WILLINGNESS TO ACCEPT AND SATISFACTION OF COVID-19 VACCINE IN EAST JAVA CULTURAL AREAS

Background: Vaccinations are considered to be most effective solution to end a pandemic. Various issues develop inclusively regarding doubts about vaccines, which can be formed by various factors, such as social and cultural environment. Aims: This study aims to analyze factors that affect willingness to accept (WTA) COVID-19 vaccine in four dominant cultural areas in East Java (Arek, Madura, Mataraman and Pandalungan) and analyze what factors influence satisfaction of vaccination. Methods: This is quantitative research which analyzes 825 participants (40% men; 60% women). By using primary data the probit regression method is applied. We use dummy variables of WTA and level of satisfaction as dependent variables, while the independent variables include economic, health, socio-demographic and internal-external factors of vaccination program. Results: This research showed different results in each cultural area; WTA of vaccines was influenced by income, assets, employment, health, education, gender, and age, while satisfaction with vaccines is associated with side effects, type of vaccine, and time of service (AOR: 0.31 to 0.56, αlpha: 1%-10%). Conclusion: This study concludes that people of Arek and Mataraman tend to be willing and satisfied with vaccination, while Madura and Pandalungan show an opposite result due to lower accessibility, welfare, and culture.


Introduction
The coronavirus pandemic, commonly referred to as COVID-19, has infected 223 countries. Meanwhile, in Indonesia, positive cases in 2021 reached 882,418 cases (KPCPEN, 2021). This condition has become a historical record as the largest global virus with negative impacts in various sectors (Perez and Abadi, 2020) With various policy steps taken, vaccines are expected to be the most effective and efficient solution to end this health disaster/pandemic (Haynes et al., 2020). Therefore, not surprisingly, various research and development institutions collaborate globally to develop a COVID-19 vaccine (Akhtar et al., 2020).
However, the fact that vaccine issues are developing in the community and often make people curious and afraid becomes a challenge that must be addressed. For example, regarding the perception of Sinovac's COVID-19 vaccine, which is considered no better than Pfizer's (Smitha and Thomas, 2020), the public has doubts because the vaccine is debated about the manufacturing process and feasibility (Ophinni et al., 2020), safety level, efficacy level and post-vaccination effects (Su et al., 2020), and various other issues that occurred not only in Indonesia but also in other countries. Therefore, in the end, it was not enough for the government to urge but also "directly point out" the list of participants who must get the vaccine first.
Vaccine hesitancy exists among people, which could be a serious problem for efforts to control the current pandemic (Kruketi, 2022). About less than half of the respondents were unwilling to accept the COVID-19 vaccines when available mainly due to misconception about the vaccines (Abubakar, 2022). Consequently, eliminating public hesitancy and skepticism in the face of vaccination campaigns is a critical factor for policymakers concerned with addressing such threats (Tsutsumi, 2022). They must have a good understanding of the willingness of the population, especially those individuals who are likely to refuse or delay vaccination.
Various issues that developed in the era of inclusive media regarding "doubt" about vaccines can be formed by various things, for example, the social and cultural environment of society (Al-Mohaithef and Padhi, 2020;Harapan et al., 2020;Malik et al., 2020). This issue has happened in the context of public perception of doubts about the spread and danger of COVID-19 in the early days of entering East Java, Indonesia, which is quite diverse in culture.
Meanwhile, based on the research of Sutarto and Sudikan (2004), East Java has at least ten cultural areas, including Arek, Mataraman, Osing (Banyuwangi) cultures, Samin, Tengger, Pandalungan (East Java's horse-shoe areas assimilation of Mataraman and Madura Javanese), Panaragan (Ponorogo region and its surroundings), large Madura, small island Madura, and Bawean Madura. If the cultural plurality existed before the vaccination program (pre-vaccine), according to the team's observations in the Madura, Surabaya, and surrounding areas, it shows a different perspective on the COVID-19 preventive attitude (through 3M and 3T).
Data from the Ministry of Health of the Republic of Indonesia, as of January 2023 show that the coverage of COVID-19 vaccination in East Java has reached 85%, where Surabaya has contributed the most to achieving the vaccination target in East Java, which is 9.4%. If viewed based on cultural areas, the achievement of vaccine coverage in the Arek area reached 5%, Pandalungan 2.9%, Mataraman 2.3% while Madura 2%. As we observed, there is a gap of vaccination coverage among those areas. So, it is quite relevant and interesting when considering the approach of the cultural area in this social humanities research to see a comparison of the Willingness to Accept (WTA) COVID-19 vaccine in the East Java community.
The WTA concept can be found in environmental and economic studies, which show an individual's ability to accept the damage that occurs in the environment (Horowitz and McConnell, 2003;Wang et Darmawan, Amarullah Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v11i1.2023 Original Research al., 2020). This concept means that there is an economic assessment of the compensation (e.g., from the factory) that the community (around the factory) is willing to accept as the environmental quality decline is equivalent to the cost of improving the environmental quality.
A simple example is if the community accepts CSR (Corporate Social Responsibility) from factories or similar assistance around their settlements, their WTA is high. In economics, WTA can also mean the minimum amount of money that a person is willing to accept to sell goods or services (producer/seller position (Skeva et al., 2016)) (consumer willingness to buy goods/services (Lanzini et al., 2016), or can be associated with a willingness to bear negative externalities, such as pollution (Sun et al., 2016), congestion (Jia et al., 2018) and others.
In association with the field of health economics or public health studies, in the context of this study, WTA is people's willingness to accept public health programs from the government in a pandemic emergency, namely the COVID-19 vaccine. This context is unique and interesting because psychologically, marketing people will generally pay attention to something free which is generally expensive, such as vaccines. However, because this vaccine is new and in the media, it shows a lot of debate and analysis of various perspectives on it. Therefore, it is not surprising that even though it is applied free of charge, the public's willingness to receive the vaccine, not necessarily acceptable. Even the policies seem to "encourage" certain parties (in order of priority) to be willing to be the first to receive the COVID-19 vaccine.
There are ten cultural areas consisting of Arek culture, Mataraman, Osing (Banyuwangi), Samin, Tengger, Pandalungan (East Java horseshoe area assimilated Java Mataraman and Madura), Panaragan (Ponorogo area and its surroundings assimilated with Mataram), Madura Besar, Madura small islands, and Madura Bawean (Sutarto and Sudikan, 2004). Such division of cultural areas is not meant to differentiate/separate but as an understanding of the characteristics of society. It is based on Kluckhohn's (2017) thinking about the seven elements of culture: religious systems, community organization systems, knowledge systems, livelihood systems, living equipment systems and technology, and language.
The previous study was carried out by Al-Mohaithef and Padhi (2020) to see the acceptance of the vaccine if the government gave it in Saudi Arabia. An online-based survey with a snowball sampling system of 1000 respondents in four cities (Riyadh, Dammam, Jeddah, and Abha) showed that 68 were willing to receive the vaccine. The chosen logistic regression model shows the dominance of those willing to receive the vaccine because of the age factor > 45 years, working in public institutions, having a minimum education of S1, and being married. Malik et al.'s (2020) research in the United States showed that an online survey included 674 participants, with 450 people (67%) saying they would receive the COVID-19 vaccine if it were recommended. Whereas adults who are already working permanently, male, over 55 years old, have higher education (minimum bachelor degree) and are not residents tend to be more accepting or have WTA on the COVID-19 vaccine if one is found. Meanwhile, Harapan et al. (2020) carried out a similar study in Indonesia, although the assumption used is WTP (Willingness to Pay). Their findings, using a simple dichotomous contingent assessment method and a linear regression model on online survey data, showed that 1,359 respondents completed the survey.
In addition, as terms of tracing previous studies on cultural pluralism, research so far tends to link the cultural area of East Java with social life/behavior, politics, livelihood, economic models, artistic styles, and the like (Setyaningsih and Rofi, 2014). Economic variables (income, asset, employment) were considered as the main factor influencing individuals' perception. Higher economic status is related to drive higher education and health which indirectly affects Original Research individuals' knowledge, awareness and willingness to accept vaccination. Other than that, in term of services and quality of the program these are assumed to determine individuals' satisfaction. The survey established by UNICEF (2020) found that community groups that have more information about vaccines are more likely to accept the vaccine. The same was true of respondents with health insurance, who said they were more likely to accept the vaccine. These findings indicate that accurate information is needed about the vaccine.
Tsutsumi el al. (2022) recorded characteristics that might influence individuals, including age, gender, household structure (living alone or with others), and job (employed or unemployed). Jabessa and Bekele (2022) stated that the factors that directly promoted vaccination behavior were a lack of vaccine hesitancy, recommendations from friends or family for vaccination and absence of perceived barriers to COVID-19 vaccination (Chen, 2021). Regarding the demographic factors, women were found to be less willing to accept the vaccine than men, while people under the age of 25 years and less well-educated respondents were marginally more willing to take the vaccine than educated (Bekele et al., 2021;Jabessa and Bekele, 2022). While Wang et al. (2021) stated that beside socioeconomic status, health condition of individuals also influences acceptance.
However, it is quite rare to find studies that lead to multicultural factors in East Java related to the health sphere, specifically referring to their willingness or volunteerism to use the new COVID-19 vaccine. It is a separate research gap that will be answered in this study.
Based on the background, this research aims to analyze what factors determine the willingness to accept and aspects that influence satisfaction after receiving COVID-19 vaccination. We anchored spatial approaches in four dominant cultural areas in East Java, Arek, Pandalungan, Mataraman and Madura, which appears as the novelty of this study. The authors' expectation that this research would be considered by any stakeholders or government in decision-making.

Method
This research is a quantitative research using primary survey data from four cultural areas in East Java. The authors use dummy variable to measure the level of willingness to accept and satisfaction after receiving the vaccine. According to the study of the literature, the willingness to accept is determined by several aspects including economics, health, and social demographics, while the level of satisfaction is influenced by internal and external factors from the vaccination program itself.

Data and scope
This study focused on four large and dominant cultural areas: (1) Madura, (2) Arek, (3) Pandalungan, and (4) Mataraman, where this survey was conducted from June -August 2021. The authors used primary data by creating and distributing online questionnaires with purposive random sampling.
Based on data from the Central Statistics Agency (2020), the population of East Java is 40 million people, where the proportion of distribution based on cultural areas in the Mataraman group is 34.62%, Arek at 30.86%, Pendalungan at 24.67%, and Madura 9.85%. In this survey, the number of individuals was 40% male and 60% female, with an age range of 16-50 years-old.
The Slovin method was used to obtain a sample to be representative of the entire population on that object. The minimum number of samples is 400 with a Mataraman distribution of 138 respondents, Arek 123 respondents, Pandalungan 99 respondents, and Madura 39 respondents. We consider Slovin due to its ability to map minimum adequate numbers of distribution sample in a given region. However, the distribution is experiencing data uniformity constraints, so estimates cannot be made. Thus, we increased the respondent number according to the East Java population Darmawan, Amarullah Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia)

Estimation models
This study uses binary logistic regression to estimate the probability trend prediction of an independent variable. Qualitatively, both models produce almost the same output (Vasisht, 2000). The diversity that exists in the four cultural areas in East Java might have implications for differences in individual willingness and satisfaction of vaccines.
Prior to formulating the model, we studied many previous researches to determine possible variables that authors would use. We use two main models in this research, the first is the willingness to accept model to analyze what factors influence individuals to accept the vaccine, and the second model to discover individual satisfaction after being vaccinated using probit estimation. Where the model is formulated as follows: WTAi = α + β1 * economici + β2 * healthi + β3 * socio_demographici + β4 *

cultural_areai + εi
Where WTA is the willingness to receive the vaccine, the economic consists of income, employment, vehicles, and work from home; health consists of comorbid, the number of neighbors affected by COVID-19, insurance, and paid vaccines; sociodemographic consists of age, gender, education, place of residence and number of families, while for the cultural area, authors use dummy variables for Arek, Mataraman, Madura and Pandalungan region, i is a representation of the individual. Authors also analyze individuals' satisfaction after receiving COVID-19 vaccination.

Satisfactioni = α + β1 * internali + β2 * externali + β3 * cultural_areai + εi
Satisfaction shows the level of individual satisfaction after receiving the vaccine, internal consisting of vaccine side effects, obstacles in activities, and pain obtained during the vaccine; external components consist of the Astra Zeneca vaccine, service time, and cost of accessing the vaccine. Table 3 shows the results of the estimated probit related to the willingness to accept the COVID-19 vaccine. In our estimation, we use six models divided in the aggregate to East Java and the model per cultural area itself.

Result and Discussion
From an economic perspective, an increase of 1% in individual income tends to increase the probability of receiving vaccines, both in the aggregate in East Java and per region. It correlates with the findings of Wake (2020) and Lazarus et al. (2021), where income indicates an individual's economic status. The higher a person's economic status, the greater the probability value shown by Arek cultural areas, where the tendency of their willingness is 90 times greater than in other regions because most Arek tribes are in urban areas with higher economic activity. Darmawan, Amarullah  Dummy for employment showed significant results for the Arek and Mataraman areas. Individuals who have a job had a two times higher probability of being willing to receive the vaccine for the Mataraman area and eight times for the Arek area, while in aggregate, East Java it was 29 times (Sub Model I.1). As previously mentioned, Arek and Mataraman areas tend to have higher economic activity because they are categorized as urban areas, thus affecting the density of individual work in both the formal and informal sectors. This statement is supported by Al-Mohaithef and Padhi (2020), who state that individual workers tend to be willing to receive vaccines because of company recommendations and health precautions to support them in doing their work.

Indonesian Journal of Health Administration
The vehicle variable refers to individual asset ownership, which is ultimately related to income or economic status, where the results show that it is significant both in the aggregate East Java (Sub Model I.1) and the region, an increase in the number of vehicles owned tends to increase the probability that individuals are willing to receive the vaccine Furthermore, from the health aspect, individuals with comorbidities in all regions tend to have a lower probability of individual willingness to receive vaccines, even at the aggregate level of East Java, which is 112 times lower (Sub Model I.1). This result is in contrast to the findings of Wake (2021), where comorbid patients tend to be more receptive to vaccines, which may be due to concerns about their low immunity.
The 1% increase in neighboring cases infected with COVID-19 tends to increase the probability of individuals being willing to receive the vaccine in the Arek, Pandalungan, and Mataraman by four times, 13 times, and six times, respectively. This result is correlated with the findings of Zewude and Habtegiorgis (2021). More people around the environment are infected, encouraging the individual to vaccinate as a motive to protect health and contain the spread.
The variable related to paid vaccines shows a significant value for the Arek and Pandalungan.
The probability of respondents in these areas tends to be willing to receive a vaccine even though the vaccine is paid for. In the Madura and Pandalungan areas, these variables do not influence an individual decision to accept the vaccine or not. However, at the aggregate level of East Java (Sub Model I.1), the opportunity increased by 93 times. That is probably due to the perception of some individuals that the more expensive the vaccine, the better the quality (Harapan et al., 2020)., In the social aspect of the population, the gender variable shows an influence for the Arek and Mataraman, where if the individual is male, the probability of being willing to receive the vaccine is 52 times greater than that of female individuals. These results are associated with Malik et al. (2020), where male individuals tend to receive the vaccine more than women (Kaplan et al., 2021;Wake, 2021). That is due to the physical mobility of males more than females, especially for work.
The age variable in all regions showed significant and negative results in the aggregate for East Java (Sub Model I.1). It indicates that the older the individual, the lower the probability of being willing to receive the vaccine. That correlates with the findings of Kaplan et al. (2021) and. Wake (2021) It can be due to concerns regarding the low immunity of older individuals, lower physical mobility, and lack of literacy related to the importance of vaccines owned by the elderly. It is the exception for Arek and Mataraman areas, where increasing age tends to increase the probability of individuals being willing to receive the vaccine. That correlates with research by Al-Mohaithef and Padhi (2020), Malik et al. (2020), and Lazarus et al. (2021), where the older the individual, the easier it is to accept vaccine recommendations.
In the Arek area, education affects a person's WTA toward vaccines. A higher education level tends to increase the probability of being willing to receive. Education is also an individual determinant in receiving a lot of information and knowledge. These results are in line with Darmawan, Amarullah Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia) p-ISSN 2303-3592, e-ISSN 2540-9301 10.20473/jaki.v11i1.2023 Original Research Al-Mohaithef and Padhi (2020), Malik et al. (2020), Lazarus et al. (2021), and Wake (2021). This is because people with a higher level of education might have a better possibility of grasping and applying knowledge, thus, they will consciously accept the COVID-19 vaccine (Belayneh et al., 2022). However, this variable is not significant for other regions.
The larger the number of families, the higher the probability that individuals will be willing to receive the vaccine. The results of this study correlate with the findings of Kaplan et al. (2021). The probability that an individual is willing to receive the vaccine is 79 times for the Arek area and 32 times for the Mataraman area, and the reason is related to the motive to protect family because there is an assumption that there will be more chances of spreading the virus.
In aggregate (Sub Model I.1), individuals living in urban areas have a two times higher probability of being willing to receive the vaccine than individuals living in rural areas, while for the Arek area, the probability is 28 times greater. That is because the rate of virus spread is higher in urban areas than in rural areas (Wake, 2021). It is because the dissemination of information and vaccination socialization in urban areas is faster than in villages (Lazarus et al., 2021). It also might be influenced by accessibility to reach vaccination services. However, the Madura region shows the opposite result, where the probability of being willing to receive the vaccine is lower if the individual is in a rural area since we know that most individuals in Madura live more rural than Arek. Jabessa and Bekele (2022) stated that individuals who resided in rural areas were 0.85 times less likely to receive the vaccination than those who resided in urban areas.
In aggregate, individuals in the Arek and Mataram areas tend to be willing to receive the vaccine, while for the Madura and Pandalungan areas, it is the opposite. The high level of willingness in the Arek and Mataram regions was due to the high level of awareness related to education and individual economic status compared to other regions. The characteristics of receiving vaccines for the Madura and Pandalungan areas tend to be similar, and this is because the Pandalungan area is a horseshoe area of East Java where the majority of the population has a Madurese cultural background (Kemendikbud, 2014).  Table 4 shows the output of individual satisfaction, where the respondents surveyed are those who have been vaccinated. The results show that the higher the number of side effects felt after being vaccinated, the lower the individual satisfaction with the vaccine program (Zewuda and Habtegiorgis, 2021). Fear of side effects from a COVID-19 vaccine was the most common concern regarding COVID-19 vaccination (Govere-Hwenje et al., 2022). In addition, if these side effects cause problems for individuals in their activities, it will reduce the probability of satisfaction.
Furthermore, if an individual uses the AstraZeneca vaccine, the probability of an individual getting the vaccine is 80 times lower (Sub Model II.1) and 53 times (Sub Model II.2) compared to individuals using a vaccine other than AstraZeneca. That is because the side effects caused by the vaccine are higher than other vaccines.
The longer the vaccine service time, the lower the probability of individual satisfaction because most people are reluctant to queue. Furthermore, related to access costs, the more expensive it is to access the vaccine, the probability of satisfaction will be 31 times lower (Sub Model II.1). This finding correlates with Wake's (2021) findings. Some respondents even stated that they did not want to do the vaccine if it cost money to receive it.
In aggregate, individuals in the Madura area tend to be dissatisfied with the vaccine program, and Arek tends to be satisfied. It is due to the possibility that the Madura region has lower accessibility than Arek, and some areas in Madura are still categorized as inland, so satisfaction with the vaccine itself is lower.
This research was conducted at the beginning of the pandemic, where the vaccination program was not as wide as present, where the vaccination achievement in East Java for the first dose has reached 85% in January 2022, and this is a limitation of this research; further research could consider it for future study. Cultural spatial approach in growing studies on willingness to accept vaccines have not been greatly explored, which appears as the novelty of this study. We find several interesting findings in each observed cultural area. We believe that the result of this study would provide stakeholders or government in decisionmaking regarding vaccination program in East Java.

Conclusion
This research attempts to analyze several factors that influence individuals' willingness to accept and satisfaction regarding COVID-19 vaccination. The results of this study showed that the willingness of individuals to receive vaccines was influenced by income, assets, employment, health, education, gender, age, and place in Arek, Madura, Pandalungan, and Mataram areas. Meanwhile, vaccine satisfaction is associated with side effects, vaccine type, and service time. This study concludes that vaccine reception in each cultural area in East Java has a different attitude, which happens because the culture in the Arek, Madura, Mataraman, and Pandalungan areas is different. Therefore, suggestions given to policymakers are expected to give vaccine doses in the East Java region according to the culture in the region, given the large diversity of cultures in East Java.

Availability of Data and Materials
Data and materials are available based on demand from journals and readers.

Authors' Contribution
APD, HA, and AE conceptualized the study; APD and HA did the survey. KSA and AE created the methodology; KSA and AE wrote, reviewed, and edited the manuscript; ADP and HA wrote the original draft.

Funding Source
Indonesian Ministry of Research, Technology, and Higher Education.