https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article Knowledge and Attitude of People about Vaccination of Corona Virus Disease in Erbil City ABSTRACT Background and Objective: Vaccine are an effective way to protect people against many infectious diseases. A variety of vaccines have been accepted against Coronavirus disease (Covid-19) and offered all over the world. Having a good level of knowledge and individual attitude regarding vaccination can have an impact on vaccinating against Covid-19. There- fore, the study aimed to investigate the knowledge and attitudes about Covid-19 vaccina- tions in Erbil City. Methods: Community-based cross-sectional study was conducted in different areas in Er- bil city. A non-probability (convenience) sample was selected for 400 participants from November 1, 2021 to November 1, 2022. The survey was conducted using a structured questionnaire containing informed consent along with three sections (socio-demographic, knowledge, and attitude). Data were analyzed by using descriptive statistics and Chi- squire to determine the level of knowledge and attitude regarding Covid-19 vaccination. Results: 60.8% of participants had an excellent knowledge regarding the Covid-19 vac- cine; education level, income status, and previously being infected with Covid-19 were significantly associated with a high level of knowledge. The majority (58.5%) of partici- pants had a positive attitude toward the Covid-19 vaccine. Having a history of Covid-19 and income status were significantly associated with a positive attitude regarding the Covid-19 vaccine. Conclusion: Despite the high level of knowledge and positive attitude regarding Covid-19 vaccination, there is still misunderstanding and hesitancy about the Covid-19 vaccine, the ministry of health must distribute and promote more health education and programs re- garding Covid-19 vaccination. Keywords: Knowledge; Attitude; Covid-19 Vaccine, Vaccination. Shivan Hamko Rasool; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq (Correspondence: shvanhawlere472@gmail.com) Ibrahum Hassan Mustafa; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq. 200 Received: 11/12/2022 Accepted: 08/02/2023 Published: 30/11/2024 Copyright ©2024The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. mailto:shvanhawlere472@gmail.com mailto:shvanhawlere472@gmail.com mailto:jawdat.baker@hmu.edu.krd?subject=jawdat.baker@hmu.edu.krd%20%20%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article In January 2020, WHO declared Covid-19 a worldwide health emergency, and on 11 March 2020, this disease was characterized as a pandemic [1]. It brought billions of people into a state of quarantine during national lockdowns, especially those with mental or physical health issues, and nega- tively affected a range of aspects of life [2]. Newly discovered Covid-19 spreads mostly through contact of respiratory droplets with mucus membranes. It was also found that the virus was able to transmit via di- rect contact with contaminated surfaces up to 5 days after incubation and that it could stay on materials for up to 5 days depending on the type of contaminated material [3]. According to epidemiological studies, SARS-CoV-2 incubation lasts be- tween 1-14 days, and the virus is also in- fectious in asymptomatic patients [4]. As a result of infection, some people expe- rience kidney failure, severe pneumonia, acute respiratory syndrome, and even death [5]. There is no approved therapeu- tic for treating SARS-CoV-2 infection at this time. Existing treatments usually target relieving symptoms or inhibiting the im- mune response. Existing drugs that are known to be effective against SARS-CoV-2, Ebola, and HIV infections are also being repurposed, but their use is being restrict- ed to patients with severe infections [6]. Various efforts are being made to suppress Covid-19's transmission rate. It involves the practice of social distancing in public to discourage close contact, followed by edu- cated hand washing to help destroy the lipid bilayer of the virus using soap, water, and 62–71% ethanol so that the virus will be less contagious. In addition to staying home, refraining from using public trans- portation, wearing masks, keeping a safe distance from people when in crowds, and avoiding areas with a high number of Covid -19 infections, various media outlets are socializing these actions [7].A vaccine is a life-saving invention that has played a crucial role in eliminating and controlling many infectious diseases all over the world [8]. Vaccination against Coronavirus is considered to be the ultimate solution to controlling this disease [9]. A vaccine with high effectiveness, a long period of protection, and low adverse reactions was easily accepted by the population [10].However, this study was conducted to assess the knowledge and attitude of people regarding Covid-19 vaccination. A community-based cross-sectional study was used to assess knowledge and attitude of people about Covid-19 vaccination in Erbil City during the period (1st November 2021 to 1st November 2022). A non- probability (convenience) sampling technique was used to collect the data; the sample size was 400 using EpiInfoTM version 7 StatCalc function of a population survey, with the assumption of a 95 % confidence interval, the margin of error was 5 % and the population proportion was 50%.A questionnaire was structured by researchers through a review of literature related to the subject. This questionnaire involved the following parts: Part I consisted of primary data about participants, including involved socio- demographic characteristics (age, sex, residential status, educational level, occupation, marital status and economic status), family size, number of bedrooms, having a chronic disease, source of knowledge regarding Covid-19 disease, history of Covid-19 disease, and history of death of a member of family due to Covid- 19 .Part II Was related to assessment of the knowledge of study participants regarding Covid-19 vaccinations, this part was composed of 12 201 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article the sum of knowledge assessment ques- tions were thought of as having a positive attitude. Both (males and females) aged 18 years and above were included in the study. The study proposal was formally ap- proved by scientific and ethical com- mittees in the College of Nursing/Hawler Medical University code number 97 on 7th October 2021. Prior to initiation of the pre- sent study, the approval from Erbil gover- norate was secured. And the permission was taken from each participant and they were informed and explained the purpose of the study and the confidentiality of the information. Data were prepared, orga- nized and entered into a computer file; the statistical package for social science (SPSS, Version 25) was used for data analysis to calculate the descriptive statistical analysis (frequency and percentage) and inferential statistical analysis was used to indicate the significance relationship between the par- ticipant’s demographical data (variable) with the level of knowledge and attitudes regarding preventive measures and Covid- 19 vaccination. A P-value is a statistically significant level of ≤ 0.05. The mean age (± SD) of participants was 32.23 ± 11.74. The male: female ratio was 0.96:1 Table 1 shows that the highest per- centage of the study sample was 38.5% aged 18-25, followed by nearly a quarter (24.7%) aged 26-33, and only 9.3% of the study were aged 50 and more. Table 1 also shows that the majority (89.2%) of the study sample was from urban areas. Re- garding educational level, the table shows that the highest percentage (58.3%), of the study sample graduated from institutes and colleges, followed by 26.2% who grad- uated from intermediate and secondary. The highest percentage of the sample (38.5%) was unemployed, followed by (26.3%) were unskilled manual workers, questions. Comprehensive knowledge of the Covid-19 vaccine was computed from summing up all relevant 12 knowledge- related positive and negative question in the form of “Yes” and “No” questions. Re- spondents were asked, “Vaccines are all designed to teach the body’s immune sys- tem to safely recognize and block the virus that causes the disease”. Respondents who respond “yes” will score 1 and “No” responses will earn zero scores. For a neg- ative question like (Only elders should vac- cinate themselves) the respondent who responds with No will score 1 and Yes will score 0. The correct answer for each item was scored “1” and the incorrect answer was scored “0.” The same pattern of ques- tioning and scoring was made for the rest of the 10 knowledge-related items. Ac- cordingly, respondents who scored less than 4 on the sum of knowledge assess- ment questions were thought to have poor knowledge, and respondents who scored 5 -8 on the sum of knowledge assessment questions were thought to have good knowledge. And respondents who scored above 8 on the sum of knowledge assess- ment questions were thought to have ex- cellent knowledge. Part III: Was related to assessing the attitudes of participants about vaccinations of Covid-19.The atti- tude of Covid-19 vaccine was computed from summing up all relevant six attitude- related ‘Agree, “Not certain and disagree” questions. Respondents were asked, “It is necessary to encourage your relatives to get vaccine”. Respondents who responded “agree” will score 2 and Not certain will score 1, and a disagree response will earn zero scores. The same pattern of question- ing and scoring was made for the rest of the five attitude-related items. According- ly, respondents who scored 1-6 value of the sum of attitude-related questions were thought of as having a negative attitude, and respondents who scored 7-12 value of 202 Copyright ©2024The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULT https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article and only (3%) were retired. The same table shows that (58%) of the sample were mar- ried and only 3(0.7%) of the sample were divorced, as shown in table 1. Table 1 also illustrated that close to two-third (66.5%) of the sample have enough income to meet their daily needs, followed by (19.5%) have enough income for daily needs. Re- garding family size, results show that the highest percentage (54.8%) of the sample was families consisting of 4 to 6 members, followed by close to a quarter (24.7%) of families with 7 to 9 members. Table 1 Shows that the majority (78.5%) of the sample live in houses with 1 to 3 bed- rooms, followed by (20.2%) with 4 to 6 bedrooms in their houses. The table shows that the majority (76.5%) of the sample owned houses, and (21.3%) were rented. Considering car ownership, results show that (77.2%) of the study sample owned a car. 203 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Distribution study sample according Socio-demographic characteristics. Variables F (%) Age 18-25 154 (38.5) 26-33 99 (24.7) 34-41 65 (16.3) 42-49 45 (11.2) 50 and above Total 37 (9.3) 400(100) Sex Male 196 (49.0) Female 204(51.0) Total 400 (100) Residence Rural 9 (2.3) Urban 357 (89.2) Suburban Total 34 (8.5) 400 (100) Education Level Illiterate 20 (5) Primary 37 (9.2) intermediate and secondary 105 (26.2) Institute and college 233 (58.3) Post graduate 5 (1.3) Total 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article 204 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Distribution study sample according Socio-demographic characteristics. Variables F (%) Occupation Unemployment 154 (38.5) Retired 12 (3) Unskilled Manual Worker 105 (26.3) Skilled Manual Worker 89 (22.2) Professional Occupation Total 40 (10) 400(100) Marital status Single 160 (40) Married 232 (58) Widowed Divorced Total 5 (1.3) 3 (0.7) 400 (100) Income Status Inadequate for daily needs 78 (19.5) Enough for daily needs 266 (66.5) Extra Saving Total 56 (14.0) 400 (100.0) Family Number 1-3 70 (17.5) 4-6 219 (54.8) 7-9 99 (24.7) 10-12 12 (3) Total 400 (100) Number of bed room Zero 1 (0.3) 1-3 314 (78.5) 4-6 81(20.2) 7-9 Total 4(1) 400 (100) House ownership Rented 82 (20.5) Partial Owned 12 (3) Owned Total 306 (76.5) 400 (100) Car Ownership Rented 85 (21.3) Partial Owned 6 (1.5) Owned Total 309 (77.2) 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article percentage (29.3%) was hypertension, fol- lowed by 24.4% diabetes mellitus. sample who mentioned that the TV is the main source of their information, and the lowest percentage, 0.8% is from journal and newspapers. Table 2 shows only (10.3%) of the study sample mentioned that they have chronic diseases; among them, the highest Table 3 shows that nearly half (48.7%) of the study sample mentioned that social media is the main source of their infor- mation, followed by (28.5%) of the study 206 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: Distribution of the study sample according to past medical history Variables F (%) Do you have any chronic disease? No 359 (89.8) Yes 41 (10.2) Total 400 (100) Those who answered yes to have chronic disease Thyroid Disease 5 (12.2) DM 10 (24.4) HTN 12 (29.3) HTN+DM 7 (17.1) Valvular Heart Disease 1 (2.4) Psychiatric disorder receive drug 2 (4.9) Asthma 3 (7.3) Peptic Ulcer 1 (2.4) Total 41 (100) Table 3: Distribution the study sample according sources of knowledge Variables F (%) The key source of knowledge TV 114 (28.5) Medical Staff 72 (18) Social Media 195 (48.7) Relatives 16 (4) Journal/Newspaper 3 (0.8) Total 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article mentioned there were died cases in their peers or families caused by Covid-19. The side effects of vaccines. Results show that (81% )of the sample answered false about vaccine causes infertility, and only (15.2%) of the study sample answered true for the question of whether one dose of vaccine is enough to keep prevent disease, complication, and death. Table 4, illustrated that (52.3%) of the study sample had been infected by Covid- 19, and (26.7%) of the study sample Table 5 shows that the majority (89.3%) of the study sample selected the false in an- swering the question, which is related to only the elderly exclusively must vac- cinate. The table shows that (80%) of the study sample selected a truth when they answered the question, which is related to 207 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4: Distribution of the study sample according to history of infection by Covid-19, and family deaths by Covid-19. Variables F(%) Have you infected with Covid-19? No 191 (47.7) Yes 209 (52.3) Has anyone died in your family caused by Covid-19? No 293 (73.3) Yes 107 (26.7) Total 400 (100) Table 5: Distribution study sample according to frequency, percentage, of knowledge in study sample N Items Responses F(%) 1 Vaccines are all designed to teach the body’s immune system to safely recognize and block the virus that causes the disease. False 121(30.2) True 279(69.8) 2 Only elders should vaccinate themselves False 357(89.3) True 43(10.8) 3 Side effects from a vaccine such as a sore arm or mild fever are usually minor and temporary False 78(19.5) True 322(80.5) 4 Covid-19 vaccines are weapon and could kill more people than Covid-19 disease False 292(73) True 108(27) 5 Covid-19 vaccines are safe for most people of 18 years and older False 179(44.8) True 221(55.2) 6 The only effective vaccine against Covid-19 is Pfizer vaccine False 268(67) True 132(33) 7 Getting vaccinated even if you have had Covid-19 means you are more likely to be protected for longer False 157(39.3) True 243(60.7) 8 Vaccination increases transmission of Covid-19. False 323(80.8) True 77(19.2) 9 The Covid-19 vaccines are very effective at preventing serious illness, hospitaliza- tion and death False 130(32.5) True 270(67.5) 10 Getting Covid-19 vaccine, causes infertility False 324(81) True 76(19) 11 Even if you have already had Covid-19, you should be vaccinated False 157(39.2) True 243(60.8) 12 Only one dose of vaccine is enough to be taken by people preventing serious illness, hospitalization and death False 339(84.8) True 61(15.2) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article knowledge related to the Covid-19 vaccine. significant differences between education- al levels, income status, house ownership, car ownership, have you infected with Covid-19 and knowledge (p=0.024, < 0.001, 0.007, 0.007 and 0.008). Table 6 shows that (60.8%) of the study sample expressed excellent overall Table 7 shows that (40.25%) of partici- pants who have an educational level be- tween 13 to 18 years expressed excellent level, and (12.75%) of people who have between 7 to 12 years of education ex- pressed excellent level. Statistically 208 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 6: Overall Knowledge regarding Covid-19 vaccine Levels F (%) Poor 59 (14.8) Good 8 (24.5) Excellent 243 (60.8) Total 400 (100) Table 7: Significant Association between socio-demographic characteristics and knowledge regarding Covid- 19 vaccine in the study sample Variables Overall knowledge P. Value Poor (%) Good (%) Excellent (%) Education Level 1-6 7 (1.75) 12 (3) 18 (4.5) 0.024 S 7-12 26 (6.5) 28 (7) 51 (12.75) 13-18 22 (5.5) 50 (12.5) 161 (40.25) 19-24 0 (0) 1 (0.25) 4 (1) Total 55 (13.75) 91 (22.75) 234 (58.5) Income Sta- tus Inadequate for daily needs 22 (5.5) 23 (5.75) 33 (8.25) <0.001 VHS Enough for daily needs 35 (8.75) 65 (16.25) 166 (41.5) Extra Saving 2 (0.5) 10 (2.5) 44 (11) Total 59 (14.75) 98 (24.5) 243 (60.75) House Own- ership Rented 22 (5.5) 22 (5.5) 38 (9.5) 0.007 S Partial Owned 2 (0.5) 3 (0.75) 7 (1.75) Owned 35 (8.75) 73 (18.25) 198 (49.5) Total 59 (14.75) 98 (24.5) 243 (60.75) Car Owner- ship Rented 22 (5.5) 22 (5.5) 41 (10.25) 0.007 S Partial Owned 2 (0.5) 1 (0.25) 3 (0.75) Owned 35 (8.75) 75 (18.75) 199 (49.75) Total 59 (14.75) 98 (24.5) 243 (60.75) Have you infected with Covid-19? No 35 (8.75) 55 (13.75) 101 (25.25) 0.008 S Yes 24 (6) 43 (10.75) 142 (35.5) Total 59 (14.75) 98 (24.5) 243 (60.75) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article about the intention to get a vaccine. Re- sults show that 34.2% of the study sample disagreed about encouraging relatives to get the vaccine, and 38.2% of the study sample disagreed for the question related to the danger of the Covid-19 vaccine. attitude regarding the Covid-19 vaccine. Table 8 shows that the highest percent- age, 54.4% of the sample selected agree when they expressed their attitude in question, which is related to the Covid-19 vaccine as social responsibility. The table shows that 53% of the sample agreed Table 9 indicated that (58.5%) of partici- pants have a positive 209 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 8: Distribution of the study sample according to their attitudes regarding Covid19 vaccine N Items Responses F(%) 1 It is dangerous to use Covid-19 vaccine Disagree 153(38.2) Not Certain 131(32.8) Agree 116(29.0) Total 400(100) 2 It is necessary to encourage your relatives to get vaccine Disagree 137(34.2) Not Certain 129(32.3) Agree 134(33.5) Total 400(100) 3 It is not possible to reduce the incidence of Covid-19 without vaccination. Disagree 118(29.5) Not Certain 149(37.2) Agree 133(33.3) Total 400(100) 4 People being vaccinated against Covid-19 will be helpful in con- trolling the pandemic. Disagree 96(24.0) Not Certain 96(24.0) Agree 208(52.0) Total 400(100) 5 I believe that taking Covid-19 vaccine is social responsibility Disagree 77(19.3) Not Certain 105(26.3) Agree 218(54.4) Total 400(100) 6 I have intention to get vaccine // or I am vaccinated. Disagree 135(34.7) Not Certain 53(13.3) Agree 212(53.0) Total 400(100) Table 9: Overall attitudes regarding Covid-19 vaccine Overall Attitude F (%) Negative 166 (41.5) Positive 234 (58.5) Total 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article have infected with Covid-19 and attitudes (P=0.002, < 0.001, 0.013 and 0.001). educational level of participants, vaccine campaigns, and differences in socio- economic, governmental and political differences. Results of the present study showed that participants with higher edu- cational levels, having cars, house owner- ship and have been infected with Covid-19 previously were significantly more knowl- edgeable regarding Covid-19 vaccine than other participants. Likewise, a study in Bangladesh [11] conducted as an online cross-sectional study to evaluate knowledge, attitude and perception Table 10 shows that statistically significant differences between income status, house ownership, car ownership, Knowledge regarding Covid-19 vaccine Re- sults of the present study showed that the majority, 60.8% of participants had excel- lent information regarding the Covid-19 vaccine. This finding was higher than the studies in Bangladesh, Ethiopia and Malay- sia, which were 57%, 40.8%, and 38% of their study participants who had good knowledge regarding the Covid-19 vaccine [11] , [12] , [13].However, this high per- centage of knowledge regarding the Covid- 19 vaccine could be due to differences in sample size, time of the study, higher 210 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 10: Significant association between socio-demographic characteristics and attitudes regarding Covid19 vaccine in the study sample Variables Overall Attitudes P. Value Negative (%) Positive (%) Income Status Inadequate for daily needs 45 (11.25) 33 (8.25) 0.002 S Enough for daily needs 105 (26.25) 161 (40.25) Extra Saving 16 (4) 40 (10) Total 166 (41.5) 234 (58.5) House Owner- ship Rented 50 (12.5) 32 (8) <0.001 VHS Partial Owned 7 (1.75) 5 (1.25) Owned 109 (27.25) 197 (49.25) Total 166 (41.5) 234 (58.5) Car Ownership Rented 43 (10.75) 42 (10.5) 0.013 S Partial Owned 5 (1.25) 1 (0.25) Owned 118 (29.5) 191 (47.75) Total 166 (41.5) 234 (58.5) Have you in- fected with Covid-19? No 95 (23.75) 96 (24) 0.001 S Yes 71 (17.75) 138 (34.5) Total 166 (41.5) 234 (58.5) Discussion https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article participants to examine the knowledge, attitude and perception regarding Covid- 19 vaccine, showing that the majority, 78% of participants had a positive attitude toward the Covid-19 vaccine. The finding of the present study was higher than the study in Ethiopia,[12] conducted an online cross-sectional study to measure aware- ness and attitude toward the Covid-19 vaccine on 425 Ethiopian people, showing that the overall score of positive attitude toward the Covid-19 vaccine was 24.2% . However, the present study showed that participants with higher income status who were infected with Covid-19 previ- ously, had a significantly positive attitude toward Covid-19 vaccine. This result was similar to the study in Turkey,[17] which conducted a cross-sectional study among adults to find out knowledge and attitude and perception regarding the Covid-19 vaccine, showing that having a previous history with Covid-19 disease was signifi- cantly associated with a positive attitude regarding the Covid-19 vaccine. On the contrary, [18] conducted a cross-sectional study in Oman including 3000 participants to examine the knowledge and attitude regarding the Covid-19 vaccine and re- ported that gender (being male) and peo- ple with chronic diseases were more likely to get the Covid-19 vaccine than others. Another study in Syria,[19] conducted an online cross-sectional study on 3402 par- ticipants to examine the factors associat- ed with intention to accept the Covid-19 vaccine, showed that males were more likely to get the Covid-19 vaccine that fe- male, income status had an impact on the acceptance of the vaccine. The study also showed that younger people were more likely to accept the vaccine than older people.in India [20] conducted a web- based cross-sectional study among 3145 participants to examine the attitude to- ward Covid-19 vaccine and showed that regarding the Covid-19 vaccine showed that the level of knowledge was signifi- cantly higher among participants who stat- ed having university/ higher levels of edu- cation. This finding is also supported by [12] which conducted a cross-sectional survey to find out awareness and attitude regarding the Covid-19 vaccine showed that the mean score of knowledge regard- ing the vaccine was high among partici- pants who described having College/ higher educational level. This could be due to people with a high level of education having more access to get the information and more understanding abilities will help them to know and react toward the Covid- 19 vaccine [14],[15]. While the present study did not find a relationship between knowledge regarding the Covid-19 vaccine with age or gender in Palestine [16] showed that (being female, being in a younger age group, having a higher edu- cational level and being infected with Covid-19 previously were statistically sig- nificant. Another study in Malaysia sup- ported the finding of the current study [13] showed that higher education level and higher income status were significant- ly associated with higher knowledge re- garding the Covid-19 vaccine. Attitude re- garding Covid-19 vaccine The finding of the current study mentioned that 58.5% of participants had a positive attitude toward the Covid-19 vaccine; this finding was in line with and slightly higher than the study in Palestine,[16] which conducted a cross- sectional study among 6226 participants to measure knowledge, attitude, and ac- ceptance toward the Covid-19 vaccine and reported that 55.1 of participants had a positive attitude toward the Covid-19 vac- cine. The result of the current study re- garding attitude toward the Covid-19 vac- cine was lower than the study in Bangla- desh,[11] which conducted a web-based cross-sectional study including 1658 211 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article [1] Ahmed NJ, Alkhawaja FZ, Alrawili AS, Almalki ZS. Public knowledge and atti- tudes toward COVID-19 Vaccination: A cross-sectional study. Medical Science. 2021;25(108):279-84. [2] Rzymski P, Zeyland J, Poniedziałek B, Małecka I, Wysocki J. The Perception and Attitudes toward COVID-19 Vac- cines: A Cross-Sectional Study in Poland. Journal of Vaccines 2021;9:382. https:// doi.org/10.3390/vaccines9040382. [3] Hershan AA. Awareness of COVID-19, Protective Measures and Attitude To- wards Vaccination among University of Jeddah Health Field Community: A Questionnaire-Based Study. Journal of Pure and Applied Microbiology 2021;15:604–12. https:// doi.org/10.22207/JPAM.15.2.02. [4] Olayemi L, Alex- Abraham J, Yemoh V, Samuelu-Matthes M. Knowledge, Risk Perception, and Preventive Measures of COVID-19 among Medical and Nursing students in Samoa: A Cross-Sectional Analysis. Pacific Health Dialog 2021;21. https://doi.org/10.26635/ phd.2021.107. [5] Nwagbara UI, Osual EC, Chireshe R, Bo- larinwa OA, Saeed BQ, Khuzwayo N, et al. Knowledge, attitude, perception, and preventative practices towards COVID- 19 in sub-Saharan Africa: A scoping re- view. Public Library of Science 2021;16:e0249853. https:// doi.org/10.1371/journal.pone.0249853. [6] Kumar V, Doshi KU, Khan WH, Rathore AS. COVID‐19 pandemic: mechanism, diagnosis, and treatment. Journal of Chemical Technology & Biotechnology 2021;96:299–308. https:// doi.org/10.1002/jctb.6641. [7] Sari DK, Amelia R, Dharmajaya R, Sari LM, Fitri NK. Positive Correlation Be- tween General Public Knowledge and Attitudes Regarding COVID-19 Outbreak 1 Month After First Cases Reported in Indonesia. Journal of Community Health 2021;46:182–9. https:// doi.org/10.1007/s10900-020-00866-0. the religion, occupation, and monthly in- come were the factors that affect the atti- tude toward intention toward the Covid- 19 vaccine. These disparities might be attributed to the nature of the population and varying questionnaire design. Limitations :The survey was conducted during the mass vaccination period in Erbil city, so this may affect the results of the study. Depending on the results of the present study, despite the high percentage of knowledge and positive attitude regarding Covid-19 vaccination; there is still misun- derstanding and less information regard- ing Covid-19 vaccination, thirty point two percent of participants did not know about the vaccine. The present study found a sig- nificant association between participants' knowledge and their educational level, in- come, house ownership, and history of being infected by COVID-19. The study al- so concluded that there was a significant association between participants’ atti- tudes and their income status, house own- ership, car ownership, and history of being infected by COVID 19. 1- It is recommended that health authori- ties distribute and promote more accurate health education programs and infor- mation. 2- By confirming adequate knowledge and positive attitudes toward Covid-19 vac- cinations, policy-makers can reduce vac- cine hesitancy facilitated and encouraged by misinformation. There are no conflicts of interest or sources of financial support for any of the authors. 212 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. CONCLUSION RECOMMENDATIONS CONFLICT OF INTEREST REFERENCES https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article a web-based cross-sectional study. Journal of Ideas in Health 2020;3:258– 65. https://doi.org/10.47108/ jidhealth.Vol3.IssSpecial2.59. [15] Juin JCY, Ern SLS, Min CEHS, Jing NK, Qi MNM, Hoe RCC, et al. Knowledge, Atti- tudes, and Practices of COVID-19 Vac- cination among Adults in Singapore: A Cross-Sectional Study. The American journal of tropical medicine and hygiene 2022:tpmd211259. https:// doi.org/10.4269/ajtmh.21-1259. [16] Al-kafarna M, Matar SG, Almadhoon HW, Almaghary BK, Zaazouee MS, Elrashedy AA, et al. Public knowledge, attitude, and acceptance toward COVID -19 vaccines in Palestine: a cross- sectional study. BMC Public Health 2022;22:529. https://doi.org/10.1186/ s12889-022-12932-4. [17] Sonmezer MC, Sahin TK, Erul E, Ceylan FS, Hamurcu MY, Morova N, et al. Knowledge, Attitudes, and Perception towards COVID-19 Vaccination among the Adult Population: A Cross-Sectional Study in Turkey. Journal of Vaccines 2022;10:278. https://doi.org/10.3390/ vaccines10020278. [18] Al-Marshoudi S, Al-Balushi H, Al-Wahaibi A, Al-Khalili S, Al-Maani A, Al-Farsi N, et al. Knowledge, Attitudes, and Practices (KAP) toward the COVID- 19 Vaccine in Oman: A Pre-Campaign Cross-Sectional Study. Journal of Vac- cines 2021;9:602. https:// doi.org/10.3390/vaccines9060602. [19] Mohamad O, Zamlout A, AlKhoury N, Mazloum AA, Alsalkini M, Shaaban R. Factors associated with the intention of Syrian adult population to accept COVID19 vaccination: a cross-sectional study. BMC Public Health 2021;21:1310. https://doi.org/10.1186/s12889-021- 11361-z. [8] Alle YF, Oumer KE. Attitude and associ- ated factors of COVID-19 vaccine ac- ceptance among health professionals in Debre Tabor Comprehensive Specialized Hospital, North Central Ethiopia; 2021: cross-sectional study. Virus Disease 2021;32:272–8. https:// doi.org/10.1007/s13337-021-00708-0. [9] Usman, J., Arshad, I., Fatima, A., Ahsan, M., Minal, N. Knowledge and attitude pertinent to COVID-19 and willingness to COVID vaccination among medical students of University College of Medi- cine & Dentistry Lahore. Journal of Ra- walpindi Medical College. 31 Aug. 2021; 25 COVID-19 Supplement-1, 61-66. DOI: https://doi.org/10.37939/ jrmc.v25i1.1643. [10] Jiang N, Baojian wei, Lin, Wang, Chai, Liu. Nursing students’ attitudes, knowledge and willingness of to receive the coronavirus disease vaccine: A cross -sectional study. Nurse Education in Practice 2021;55:103148. https:// doi.org/10.1016/j.nepr.2021.103148. [11] Islam MS, Siddique AB, Akter R, Tasnim R, Sujan MSH, Ward PR, et al. Knowledge, attitudes and perceptions towards COVID-19 vaccinations: a cross- sectional community survey in Bangla- desh. MedRxiv 2021:2021.02.16.21251802. https:// doi.org/10.1101/2021.02.16.21251802. [12] Mesesle M. Awareness and Attitude Towards COVID-19 Vaccination and As- sociated Factors in Ethiopia: Cross- Sectional Study. Infection and Drug Re- sistance 2021;Volume 14:2193–9. https://doi.org/10.2147/IDR.S316461. [13] Mohamed NA, Solehan HM, Mohd Rani MD, Ithnin M, Che Isahak CI. Knowledge, acceptance and perception on COVID-19 vaccine among Malaysi- ans: A web-based survey. Public Library of Science 2021;16:e0256110. https:// doi.org/10.1371/journal.pone.0256110. [14] Jadoo SAA, Alhusseiny AH, Yaseen SM, Al-Samarrai MAM, Al-Rawi RA, Al- Delaimy AK, et al. Knowledge, attitude, and practice toward COVID-19 among 213 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2024.19 Erbil j. nurs. midwifery, Vol. 7, No. (2), Nov 2024 Original Article [20] Leelavathy M, Messaline S, Ramachan- dran D, Sukumaran A, Jose R, Noufel AN. Attitude towards COVID-19 vaccina- tion among the public in Kerala: A cross sectional study. Journal of Family Medi- cine and Primary Care 2021;10:4147– 52. https://doi.org/10.4103/ jfmpc.jfmpc_583_21. 214 Copyright ©2024 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/