Vaccination could be an effective strategy for slowing the spread of the current coronavirus disease 2019 (COVID-19) pandemic. Vaccine hesitancy could pose a serious problem for COVID-19 prevention, due to the spread of misinformation surrounding the ongoing pandemic. The aim of this study was to assess the attitudes towards the prospective COVID-19 vaccines among the general public in Jordan, Kuwait and other Arab countries. We also aimed to assess the association between COVID-19 vaccine acceptance and conspiracy beliefs. This study used an online survey distributed in December 2020, with items assessing conspiracies regarding COVID-19's origin and vaccination. Attitudes towards COVID-19 vaccines were assessed using the Vaccine Conspiracy Belief Scale (VCBS), with higher scores indicating a greater belief in vaccine conspiracy. A total of 3414 respondents completed the survey, the majority being residents of Jordan (n = 2173, 63.6%), Kuwait (n = 771, 22.6%) and Saudi Arabia (n = 154, 4.5%). The acceptance rates for COVID-19 and influenza vaccines were 29.4% and 30.9%, respectively. Males, respondents with higher educational levels and those with histories of chronic disease had higher rates of COVID-19 vaccine acceptance. Beliefs that COVID-19 vaccines are intended to inject microchips into recipients and that the vaccines are related to infertility were found in 27.7% and 23.4% of respondents, respectively. Higher VCBS scores were found among females, respondents with lower educational levels and respondents relying on social media platforms as the main source of information. The high rates of vaccine hesitancy in Jordan and Kuwait, among other Arab countries, are alarming. They could hinder the proper control of COVID-19 in the region. The harmful effect of COVID-19 misinformation and conspiracy beliefs was manifested in vaccine hesitancy. This may represent a massive obstacle to the successful control of the pandemic. A reliance on social media as the main source of information about COVID-19 vaccines was associated with vaccine hesitancy. This should alert governments, policy makers and the general public to the importance of vigilant fact checking.
Sallam M, Dababseh D, Eid H, Hasan H, Taim D, Al-Mahzoum K, Al-Haidar A, Yaseen A, Ababneh NA, Assaf A, Bakri FG, Matar S, Mahafzah A.Int J Environ Res Public Health. 2021 Mar 1;18(5):2407. doi: 10.3390/ijerph18052407.PMID: 33804558 Free PMC article.
Nyamuryekung'e KK, Amour M, Mboya I, Ndumwa H, Kengia J, Njiro BJ, Mhamilawa L, Shayo E, Ngalesoni F, Kapologwe N, Kalolo A, Metta E, Msuya S.PLOS Glob Public Health. 2023 Jun 7;3(6):e0001223. doi: 10.1371/journal.pgph.0001223. eCollection 2023.PMID: 37285332 Free PMC article.
MacDonald N.E., SAGE Working Group on Vaccine Hesitancy Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33:4161–4164. doi: 10.1016/j.vaccine.2015.04.036. - DOI - PubMed
Poland G.A., Jacobson R.M. The age-old struggle against the antivaccinationists. N. Engl. J. Med. 2011;364:97–99. doi: 10.1056/NEJMp1010594. - DOI - PubMed
Oliver J.E., Wood T. Medical conspiracy theories and health behaviors in the United States. JAMA Intern. Med. 2014;174:817–818. doi: 10.1001/jamainternmed.2014.190. - DOI - PubMed
Salali G.D., Uysal M.S. COVID-19 vaccine hesitancy is associated with beliefs on the origin of the novel coronavirus in the UK and Turkey. Psychol. Med. 2020;10:1–3. doi: 10.1017/S0033291720004067. - DOI - PMC - PubMed
Phadke V.K., Bednarczyk R.A., Salmon D.A., Omer S.B. Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United States: A Review of Measles and Pertussis. JAMA. 2016;315:1149–1158. doi: 10.1001/jama.2016.1353. - DOI - PMC - PubMed
Oostvogel P.M., van Wijngaarden J.K., van der Avoort H.G., Mulders M.N., Conyn-van Spaendonck M.A., Rumke H.C., van Steenis G., van Loon A.M. Poliomyelitis outbreak in an unvaccinated community in The Netherlands, 1992–1993. Lancet. 1994;344:665–670. doi: 10.1016/S0140-6736(94)92091-5. - DOI - PubMed
Jansen V.A., Stollenwerk N., Jensen H.J., Ramsay M.E., Edmunds W.J., Rhodes C.J. Measles outbreaks in a population with declining vaccine uptake. Science. 2003;301:804. doi: 10.1126/science.1086726. - DOI - PubMed
Huang C., Wang Y., Li X., Ren L., Zhao J., Hu Y., Zhang L., Fan G., Xu J., Gu X., et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506. doi: 10.1016/S0140-6736(20)30183-5. - DOI - PMC - PubMed
Coronaviridae Study Group of the International Committee on Taxonomy of Viruses The species Severe acute respiratory syndrome-related coronavirus: Classifying 2019-nCoV and naming it SARS-CoV-2. Nat. Microbiol. 2020;5:536–544. doi: 10.1038/s41564-020-0695-z. - DOI - PMC - PubMed
Jahanshahi A.A., Dinani M.M., Madavani A.N., Li J., Zhang S.X. The distress of Iranian adults during the Covid-19 pandemic—More distressed than the Chinese and with different predictors. Brain. Behav. Immun. 2020;87:124–125. doi: 10.1016/j.bbi.2020.04.081. - DOI - PMC - PubMed
Morgantini L.A., Naha U., Wang H., Francavilla S., Acar O., Flores J.M., Crivellaro S., Moreira D., Abern M., Eklund M., et al. Factors contributing to healthcare professional burnout during the COVID-19 pandemic: A rapid turnaround global survey. PLoS ONE. 2020;15:e0238217. doi: 10.1371/journal.pone.0238217. - DOI - PMC - PubMed
Bandyopadhyay S., Baticulon R.E., Kadhum M., Alser M., Ojuka D.K., Badereddin Y., Kamath A., Parepalli S.A., Brown G., Iharchane S., et al. Infection and mortality of healthcare workers worldwide from COVID-19: A systematic review. BMJ Glob. Health. 2020;5:e003097. doi: 10.1136/bmjgh-2020-003097. - DOI - PMC - PubMed
Mukaetova-Ladinska E.B., Kronenberg G. Psychological and neuropsychiatric implications of COVID-19. Eur. Arch. Psychiatry Clin. Neurosci. 2020:1–14. doi: 10.1007/s00406-020-01210-2. - DOI - PMC - PubMed
Nicola M., Alsafi Z., Sohrabi C., Kerwan A., Al-Jabir A., Iosifidis C., Agha M., Agha R. The socio-economic implications of the coronavirus pandemic (COVID-19): A review. Int. J. Surg. 2020;78:185–193. doi: 10.1016/j.ijsu.2020.04.018. - DOI - PMC - PubMed
Hodgson S.H., Mansatta K., Mallett G., Harris V., Emary K.R.W., Pollard A.J. What defines an efficacious COVID-19 vaccine? A review of the challenges assessing the clinical efficacy of vaccines against SARS-CoV-2. Lancet Infect. Dis. 2020 doi: 10.1016/S1473-3099(20)30773-8. - DOI - PMC - PubMed
Conte C., Sogni F., Affanni P., Veronesi L., Argentiero A., Esposito S. Vaccines against Coronaviruses: The State of the Art. Vaccines. 2020;8:309. doi: 10.3390/vaccines8020309. - DOI - PMC - PubMed
Kaur S.P., Gupta V. COVID-19 Vaccine: A comprehensive status report. Virus Res. 2020;288:198114. doi: 10.1016/j.virusres.2020.198114. - DOI - PMC - PubMed
Wang J., Peng Y., Xu H., Cui Z., Williams R.O., 3rd The COVID-19 Vaccine Race: Challenges and Opportunities in Vaccine Formulation. AAPS PharmsciTech. 2020;21:225. doi: 10.1208/s12249-020-01744-7. - DOI - PMC - PubMed
Sharma O., Sultan A.A., Ding H., Triggle C.R. A Review of the Progress and Challenges of Developing a Vaccine for COVID-19. Front. Immunol. 2020;11:585354. doi: 10.3389/fimmu.2020.585354. - DOI - PMC - PubMed
Teerawattananon Y., Dabak S.V. COVID Vaccination Logistics: Five Steps to Take Now. Nature Publishing Group; London, UK: 2020. - PubMed
Dror A.A., Eisenbach N., Taiber S., Morozov N.G., Mizrachi M., Zigron A., Srouji S., Sela E. Vaccine hesitancy: The next challenge in the fight against COVID-19. Eur. J. Epidemiol. 2020;35:775–779. doi: 10.1007/s10654-020-00671-y. - DOI - PubMed
Dube E., Laberge C., Guay M., Bramadat P., Roy R., Bettinger J. Vaccine hesitancy: An overview. Hum. Vaccin Immunother. 2013;9:1763–1773. doi: 10.4161/hv.24657. - DOI - PMC - PubMed
Palamenghi L., Barello S., Boccia S., Graffigna G. Mistrust in biomedical research and vaccine hesitancy: The forefront challenge in the battle against COVID-19 in Italy. Eur. J. Epidemiol. 2020;35:785–788. doi: 10.1007/s10654-020-00675-8. - DOI - PMC - PubMed
Abo S. Is a COVID-19 Vaccine Likely to Make Things Worse? Vaccines. 2020;8:761. doi: 10.3390/vaccines8040761. - DOI - PMC - PubMed
Billah M.A., Miah M.M., Khan M.N. Reproductive number of coronavirus: A systematic review and meta-analysis based on global level evidence. PLoS ONE. 2020;15:e0242128. doi: 10.1371/journal.pone.0242128. - DOI - PMC - PubMed
Anderson R.M., Vegvari C., Truscott J., Collyer B.S. Challenges in creating herd immunity to SARS-CoV-2 infection by mass vaccination. Lancet. 2020;396:1614–1616. doi: 10.1016/S0140-6736(20)32318-7. - DOI - PMC - PubMed
Shen S.C., Dubey V. Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents. Can. Fam. Physician. 2019;65:175–181. - PMC - PubMed
Salmon D.A., Dudley M.Z., Glanz J.M., Omer S.B. Vaccine hesitancy: Causes, consequences, and a call to action. Vaccine. 2015;33(Suppl. 4):D66–D71. doi: 10.1016/j.vaccine.2015.09.035. - DOI - PubMed
De Figueiredo A., Simas C., Karafillakis E., Paterson P., Larson H.J. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: A large-scale retrospective temporal modelling study. Lancet. 2020;396:898–908. doi: 10.1016/S0140-6736(20)31558-0. - DOI - PMC - PubMed
Dube E., Gagnon D., Nickels E., Jeram S., Schuster M. Mapping vaccine hesitancy--country-specific characteristics of a global phenomenon. Vaccine. 2014;32:6649–6654. doi: 10.1016/j.vaccine.2014.09.039. - DOI - PMC - PubMed
Jolley D., Douglas K.M. The effects of anti-vaccine conspiracy theories on vaccination intentions. PLoS ONE. 2014;9:e89177. doi: 10.1371/journal.pone.0089177. - DOI - PMC - PubMed
Hornsey M.J., Lobera J., Diaz-Catalan C. Vaccine hesitancy is strongly associated with distrust of conventional medicine, and only weakly associated with trust in alternative medicine. Soc. Sci. Med. 2020;255:113019. doi: 10.1016/j.socscimed.2020.113019. - DOI - PubMed
Diaz Crescitelli M.E., Ghirotto L., Sisson H., Sarli L., Artioli G., Bassi M.C., Appicciutoli G., Hayter M. A meta-synthesis study of the key elements involved in childhood vaccine hesitancy. Public Health. 2020;180:38–45. doi: 10.1016/j.puhe.2019.10.027. - DOI - PubMed
Bertin P., Nera K., Delouvee S. Conspiracy Beliefs, Rejection of Vaccination, and Support for hydroxychloroquine: A Conceptual Replication-Extension in the COVID-19 Pandemic Context. Front. Psychol. 2020;11:565128. doi: 10.3389/fpsyg.2020.565128. - DOI - PMC - PubMed
Romer D., Jamieson K.H. Conspiracy theories as barriers to controlling the spread of COVID-19 in the US. Soc. Sci. Med. 2020;263:113356. doi: 10.1016/j.socscimed.2020.113356. - DOI - PMC - PubMed
Uscinski J.E., Enders A.M., Klofstad C., Seelig M., Funchion J., Everett C., Wuchty S., Premaratne K., Murthi M. Why do people believe COVID-19 conspiracy theories? Harv. Kennedy Sch. Misinf. Rev. 2020;1 doi: 10.37016/mr-2020-015. - DOI
Shahsavari S., Holur P., Wang T., Tangherlini T.R., Roychowdhury V. Conspiracy in the time of corona: Automatic detection of emerging COVID-19 conspiracy theories in social media and the news. J. Comput Soc. Sci. 2020;3:1–39. doi: 10.1007/s42001-020-00086-5. - DOI - PMC - PubMed
Ahmed W., Vidal-Alaball J., Downing J., Lopez Segui F. COVID-19 and the 5G Conspiracy Theory: Social Network Analysis of Twitter Data. J. Med. Internet Res. 2020;22:e19458. doi: 10.2196/19458. - DOI - PMC - PubMed
Sallam M., Dababseh D., Yaseen A., Al-Haidar A., Ababneh N.A., Bakri F.G., Mahafzah A. Conspiracy Beliefs Are Associated with Lower Knowledge and Higher Anxiety Levels Regarding COVID-19 among Students at the University of Jordan. Int J. Environ. Res. Public Health. 2020;17:4915. doi: 10.3390/ijerph17144915. - DOI - PMC - PubMed
Sallam M., Dababseh D., Yaseen A., Al-Haidar A., Taim D., Eid H., Ababneh N.A., Bakri F.G., Mahafzah A. COVID-19 misinformation: Mere harmless delusions or much more? A knowledge and attitude cross-sectional study among the general public residing in Jordan. PLoS ONE. 2020;15:e0243264. doi: 10.1371/journal.pone.0243264. - DOI - PMC - PubMed
Shapiro G.K., Holding A., Perez S., Amsel R., Rosberger Z. Validation of the vaccine conspiracy beliefs scale. Papillomavirus Res. 2016;2:167–172. doi: 10.1016/j.pvr.2016.09.001. - DOI - PMC - PubMed
Greenwood B. The contribution of vaccination to global health: Past, present and future. Philos. Trans. R. Soc. Lond. B Biol. Sci. 2014;369:20130433. doi: 10.1098/rstb.2013.0433. - DOI - PMC - PubMed
Xiong J., Lipsitz O., Nasri F., Lui L.M.W., Gill H., Phan L., Chen-Li D., Iacobucci M., Ho R., Majeed A., et al. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. J. Affect. Disord. 2020;277:55–64. doi: 10.1016/j.jad.2020.08.001. - DOI - PMC - PubMed
Ball P., Maxmen A. The epic battle against coronavirus misinformation and conspiracy theories. Nature. 2020;581:371–374. doi: 10.1038/d41586-020-01452-z. - DOI - PubMed
Khan Y.H., Mallhi T.H., Alotaibi N.H., Alzarea A.I., Alanazi A.S., Tanveer N., Hashmi F.K. Threat of COVID-19 Vaccine Hesitancy in Pakistan: The Need for Measures to Neutralize Misleading Narratives. Am. J. Trop. Med. Hyg. 2020;103:603–604. doi: 10.4269/ajtmh.20-0654. - DOI - PMC - PubMed
Voysey M., Clemens S.A.C., Madhi S.A., Weckx L.Y., Folegatti P.M., Aley P.K., Angus B., Baillie V.L., Barnabas S.L., Bhorat Q.E., et al. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: An interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet. 2020;397:99–111. doi: 10.1016/S0140-6736(20)32661-1. - DOI - PMC - PubMed
Mahase E. Covid-19: Moderna vaccine is nearly 95% effective, trial involving high risk and elderly people shows. BMJ Br. Med J. (Online) 2020;371:371.
Mahase E. Covid-19: Vaccine candidate may be more than 90% effective, interim results indicate. BMJ. 2020;371:371. doi: 10.1136/bmj.m4347. - DOI - PubMed
Omer S.B., Yildirim I., Forman H.P. Herd Immunity and Implications for SARS-CoV-2 Control. JAMA. 2020;324:2095–2096. doi: 10.1001/jama.2020.20892. - DOI - PubMed
Aschwanden C. The false promise of herd immunity for COVID-19. Nature. 2020;587:26–28. doi: 10.1038/d41586-020-02948-4. - DOI - PubMed
Harrison E.A., Wu J.W. Vaccine confidence in the time of COVID-19. Eur. J. Epidemiol. 2020;35:325–330. doi: 10.1007/s10654-020-00634-3. - DOI - PMC - PubMed
European Centre for Disease Prevention and Control Threat Assessment Brief: Rapid Increase of a SARS-CoV-2 Variant with Multiple Spike Protein Mutations Observed in the United Kingdom. [(accessed on 26 December 2020)]; Available online: https://www.ecdc.europa.eu/en/publications-data/threat-assessment-brief-....
Sallam M. COVID-19 vaccine hesitancy worldwide: A systematic review of vaccine acceptance rates. medRxiv. 2021 doi: 10.1101/2020.12.28.20248950. - DOI
Pogue K., Jensen J.L., Stancil C.K., Ferguson D.G., Hughes S.J., Mello E.J., Burgess R., Berges B.K., Quaye A., Poole B.D. Influences on Attitudes Regarding Potential COVID-19 Vaccination in the United States. Vaccines. 2020;8:582. doi: 10.3390/vaccines8040582. - DOI - PMC - PubMed
Fisher K.A., Bloomstone S.J., Walder J., Crawford S., Fouayzi H., Mazor K.M. Attitudes Toward a Potential SARS-CoV-2 Vaccine: A Survey of U.S. Adults. Ann. Intern. Med. 2020;173:964–973. doi: 10.7326/M20-3569. - DOI - PMC - PubMed
Lazarus J.V., Ratzan S.C., Palayew A., Gostin L.O., Larson H.J., Rabin K., Kimball S., El-Mohandes A. A global survey of potential acceptance of a COVID-19 vaccine. Nat. Med. 2020:1–4. doi: 10.1038/s41591-020-1124-9. - DOI - PMC - PubMed
Harapan H., Wagner A.L., Yufika A., Winardi W., Anwar S., Gan A.K., Setiawan A.M., Rajamoorthy Y., Sofyan H., Mudatsir M. Acceptance of a COVID-19 Vaccine in Southeast Asia: A Cross-Sectional Study in Indonesia. Front. Public Health. 2020;8:381. doi: 10.3389/fpubh.2020.00381. - DOI - PMC - PubMed
Wang J., Jing R., Lai X., Zhang H., Lyu Y., Knoll M.D., Fang H. Acceptance of COVID-19 Vaccination during the COVID-19 Pandemic in China. Vaccines. 2020;8:482. doi: 10.3390/vaccines8030482. - DOI - PMC - PubMed
Taylor S., Landry C.A., Paluszek M.M., Groenewoud R., Rachor G.S., Asmundson G.J.G. A Proactive Approach for Managing COVID-19: The Importance of Understanding the Motivational Roots of Vaccination Hesitancy for SARS-CoV2. Front. Psychol. 2020;11:575950. doi: 10.3389/fpsyg.2020.575950. - DOI - PMC - PubMed
Graffigna G., Palamenghi L., Boccia S., Barello S. Relationship between Citizens’ Health Engagement and Intention to Take the COVID-19 Vaccine in Italy: A Mediation Analysis. Vaccines. 2020;8:576. doi: 10.3390/vaccines8040576. - DOI - PMC - PubMed
Group C. A future vaccination campaign against COVID-19 at risk of vaccine hesitancy and politicisation. Lancet Infect. Dis. 2020;20:769–770. doi: 10.1016/S1473-3099(20)30426-6. - DOI - PMC - PubMed
Bhopal S., Nielsen M. Vaccine hesitancy in low- and middle-income countries: Potential implications for the COVID-19 response. Arch. Dis. Child. 2020 doi: 10.1136/archdischild-2020-318988. - DOI - PubMed
Al-Mohaithef M., Padhi B.K. Determinants of COVID-19 Vaccine Acceptance in Saudi Arabia: A Web-Based National Survey. J. Multidiscip. Healthc. 2020;13:1657–1663. doi: 10.2147/JMDH.S276771. - DOI - PMC - PubMed
Bednarczyk R.A., Chu S.L., Sickler H., Shaw J., Nadeau J.A., McNutt L.A. Low uptake of influenza vaccine among university students: Evaluating predictors beyond cost and safety concerns. Vaccine. 2015;33:1659–1663. doi: 10.1016/j.vaccine.2015.02.033. - DOI - PubMed
Schmid P., Rauber D., Betsch C., Lidolt G., Denker M.L. Barriers of Influenza Vaccination Intention and Behavior—A Systematic Review of Influenza Vaccine Hesitancy, 2005–2016. PLoS ONE. 2017;12:e0170550. doi: 10.1371/journal.pone.0170550. - DOI - PMC - PubMed
Abu-Gharbieh E., Fahmy S., Rasool B.A., Khan S. Influenza vaccination: Healthcare workers attitude in three Middle East countries. Int. J. Med. Sci. 2010;7:319–325. doi: 10.7150/ijms.7.319. - DOI - PMC - PubMed
Awaidy S.T.A., Al Mayahi Z.K., Kaddoura M., Mahomed O., Lahoud N., Abubakar A., Zaraket H. Influenza Vaccination Hesitancy among Healthcare Workers in South Al Batinah Governorate in Oman: A Cross-Sectional Study. Vaccines. 2020;8:661. doi: 10.3390/vaccines8040661. - DOI - PMC - PubMed
Nguyen T., Henningsen K.H., Brehaut J.C., Hoe E., Wilson K. Acceptance of a pandemic influenza vaccine: A systematic review of surveys of the general public. Infect. Drug Resist. 2011;4:197–207. doi: 10.2147/IDR.S23174. - DOI - PMC - PubMed
Yang J., Zheng Y., Gou X., Pu K., Chen Z., Guo Q., Ji R., Wang H., Wang Y., Zhou Y. Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: A systematic review and meta-analysis. Int. J. Infect. Dis. 2020;94:91–95. doi: 10.1016/j.ijid.2020.03.017. - DOI - PMC - PubMed
Earnshaw V.A., Eaton L.A., Kalichman S.C., Brousseau N.M., Hill E.C., Fox A.B. COVID-19 conspiracy beliefs, health behaviors, and policy support. Transl. Behav. Med. 2020;10:850–856. doi: 10.1093/tbm/ibaa090. - DOI - PMC - PubMed
Wilson S.L., Wiysonge C. Social media and vaccine hesitancy. BMJ Glob. Health. 2020;5:e004206. doi: 10.1136/bmjgh-2020-004206. - DOI - PMC - PubMed
Freeman D., Waite F., Rosebrock L., Petit A., Causier C., East A., Jenner L., Teale A.L., Carr L., Mulhall S., et al. Coronavirus conspiracy beliefs, mistrust, and compliance with government guidelines in England. Psychol. Med. 2020;10:1–13. doi: 10.1017/S0033291720001890. - DOI - PMC - PubMed
Blaskiewicz R. The Big Pharma conspiracy theory. Med. Writ. 2013;22:259–261. doi: 10.1179/2047480613Z.000000000142. - DOI
Eastwood K., Durrheim D.N., Jones A., Butler M. Acceptance of pandemic (H1N1) 2009 influenza vaccination by the Australian public. Med. J. Aust. 2010;192:33–36. doi: 10.5694/j.1326-5377.2010.tb03399.x. - DOI - PubMed
Maurer J., Uscher-Pines L., Harris K.M. Perceived seriousness of seasonal and A (H1N1) influenzas, attitudes toward vaccination, and vaccine uptake among US adults: Does the source of information matter? Prev. Med. 2010;51:185–187. doi: 10.1016/j.ypmed.2010.05.008. - DOI - PubMed
Rawat K., Kumari P., Saha L. COVID-19 vaccine: A recent update in pipeline vaccines, their design and development strategies. Eur. J. Pharmacol. 2020;892:173751. doi: 10.1016/j.ejphar.2020.173751. - DOI - PMC - PubMed