Factors Associated with COVID-19 Vaccine Hesitancy Among Adults in Saudi Arabia: Systematic Review

Abstract

Background: Vaccine hesitancy (VH) is recognised by the World Health Organization as a major global health threat. In Saudi Arabia, despite high institutional trust and religious endorsement of vaccination, hesitancy persists, challenging Vision 2030 health targets. The psychological and cultural determinants of VH remain underexplored and fragmented. Aim: This systematic review synthesised evidence on psychological and cultural determinants of COVID-19 VH among Saudi adults, assessed the methodological quality of the literature, and identified directions for research and policy. Methods: Following PRISMA 2020 guidelines, PubMed, Embase, Scopus, and PsycINFO were searched in May 2025. Twenty-five peer-reviewed studies (24 cross-sectional, one mixed-methods) were eligible. The Mixed Methods Appraisal Tool (MMAT, 2018) assessed quality. Findings were synthesised narratively, mapped to the Health Belief Model (HBM). Results: Psychological factors were the most consistent predictors of VH. Fear of side effects, distrust in rapid vaccine development, and misinformation (HBM: barriers) fuelled hesitancy, while trust in health authorities and perceived susceptibility/benefits facilitated acceptance. Cultural determinants, especially family influence, religious leadership, and institutional trust (HBM: cues to action), shaped decision-making but were often reported implicitly rather than systematically measured. Sociodemographic influences were context-dependent: women and youth expressed greater hesitancy, while older adults and healthcare professionals were generally more accepting. Mandates successfully increased uptake in the short term but raised concerns about autonomy and sustainability. Methodological weaknesses, including urban convenience sampling, low response rates, unvalidated scales, and heterogeneity in behavioural models (HBM, TPB, SAGE), limit generalisability. Conclusions: COVID-19 VH in Saudi Arabia is primarily shaped by psychological concerns, with cultural and demographic contexts playing important but underexamined roles. Trust in institutions and religious leadership enhances acceptance, while persistent safety concerns and misinformation act as entrenched barriers. To inform Vision 2030-aligned interventions, future research should prioritise representative sampling, validated measures, and integration of cultural determinants, with comparative behavioural modelling and qualitative inquiry into religion, social norms, and intergenerational dynamics. These steps are vital for developing culturally grounded, autonomy-supportive policies capable of ensuring sustainable vaccine confidence.