronic diseases toward COVID-19 vaccines [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A recent study reported that a second booster dose was more likely to be accepted by patients who had combined chronic diseases [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRespondents who had higher secondary and above education are more likely to accept COVID-19 second booster vaccine. Social determinants like education have a strong association with COVID-19 vaccine willingness among people with underlying health conditions [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The importance of vaccines and their safety and efficacy were more concerned with people with a higher level of education. Those with low education were less willing to get the COVID-19 booster vaccine [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and education level influenced how well people received the SARS-CoV-2 vaccine [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The people with higher secondary education and above may be able to get enough information about the booster vaccine and the disease through reading different sources and learning. Psychological antecedents accounted for the greatest variance in second booster vaccine acceptance, with perceived side effects in the booster vaccine and equal safety emerging as the most robust and significant factor. Concerns about vaccine safety and post-vaccination side effects were on the top of reasons for hesitancy or refusal of vaccines. Individuals who were confident about the safety of a second COVID-19 booster were more likely to accept it compared to those who were not. Skepticism about vaccine safety was a common reason for individuals not intending to pursue a primer vaccination against COVID-19. There was a significant difference in perceived side effects of second booster vaccination among the general people. The perception of potential harms associated with the vaccine also acts as a barrier to vaccine uptake. The willingness to receive priming vaccine was decreased by 5% when perceived potential harms for COVID-19 increased by one unit [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. There has been growing evidence that fear of adverse effects increases vaccine hesitancy, and this concern was also predominant for booster doses in Asian areas [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Perceived side effects were identified as a barrier of COVID-19 primer vaccination drive in Bangladesh [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and other nations [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. These findings are consistent with our results. Respondents who have strong trust in the booster vaccine effectiveness are higher odds of accepting the second booster vaccine. It might be justifiable for those who have strong confidence and trust that the vaccine is safe to take it without fear of side effects. It aligns with the emphasis on trust in numerous previous studies, suggesting that enhancing public acceptance of vaccines could begin with bolstering trust and confidence [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Public health authorities can build trust on booster vaccine\u0026rsquo;s information to develop intentional messaging for the public. Acceptance was more likely to be influenced by confidence in the COVID-19 vaccine and feelings of hope from the booster than prior vaccination history [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study mist addresses a few limitations, and the first being an insufficient sample size. The representativeness of the sample is small, as the study was conducted in only five districts within the Khulna Division. This limits the generalizability of the findings nationwide and may introduce selection bias. Moreover, certain population groups such as pregnant women and individuals with disabilities were excluded, potentially restricting the scope of the conclusions. Several health behavior theories have been applied to understand the complex phenomenon of vaccine hesitancy and a lack of theoretical grounding weakens the interpretability and generalizability of the findings. In addition, recall bias, selection bias, measurement bias, and social desirability bias were major limitations in interpreting the results of the study.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eAdded value\u003c/h2\u003e\u003cp\u003eFor the first time, this study assessed second COVID-19 booster vaccination willingness among the general people of southern Bangladesh using a multivariate framework, simultaneously assessing a variety of socio-demographic predictors to focus insight into their relative importance, such as gender, education, marital status, and age. We found low level of confidence in the second COVID-19 booster vaccination. Less than 50% of southern polls who were administered priming COVID-19 vaccines were confident about the booster vaccine therapy. The results of binary regression analysis and prior studies indicated that young people and those with lower education level are less likely to trust the second booster vaccine. Furthermore, unmarried person and co-morbid people were more likely than others to be vaccinated with booster dose-a finding that had been masked by different vaccine hesitancy measurements in previous studies. Using a binary logistic regression framework for inference, we quantified the link between COVID-19 second booster vaccine confidence and actual uptake, as well as the effects of socio-psychological and trust-related factors on booster vaccine confidence. Public willingness in the second COVID-19 booster vaccine uptake was associated with several multi-dimensional predictors, including equal safety, trust in healthcare facilities, booster effectiveness, and community care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003ePublic health policy implications\u003c/h2\u003e\u003cp\u003eSecond COVID-19 booster vaccine willingness among the people of the Southern region in Bangladesh indicated that a significant portion of them were still hesitant to receive it. It appears that public health campaigns aimed at boosting vaccine confidence are most effective among people who were underlying health, unmarried, and less educated. This study also demonstrates the importance of enhancing vaccine confidence and reducing side effects related misinformation to increase second booster vaccine confidence throughout the country. A country-specific approach to addressing vaccine hesitancy is also warranted, given the differences in individual drivers' effects on booster vaccine sentiments. Monitoring trends in adult people's perceptions of booster vaccines in real-time enables health policymakers and other stakeholders to develop and adjust strategies for enhancing second booster immunization and reducing the burden of future infectious diseases. The effectiveness of the booster vaccination program depends on continuous monitoring of confidence in the COVID-19 booster vaccine and its associated factors, as well as evaluating and adjusting the booster vaccination program.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe SARS-CoV-2 strain and waning immunity have recently prompted a second booster shot recommendation. Findings of this study indicated that less than half of respondents across all demographic groups were willing to accept a second COVID-19 booster vaccine, while educational status, pre-existing medical illness, vaccine confidence, booster safety, and perceived side effects were independent predictors of second vaccine acceptance. Due to the COVID-19 pandemic, informed decision-making is more important than ever, especially in regards to booster vaccines. People need to be informed of their continuing risks of infection, booster vaccines\u0026rsquo; data, and encouraged to take advantage of boosters through positive, particularly optimistic emotions. The study findings explicitly linked to public health policy implications, particularly regarding health communication, institutional trust, and regional vaccine outreach strategies. Public health surveillance and regionalized health education intervention, building public trust in the booster vaccine, and improving the booster vaccine's safety all contribute to increasing the booster vaccine's acceptability among vulnerable groups. Future research should explore the long-term effectiveness of such interventions and address barriers like vaccine accessibility, misinformation, and logistical challenges in delivering booster doses to remote areas and people with underlying health. These steps are vital for improving booster vaccine uptake and ensuring broader protection against COVID-19 in the region.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOVID-19\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCoronavirus disease-2019\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSARS-CoV-2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSevere Acute Respiratory Syndrome Coronavirus-2\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003emRNA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emessenger Ribo Nucleic Acid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCDC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCenters for disease control and prevention\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSAGE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStrategic Advisory Group of Experts on Immunization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eH1N1\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThe influenza type-A virus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFDA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFood and Drug Administration\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidance Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eaOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproved as exempt.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe author(s) received no specific funding for this work.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eD.N.R. conducted the field investigation, performed the experiments and drafted the manuscript. A.A. was responsible for formal data analysis and interpretation. M.R. assisted with data entry. M.S.P. contributed to statistical analysis, methodology design and data visualization. M.E.I. supervised the overall project administration, provided resources and led the conceptualization of the study. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eFull data for this research is available through the corresponding author up on request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMoreno-Eutimio, M. A., Lopez-Macias, C. \u0026amp; Pastelin-Palacios, R. 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Changes in confidence, feelings, and perceived necessity concerning COVID-19 booster. \u003cem\u003eVaccines\u003c/em\u003e \u003cb\u003e11\u003c/b\u003e (7), 1244 (2023).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, booster dose, underlying health, education, Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-6796973/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6796973/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe global transmission of SARS-CoV-2\u0026rsquo;s new variant led to a public health emergency, overwhelming healthcare systems and causing significant loss of life. Despite the therapeutic potential of priming vaccine doses, the waning immunity from COVID-19 vaccines and the first booster vaccination underscore the unprecedented importance of administering a second booster dose to protect public health. This study aimed to assess the willingness of general people in Southern Bangladesh to receive a second COVID-19 booster or a new vaccine and the factors influencing their acceptance. Using a validated paper-based semi-structured questionnaire, this cross-sectional study employed a face-to-face data collection approach from April 1 through May 31, 2024, during the nationwide spread of the SARS-CoV-2 Delta variant. Binary logistic regression analysis was used to explore the crude significance of each predictor variable to the dependent variable. The pooled willingness for a second COVID-19 booster was 44.2% (95% CI: 42.1\u0026thinsp;\u0026minus;\u0026thinsp;46.3) among respondents. Underlying health conditions (AOR\u0026thinsp;=\u0026thinsp;3.2, 95% CI: 1.58\u0026thinsp;\u0026minus;\u0026thinsp;5.43), education (AOR\u0026thinsp;=\u0026thinsp;3.6, 95% CI: 1.89\u0026thinsp;\u0026minus;\u0026thinsp;5.96), area of residence (AOR\u0026thinsp;=\u0026thinsp;1.7, 95% CI: 0.93\u0026thinsp;\u0026minus;\u0026thinsp;3.64), vaccine confidence (AOR\u0026thinsp;=\u0026thinsp;3.9, 95% CI: 1.93\u0026thinsp;\u0026minus;\u0026thinsp;5.77), and equal safety (AOR\u0026thinsp;=\u0026thinsp;2.48, 95% CI: 1.01\u0026thinsp;\u0026minus;\u0026thinsp;4.95) were significantly associated with acceptance of a second booster vaccine. In addition, this study found that perceived side effects (AOR\u0026thinsp;=\u0026thinsp;1.89, 95% CI: 0.89\u0026thinsp;\u0026minus;\u0026thinsp;4.81) were a barrier and a key reason for skepticism about a second COVID-19 booster dose. The second booster vaccine dose is particularly essential for older adults, immunocompromised individuals, and other high-risk groups. These findings indicated that less than half of respondents across all demographic groups were willing to accept a second COVID-19 booster vaccine, while medical illness, education, and confidence were three key predictors of second booster acceptance. This study highlights the need for regionalized education and trust-building efforts to address booster hesitancy, with implications for global public health efforts.\u003c/p\u003e","manuscriptTitle":"Public response to the second COVID-19 booster vaccination in Bangladesh: exploring the intersection of health status, education, and vaccine acceptance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 21:37:46","doi":"10.21203/rs.3.rs-6796973/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"81f98f02-fc6f-4f50-8036-fe9de807caf4","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":52361523,"name":"Health sciences/Health care"},{"id":52361524,"name":"Health sciences/Health occupations"}],"tags":[],"updatedAt":"2025-08-12T06:23:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-01 21:37:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6796973","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6796973","identity":"rs-6796973","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}