The principal finding of this study was the significant role of psychological factors in shaping attitudes towards cholera vaccination. The WHO recommends the public readiness to accept cholera vaccination in outbreak regions, a measure that is considered crucial for reducing the negative impact and burden of this severe and deadly diarrheal disease [21]. In the study sample, although cholera vaccine acceptance exceeded 69%, there remains a room for improving such an attitude. Based on the results of the study, the efforts to promote cholera vaccine acceptance should focus on boosting confidence in the vaccine safety and efficacy, reducing the logistical and financial barriers, and emphasizing the concept of collective responsibility.
Considering the large sample of participants included in the study, the findings provided a comprehensive overview of the knowledge and attitudes towards cholera and cholera vaccination shortly after the declaration of the cholera outbreaks in the neighboring countries, namely Iraq, Syria, and Lebanon [43, 56–59]. The substantial engagement of 1339 respondents in the current study likely reflects the pertinence of cholera awareness in the Middle East, which was evidenced by the 91% of participants with pre-existing knowledge of the disease. This widespread awareness may stem from the extensive media coverage and government-led community engagement initiatives, particularly in reaction to the outbreaks in neighboring countries [17]. Such efforts aimed to strengthen the preparedness against cholera, highlighting the importance of community engagement in disease prevention strategies [17, 43].
The overall level of cholera knowledge in the study sample can be described as above-average, with a mean K-score of 13/20. Such a level of knowledge appears better in comparison to past studies from the Middle East region among other world regions afflicted by cholera outbreaks. For example, a study from 2021 among the general public in Jazan, Saudi Arabi showed poor level of cholera knowledge manifested in less than 44% who knew that the causative agent is a bacterium [45]. A higher level of knowledge regarding cholera transmission, treatment, and prevention was reported by Malaeb et al. in a sample of 553 participants surveyed in late 2022 amid the outbreak in Lebanon [52]. An earlier study that was conducted in 2017 in the Yemeni Southern city of Aden identified poor level of knowledge regarding cholera transmission and prevention [60]. Similarly, lower levels of knowledge regarding cholera transmission and prevention as opposed to better knowledge about cholera symptoms was reported in Tanzania, with less than half of the participating households being aware of the 2015 cholera outbreak in the country [61]. An early large study that involved a survey and in-depth interviews in the Capital of Bangladesh, Dhaka with over 2800 respondents, poor cholera knowledge was described among 54% of the study sample [62].
The observed difference in cholera knowledge levels across studies can be attributed to several factors. For example, the timing of our study shortly following the declaration of several outbreaks in neighboring countries may have contributed to heightened level of cholera awareness [17, 43]. Additionally, variable levels of cholera knowledge in various settings could be related to differences in the effectiveness of public health campaigns, varying levels of accessibility to accurate health information, and different levels of community engagement in the preventive efforts [26, 63, 64].
The demographic dissection of the determinants of significantly different cholera knowledge scores among the participants in this study highlighted critical areas for targeted educational campaigns. In this study, the discernible lower levels of cholera knowledge among younger participants appears fathomable, given that the last encounter with cholera in Jordan occurred over four decades ago [17, 65]. Moreover, the superior knowledge observed among HCWs is understandable which can be attributed to their educational background and the heightened awareness resulting from governmental campaigns, especially in response to the recent outbreaks in neighboring countries [17]. These findings highlight the necessity for public health strategies aimed at closing the observed knowledge gaps, advocating for customized educational interventions targeted at the general public and specifically at the younger demographic.
In this study, the majority of participants exhibited positive attitude to cholera vaccination with acceptance rate slightly exceeding 69%. However, the presence of vaccination hesitancy and resistance, albeit in smaller proportions, indicated the need for comprehensive communication strategies to address concerns and possible misconceptions about cholera vaccination. From a broader perspective, the acceptance rate of cholera vaccine in this study which was 69%, appeared lower compared to the rates reported in various different settings. For example, a 2010 study in the Katanga province of the Democratic Republic of the Congo (DRC) revealed a near universal acceptance of cholera vaccination, with 97% of the participants being willing to receive OCVs if provided free of charge [66]. Similarly, a recent study from Lebanon revealed an acceptance rate or at least possible acceptance of 86% for a freely provided cholera vaccine [67]. Employing meta-analytic approach, three cross-sectional studies involving 1095 respondents across three African regions, namely Southeastern DRC, Western Kenya, and Zanzibar demonstrated a high acceptance rate for free OCV of over 93% [68]. Taken together, these observations indicate a comparatively lower cholera vaccine acceptance in our study relative to other regions, suggesting a potential for improvement in cholera vaccine acceptance rates in Jordan. This pattern is consistent with previous studies indicating the pervasive occurrence of vaccination hesitancy in Jordan for other vaccines, which emphasize the need for targeted interventions to promote vaccine acceptance in the country [50, 69].
A novel finding of our study in the context of attitude to cholera vaccination was the elucidation of the central role of the psychological factors, namely confidence, constraints, and collective responsibility, as predictors of cholera vaccine acceptance. This particular insight based on the central role of psychological determinants of vaccine acceptance could have several implications for public health policy for cholera prevention. Such a result highlights the importance of tailoring the public health messages in the psychological framework to build trust in vaccine safety and efficacy, reduce barriers to vaccine access, and emphasize the role of vaccination as a commitment to protect vulnerable groups in communities. The central role of the psychological factors as determinants of vaccination attitudes in various vaccination contexts appears universal [27, 28, 33, 70, 71]. Such an association was reported previously in the context of COVID-19, influenza, and recently monkeypox vaccination [31, 72, 73].
Finally, several limitations of this study should be fully acknowledged and taken into consideration in the interpretation. First, despite the large sample size in this study with over 1300 participants, selection bias may have influenced the outcomes due to a notable female predominance among the participants. This outcome is possibly related to sex distribution of the research team with eight out of ten Jordanian authors being females. Second, the dependence on single-item measures for assessing psychological predictors for vaccine attitude might limit the robustness of the findings; however, this methodological approach was chosen to minimize the possibility of respondent fatigue considering the length of the questionnaire. Additionally, the potential for social desirability bias should be considered, as the participants might have responded in a way they perceive as favorable to the researchers in terms of attitude to vaccination and its psychological determinants. Finally, while the convenience sampling strategy expedited sample collection, it inherently carries the risk of selection bias, which in turn could affect the generalizability of the study conclusions.